Medical Chronicle November/December 2013

INFECTION CONTROL PART 1 LAURA ZIADY Nurse educator/IPC assessor, Mediclinic Southern Africa Preventing HAIs Infection prevention and control of healthcare-associated infection (HAI) is receiving a lot of attention presently, as the threat to the number of available antimicrobial drugs in reserve keeps increasing. Antibiotic stewardship has some way to go before any benefit from the programme will be observed. In the meantime, hospitals have to fall back on hand hygiene programmes and environmental hygiene in an effort to prevent the spread of infection. Unfortunately, in the general ward setting at least, it seems as if hand washing and disinfection is not having the restricting impact always hoped for, so more attention is being paid to environmental cleaning and hygiene than ever before. Environmental cleaning and hygiene has always been the figurative orphan child of infection prevention and control programmes. Many past healthcare practitioners and even epidemiologists have referred to cleaning and hygiene in passing as one of the measures of infection control programmes - mops and cleaning equipment usually generated yawns and other signs of boredom among hospital staff. And yet, presently, we are looking to this orphan child to save our hospitals from being overrun by HAI. Suddenly, cleaning and the status of cleaners is generating a lot more attention. This series looks at general cleaning in a hospital setting, as well as t he risk assessment for HAI from a cleaning perspective, as well as some suggested methods to make cleanliness more objectively measurable. Pseudomonas usually live in soil and water, but are carried into hospitals from the outside world on people’s hands, clothing, shoes and belongings. In contrast, VRE, gram-negative Escherichia coli (E coli), Klebsiella and C diff. thrive inside the human body. These bacteria land up in hospitals inside patients’ intestines and are released when bedridden patients suffer from diarrhoea, contaminating the environment, air, furnishings and equipment around them. Truth of fiction? In many cases of healthcareassociated infection (HAI), the communities in the region of the healthcare facilities link the existence of so-called ‘superbugs’ to their experience of dirty hospitals. Sadly, the Unfortunately, the case study is all too true. This diverse grouping of pathogens regularly enters hospitals via multiple avenues, and then resides there. Acinetobacter and Discussion The new generation of pathogens are particularly difficult to treat for several reasons. The gram-negative pathogens have a double cell wall that gives them extra defence against antibiotics and shields them from damage by other chemicals, including cleaning solutions. Many of the pathogens can survive in low-nutrient environments, such as on glass, plastic, metal and other surface materials often used in a hospital environment. Healthcare-associated infection 52 MEDICAL CHRONICLE NOVEMBER/DECEMBER 2013 Poppy B was admitted to Ward D for the treatment of a persistent bout of acute pneumonia. She had previously been treated with a broadspectrum antibiotic and corticosteroids in the sick-bay of the longterm resident care facility where she stayed, without alleviation of her symptoms. The facility’s general physician had consequently referred the elderly woman to a medical specialist for further treatment. On admission to the hospital, a sputum specimen was collected from Poppy, which yielded a growth of vancomycin-resistant enterococci (VRE). The bacterium had slowly developed a resistance against the various antibiotics used in the community to treat Poppy over the past months for the mixture of infections that had been plaguing her. Unfortunately, shortly after 48 hours in hospital, Poppy was desperately ill, having developed Clostridium difficile (C diff.) diarrhoea and an acinetobacter baumannii sepsis of the intravenous catheter puncture area. All these later infections had been cross-transferred from the contaminated environment to various entry points in Poppy’s body, with disastrous consequences. The identified pathogens were all associated with a variety of infections from the previous occupants of the hospital room and ward environment. Difficult to grasp, as the room had been terminally cleaned between patients, and on inspection had seemed to be clean... Poor Poppy never made it home again. If only someone had cleaned more carefully between patients, the executive housekeeper and the infection prevention and control risk manager subsequently sighed to each other... precise scientific role of environmental cleaning in the control of these pathogens is as yet unknown. Until cleaning becomes an evidence-based science with credible assessment tools, the importance of a clean environment is likely to remain pure speculation. Research has shown that common skin-touch sites are regularly contaminated with hospital pathogens, which are then transmitted to patients via the hands of staff and visitors. The closer a site is to a patient, the more risk there is that if an organism is allowed to remain there, it will infect a patient. Skin-touch sites are a less obvious aspect of the hand hygiene equation. Concentrating on the cleaning of common touch sites might be a positive addition to the current fixation on hand hygiene. In addition, setting minimum standards for hospital hygiene should provide further evidence that cleaning is a cost-effective method of controlling healthcare associated infection. In general, there are three main methods to prevent HAI. The first is hand washing, second is antibiotic prescribing and antibiotic consumption, and number three is ordinary environmental cleaning. WHO principles • Separating the source of infection from the rest of the hospital • Disrupting all possible routes of transmission. Friction and thorough cleaning is able to remove as much as 80%-90% of the microorganisms present on surfaces. Most non-sporulating bacteria and viruses survive only when they are protected by dirt or a film of organic matter; otherwise they quite speedily dry out and die off. Non-sporulating bacteria are unlikely to survive on clean and dry surfaces. Aseptically, the effectiveness of disinfection and sterilisation is increased by preceding or simultaneous cleaning. Other risk factors for the spread of hospital-acquired infections such as MRSA are staff shortages, patient over-crowding, inadequately trained and supervised staff, and frequent transfers of patients and staff between wards and hospitals.

Medical Chronicle November/December 2013 | Page 52