Cleaning in the ICU: Cleaning in the ICU: strong evidence, strong evidence, strong convictions strong convictions and a dose of and a dose of realityreality ??

APR Wilson, G Moore, D Smyth, R APR Wilson, G Moore, D Smyth, R Jackson, J Singleton, E James, V Gant, S Jackson, J Singleton, E James, V Gant, S Shaw, M Singer G BellinganShaw, M Singer G Bellingan

University College London HospitalsUniversity College London HospitalsRoyal Free HospitalRoyal Free Hospital

What do we know about MRSA transmission?

How it is MRSA transmitted – Hands?Airbourne?

How effective is isolation of MRSA patients?

Why don’t some patients get MRSA?

Where are patients colonised?

Evidence MRSA can be controlled

Yap, Gomersall et al. (Hong Kong) Clin Infect Dis 2004; 39: 511

Observational report of MRSA incidence on ICU100% compliance with contact precautions during SARS8 fold INCREASE in MRSA during this period Returned to baseline after return to normal precautions

Souweine (France 2000)• Retrospective: contact, surveillance, isolation, mupiricin• One year pre and one year post introduction• MRSA rates fell from 4/1000 pt days to 2.2/1000

Jernigan (Charlottesville 1996) Prospective, Neonatal ICU 4.8% colonised/infected – single strain Contact, cohort, surveillance staff + patients Transmission rates Isolation 0.009/day

Not isolated 0.14/day p<0.0001

Isolation

No Isolation

Air Communal Surfaces

PatientCarrier of pathogen known or unknown

Near patient surfaces

Hands of staff and visitors

Hospital acquired Hospital acquired pathogenspathogens Transmitted by unwashed hands, Transmitted by unwashed hands,

air or environment or other?air or environment or other? In ICU hand hygiene more In ICU hand hygiene more

important than physical important than physical segregation??segregation??

Towards Cleaner Hospitals, Towards Cleaner Hospitals, Matrons Charter, linked to 50% Matrons Charter, linked to 50% MRSA reduction targetMRSA reduction target

CleaningCleaning

ICU patient susceptible to ICU patient susceptible to repeated contaminationrepeated contamination

Microfibre removes 99% of Microfibre removes 99% of surface bacteriasurface bacteria

Near patient equipment cleaned Near patient equipment cleaned by unsupervised nurses not by unsupervised nurses not domesticsdomestics

AimsAims

Compare standard cleaning and Compare standard cleaning and intensively monitored enhanced intensively monitored enhanced cleaningcleaning

Effect on local contamination ratesEffect on local contamination rates Effect on colonisation of patientsEffect on colonisation of patients Effect on hospital acquired Effect on hospital acquired

infectioninfection

Two month phases Two month phases Apr 07-Mar 08Apr 07-Mar 08 Randomised standard or enhanced Randomised standard or enhanced

cleaning with one week washoutcleaning with one week washout Standard – existing practices plus Standard – existing practices plus

nurses clean equipmentnurses clean equipment Enhanced – microfibre monitored Enhanced – microfibre monitored

by ATP bioluminescence. by ATP bioluminescence. MRSA screening on admission and MRSA screening on admission and

weeklyweekly

Methods

Normal domestic staff routine cleaning beds, floors and walls

Nursing staff bedside equipment Enhanced – team of technicians

used colour coded microfibre cloths, 15 min per bed area

MethodsMethods

Sampling daily - 20% of beds i.e. Sampling daily - 20% of beds i.e. 12 bed days each ICU each week, 12 bed days each ICU each week, total 1152 bed days, total 1152 bed days, 20736 20736 samplessamples

1:4 MRSA bed1:4 MRSA bed Air and environmental samples, Air and environmental samples,

patient and general areaspatient and general areas Hourly sampling 1 day each phaseHourly sampling 1 day each phase

Methods

Sites: drawer, bed rail, syringe driver, nurse hands, monitor and keyboard/chart

Three times each sampling day Communal sites: apron dispenser,

doctors hands, telephone, air

Methods

Both ICU screened for MRSA on Both ICU screened for MRSA on admission and 1-2 times/weekadmission and 1-2 times/week

90% chance of detecting 50% 90% chance of detecting 50% reduction in reduction in contaminated bed contaminated bed areasareas

67% chance of detecting 50% 67% chance of detecting 50% reduction in rate of reduction in rate of acquisition of acquisition of MRSAMRSA

Expected OutcomeExpected Outcome

Show if enhanced cleaning Show if enhanced cleaning beneficial for environmental beneficial for environmental contamination and acquisition of contamination and acquisition of hospital pathogens hospital pathogens

Acquisition of pathogens is/is not Acquisition of pathogens is/is not related to level of contamination related to level of contamination in environmentin environment

MonitoringMonitoring

Steering Group meeting every 3-4 Steering Group meeting every 3-4 weeksweeks

Daily supervision of staff by Daily supervision of staff by investigatorsinvestigators

Typical Clean Trace Typical Clean Trace AuditAudit

ATP audit Phase 5

0

500

1000

1500

2000

Rel

ativ

e lig

ht u

nits

ATP pre clean

ATP post clean

Hand hygiene auditsHand hygiene audits

Used Pittet criteria Used Pittet criteria

Compliance in enhanced phases: Compliance in enhanced phases: UCH 50% RFH 58% UCH 50% RFH 58%

Compliance in standard phases: Compliance in standard phases: UCH 53% RFH 50% UCH 53% RFH 50%

Patients

A Enh

A Std B Enh

B Std

Patients 799 863 453 468

>48h 346 379 222 242

Median APACHE

17 16 17 17

Median age 61.2 61.3 58.1 59.0

Patients

A Enh A Std B Enh

B Std

Female % 41.9 46.4 42.4 41.2

ICU stay (IQR) 1-6 1-6 1-11 1-11

% pts MRSA positive o/a

8.5 6.5 10.8 8.3

0

10

20

30

40

50

60

70

80

90

standard cleaning enhanced cleaning

Nu

mb

er

of

be

d a

rea

s c

on

tam

ina

ted

wit

h M

RS

A

Enhanced Cleaning reduced MRSA in the

environment

MRSA in environment

Bedspaces with MRSA

Samples tested

Odd ratio

Standard 1651.6%

10141

Enhanced

700.7%

10068 0.450.34, 0.61

Median Total Viable Count

0

5

10

15

20

25

08:00

10:00

12:00

14:00

16:00

18:00

20:00

Med

ian

C

FU

/co

nta

ct s

lid

e

enhanced A

enhanced B

standard A

standard B

Repeated sampling 12h

MRSA sites

0

1

2

3

4

5

6

7Drawer handleChartKeyboardBed railSyringe driverNurse's handMonitorApron dispenserAirDoctor handTelephone

%

Enhanced cleaning reduced MRSA at all sites in patient

environment

0

10

20

30

40

50

60

70

chart orkeyboard

bed rail syringedriver

drawerhandle

monitor nurse'shandN

um

ber

of

site

s co

nta

min

ated

wit

h

MR

SA

standard cleaning enhanced cleaning

Hands

MRSA reduced on doctors’ hands (OR 0.26 [0.07, 0.95]) during enhanced cleaning

Nurse hands trend (OR 0.6 [0.29, 1.08])

Enhanced Cleaning had no measurable effect on MRSA

acquisition or infections

A Enh A Std B Enh B Std

% pts MRSA positive o/a

8.5 6.5 10.8 8.3

MRSA acquisitions

121.5%

101.2%

184.0%

245.1%

MRSA new infection

8 4 1 3

Patient acquisition of MRSA

OR 95% CI

Enhanced vs. standard

0.98 (0.58, 1.65)

Acquisition of other pathogens – too low

Enh Std Enh Std

Patients 799 863 453 468

Acinetobacter 2 0 2 9

ESBL 4 5 7 3

VRE 1 1 0 0

C difficile 2 6 8 2

Conclusions

Enhanced cleaning reduced MRSA load in environment 40%

Enhanced cleaning reduced bacterial load on nurse/doctor hands

No significant reduction in acquisition or infection

Bed rails highly touched and contaminated – texture effect

Origin MRSA

7 of 64 cases MRSA in environment preceded isolation from patient of a strain indistinguishable by PFGE

Further typing to establish chains of transmission

Airborne Spread

Why is MRSA commonly detected in the nose?

Can detect distant MRSA in the air after: – physiotherapy or NIV for non-intubated

patients with MRSA pneumonia,– bed linen changes from colonised patients

Would expect the isolation study to have shown a difference

The gut as a source of colonisation?

Silvestri et al. – oropharyngeal carriage in up to 80% of cases during

an outbreak– 33% in the absence of an outbreak.

Oral vancomycin – significantly reduced colonisation, – reduce MRSA nosocomial pneumonia and – contained an MRSA outbreak.

No vancomycin resistant enterococci (VRE) or intermediate sensitivity S. aureus (VISA) found

Did not screen for topical MRSA - incidence of skin with gut carriage unknown

Local variations in MRSA incidence in ICU’s in the UK

London Teaching Hospitals with >1000 admissions/year

Hospital a) no bacteraemias in 6 months

Hospital b) 1 bacteraemia in 14 months

Hospital c) 12 bacteraemias in 12 months

Local variations in MRSA incidence in ICU’s in the UK

Hospital a) chlorhexidine wash daily for all, CVC bundles, no 3 way taps, rapid screening, isolation, linezolid for specific cases,

standard plus precautions for all.

Hospital b) chlorhexidine wash daily for all, CVC bundle, full gowns, rapid screening, no isolation.

Hospital c) rapid screening and chlorhexidine for positive cases, CVC bundles, no 3 way taps, isolation, standard plus precautions for all.

The evidence

We could not identify a major source for environmental transmission of MRSA.

Enhanced cleaning may not reduce colonisation or infection

Isolation may not reduce colonisation or infection

Clearly a broad “attack” on the environment, the patient and ICU processes can reduce MRSA rates

Does it matter that we don’t know which of these are effective…???

It would be great if infection control techniques could be based on evidence rather than conjecture.