Nosocomial Infections The Role of the Environment

22.10.2014

Widmer AF 1

Andreas F. Widmer, MD,MSAndreas Voss, MD,PhD

Prof. of Medicine & Infectious DiseasesHead, Hospital Epidemiology

University of Basel, Basel, SwitzerlandTask Force Member WHO Patient Safety

Nosocomial InfectionsThe Role of the

Environment

Transmission of Infectious Agents viaAnimate and Inanimate surfaces

Colonized/Infected Host orEnvironmentalReservoir

Animate Surfaces(principally hands)

Inanimate Surfaces(fomites, environmental surfaces,medical and surgical Instruments

Other Vehicles(water, air, food, soil

and insects)

Susceptible Host

Colonized Host Infected Host

Infectious Dose

Interruption viaCleaning/Disinfection/Sterilization

inanimate_environment2_00

Interruption viaHandhygiene/

Antisepsis

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Widmer AF 2

MDROs: Beyond MRSA, VREenvironmentally stable pathogens

Wenzel RP, ICHE 2008;29(11):1012-1018

Timeline showing the progression in the estimated prevalence in the United Statesof antimicrobial resistance for selected pathogen-antimicrobial pairs.

Survival of Pathogens in the EnvironmentType of bacterium Duration of persistence (range)Acinetobacter spp. 3 days to 5 monthsClostridium difficile (spores) 5 monthsEnterococcus spp. Including VRE and VSE 5 days – 4 monthsHaemophilus influenzae 12 daysKlebsiella spp. 2 hours to > 30 monthsListeria spp. 1 day – monthsMycobacterium tuberculosis 1 day – 4 monthsPseudomonas aeruginosa 6 hours – 16 months (on dry floor: 5 weeks )Salmonella typhi 6 hours – 4 weeksSalmonella typhimurium 10 days - 4.2 yearsSalmonella spp. 1 daySerratia marcescens 3 days – 2 months (on dry floor: 5 weeks )Shigella spp. 2 days – 5 monthsStaphylococcus aureus, including MRSA 7 days - 7 monthsStreptococcus pneumoniae 1 – 20 daysStreptococcus pyogenes 3 days – 6.5 months

Kampf G. BMC Infectious Diseases 2006, 6:130

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Widmer AF 3

Survival of Influenza in the Environment

.Walther BA. Biol. Rev. (2004), 79, pp. 849–869

Environmental Surface Disinfection?

• 1 – 2 hours after floor disinfection identical number of bacteriaas prior to disinfection

[Ayliffe GAJ et al. BMJ 1966; 2: 442]

• “There is no difference in hospital-acquired infection rateswhen floors are cleaned with detergent vs. disinfectant“

[Rutala WA et al: J Hosp Infect 2001; 48 Suppl. A: 66]

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Widmer AF 4

Cross-over Aldehyde vs Glucoprotamin disinfection of BoneMarrow Transplant Unit

Recontamination after disinfection

Meinke R. & Widmer AF. Infect Control Hosp Epidemiol. 2012 Nov;33(11):1077-80

v

Cross-over Aldehyd vs Glucoprotamin disinfection of BoneMarrow Transplant Unit.

Recontamination after disinfection

Meinke R. & Widmer AF. Infect Control Hosp Epidemiol. 2012 Nov;33(11):1077-80

Recontamination with enterococci within 0,5-2 hours

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Widmer AF 5

Disinfectant Product SubstitutionsDonskey CJ. AJIC. May 2013

• Six of the 7 interventions were quasi-experimentalstudies in which rates were compared before andafter interventions with no concurrent control group

• Confounding factors not reported (e.g., hand hygieneor Contact Precaution compliance)

• Decrease in the incidence in 6 of 7 studies

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Widmer AF 6

Handhygiene Techniqueold 6 steps / new 3

WHO_Update_Juni_07

http://www.who.int/patientsafety/en/

Chair: Didier PittetWidmer AF.Surgical Hand Hygiene in:WHO Guideline for Hand Hygiene 2009Widmer AF. Infect Control Hosp Epidemiol 2004Widmer AF. Infect Control Hosp Epidemiol 2007Widmer AF. J Hosp Infect 2009Tschudin S & Widmer AF. Crit Care Med 2010Tschudin S & Widmer AF. ICHE 2010Widmer AF. J Hosp Infect 2013Widmer AF. WHO guideline 2014

FREQUENCY OF ACQUISITION OF MRSA ON GLOVED HANDSAFTER CONTACT WITH SKIN AND ENVIRONMENTAL SITES

40 patients, MRSA carriershand contamination was equally likely after contact with commonly examined skin sites

and commonly touched environmental surfaces in patient rooms (40% vs 45%)

Stiefel U, et al. ICHE 2011;32:185-187

No significant difference on contamination rates of gloved handsafter contact with skin or environmental surfaces (40% vs 45%; p=0.59)

% positive gloved hands after contact with skinand environmental sites (A)

mean number of MRSA colonies acquired onhands (B).

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Widmer AF 7

Case-control study of risk factors for human infection withinfluenza A(H7N9) virus in Jiangsu Province, China, 2013

Risk Factor for Human infection A(H7N9)

Eurosurveillance, June 2013;18: Issue 26, 27

Evidence for Airborne Transmission of Acinetobacter ssp

Sedimentation plates placed in rooms of 7 patients’with respiratory infection or colonization

Brooks SE et al. Infect Control Hosp Epidemiol 2000;21:304.

% o

f pla

tes

grow

ing

Aci

neto

bact

er

LetterTo theeditor

22.10.2014

Widmer AF 8

Aerosolization of carbapenem-resistantA. baumannii in a Trauma /Burn ICU

Settings: A 1,500-bed public teaching hospital Miami53 patient areas cultured,12 (22.6%) air positive for A. baumannii11 (91.6%) corresponded to beds occupied by positive patients

Munoz-Price LS. Crit Care Med 2013; 41:1915・918)

A Long-Term Low-Frequency Hospital Outbreak of KPC-ProducingK. pneumoniae Involving a Persisting Environmental Reservoir

Tofteland S,. PLoS ONE 8(3): e59015.

6

10

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Widmer AF 9

Correlation between number of body sites colonisedwith VRE and environmental contamination in the

same room

Marc JM Bonten: The Lancet Volume 348, 1996 1615 - 1619

Design: retrospective cohort study ,10 ICUs, 750-bed teaching hospitalIntervention: targeted feedback using a black-light marker, cleaning clothssaturated with disinfectant via bucket immersion, and increased education

Acquisition of MRSA and VRE was lowered from3.0% to 1.5% for MRSA and from3.0% to 2.2% for VRE (P < .001 for both).

Patients in rooms previously occupied by MRSA carriers had anincreased risk of acquisition during the baseline (3.9% vs 2.9%, P = .03)but not the intervention (1.5% vs 1.5%, P = .79) period.

In contrast, patients in rooms previously occupied by VRE carriershad an increased risk of acquisition during the baseline (4.5% vs2.8%, P = .001) and intervention (3.5% vs 2.0%, P < .001) periods.

Predictors of MRSA and VRE Acquisitionby patients previously occupied by MRSA or VRE

R. Datta et al. Arch Intern Med 2011;171(6):491-94

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Widmer AF 10

Chart showing the increased riskassociated with the prior room occupant

Otter JA Am J Infect Control 2013;41:S6-11.

Chart showing theincreased risk associatedwith the prior roomoccupant. Thefigures of difference in riskare unadjusted based onraw data. Several of thestudies included adjustedmeasures of risk, butthese were not includedbecause of differencesin study design. * Anypatient infected orcolonized with VRE in thetwo weeks prior toadmission. y Theimmediate prior roomoccupant was known tobe infected or colonizedwith VRE.

Scientific American 2008;298:17JAMA 2007;Oct 17

22.10.2014

Widmer AF 11

Survival of MSSA and MRSAon Fabrics and Plastic

0 10 20 30 40 50 60

Cotton

Terry

Blend

Polyester

Polyethylene

MRSA MSSA Neely AN. JCM 2000;38:724-726

Days after exposure

MRSA contaminated Environment

MRSA Urine/woundn = 27

Blood/Sputumn=11

OR P

Surfaces 85 % 36 % 10.1 0.005

Gowns 65 % ND NA NA

Gloves 58 % ND NA NA

Boyce J. ICHE 1997;18:622-7

mrsa2_98

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Widmer AF 12

Environmental control

• Any registeredDisinfectant for surfaces– CE (Europe)– EPA / FDA (USA)

Bacterialspores

(e.g. C. perfr.,B. stearo-

thermophilus)

Mycobacteria(e.g. M. tuberculosisvar. bovis, M.terrae)

Nonlipid or small viruses(e.g. poliovirus, coxsackievirus)

Fungi (e.g. Candida spp.)

Vegetative bacteria (e.g. S. aureus,P. aeruginosa, Salmonella spp.)

Lipid or medium-size viruses(e.g. HSV, CMV, RSV, HIV, CV-urbanii)

Increasing Order of Resistanceof Microorganisms to Disinfectants

resistant

susceptible

Sterilization EN 554

Disinfectant level

sterilant (high leveldisinfectant with pro-longed exposure time)

high level

intermediate level

low level

PRIONS

Widmer AF. in: Manual of Clinical Microbiology.American Society of Microbiology 2006 /2011

Autoclaving134º/18m (?)

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Widmer AF 13

Pathogens of Concern

• Innate Surfaces– Methicillin-resistant S.aureus (MRSA)– C.difficile– Acinetobacter ssp– Vancomycin-resistant Enterococci (VRE)

• Water– Pseudomonas ssp, non-fermenter

• Air– Moulds, es. Aspergillus

Natl Vital Stat Rep 2009;57(14). Hyattsville, MD: US Department of Health and Human Services, CDC; 2009. Availableat http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf.

22.10.2014

Widmer AF 14

Cluster von CDAD durchC. difficile Ribotyp 027

Aug

07

Num

ber

of p

atie

nts w

ith.difficile

Rib

otyp

e 02

7

University Hospital Basel

3

2

1

(Felix Platter Hospital)Geriatric Clinics

Mar

07

Apr

07

May

07

June

07

Nov

06

Dec

06

Jan

07

Feb

07

Jul 0

6

Jul 0

7

Aug

06

Sep

06

Oct

06

Fenner, A. F. Widmer, A. Stranden, M. Conzelmann, A. Goorhuis, C. Harmanus, E. J. Kuijper, and R. Frei.First cluster of clindamycin-resistant Clostridium difficile PCR ribotype 027 in Switzerland.Clin Microbiol.Infect. 14 (5):514-515, 2008.L. Fenner, R. Frei, M. Gregory, M. Dangel, A. Stranden, and A. F. Widmer.Epidemiology of CDAD. Eur.J.Clin.Microbiol.Infect.Dis., 2008.

25 Stuhl-Isolate von 16 Pat.4 vom USB

12 vom Felix Platter-Spital

22.10.2014

Widmer AF 15

Risk factors for Dissemination of C.difficile

“Hygiene of patient and underlyging disease(Worsley M.A., JAC 1998;41,suppl C:59-66)

Effectivenes of Environmental Disinfections against spores(floors, devices )

(Jones et al, Lancet;352:505-6/Wilcox and Fawley, Lancet 2000;356:1324)

Compliance with contact isolation of patients with CDAD(Johnson et al, Am J Med 1990;88:137-40/Struelens et al, Am J Med, 1991;91:138S-144S)

Virulence(Wilcox et al, J Hosp Infect 1997;37:331-343)

Immunity of patients(Barbut Bull Soc Fr Microbiol 2002;17 (2)

Antimicrobial use(Wilcox et al, J Hosp Infect Lett. to the Editor 1997, ECCMID Glasgow 2003)

C.difficile_CID_08 Bobulsky GS et al, Clin Infect Dis 2008;46:447-450

CDAD: Colonized patients andTransmission to Gloves of HCWs

C

Frequency of Clostridium difficile contamination of skin sites of 27 patients with C. difficile-associated disease (CDAD) (A) andfrequency of acquisition on sterile gloves after contact with skin sites of a subset of 10 patients (B). C, Typical illustration ofacquisition of C. difficile on sterile gloves after contact with a CDAD-affected patient’s groin. The larger yellow colonies outliningthe fingers are C. difficile. Of note, the patient had showered 1 h before collection of the culture specimen.

Frequency of acquisition on sterilegloves after contact with skin sites of a

subset of 10 patients

Frequency of Clostridium difficile contamination ofskin sites of 27 patients with C. difficile-associateddisease (CDAD)

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Widmer AF 16

Bacterialspores

(e.g. C. perfr.,B. stearo-

thermophilus)

Mycobacteria(e.g. M. tuberculosisvar. bovis, M.terrae)

Nonlipid or small viruses(e.g. poliovirus, coxsackievirus)

Fungi (e.g. Candida spp.)

Vegetative bacteria (e.g. S. aureus,P. aeruginosa, Salmonella spp.)

Lipid or medium-size viruses(e.g. HSV, CMV, RSV, HIV, CV-urbanii)

Increasing Order of Resistanceof Microorganisms to Disinfectants

resistant

susceptible

Sterilization EN 554

Disinfectant level

sterilant (high leveldisinfectant with pro-longed exposure time)

high level

intermediate level

low level

PRIONS

Widmer AF. in: Manual of Clinical Microbiology.American Society of Microbiology 2006 /2011

Autoclaving134º/18m (?)

Does the environment need to be disinfected?

Intervention Reduction of initialcontamination or Incidenceof CDAD

References

Unbuffered hypochlorite (500 ppm)Phosphate buffered hypochlorite(1600 ppm pH 7,6)

5 X

100 X

Kaatz, Am JEpidemiol 1988

Unbuffered 1:10hypochlorite solutions

Before 8.6/1000 pt-dAfter 3.3/1000 pt-d

Mayfield, CID 2000

Diluted aldehyde-containingdisinfectant + other infection controlmeasures

4 X p=0.04Before 1.5/1000 admAfter 0.3/1000 adm

Struelens, Am JMed 1991

Cases with C.difficile:Disinfection with an active disinfectant against spores necessary

No gluoprotamin. No Quats. No AminesWidmer AF & Frei R.. Infect Control Hosp Epidemiol Nov 2003Widmer AF & Frei R. Disinfection. Manual of Clinical Microbiology, ASM 2007 /2011

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Widmer AF 17

Oxygen-releasing Agentse.g. Magnesium monoperoxyphthalate hexahydrate (MMPP) 80.0 g

Directions for useSurfaces 0,5 % - 1 hrs.Surfaces during epidemics (NLV) 4,0 % - 1 hrs.HBV 0,5 % - 5 min.HIV 0,25 % - 5 min.BVDV* (Surrogate virus for Hep C). 0,5 % - 1 min.Rotavirus 0,25 % - 1 min.Poliovirus 1,0 % - 1 hrs.Adeno-, Vaccinia-, Papovaviruses 0,25 % - 5 min.Bacterial spores 1,0 % - 4 hrs.M.tuberculosis 0,5 % - 1 hrs.

Data on file BDF 2003

HPVGenerator

CatalyticConverter

Hydrogen peroxide vapor(HPV)decontamination,

Picture: Courtesy of Johne Boyce, USA

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Widmer AF 18

Picture: Courtesy of Johne Boyce, USA

Incidence of nosocomial CDAD on 5 wards (A–E) that underwent intensivehydrogen peroxide vapor decontamination, during the preintervention period

(gray bars; June 2004 through March 2005) and the intervention period(red bars; June 2005 through March 2006)

Cdiff_medart.ppt Boyce JM et al. ICHE 2008;29:723-9

Inte

rven

tion

perio

d

Inte

rven

tion

perio

d

Inte

rven

tion

perio

d

Inte

rven

tion

perio

d

Inte

rven

tion

perio

d

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Widmer AF 19

Comparison of Hydrogen Peroxide Vapor Decontamination and Bleach Cleaning, Accordingto the Time Required for Each Phase of Disinfection

Otter JA et al, Infect Control Hosp Epidemiol 2009;30(6):Decontamination_ICHE_09.ppt

Note: There were 93 rooms decontaminated with hydrogen peroxide vapor and 64 matched rooms disinfected by use of bleachcleaning. Bold type indicates statistically significant P values (P <.05). The sum of means for the constituent phases may not equalthe mean of the whole data set. Cumulative times were calculated using absolute times and are thus more accurate than the sumof the mean for the constituent phases. NA, not applicable.a Calculated by use of a 2-tailed t test.b Detergent-based cleaning to remove visible dirt prior to hydrogen peroxide vapor decontamination or bleach cleaning for rooms

that were not decontaminated using hydrogen peroxide vapor.c Time required to set up the decontamination equipment was included in the hydrogen peroxide vapor cycle time.d In rooms decontaminated with hydrogen peroxide vapor, a second visit by housekeeping was necessary to make the bed and

prepare the room for the subsequent occupant.

Hydrogen peroxide vapordecontamination, min Bleach cleaning, min

Phase of process Mean Median (range) Mean Median (range) Pa

Room vacant awaiting housekeeping 21 16 (0-180) 34 21 (0–242) .02First cleaning by housekeepingb 24 24 (0-48) 32 29 (8–73) <.001End of first cleaning to set up of hydrogenperoxide vapor system 19 0 (0-265) NA NA

Hydrogen peroxide vapor cyclec 139 135 (102-225) NA NACumulative time from when room was vacatedto end of hydrogen peroxide vapor cycle 206 179 (141-567) NA NA

End of hydrogen peroxide vapor cycle toarrival of housekeeping 42 23 (0-272) NA NA

Second cleaning by housekeepingd 23 24 (0-46) NA NACumulative time for all phases 270 234 (174-838) 67 55 (28-256) <.001End of disinfection process to occupation 198 119 (0-1025) 147 98 (15-1253) .22

What is on that keyboard? Detecting hidden Environ-mentalReservoirs during a C. difficile outbreak NAP1/027

• 20 of 87 (23%) surfaces cultured outside of patient rooms contaminatedwith toxin-producing C difficile.

• 9 of 29 (31%) surfaces in physician areas were contaminated,– 2 of 6 (33%) telephone keypads– 5 of 19 (26%) desktop computers– 2 of 2 doorknobs.

• 1 of 10 (10%) surfaces in nursing areas were contaminated,– 0 of 2 telephones– 1 of 4 (25%) desktop computers– 0 of 2 doorknobs.

• 9 (21%) of portable medical equipment were contaminated– 0 of 1 ultrasound machines– 1 of 5 (20%) pulse oximeter finger probes,– 3 of 9 (33%) portable computers– 2 of 13 (15%) medication carts– 3 of 11 (27%) medication bar code scanners.

Dumford DM. Am J Infect Control. 2009 Feb;37(1):15-9.

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Widmer AF 20





Munoz-Price L and Weinstein R.N Engl J Med 2008;358:1271-1281

Reservoirs, Sources, and Transmission Patterns forAcinetobacter in Health Care Facilities

Acinetobacter_NEJM_08

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Widmer AF 21

Acinetobacter outbreaks 1977-2000

13 Studies with a common source outbreak with a respiratory cluster:•Clonal transmission confirmed by PFGE or PCR-based typing

Setting: Common Source:Adult ICUAdult,neonatal and pediatric ICUAdult mixed ICUSurgical and medical ICUAdult ICUNeonatal ICUAdult mixed ICU

Ventilator spirometersReusable ventilator circuitsIn line temperature monitor probesVentilator temperature probes‘Y’ piece of ventilatorSuction catheter and bottlePeak flow meter

Villegas M, Hartstein A. Infect Control Hosp Epidemiol. 2003;24:284-295





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Widmer AF 22

VRE ENVIRONMENTALCONTAMINATION

Reference Sites Contaminated Frequency

Karanfil 1992 EKG pressure monitor dials,doorknob

12%

Boyce 1994 Patient gowns, linens,bedrails, IV pumps, BP cuff

28%

Boyce 1995 Patient gowns, linens,bedrails, BP cuff, IV pump

37%

Slaughter 1996 Bed linen, siderails, BP cuffs,bedside tables

7%





22.10.2014

Widmer AF 23

Pseudomonas aeruginosa infections inhealth-care facilities (CDC Guideline

2003)

MMWR June 6, 2003 / Vol. 52 / No. RR-10

Nosocomial Outbreaks fromHospital Tap Water

• Legionella spp Kool JL. ICHE. 1999; 20:798-805,

• P.aeruginosa Widmer AF ICAAC 2000 #123

• Stenotrophomonas maltophilia Denton M. AJIC 2000;28 323-324

• Mycobacteria spp. von Reyn CF. Lancet 1994;343:1137-1141

• Acinetobacter spp. Kappstein I. J.Hosp.Infect 44 (1):27-30, 2000.

• S.aureus LeChevallier MW.Appl.Environ.Microbiol. 39 (4):739-742, 1980.

• Moulds Anaissie E. Clin Infect Dis. 2001;33(9):1546-8.

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Widmer AF 24

P.aeruginosaSources of nosocomial infection

• Endogenous :

– Antibiotic exposure: Selection e.g.Amoxicillin/clavulanate

• Exogenous:

– Waterborne via faucets: ICU, hydrotherapy– Iatrogenic: ventilators, humidifiers, endoscopes, IV

solutions, disinfectant, soap, distilled water,

– Cross-colonisation by HCWs (hands) e.g. Afterhandling fresh flowers

P. aeruginosa : Exogenous Source ofEndemic Nosocomial Infection

Nb of pts Nb of Nb of Nb (%) ofSetting (country) (%) genotypes type/pts exogenous

o. ICU 14 (23%) 1 ?1. Burn unit (D) 12 (?) 14 1-5 9 (75%)2. ICU (D) 15 (26%) 11 1 8 (53%)3. ICUs (CH) 132 (6%) 56 ? 60 (45%)4. ICUs (NL) 23 (23%) 11 ? 8 (35%)5. Acute leukemia pts (D) 18 (15%) 12 1 6 (33%)6. ICUs (D) 48 (4%) 42 ? 6 (13%)7. Surgical ICU (D) 18 (18%) 16 1 2 (11%)8. All wards (CH) 51 (8%) 32 1-4 2 (4%)

0: Widmer AF. Clin Infect Dis 19941. S. Pradella et al. Eur. J. Clin. Microbiol. Infect. Dis. 1994,

13:122-82. G. Döring et al., Epidemiol. Infect., 1993, 110:427-363. Blanc, Intensive Care Med 2004;30:1964-84. D.C.J.J. Bergmans et al. Thorax, 1998, 53:1053-8

5. W. Kern et al., Eur. J. Clin. Microbiol. Infect. Dis., 1990,9:257-61

6. H. Grundmann et al. Clin. Microbiol. Inf., 1999, 5:355-637. E. Gruner et al. JID, 1993, 167:1216-208. D.S. Blanc et al., Clin. Microbiol. Inf., 1998, 4:242-7

Slide by M. Strulens

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Widmer AF 25

Geographical and cases distributions P. aeruginosagenotypes isolated from both the faucets and the ICU patients

hospitalized

Blanc_2004

Blanc DS et al. Intensive Care Med 2004;30:1964-8Blanc DS et al. Intensive Care Med 2004;30:1964-8

Faucet Aerator as probable sourceof an epidemic

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WWWiiilllsssooonnn NNNuuurrrssseeerrryyy 111 PPP...aaaeeerrruuugggiiinnnooosssaaa JJJAAAMMMAAA 111999666111

CCCrrrooossssss IIICCCUUU 444 PPP...aaaeeerrruuugggiiinnnooosssaaa NNNEEEJJJMMM 111999666666

KKKooolllmmmooosss BBBuuurrrnnnsss 555 PPP...aaaeeerrruuugggiiinnnooosssaaa JJJHHHIII 111999999333

VVVeeerrrwwweeeiiijjj NNNIIICCCUUU 555 SSS...mmmaaallltttoooppphhhiiillliiiaaa EEEpppiii IIInnnfffeeecccttt 111999999888

KKKaaappppppsssttteeeiiinnn PPPeeedddiiiaaatttrrriiicccooonnncccooolllooogggyyy

333 AAA...jjjuuunnniiiiii JJJHHHIII 111999999999

WWWeeebbbeeerrr SSSIIICCCUUU 777 PPP...aaaeeerrruuugggiiinnnooosssaaa AAAJJJIIICCC 111999999999

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Widmer AF 26

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

0

1

2

3

4

5

6

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Anz

ahl P

at. m

it P.

aer

ugin

osa

in B

B

Inzidence P. aeruginosa Bloodstream InfectionsBone Marrow Transplant Unit 01.01.2000 - 25.02.2009

Patients with Pseudomonas BSIs

Incidence density Pseudomonas BSIs

Linear (Incidence density Pseudomonas BSIs)

Impact of Sterile Water Supply onthe Incidence of NosocomialBloodstream Infectios in BMT

patients

63 mineral waterfrom Switzerland, Italy and France21/63 33% positive for Norovirus

only 1 with gas11% of Swiss mineral waters positiveNo correlation with- chemical- type of bottle (plastic / glass) Beuret C. J Food Prot 2000;63:1576-82

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Widmer AF 27




• Air– Moulds, esp. Aspergillus

Summary of ventilation specificationsin selected areas of health-care

facilities*

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Widmer AF 28

Incidence of Surgical Site Infections by Type of Air quality inthe OR: Standard vs Laminar Air Flow

0.9031.37

0.6460.918

2.77

7.14

0.98

2.55

0

1

2

3

4

5

6

7

8

Turbulent AirFlow

Laminar Air Flow Turbulent AirFlow

Laminar Air Flow

Infe

ctio

n R

ate

Hip Knee

C. Brandt. &P.GastmeierAnn.Surg. 2008;248:695-700

N=28,623 N=10,966

Analysis fromsurveillance dataAdjusted OR

• Prosthetic valve endocarditis (PVE) due to fast-growing nontuberculous mycobacteria (NTM) hasbeen reported anecdotally. Reports of PVE withslowly growing NTM, however, are lacking. Wepresent here one case of PVE and one case ofbloodstream infection caused by Mycobacteriumchimaera.

• Randomly amplified polymorphic DNA (RAPD)-PCRindicated a relatedness of the two M. chimaerastrains.

• Both patients had heart surgery 2 years apart fromeach other. A nosocomial link was not detected.

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Widmer AF 29

Office of Public Health July 14, 2014

• Bern, 14.07.2014 - Hospitals in Switzerland thatperform open heart surgery have taken measures toincrease patient safety. In rare cases, infections havebeen observed that did not result in illness until someyears after surgery.

• These infections are believed to be due to the use of adevice that is used during cardiac surgery.

• In conjunction with Swissmedic, the Federal Office ofPublic Health has informed all hospitals and cardiacsurgeons about this problem. Immediate measuresare being taken to prevent such infections fromoccurring in future.

http://www.admin.ch/aktuell/00089/index.html?lang=en&msg-id=53774

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Widmer AF 30

Cooler / Heater: all contaminated byM.chimaera

Clinical Data

• 2 Deaths (published)• 4 infections Osteomyelitis after incubation of

1-2 years– Treatment not standarized– Look-back in progress in Switzerland

• No clinical cases from USB and otherUniversities

Andreas F. Widmer, MD,MSWHO - SSI

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Widmer AF 31

Microbiological Data

• >3 Universities positive samples ofM.chimaera in air sampling

• Airsampling at the surgical site– positive when cooler is running– Negative, when not running– Confirmed by at least 2 university hospitals

• Source of M.Chimaera unknown– Not isolated from water– But cooler must be filled with tap water



0

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10.06.2014 12.06.2014 14.06.2014 16.06.2014 18.06.2014 20.06.2014 22.06.2014 24.06.2014 26.06.2014 28.06.2014

KBE/

1000

L

GKZ allg Bakt Saal 9_Sorin MT82977

Prior surgery

during surgery

OR Table

Up to 60 CFU/m3 at the surgical sie

Laminar air flow (1978)

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Widmer AF 32


Ventilator

compressor


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Widmer AF 33

Phylogenetic tree of M.chimaera


Actions July/Aug 2014• Sterile Water filter• Decontamination of Cooler/heaters by the

manufacturer• After standard disinfection by perfusionist AND

> 1 week not filled with waterrunning 24h with water

• High density of M.chimaera in air sampling• Definite safe method pending• Problem: incubation time for M.chimaera 7

weeks


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Widmer AF 34


Atypical Mycobacteria: an Underestimated Cause of InfectiveEndocarditis on Bioprosthetic Valve

Pres. Time: Sunday, Sep 07, 2014, 11:00 AM - 1:00 PM L-1066

Author(s): C. Bouchiat, A. Boibieux; Hospices Civils de Lyon, Lyon, France

Abstract:

Background: Atypical Mycobacteria infective endocarditis (IE) has been barely described and is uneasy to diagnose. Methods: From January2010 to December 2013, 5 patients presented to the hospital for blood culture-negative IE suspicion, requiring surgery. 16s rDNA PCR-sequencing was performed on the explanted material, followed by specific hsp PCR-sequencing for species confirmation. Demographic, clinical,histopathologic, Ziehl-Neelsen stain, echocardiographic data, treatment and outcome were collected. Results: The cardiac samples of these 5patients were positive to Mycobacterium chelonae (n=4) and M. lentiflavum (n=1). Patients all presented to hospital for heart failure withoutfever 7.1-18.9 months (median=13.1) after biologic prosthetic valve replacement. Echocardiography revealed paravalvular regurgitation due toprosthesis dehiscence for all. Histopathology examination of the explanted material revealed the presence of macroscopic multi-focalulcerations and inflammatory infiltrates in all specimens, associated with giant cells granulomas (n=3), confirming the diagnosis of IE. Ziehl-Neelsen stain showed numerous Acid Fast Bacilli for all patients. Allergic etiology was ruled out by anti-porcine IgE dosages. These infectionswere significantly associated with biologic prostheses (p<0.01) since none of the 390 other samples (74 bioprostheses, 77 mechanicalprostheses, 239 vegetations or native valves) analyzed in our laboratory over the study period was positive to atypical Mycobacteria

Conclusions: We report 5 cases of atypical Mycobacteria IE on biologicprosthesis. It is thus of importance to encourage a systematic Ziehl-Neelsenstain on explanted bio-prosthetic valves in case of blood culture-negative IEsuspicion. Even though the contamination source remains unclear, we canquestion the conditioning process of the explant following its removal frompigs.


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CONCLUSIONS and Personal Remarkson Hospital Environment and Infection Control

• Dirty Hospitals are dirty and potentially infectious• Floors/Surfaces

– Daily cleaning of patient areas standard– Daily disinfection of rooms with patients colonized/infected with pathogens

who should be isolated or high-turn over areas (e.g.ICU)• MRSA,VRE, Acinetobacter,• Highly active disinfection for C.difficile, Norovirus.

• Water– Filtered Water for PSCT or Bone Marrow Transplant Unit and ICUs with

ventilated patients– Regularly clean shower heads

• Air– PSCT/BMT clean air (Laminar air flow ?????)– OR clean air (laminar air flow for orthopedic surgery?)

Hospital-wide incidence of nosocomial CDAD11/ 2003-3/2006.


HPV, hydrogen peroxide vapor

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Quantities of Antimicrobials Used During the Preintervention andIntervention Periods


1565 Rooms Decontaminated with Hydrogen Per-oxide Vapor from January 2006 -September 2007


Number of rooms decontaminated with hydrogen peroxide vapor and the number of rooms that met the criteria fordecontamination but could not be decontaminated (rooms missed; see Results for details), as well as percentageoccupancy. Data are quarterly, from January 2006 through September 2007.

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Comparison of Hydrogen Peroxide Vapor Decontamination and Bleach Cleaning, Accordingto the Time Required for Each Phase of Disinfection


Note: There were 93 rooms decontaminated with hydrogen peroxide vapor and 64 matched rooms disinfected by use of bleachcleaning. Bold type indicates statistically significant P values (P <.05). The sum of means for the constituent phases may not equalthe mean of the whole data set. Cumulative times were calculated using absolute times and are thus more accurate than the sumof the mean for the constituent phases. NA, not applicable.a Calculated by use of a 2-tailed t test.b Detergent-based cleaning to remove visible dirt prior to hydrogen peroxide vapor decontamination or bleach cleaning for rooms

that were not decontaminated using hydrogen peroxide vapor.c Time required to set up the decontamination equipment was included in the hydrogen peroxide vapor cycle time.d In rooms decontaminated with hydrogen peroxide vapor, a second visit by housekeeping was necessary to make the bed and

prepare the room for the subsequent occupant.

Hydrogen peroxide vapordecontamination, min Bleach cleaning, min

Phase of process Mean Median (range) Mean Median (range) Pa

Room vacant awaiting housekeeping 21 16 (0-180) 34 21 (0–242) .02First cleaning by housekeepingb 24 24 (0-48) 32 29 (8–73) <.001End of first cleaning to set up of hydrogenperoxide vapor system 19 0 (0-265) NA NA

Hydrogen peroxide vapor cyclec 139 135 (102-225) NA NACumulative time from when room was vacatedto end of hydrogen peroxide vapor cycle 206 179 (141-567) NA NA

End of hydrogen peroxide vapor cycle toarrival of housekeeping 42 23 (0-272) NA NA

Second cleaning by housekeepingd 23 24 (0-46) NA NACumulative time for all phases 270 234 (174-838) 67 55 (28-256) <.001End of disinfection process to occupation 198 119 (0-1025) 147 98 (15-1253) .22

Wu_Noro_ICHE_2005.ppt Wu HM et al. ICHE 2005;26:802-10

Onset of symptoms among the case-residents and case employees of a long-term-care facility in Philadelphia during a norovirus outbreak from

Jan/Feb 2003

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Impact of Chloramin with andwithout Ultraviolet on CFUs onContact Plates for Samples (4

Isolation Units

Anderson BM.Infect Control Hosp Epidemiol 2006; 27:729-734

Disinfection with UVC light may significantly reduce environmental bacterialcontamination and thereby protect the next patient housed in an isolation room.UVC disinfection may not be used alone but is a good addition to chemicaldisinfection.

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Environmental fungal pathogens: entryinto and contamination of the

healthcare facility

Microorganisms associated withairborne transmission

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Summary of ventilation specificationsin selected areas of health-care

facilities*

Water and point-of-use fixturesas sources and reservoirs of

waterborne pathogens* (Cont.)

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Water and point-of-use fixtures as sources andreservoirs of waterborne pathogens* (Cont.)

Nosocomial Infections The Role of the Environment

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