Selection of the Ideal Disinfectant

by William A. Rutala          

               Healthcare-associated infections (HAIs) remain an important source of morbidity and mortality with an estimated 1.7 million infections and 99,000 deaths annually. A major source of nosocomial pathogens is thought to be the patient’s endogenous flora, but an estimated 20-40% of healthcare-associated infections have been attributed to cross-infection via the hands of healthcare personnel.  Contamination of the hands of healthcare personnel could in turn result from either direct patient contact or indirectly from touching contaminated environmental surfaces. Healthcare personnel have frequent contact with the environmental surfaces in patients’ rooms providing ample opportunity for contamination of gloves and/or hands.  Two recent studies demonstrated that contact with the environment was just as likely to contaminate the hands of healthcare workers as was direct contact with the patient.  Donskey has reviewed the scientific literature and found that improving surface cleaning and disinfection reduces healthcare-associated infections (Am J Infect Control 2013: 41:S12-S19).  Another recent paper showed that daily disinfection of surfaces (versus standard cleaning surfaces when visibly soiled) with a sporicidal disinfectant in rooms of patients with Clostridium  difficile and methicillin-resistant Staphylococcus aureus (MRSA) reduced acquisition of pathogens on gloved hands after contact with room surfaces.  While disinfectants are used to prevent transmission of pathogens from both noncritical and semicritical items, the purpose of this brief article is to assist the user in the selection of the optimal disinfectant for use with environmental surfaces and noncritical patient care items (devices that contact only intact skin such as stethoscopes).  The same characteristics for an ideal low-level disinfectant would be used for high-level disinfectants; however, the contact time would be longer and antimicrobial spectrum would be broader (e.g., may include C. difficile spores).  To date, the perfect product for healthcare disinfection has not been introduced; however, there is a wide array of disinfectants that offer a range of characteristics. 

Review of New and Current ACIP Recommendations

by David J. Weber, MD, MPH

The Centers for Disease Control and Prevention (CDC) has just released the 2014 vaccine schedules from the Advisory Committee on Immunization Practices (ACIP).  Changes in vaccine adult schedule (19 years or older) can be found in the MMWR 2014;63:1-2 { http://www.cdc.gov/mmwr/preview/mmwrhtml/mm63e0203a2.htm?s_cid=mm63e0203a2_w} .  The schedule itself can be found at http://www.cdc.gov/vaccines/schedules/hcp/adult.html). 

Vaccines recommended for susceptible HCP include the following:

·         Mumps (2 doses):  MMR preferred (assume immune if born before 1957 except during an outbreak)

·         Measles (2 doses):  MMR preferred (assume immune if born before 1957 except during an outbreak)

·         Rubella (1 dose):  MMR preferred (indicated for all female HCP of childbearing potential)

·         Influenza (1 dose yearly)

·         Varicella (2 doses)

·         Tetanus toxoid, diphtheria toxoid, pertussis (1 dose of Tdap)

·         Hepatitis B (3 doses with quantitative anti-HBsAg titer 1-2 months after 3^rd dose):  Indicated for HCP who have potential exposure to blood or contaminated body fluids.

·         Meningococcal vaccine (1 dose; booster every 5 years if risk continues):  Indicated for lab personnel who spin cerebrospinal fluid.

New changes in the vaccine schedule relevant to HCP include:

·         Recombinant influenza vaccine (RIV) or inactivated influenza vaccine (IIV) can used among HCP with hives-only allergy to eggs.  RIV contains no egg protein and can be used among persons aged 18 to 49 years who have egg allergy of any severity.

·         A single dose of Tdap vaccine is recommended for HCP; a Td booster should be administered every 10 years thereafter.

Public Reporting of MRSA and Clostridium difficile LabID Events

by Zack Moore, MD and Jennifer MacFarquhar, RN, MPH, CIC

Clostridium difficile (C. diff) and methicillin-resistant Staphylococcus aureus (MRSA) are both important public health problems, responsible for approximately 14,000 and 11,000 deaths in the United States each year, respectively. Both of these infections are frequently acquired in healthcare settings and have therefore been the target of many control efforts by hospitals working independently and in collaboration. These efforts have led to a 54% reduction in the number of invasive MRSA infections occurring during hospitalization between 2005 and 2011.¹ However, the incidence of C. diff infections has continued to increase in recent years, as has the number of deaths attributed to C. diff in North Carolina.^2,3

Beginning in January 2013, all acute care hospitals in North Carolina began reporting MRSA bacteremia and C. diff LabID events through the CDC’s National Healthcare Safety Network (NHSN).  These hospital-specific data were first made public on the Centers for Medicare and Medicaid Services’ Hospital Compare website beginning in December 2013 and were first included in the North Carolina Division of Public Health’s Healthcare-Associated Infections Quarterly Report in January 2014.^4,5

LabID event reporting is based solely on laboratory results, and therefore some of the events reported may not represent true infections. However, this method of reporting has the advantages of being relatively more objective and less labor-intensive than case-based reporting using clinical case definitions. Moreover, publication of these infection data provides an opportunity to examine and understand the information on a statewide and individual hospital level. In North Carolina, infection rates for the first nine months since reporting began (January–September 2013) were within the predicted range for both C. difficile and MRSA bacteremia. Data from the first full year of reporting will be published in the upcoming annual report, anticipated in April 2014. 

No Foolin’! SPICE rolls out new educational offerings

On April 1^st, SPICE will launch two more free educational modules that address infection control in long term care facilities. Funding from a CMS – NC DHSR partnership has supported the development of four modules. The newest modules focus on safe injection practices employing an American Idol-themed show called The Technique, and on environmental disinfection utilizing an upbeat “infomercial” to educate viewers. Go to spiceducation.unc.edu to view the modules, or to order a DVD. More modules are on the way: SPICE has just been awarded a second round of funding to produce two new modules that will focus on Clostridium difficile and urinary tract infections.

Also, on April 1^st, SPICE will launch its newly revised Curriculum for Infection Control in Dental Settings. The course is offered through the SPICEducation website for $150 (go to spiceducation.unc.edu), as well as through approved providers in classroom and webinar formats (more information at spice.unc.edu/dental).

National Action Plan to Prevent Healthcare-Associated Infections Current Progress and Proposed Targets for 2020

The U.S. Department of Health and Human Services released proposed targets and metrics for the National Action Plan to Prevent Healthcare-Associated Infections, as virtually all of the previous targets and metrics expired December 2013.

A national stakeholder meeting was held in September 2013 and helped shape the proposed targets along with a federal steering committee of HAI prevention experts from federal agencies.

The proposed targets would set 2015 as the new baseline, with the exception of invasive MRSA, which was included in the federal government’s Healthy People 2020 goals and has an existing 2007-2008 baseline, which has not expired. 

This table outlines the proposed new targets for 2020, alongside the most recent progress on the measures to date.  The proposed metrics can also be viewed here.

 

CDC Vital Signs: Antibiotic Prescribing in Hospitals

CDC’s March VitalSigns highlighted the effect poor prescribing habits can have on the ability to protect patients from unnecessary risk and preserve the power of antibiotics. The report found that approximately one-third of the time, prescribing practices to treat urinary tract infections and prescriptions for vancomycin included a potential error – given without proper testing or evaluation, or given for too long. In addition to the potential errors, prescribing practices vary widely between hospitals and doctors within a hospital. According to CDC, doctors in some hospitals prescribed 3 times as many antibiotics as doctors in other hospitals.

CDC estimates that reducing the use of high-risk antibiotics by 30% can lower C. difficile infections by 26%. CDC recommends that hospitals have an antibiotic stewardship program in place to reduce instances of inappropriate antibiotic prescribing.

The release of the March Vital Signs coincides with CDC’s announcement of a new antibiotic resistance initiative, that will focus on the four core actions called for in CDC’s Antibiotic Resistance Threat Report: detection of antibiotic resistance; response to outbreaks; prevention of infections; discovery of new antibiotics and diagnostic tests for resistance. The initiative aims to reduce the threats of seven antibiotic resistant organisms, including carbapenem-resistant Enterobacteriaceae (CRE), by improving detection through regional laboratories and strengthening antibiotic prescribing practices.

CDC recommends that hospitals institute an antibiotic stewardship program that includes:

•Leadership commitment

•Accountability

•Drug expertise

•Taking at least one prescribing improvement action

•Tracking prescribing and antibiotic resistance patterns

•Regularly reporting to staff prescribing and antibiotic resistance patterns

•Education

CDC Unveils New Website to Improve Infection Control Practices in Long-Term Care Facilities

The Centers for Disease Control and Prevention (CDC) announced the launch of a new website with infection prevention resources for long-term care settings such as nursing homes and assisted living. This site organizes existing infection prevention guidance and resources into sections for clinical staff, infection prevention coordinators, and residents.

Facilities can also directly access the new infection tracking system for long-term care facilities in CDC’s National Healthcare Safety Network, and the innovative infection prevention tools and resources developed as part of the partnership between CDC and the Advancing Excellence in America’s Nursing Homes Campaign (AE).

On the CDC’s Safe Healthcare blog, Nimalie Stone, MD, medical epidemiologist and long-term care expert at CDC, discusses this new website, including the resources developed under the partnership between CDC and Advancing Excellence to prevent C. difficile infections in nursing home residents.

Case of CJD Disease in New Hampshire

Bill Rutala

by Bill Rutala, Ph.D.

In September 2013, health officials confirmed that a patient who underwent neurosurgery at a New Hampshire hospital earlier in the year had Creutzfeldt-Jacob disease.  The death, and suspicions that the patient may have had the devastating brain ailment, prompted authorities in two states to warn that as many as 13 patients may have been exposed to surgical equipment used during the patient's surgery, thus to the same disease. The now-deceased patient had undergone neurosurgery at a New Hampshire hospital and the patient was later suspected of having sporadic Creutzfeldt-Jakob disease, a rare, rapidly progressing and always-fatal degenerative brain disease. But by the time this diagnosis was suspected, equipment used in the patient's surgery had been used several other operations. This raised the possibility that the equipment might have been contaminated -- especially since normal sterilization procedures are not enough to get rid of the disease proteins, known as prions, tied to Creutzfeldt-Jakob disease -- thus potentially exposing the other patients to infection (Botelho, CNN, September 2013).  This exposure scenario could happen in any hospital and this is why we must remain vigilant and implement practices that minimize its occurrence in our hospitals.

           Creutzfeldt-Jakob disease (CJD) is a degenerative neurologic disorder of humans with an incidence in the United States of approximately 1 case per million population per year. CJD is caused by a proteinaceous infectious agent, or prion.  Prion diseases elicit no immune response, result in a noninflammatory pathologic process confined to the central nervous system, have an incubation period of years, and usually are fatal within 1 year after diagnosis.