Microbiologists will
be interested to learn of new research designed to better identify sources of hospital-acquired
infections, including investigating possibilities that have not been previously
considered
Does the proximity of toilets to sinks in medical intensive care units (MICUs) affect the health and recovery of the patients staying there? Until recently, that wasn’t questioned. But clinical laboratory managers will be interested to learn why researchers now believe this could very well lead to nosocomial infections—also known as hospital-acquired infections (HAIs)—a topic Dark Daily has covered extensively for many years.
Thus, the results of this research could impact not only the
hygiene and disinfectant procedures of healthcare workers, but the designs of
future MICU rooms and possibly even change the plumbing requirements throughout
entire healthcare facilities. These new findings may also create new factors
for hospital infection control teams and microbiologists to consider when
investigating the sources of nosocomial infections.
The MCW researchers conducted their investigation in a
600-bed Wisconsin hospital with a 26-bed MICU “in which each room has:
“a patient bed;
“two sinks; and,
“a toilet without physical barriers in between.
“Each room is surface-cleaned (including sink bowls, but not drains) with hydrogen peroxide/peracetic acid on a daily basis. Separate cloths are used to clean each of the two sinks in patient rooms to avoid cross-contamination,” the study notes.
The photo above (taken from the MCW study) illustrates the configuration of the medical intensive care unit room surveyed in this study. The location of the toilet with a sink adjacent to the toilet and sink far from the toilet are all labeled. (Photo copyright: Medical College of Wisconsin, Milwaukee.)
The MCW researchers found:
“KPC–producing organisms persist in sink drains
in intensive care units without recent history of carbapenem-resistant
Enterobacteriaceae infections;
“A high prevalence of [beta-lactamase Klebsiella pneumoniae carbapenemase]
(blaKPC) polymerase chain reaction-positive (54%) and culture-positive (9%)
sink drains; and,
“Sinks near toilets were four times more likely
to be positive (87%) than sinks distal to toilets (22%).”
However, the MICU did not have any documented interactions
with KPC-producing organisms within the past year, the press release noted.
“This study, if validated, could have major implications for infection control,” study authors, Blake Buchan, PhD (left), and Silvia Munoz-Price, MD, PhD (right), stated in the press release. “If sinks next to toilets are indeed a reservoir for KPC, additional interventions—such as modified hand hygiene practices and sink disinfection protocols—may be needed to stem the risk of transmission among healthcare providers and patients alike.” (Photos copyright: Medical College of Wisconsin.)
Other Studies into KPCs,
HAIs, and Human Gut Microbiota
Another study, which looked at the risk factors for carbapenem-resistant KPC (CRKP) in pediatric patients in Beijing Children’s Hospital, found that hematologic malignancies and previous cephalosporin administration were better predictors of mortality due to CRKP bloodstream infections than mechanical ventilation for septic shock.
New technologies that allow researchers to follow novel,
unexplored paths to learn about potential sources of infections might
contribute to fewer hospital-acquired infections and improved outcomes for both
patients and those who work in healthcare settings.
Medical laboratories play a critical important role in this
by identifying and typing bacteria in hospital settings, especially those that
are resistant to current antibiotics. New approaches to locating such bacteria
continue to be investigated and the tools available to learn more about them
are becoming more powerful and widely available.
Regardless of the origin, protecting staff and patients from
HAIs is critical. Clinical laboratory involvement in protecting patients, and monitoring,
investigating, and managing outbreaks, are key to controlling the spread of
these dangerous bacteria.
Brazilian study finds Staph, E. coli, and other bacteria that contribute to hospital-acquired infections in reusable water bottles used by members of multiple fitness centers
In the latest example of Microbiologists swabbing
and culturing samples taken from common, everyday items, a research team in
Brazil has found germs associated with hospital-acquired
infections (HAIs) infections on reusable water bottles carried by
individuals working out in local fitness clubs.
Their results may cause gym members to consider the impact
the bottles they tote can have on their health.
Worse than Licking a
Dog Toy
The researchers analyzed the presence of different bacterial
strains in the water bottles of 30 fitness club members at two different
fitness center locations, as well as 30 new unused bottles. They also conducted
antimicrobial
susceptibility tests for the isolated strains.
The scientists found contamination in 90% of the used
plastic bottles, while none of the new bottles showed signs of bacterial
contamination. Twenty-five (83%) of the used bottles contained Staph (26.66%)
and E. coli (16.66%). In addition, four of the reused bottles tested positive
for the presence Pseudomonas,
an antibiotic-resistant bacterium that also causes HAIs.
Similar results were found in testing performed by the website
TreadmillReviews.net. That study
revealed an average athlete’s water bottle contained 313,499 viable bacteria
cells (313,400 colony-forming units per square centimeter).
“To put it bluntly, drinking from the average refillable
bottle can be many times worse than licking your dog’s toy,” Treadmill Reviews noted.
Philip M. Tierno, Jr., Professor of Microbiology and Pathology at New York University and NYU Langone Medical Center, is not surprised by the findings of the Brazilian study, which found that 83% of fitness club members’ reusable water bottles were contaminated with bacteria. He suggests frequent handwashing before refilling reusable water bottles will help prevent spreading the bacteria. Clinical pathologists will agree that diligent cleaning of hands, clothes, and medical instruments can prevent the spread of deadly diseases. (Photo copyright: NYU Langone Health.)
CDC Downplays
Presence of Staph and E. coli
Despite the ick-factor of the water-bottle testing results, Runner’s World also notes that the Centers for Disease Control and Prevention (CDC)
determined that Staph bacteria can be found in the noses of 30% of the
population, while E. coli is present in healthy gastro intestinal tracts, with
only certain strains causing illness.
The Brazilian study’s authors also noted that most of the
bacteria isolated in their research belong to the Enterobacteria group,
which lives in the intestines and are pathogenic. Thus, the
researchers surmised that “manipulation with contaminated hands may contribute
to the colonization of the [reusable water bottles].
“We conclude the best way to avoid bacterial proliferation
in the [reusable water bottles] is to make sure they are correctly and
frequently cleaned, such as daily washing with neutral soup in association with
proper hand hygiene to prevent contamination,” Senna and co-authors wrote.
Philip M.
Tierno, Jr, PhD, Professor of Microbiology and Pathology at New York University (NYU) and the NYU Langone Medical Center supports the study’s conclusions.
He suggests water bottles likely become contaminated through handling by their
owners, an issue proper hand hygiene can help remedy. He recommends properly
washing hands before filling a gym water bottle.
“Wash 20 seconds,” Tierno told Runner’s World. “Get soap on the top and bottom of hands and in
between digits and under the nail bed. Run your hands like a claw in the center
of the opposite palm to get suds into the nail bed, and sing the song ‘Happy
Birthday’ twice to wash hands adequately.”
Reusable water bottles also should be cleaned thoroughly,
preferably in a dishwasher.
Until the general public begins routinely following such
advice, microbiologists and clinical
pathologists will remain the tip of the spear in infection control programs
and education. But that should not stop clinical laboratory managers from
implementing constant monitoring and cleaning protocols to stop the spread of
infectious bacteria in their labs.
Even more compelling was the discovery of DNA from the Staph bacteria on the stethoscopes even after they were cleaned. Though the tests could not differentiate between live and dead bacteria, the researchers found other non-Staph bacteria as well, including Pseudomonas and Acinetobacter.
Similar conditions could no doubt be found in most
healthcare settings in America, highlighting the critical importance for
rigorous cleaning procedures and protocols.
“The study underscores the importance of adhering to rigorous infection control procedures, including fully adhering to CDC-recommended decontamination procedures between patients, or using single-patient use stethoscopes kept in each patient’s room,” said Ronald Collman, MD (above), the study’s senior author and Professor of Medicine, Pulmonary, Allergy, and Critical Care at UPenn’s Perelman School of Medicine, in a news release. (Photo copyright: Penn Medicine.)
The researchers acknowledged that previous culture-based bacterial
studies looked at stethoscopes, but noted the results fell short of the view
next-generation sequencing technology can offer for identifying bacteria, as
well as determining the effectiveness of cleaning chemicals and regiments.
“Culture-based studies, which focus on individual organisms,
have implicated stethoscopes as potential vectors of nosocomial bacterial
transmission [HAI]. However, the full bacterial communities that contaminate
in-use stethoscopes have not been investigated,” they wrote in Infection Control and Hospital Epidemiology.
• 20 worn by physicians, nurses, and respiratory therapists;
• 20 single patient-use disposable stethoscopes available in ICU patient rooms; and,
• 10 unused single-use disposable stethoscopes to serve as a control.
All stethoscopes worn and/or used in the ICU were found to be contaminated with abundant amounts of Staphylococcus DNA. “Definitive” amounts of Staph was found by researchers on 24 of 40 tested devices, noted MedPage Today.
“Genera relevant to healthcare-associated infections (HAIs)
were common on practitioner stethoscopes, among which Staphylococcus was ubiquitous
and had the highest relative abundance (6.8% to 14% of containment bacterial
sequences),” the researchers noted in their paper.
Cleaning Methods Also
Examined
The researchers also studied the hospital’s cleaning agents
and procedures:
• 10 practitioner stethoscopes were examined before and after a standard 60-second cleaning procedure using hydrogen peroxide wipes;
• 20 additional stethoscopes were assessed before and after cleaning by practitioners using alcohol wipes, hydrogen peroxide wipes, or bleach wipes.
All methods reduced bacteria. But not to the levels of a new
stethoscope, the study showed.
“Stethoscopes used in an ICU carry bacterial DNA reflecting complex microbial communities that include nosocomially important taxa. Commonly used cleaning practices reduce contamination but are only partially successful at modifying or eliminating these communities,” the researchers concluded in their paper.
Prior Studies to Find
and Track Dangerous Bacteria
Studies tracking bacteria where people live, work, and
travel are not new. For years, medical technologists and microbiologists have
roamed the halls of hospitals and other clinical settings to swab and culture
different surfaces and even articles of clothing. These efforts are often
associated with programs to reduce nosocomial infections (HAIs).
This new study by UPenn Perelman School of Medicine researchers—published
in a peer-reviewed medical journal—will hopefully serve as a contemporary
reminder to doctors and other caregivers of how bacteria can be transmitted and
the critical importance of cleanliness, not only of hands, but also
stethoscopes (and neckties).
Hospital-based medical laboratory leaders and microbiology professionals also can help by joining with their infection control colleagues to advocate for CDC-recommended disinfection and sterilization guidelines throughout their healthcare networks.
Contrary to CMS and Joint Commission programs implemented in 2017 to reduce them, incidents of hospital-acquired infections have risen for the past few years
Nevertheless, a recent Leapfrog Group report indicates hospitals are finding it increasingly difficult to remove infections all together. This has many healthcare leaders concerned.
The report, which was analyzed by Castlight Health, states that the number of hospitals reporting zero infections has declined significantly since 2015, according to a news release. According to the Leapfrog Group’s report:
Two million people acquire HAIs every year;
90,000 people die annually from HAIs;
HAI costs range from $1,000 to $50,000 depending on the infection.
Hospitals spend $28 to $45 billion annually on HAI costs, Healthcare Finance reported.
“I think it’s far too easy to let something slip, so it’s clear that there really needs to be a renewed focus on getting back to zero. We do still see some hospitals that are getting to zero, so it’s clearly possible,” Erica Mobley (above), Leapfrog Group’s Director of Operations, told Fierce Healthcare. (Photo copyright: LinkedIn.)
Regressing Instead of Progressing Toward Total HAI Elimination
Leapfrog Group’s report is based on 2017 hospital survey data submitted by 2,000 providers. The data indicates that in just two years the number of hospitals reporting zero HAIs dropped by up to 50%. The reported HAIs include:
Central line-associated bloodstream infections (CLABSI) occurring in Intensive Care and other units: 12.7% of hospitals reporting zero CLABSI infections in 2017, down from 25% in 2015;
The remaining infection measures studied by Leapfrog Group had less dramatic decreases over the same time period, according to Fierce Healthcare. Nevertheless, they are significant. They include:
Surgical site infections (SSI) following colon surgery: 19% zero infections compared to 23% previously;
Clostridium difficile (C. difficile) inpatient infections: 3% zero inpatient infections in 2017, compared to 5% in 2015.
Joint Commission Studies Antimicrobial Program Progress
Hospitals have revised their antimicrobial programs, which originally operated on a “top-down” structure, to programs that include clinicians from throughout entire provider organizations;
Health information technology (HIT) can enable real-time opportunities to launch antimicrobial therapy and treat patients; and,
Some barriers exist in getting resources to integrate technology and analyze data.
“These programs used expansion of personnel to amplify the antimicrobial stewardship programs’ impact and integrated IT resources into daily workflow to improve efficiency,” the researchers wrote. “Hospital antimicrobial stewardship programs can reduce inappropriate antimicrobial use, length of stay, C. difficile infection, rates of resistant infections, and cost.”
What Do CMS and Joint Commission Expect?
According to Contagion, while the Joint Commission program is part of medication management, CMS places its requirements for the antimicrobial stewardship program under “infection prevention.”
CMS requirements for an antimicrobial stewardship program include:
Developing antimicrobial stewardship program policies and procedures;
Implementing hospital-wide efforts;
Involving antimicrobial stakeholders for focus on antimicrobial use and bacterial resistance;
Setting evidence-based antimicrobial use goals; and,
Reducing effects of antimicrobial use in areas of C. difficile infections and antibiotic resistance.
Leapfrog Group’s data about fewer hospitals reporting zero infections offers opportunities for hospital laboratory microbiology professionals to get involved with hospital-wide antimicrobial program teams and processes and help their hospitals progress back to zero HAIs. Clinical laboratories, both hospital-based and independent, also have opportunities to contribute to improving the antimicrobial stewardship efforts of the physicians who refer them specimens.
Decline in hospital-acquired conditions (HACs) overall since 2010 attributed to increased attention to safety protocols and practices by hospital staff in cooperation with clinical laboratory services
It’s now been almost nine years since the Medicare Program stopped paying hospitals and other providers for certain hospital-acquired conditions (HACs). Included in this list are hospital-acquired infections (HAIs). The goal is to substantially reduce the number of HACs and HAIs, thus improving patient outcomes, while substantially reducing the healthcare costs associated with these conditions.
So, almost nine years into these programs, has there been progress on these goals? This is a question of key interest to Medical laboratories and pathology groups because they have a front-line role in working with clinicians to diagnose and treat HAIs, while also looking to identify the transmission of HAIs within the hospital.
A recent report by the Agency for Healthcare Research and Quality (AHRQ), a division of the US Department of Health and Human Service (HHS), indicates that there has been progress in the goal of reducing HACs. The AHRQ report noted a 21% decline in HACs between 2010 and 2015. Data collected during that time indicates a reduction of more than 3.1 million HACs and nearly 125,000 patient deaths due to HACs.
In 2015 alone, nearly one million fewer HAC incidents occurred. The reduction saved “approximately $28 billion in healthcare costs,” an outcome which, the AHRQ report notes, is the result of increased attention to safety protocols in hospitals and a “period of concerted effort by hospitals throughout the country to reduce adverse events.”
Clinical Pathologists/Laboratories Play Key Role in HAI Prevention
Though many reported incidents are associated with adverse drug events, HAIs have been significantly reduced in recent years due to focused efforts on infection prevention. The report notes that clinical pathologists have become vital players in infection prevention programs, and that increased coordination between hospital medical laboratories and clinicians played a crucial role in the reduction.
Eileen O’Rourke is an Infection Preventionist at the Lankenau Medical Center in Philadelphia. And she has served as a leader and consultant for hospital-based infection prevention programs in Pennsylvania since 1984. In an article on the Wolters Kluwer Pharmacy OneSource blog, O’Rourke noted that successful infection prevention and control requires development of “a highly visible and administratively supported infection prevention and control program with qualified and trained personnel.” Clinical pathologists are part of that support team, providing surveillance, testing, and interpretation of data essential for identifying epidemiological origins of infection and pathogen distribution. And the vital services that clinical laboratories provide to reduce HAIs center on surveillance, prevention, and control.
The chart above was calculated on US Dollars in 2012. Since then, thanks to contributions by medical laboratories and pathologists in collaboration with hospitals, those costs have decreased significantly. (Image copyright: MLive.com.)
In an article for Lab Testing Matters, John Daly MD, Chief Medical Officer at the Commission on Office Laboratory Accreditation, and former Director of Clinical Laboratories for the Duke University Health System, highlights the importance of surveillance. He states that it is “an essential element of an infection control program” providing “data to identify infected patients and determine the site of infection” as well as “factors that contributed to the infection.” Medical laboratories must, Daly stresses, provide “easy access to high-quality and timely data and give guidance and support on how to use its resources for epidemiologic purposes.”
Daly argues that medical laboratories function as liaisons to clinical services, working to “improve the quality of specimens sent to the laboratory and promoting appropriate use of cultures and other laboratory tests.” The laboratory should, according to Daly, be involved in all aspects of the infection control programs. This ensures:
Proper specimen collection;
Accurate and rapid testing; and
Accurate reporting of laboratory data.
Laboratory Data Provide ‘Early Warning’ for HAI Surveillance Systems
Robert A. Weinstein, MD, wrote in his 1978 article, “The Role of the Microbiology Laboratory in Surveillance and Control of Nosocomial Infections,” that medical laboratories and pathologists are central to prevention and control of HAIs. Laboratory records, Weinstein remarked, serve as important data sources that can identify early spread of infection, thus becoming an “early warning system” for a potential outbreak of infections. The sampling that laboratories perform identifies not only the strain of infection, but the method by which infection is spread, and the best treatment options. Nearly 40 years later his statements ring truer than ever, as anatomic pathology laboratory data continues to reveal patterns of infection faster and more precisely than ever before.
Sarah Mahoney, PhD, is a research scientist at Navitor Pharmaceuticals in Cambridge, Mass. In an article published in the American Journal of Clinical Pathology, she states that in surveilling patterns of infection, pathologists also decipher the source of infection. Mahoney wrote that it is “necessary to identify the causative organism” for surveillance and management control of HAIs. She also noted that pathologists must strive to discriminate between “hospital- and community-acquired infection” in order to provide clinicians with guidance for treatment, and to map “infection transmission within a clinical setting.”
Hospitals Rely on Medical Laboratories and Pathologists to Help Reduce HAIs
The concerted effort to reduce HACs and HAIs was inspired by incentives put forth by the US government. In 2008-2009, the Centers for Medicare and Medicaid Services (CMS) ceased paying for hospital-acquired conditions, including HAIs. Since that time, hospitals have worked to prevent and better manage HAIs. In the years since those incentives went into effect, hospitals have increasingly relied on medical laboratories and pathologists to provide necessary testing to prevent HAIs.
The CDC’s Antimicrobial Stewardship Programs create a further need for lab professionals to be involved in the identification, prevention, and treatment of HAIs. The core elements of the program state that the role of diagnostic laboratory testing—especially rapid diagnostic tests—is imperative in providing the necessary data needed to combat HAIs. The pressure is on for hospitals to reduce HAIs further to save lives and reduce costs. Thus, there is increased pressure on medical laboratories as well.
Larry Massie, MD, Professor of Pathology at the University of New Mexico, and Chair of Pathology and Laboratory Medicine for the New Mexico VA Health Care System in Albuquerque, states that turn-around time is crucial for HAIs, but that laboratories often have difficulty keeping up with large volumes of samples. Massie suggests the use of new technologies could speed up turnaround time, particular for large healthcare providers.
The fight to reduce HAIs and HACs is showing significant progress, and clinical laboratories, working in tandem with clinicians and prevention programs, are a fundamental part of the success of HAI reduction. Clinical pathologists and laboratories often are the front line in prevention and management of HAIs, and the work they do in identifying infections is essential in the assessment and control of those infections.
