using a sporicidal disinfectant …using a sporicidal disinfectant everywhere is not the solution to...

USING A SPORICIDAL DISINFECTANT EVERYWHERE

IS NOT THE SOLUTION TO ONGOING CLOSTRIDIUM

DIFFICILE TRANSMISSION

Jim Gauthier, MLT, CIC

Senior Clinical Advisor, Infection Prevention

Objectives

• Review impact of Clostridium difficile Infection (CDI)

• Understand literature and recommendations to

prevent the risk of CDI in the healthcare

environment

• Understand when moving to special practices may

make sense

• Explore bundled approaches and evidence-based

options to reduce CDI risk

• Spore-forming, Gram-positive

anaerobic bacillus

• Most common cause of healthcare-

associated diarrhea

• Opportunistic bacteria – usually needs

a change in gut flora to grow and

produce toxins (antibiotics,

chemotherapy)

3

Clostridium difficile


• C. difficile spores pose unique challenges for hand

hygiene and disinfection practices since they are

resistant to the bactericidal effects of alcohol hand rubs

and many common disinfectants

• Some studies have shown spores are also difficult to

wash off of hands


• CDI rates are increasing - C. difficile now rivals

MRSA as the most common cause of HAIs in the

United States

• CDI has moved outside of the hospital walls, with

more than 50% of CDIs having onset in the

community and more than 75% of CDI cases having

onset outside the acute care hospital

Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update Author(s): Erik R. Dubberke, MD, MSPH; Philip Carling, MD; Ruth Carrico, PhD, RN; Curtis J. Donskey, MD; Vivian G. Loo, MD, MSc; L. Clifford McDonald, MD; Lisa L. Maragakis, MD, MPH; Thomas J. Sandora, MD, MPH; David J. Weber, MD, MPH; Deborah S. Yokoe, MD, MPH; Dale N.Gerding, MD Source: Infection Control and Hospital Epidemiology, Vol. 35, No. 6 (June 2014), pp. 628-645


• CDI present on admission to the hospital may increase

the risk of CDI for other patients

• CDI is associated with increased length of stay (2.8 – 5.5

days), morbidity and death and is estimated to add up to

$4.9 billion in excess cost

Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update

• A collaboration of key industry experts highlighting

practical recommendations to assist acute care hospitals

with Clostridium difficile infection (CDI) prevention efforts

• Updates the 2008 “Strategies to Prevent Clostridium

difficile infections in Acute Care Hospitals”

• This guidance document is collaborative effort led by

SHEA, IDSA, AHA, APIC and the Joint Commission

SHEA/IDSA Practice Recommendation

Strategies to Prevent Clostridium difficile

Infections in Acute Care Hospitals

General Strategies to Prevent CDI

• Antimicrobial usage restriction and stewardship

• Restriction of specific high-risk antimicrobials has been

effective in outbreak settings

• Improving antimicrobial prescribing practices has been

effective in outbreak and non-outbreak settings

General Strategies to Prevent CDI

• Prevent patient exposure to C. difficile (disinfection and

barrier methods) • Avoid use of electronic thermometers

• Use of dedicated patient care items and equipment

• Use of contact precautions (gowns/gloves)

• Private rooms/isolation; preference to those with fecal incontinence

• Hand hygiene

• Environmental cleaning and disinfection; sporicidal for outbreak or

hyperendemic situations

• Staff, Patient and Visitor Education

Transmission of C. difficile

• Patient-to-patient transmission of C. difficile is thought to

occur primarily through transient contamination of the

hands of healthcare personnel (HCP)

• Glove use when caring for patients with CDI or touching

surfaces in their rooms has been shown to be effective

in preventing transmission

Transmission of C. difficile

• Daily disinfection of high touch surfaces in CDI rooms

has been shown to reduce acquisition of pathogens on

hands after contact with surfaces and to decrease

contamination of the hands of the providers caring for

patients

Transmission of C. difficile • Sharing a room with a patient diagnosed with CDI or being

admitted to a room after a patient with CDI was

discharged from that room, have not been found to

increase the risk factor for CDI in several studies

• Several studies have found that the use of sporicidal

methods to clean the environment, outside of outbreak

settings, has not consistently demonstrated a reduction of

CDI, which indicates that although the environment can be

an important source for C. difficile, indirect transmission by

healthcare professionals may be the major route by which

patients acquire C. difficile

Ensure Cleaning and Disinfection of

Equipment and the Environment

• C. difficile spores contaminate the environment in which

patients are housed and the equipment used to care for

them. This includes the following:

• Furnishings in the room, such as overbed tables, bedrails,

furniture, sinks, floors, commodes, and toilets

• Patient care equipment that directly touches patients, such as

thermometers, stethoscopes, and blood pressure cuffs

Basic Practices vs. Special Approaches Basic practices – should be adopted by all acute care hospitals –

includes recommendations where the potential to impact HAI risk

clearly outweighs the potential for undesirable effects

Special approaches – can be considered for use in locations and/or

populations within hospitals when HAIs are not controlled by use of

basic practices – these can include recommendations where the

intervention is likely to reduce HAI risk, but where there is concerns

about the risk of undesirable outcomes; where the quality of evidence is

low; or when evidence supports the intervention in select settings or for

select patient populations

C. Diff isolation

Task Oriented vs.

Daily Use

Before Moving to Special Practices

• Develop and implement protocols for disinfection of equipment and

the environment • On a routine basis, assess adherence to protocols and the adequacy of

cleaning and disinfection

• Assess the adequacy of cleaning and disinfection practices before

changing to a new cleaning product (e.g., bleach). If cleaning and

disinfection practices are not adequate, address this before changing

product

• Ensure patient care equipment and electronic equipment that remain in

the patient room are cleaned and disinfected

• Educate environmental service personnel on proper cleaning and

disinfection technique and ensure competency

Are Your HAI rates still high?

Review basic practices

+

Rutala 2014

~27%

+

Rutala 2014

~53%

+

Rutala 2014

79%

(without

Yeasts)

Effect of Disinfectants on Microorganisms Organism Type Examples

Bacterial Spores Spore Bacillus anthracis, Clostridium difficile

Mycobacteria Bacteria M. tuberculosis

Small non-enveloped virus Virus Poliovirus, Norovirus

Fungal spores Fungus Aspergillus, Penicillium, Trichophyton

Gram negative bacteria Bacteria E. coli, Klebsiella including CRE,

Pseudomonas, Acinetobacter

Fungi (Vegetative) Fungus Candida

Large Virus (non-enveloped) Virus Adenovirus, Rotavirus

Gram positive bacteria Bacteria Staphylococcus including MRSA

Enterococcus including VRE

Virus (enveloped) Virus HIV, HBV, HCV, Influenza

^Resistant * Sensitive

R^

S*

Adapted from Rutala et al. ICHE 2014;35(7):862

Evaluate the Risk of Soiling

Procedure

Incontinent product change (feces)

Assisting a vomiting patient

Performing a bed bath

Open Suctioning

Wound dressing change

Removing Central Line

Removing urinary or peripheral catheter

Phlebotomy

Dressing patient

Placing or removing food tray

^Hi Soiling Risk * Low Soiling Risk

HS^

LS*

Copyright © Sealed Air Diversey

Is Hand Hygiene Your Issue?

• Do staff, visitors and patients understand the

importance?

• Do they know when to perform hand hygiene?

• Do they understand what product is to be used?

• Is the product accessible – when and where they need

it?

• Are they using the appropriate technique?

Is Environmental Cleaning and

Disinfection Your Issue?

• Do all staff members understand why cleaning and

disinfection so important?

• Is it clearly defined who is responsible for cleaning what

(EVS, nursing, other)?

Cleaning and Disinfection

• What surfaces/equipment need to be cleaned, how

often, what product should be used, what cleaning tool,

compatibility of cleaning tool to disinfectant, what

dilution, amount needed, contact time?

• Is there product available where/when needed?

• Is the product being used properly, PPE donned

correctly (if needed), right technique used, contact time

achieved, feedback provided?

Cleaning and Disinfection

• Assess the adequacy of room cleaning • If room cleaning and disinfection practices are deemed to be

inadequate, focus on reviewing and improving cleaning and

disinfection techniques

• Create a unit-specific checklist based on cleaning protocols and

perform observations to monitor cleaning practice

• Consider environmental decontamination with sodium hypochlorite

or EPA-approved sporicidal agent if room cleaning and disinfection

is deemed to be adequate but there is ongoing CDI transmission


Numerous studies indicate that environmental

cleaning in patient rooms is suboptimal • Carling conducted two multi-facilities studies that demonstrated that on

average less than 50% of high touch surfaces were cleaned thoroughly

• Significant variation existed within object categories – with ranges

between 0-90%

Carling 2008

Sporicidal Concerns

• Data are conflicting as to whether inactivation of spores is necessary

to prevent C. difficile transmission, especially in an endemic setting

• Sporicidal agents can be harsh on surfaces • Discoloration

• Shorter Asset Life Cycle

• Oxidation and wear

• Sporicidal agents can be harsh on people • Asthmagen

• Foul odor

• Irritating to lungs, skin, eyes

SHEA Poster Presentation

Change Management Plan – Interventions • Stakeholder meetings

• Education

• Cleaning carts and checklists

• Daily duties distributed to staff

• Switched to sporicidal for daily cleaning

Study results raised

the question:

Are people not using

disinfectant because

they are concerned? Derya Mahmutoglu, MD, Javeria Haque, MD, Mary Beth Graham, MD and L. Silvia Munoz-Price, MD PhD, Division of Infectious Diseases, Medical College of WI

Use of Sporicidal Agents

• Data on the ability of sporicidal agents used to control CDI in the

environment have not been consistent; however a beneficial effect has

been reported when used in outbreak or hyperendemic settings when used

with other enhanced CDI control measures

• When in use:

• Avoid toxicity to patients and staff and damage to the equipment and the

environment from use.

• Sodium hypochlorite can be corrosive and irritating to patients and

healthcare workers

• Coordinate activities with EVS, IP to determine when/how it will be used


Are There Alternative Options?

Elbow grease does the job

Efficacy of Different Cleaning and Disinfection Methods

against Clostridium difficile Spores: Importance of

Physical Removal versus Sporicidal Inactivation • Tested the removal of C. difficile spores from environmental surfaces using

various cleaners, disinfectants and wipes. Wipes with a non-sporicidal

agent showed 2.9 log10 reductions of C. difficile spores. Wiping with a

sporicidal agent increased the removal efficacy by 1 log10 (3.9 log10)

• Results: Any method that included wiping the surface (physical removal)

resulted in a 3 log10 reduction in C. difficile spores, even if the cleaner or

disinfectant was not a sporicidal agent

Rutala 2012 ICHE

C. difficile Eradication from Toilets

Few alternatives to bleach for non-outbreak conditions

have been evaluated in controlled healthcare studies

METHODS

• This study was a prospective clinical comparison during non-outbreak

conditions of the efficacy of a disinfectant cleaner (0.5% IHP) with respect to

spore removal from toilets in a tertiary care facility

CONCLUSION

• 0.5% IHP formulation evaluated has shown some sporicidal activity (2-3

log10 kill after 1 minute) and provides a one-step process that significantly

lowers the C. difficile spore level in toilets during non-outbreak conditions

without the workplace safety concerns associated with 5000 ppm bleach Alfa 2010

36

Reducing the risk is more than just using a disinfectant

It takes an integrated approach designed to protect people and assets

with effective products, procedures and a validation program designed

to objectively measure cleaning and disinfection effectiveness.

Key Elements of HAI Reduction

37

A clearly defined protocol with education

Compliance monitoring with staff feedback

The use of an effective disinfectant cleaner

First Clinical study to show that improved compliance with environmental surface disinfection using IHP reduced HAI rates for VRE, MRSA and C. difficile

Alfa 2015

Proven Solution to Reduce HAI


Alfa 2015


All rates reduced by > 20%


3 key components to ensure reduction of HAI:

Alfa 2015

Cost avoidance of $668,000/year due to HAI rate reduction


All rates reduced by > 20%




A New Study with Improved Hydrogen

peroxide (IHP) Presented at APIC

John M. Boyce, MD Presented at APIC 2016

AJIC 2016;44(6)Suppl:S16

Study Design

• 12-month prospective trial with cross-over design conducted on two

campuses of a university-affiliated hospital

• On each campus, 2 wards were randomized to have housekeepers perform

routine daily cleaning/disinfection of surfaces

• IHP disinfectant wipes containing 0.5% IHP

• Quat disinfectant currently used in the hospital, applied using a disposable wipe

made of meltblown polypropylene (same material as disposable wipe above)

• The 4 study wards included

• An MICU and its step-down unit on one campus

• Two general medical wards on the other campus

• After the initial 6 months, ward assignments were changed

Results

• Mean Aerobic Colony Count (ACC)/surface after cleaning

• On IHP wards (14.0 CFUs/surface)

• On Quat wards (22.2 CFUs/surface)

(p = 0.003)

• Logistic regression analysis revealed that the proportion of surfaces

yielding no growth after cleaning

• On IHP wards (240/501 [47.9%])

• On Quat wards (182/517 [35.2%])

(p < 0.0001)

Both microbiological outcomes favored IHP over Quat

Results

23% fewer cases/1000 Pt-days on IHP wards

• Hand hygiene compliance rates comparable on study wards • Antibiotic usage: Non-C. difficile agent use was 10.8% higher on IHP wards which would

be expected to lead to more VRE, MRSA and CDI outcomes, not fewer as observed

)

Proven Formula for HAI Reduction

45




Additional Learnings

• It is critical to ensure there is a proper process, procedure and

training program in place, along with an objective means to

measure compliance

• Also, there is no substitute for good hand hygiene!!

Summary

47

48

C. Diff isolation

Task Oriented vs. Daily Use

Why you don't need to use a C. diff

sporicidal everywhere

1. Guidelines recommend sporicidal

disinfectants during hyperendemic or

outbreak situations; not for daily

cleaning

2. Data on use of sporicidal agents to

control CDI has been inconsistent

3. Potential negative side effects of

sporicidal agents (air quality,

equipment compatibility, worker and

patient safety) may outweigh benefits

of daily use

4. Non-sporicidal cleaners, used in

conjunction with effective protocol

have been proven to physically

remove a spores and can be

effectively used for daily disinfection of

C. diff rooms in non-outbreak settings.

Healthcare Associated Infection

HAI(p) = HH + ASP + CP + FWM + ED Where:

HAI(p) = Healthcare Associated Infection Prevention

HH = Hand Hygiene

ASP = Antibiotic Stewardship Program

CP = Clinical Practices

FWM = Fecal Waste Management

ED = Environmental Disinfection

Questions?

50

References

Alfa MJ, et al. Improved eradication of Clostridium difficile spores from toilets of

hospitalized patients using an accelerated hydrogen peroxide as the cleaning

agent. BMC Infect Dis 2010 http://www.biomedcentral.com/1471-2334/10/268

Assessed June 27, 2016

Alfa MJ, et al. Use of a daily disinfectant cleaner instead of a daily cleaner

reduced hospital-acquired infection rates. AJIC 2015;43:141-6

Carling PC, et al. Improving Cleaning of the Environment Surrounding Patients

in 36 Acute Care Hospitals ICHE 2008;29(11):1035-41

http://www.biomedcentral.com/1471-2334/10/268 Assessed June 27





References

Centers for Disease Control. Options for Evaluating Environmental Cleaning.

2010 http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html

(assessed on June 27, 2016)

Dubberke ER, et al. Strategies to prevent Clostridium difficile Infections in acute

care hospitals: 2014 update. ICHE 2014;35(6):628-45

Greater New York Hospital Association. Reducing C. difficile infections toolkit:

Best practices from the GNYHA/UHF collaborative. Accessed online May 27,

2016. http://gnyha.org/resourcecenter/?catid=55&typeid=94

Rutala W, et al. Selection of the ideal disinfectant. ICHE 2014;35(7):855-65

http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html





http://gnyha.org/resourcecenter/?catid=55&typeid=94

References

Rutala WA, et al. Efficacy of different cleaning and disinfection methods against

Clostridium difficile spores: importance of physical removal versus sporicidal

inactivation. ICHE 2012;33(12):1255-8

Thank you!

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