The Role of Clothing in the Transmission of Infection · Bare below the elbows Chlorhexidine...
Transcript of The Role of Clothing in the Transmission of Infection · Bare below the elbows Chlorhexidine...
5/6/2019
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The Role of Clothing in the
Transmission of Infection
Michael Edmond, MD, MPH, MPAChief Quality Officer
Clinical Professor of Infectious Diseases
Goals• To examine the literature on
clothing contamination in
clinical care
• To review the experimental
evidence on transmission of
pathogens from clothing
• To examine interventions
designed to reduce
transmission of infection by
clothing
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The patient-provider encounter
• Common points of physical contact
– Hands/wrists
– Sleeves
– Stethoscope
– Wristwatch
Contact precautions• Patients with epidemiologically important organisms:
– Placed in a private room or cohorted with another patient
infected or colonized with the same organism
– All persons don gowns & gloves on entry to the room
• Based on:
• Evidence that clothing can become
contaminated
• Assumption that pathogens on
contaminated clothing can be
transmitted to patients
Bare below the elbows:
How it began
• In January 2008, the UK’s NHS mandated measures to
decrease MRSA & C. difficile in the healthcare setting
– Public reporting by hospitals on:
• compliance with infection control & cleanliness standards
• all MRSA BSIs & C. difficile cases
– Greater use of single rooms, cohort nursing & better
management of isolated patients
– Extension of the hand hygiene campaign to the outpatient
setting
– Bare below the elbows
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Bare below the elbows
• Short sleeves
• No wrist watch
• No jewelry except wedding band
• No neck ties
• No white coats
• Intent: allow good hand/wrist washing, & avoid
contamination of sleeve cuffs
Infection prevention strategies
Horizontal Vertical
Wenzel RP, Edmond MB. Int J Infect Dis 2010;14(S1):S3-S5.
Edmond MB, Wenzel RP. N Engl J Med 2013;368:2314-2315.
Strategic Approaches to Infection PreventionVertical Horizontal
GoalReduce infection or colonization due to specific
pathogen(s) [pathogen-based]
Reduce all infections
[population-based]
Application Selective or universal Generally universal
Interventions Unipotent Multipotent
Resource utilization/
opportunity costTypically high Lower
Philosophy Exceptionalism Utilitarianism
Values favored Hospital, infection prevention experts, advocates Patient
Temporal effectiveness Present Present & future
Examples MDRO active detection & isolation
Hand hygiene
Bare below the elbows
Chlorhexidine bathing
Universal decolonization
Care bundles
Environmental hygiene
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Postulated role of clothing in
the transmission of pathogens
Patients’ skin & environment are
contaminated with pathogens
Clothing becomes contaminated via contact with
patient or environment + infrequent laundering
Pathogens are transmitted from HCW
clothing to a subsequent patient
60% of physician-patient encounters involve the potential for contamination
of clothing
Kanwar A et al. Am J Infection Control 2019;47:577-9.
Contamination in the clinical setting:
Neckties Study Pathogen N % positive
Steinlechner C2002
S. aureus
Gram-negative bacilli26
8
23
Nurkin S2005
S. aureus
Gram-negative bacilli
Aspergillus spp
42
29
12
2
Ditchburn I 2006
S. aureus 40 20
Koh K2009
S. aureus
Gram-negative bacilli50
52
32
Lopez PJ2009
S. aureus 50 26
McGovern B2010
S. aureus
Gram-negative bacilli95
11
11
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Study Pathogen N % positive
Perry C
2001
MRSA
VRE57
14
38
Weiner-Well Y
2011
S. aureus
Acinetobacter75
41
10
Munoz-Price LS
2012
S. aureus
Acinetobacter
Enterococcus
97
11
11
3
Krueger CA
2012S. aureus 268 33
Bearman G
2012MRSA 31 52
Williams C
2015
S. aureus, Enterococcus,
pathogenic GNRs169 30
Scott E
2015S. aureus 85 18
Contamination in the clinical setting:
Scrubs & Uniforms
Contamination
in the clinical setting:
White coats
Pathogen % positive
Wong D, 1991; n=100 S. aureus 29
Loh W, 2000; n=100S. aureus
Acinetobacter
5
7
Osawa K, 2003; n=14 MRSA 79
Treakle AM, 2008; n=149 S. aureus 23
Uneke CJ, 2010; n=103S. aureus
Ps. aeruginosa
19
10
Weiner-Well Y, 2011; n=60S. aureus
Acinetobacter
18
31
Munoz-Price LS, 2012; n=22
S. aureus
Acinetobacter
Enterococcus
32
32
5
Romano-Bertrand S, 2014; n=35 S. aureus 23
Williams C, 2015; n=44S. aureus
Enterococcus
7
7
Qaday J, 2015; n=132S. aureus
Ps. aeruginosa
91
7
Mwamungule M, 2015; n=107S. aureus
Gram negative bacilli
18
6
Berktold M, 2018; n=100S. aureus
Gram negative bacilli
3
6
The white coat is
20 square feet of a
microbiological zoo.Shivam Joshi, MD
3
5
6
7
18
18
19
23
23
29
32
79
91
0 20 40 60 80 100
Bertold M, 2018; n=100
Loh W, 2000; n=100
Pandey A, 2010; n=130
Williams C, 2015; n=44
Weiner-Well Y, 2011; n=60
Mwamungule M, 2015; n=107
Uneke CJ, 2010; n=103
Romano-Bertrand S, 2014; n=35
Treakle AM, 2008; n=149
Wong D, 1991; n=100
Munoz-Price LS, 2012; n=22
Osawa K, 2003; n=14
Qaday J, 2015; n=132
S. aureus contamination of white coats
%
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Occupational bacterial contamination
20
29
2
44
17 17
2
29
25
0
7
0
7
0
7
Clothing Shoes Hands Any site
Any pathogen MRSA CR-GNR C diff
Kanwar A et al. Am J Infection Control 2019;47:577-9.
• Cultures of hands, clothing & shoes of 41 physicians & nurses at the end of their work day
• Organisms assessed: MRSA, C difficile, carbapenem(R) gram-negative bacilli
%
Survival of pathogens on fabricLength of survival (days)
Organism Cotton Polyester
S. aureus (methicillin S) 4, 5, 19 10, 12, 56
S. aureus (methicillin R) 4, 5, 21 1, 16, 40
E. faecalis (vancomycin S) 11, 33 >90, >90
E. faecalis (vancomycin R) 18, 22 73, 80
E. faecium (vancomycin S) 22, 90 43, >90
E. faecium (vancomycin R) 62, >90 >80, >80
C. albicans 1, 3 1, 1
C. parapsilosis 9, 27 27, >30
A. fumigatus 1, 10, >30 1, 7, 30
Neely AN, Orloff MM. J Clin Microbiol 2001; 39:3360-3361.
Neely AN, Maley MP. J Clin Microbiol 2000;38:724-726.
White coats & scrubs:
Frequency of laundering
Mean frequency (days)
Munoz-Price LS et al. Am J Infect Control 2013;41:565-7.
N=160
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1% 2%
39% 40%
17%
Daily Everyother day
Weekly Monthly Never
0%
45%
40%
15%
Daily Weekly Monthly Never
Frequency of white coat laundering
Pellerin J, Edmond MB et al. Infect Control Hosp Epidemiol
2014;35:740-2.
Attending MDs, housestaff and
medical students (n=183)
Travers J et al. J Hospital Infect 2018;epub ahead of print.
Medical students (n=40)
Transfer of pathogens from white coat to skin
Time
(min)
Number of organisms inoculated onto lab coat
106 105 104 103 102
MRSA
1 + + – – –
5 + + – – –
30 + + – – –
VRE
1 + + – – –
5 + + – – –
30 + + – – –
PRA
1 + + – – –
5 + + – – –
30 + + + – –
+ = organism transferred from coat to skinButler D, Edmond M. J Hosp Infect 2010;75:137-138.
Experimental bacterial transmission
• Clothing was inoculated with Micrococcus (distal tie or
corresponding area on shirt, cuffs of long and short sleeves)
• Standardized 2.5 minute exam was performed on a mannequin
• Mannequin cultured
Mannequins contaminated
With tie Without tie
Long sleeve 4/5 1/5
Short sleeve 2/5 0/5
Tie vs. no tie: p = 0.036
Long sleeve vs short sleeve: p > 0.05
Weber RL et al. J Hosp Infection 2012:80:252-254.
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Experimental viral transmission• 34 HCWs randomized to long- or short-sleeved white coat while
performing a standardized 2-minute exam on a mannequin that was
inoculated with cauliflower mosaic virus DNA fluorescent marker
• Exam was then performed on a second (uncontaminated) mannequin
after glove removal, hand hygiene for 30 seconds, and donning new
gloves
Contamination
Cuffs/wrists 2nd mannequin
Long sleeve 5/20* 1/5
Short sleeve 0/20* NA
*p = 0.001
John AR et al. Infect Control Hosp Epidemiol 2018;39:233-4.
Transmission via contaminated clothing
• 50 patients in LTC or hospital colonized with
MRSA but no open wounds or active infection
– Cultures of clothing at neck, chest waistline, sleeve
cuffs, over pockets
– Gloved hands applied to contaminated clothing to
assess transfer
– Patients w/ contaminated clothing sat in wheelchair
for 20 seconds, then wheelchair seat cultured
Kanwar A et al. Am J Infect Control 2018; 46:1414-6.
Transmission via contaminated clothing
• 74% of carriers had
MRSA cultured from
clothing
• Of those with
contaminated clothing:
– 62% transferred MRSA to
gloved hands
– 50% transferred MRSA to
wheelchair seat
50
90
Daily (n=20) Less than daily (n=30)Frequency of clothing change
% MRSA+
Kanwar A et al. Am J Infect Control 2018; 46:1414-6.
P=.002
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Summary of evidence:
Clothing & the cycle of transmission
Component Strength of evidence
Pathogens contaminate patients’skin
& the environmentConclusive
HCW clothing become contaminated with pathogens Conclusive
Clothing can transmit pathogens In vitro evidence
Removal of white coats/ties reduces infection rates No evidence to date
Biologic plausibility
When is biologic plausibility enough to
support a change in practice?
• Potential for benefit
• No risk for harm
• Minimal cost
But without strong evidence for benefit, we
should recommend, not mandate, the new
practiceBraithwaite RS. JAMA 2013;310:2149-50.
There is no evidence
to suggest that….
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Pellerin J, Edmond MB et al. Infect Control Hosp Epidemiol 2014;35:740-2.
Percentage of
respondents who
believe the white
coat can transmit
pathogens
White coat
as vector?Bare below the elbows
White coats:
• HCWs should possess >2 white coats and have access to a convenient and economical means for
laundry
• Hospitals should provide coat hooks that allow removal of white coats prior to contact with patients or
the patient’s immediate environment
Neckties: If worn, they should be secured to prevent them from coming into direct contact with the
patient or near-patient environment.
Laundering: Optimally, any apparel worn at the bedside that comes into contact with the patient or
patient environment should be laundered after daily use. White coats worn during patient care should be
laundered no less frequently than once a week and when visibly soiled. If laundered at home, a hot-water
wash cycle (ideally with bleach) followed by a cycle in the dryer is preferable.
SHEA expert guidance on HCW attireApproaches for facilities to consider
Bearman G. Infect Control Hosp Epidemiol 2014;35:107-121.
Some experts may argue that we should
focus on proven infection control practices,
such as hand hygiene. Yet it's hard to see
how voluntarily giving up your white coat
would distract from that.
The risks of doing nothing seem much
greater than of making the change.
Peter Pronovost, MDFormer Director, Armstrong
Institute for Patient Safety
and Quality, Johns Hopkins
Hospital
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Given what we know,
how do we move forward?
Conventional wisdom:
The paradox
• On the basis of the same evidence and assumptions:
– We are willing to wrap ourselves in plastic & restrict patients to their hospital rooms (contact precautions)
– We are not willing to eliminate white coats & ties
VCU Medical Center
Infection Control
Committee
recommended (but did
not mandate) a bare
below the elbow
approach in the
inpatient setting, 1/09
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Seasonal Variation in BBE Compliance
0
10
20
30
40
50
60
70
80
0%
10%
20%
30%
40%
50%
60%
70%
80%
May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
2014 2015
Avera
ge T
em
pera
ture
(○
F)
BB
E C
om
plia
nce
BBE Compliance
Average Temperaturer = 0.89
Masroor N, Edmond M et al. Infect Control Hosp Epidemiol 2017;38:504-6..
BBE Compliance VCU Medical Center 2017
67
80
87
93
85
86
86
90
84
0 10 20 30 40 50 60 70 80 90 100
MD
Med Student
RN
RN Student
Physcial Therapist
Respiratory Therapist
Radiologic Tech
Nursing Asst
ALL
Goudbout EJ, Masroor N, Doll M, Edmond MB et al. Am J Infect Control 2019. Epub ahead of print.
33,277 patient encounters
%
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Personal Infection Prevention Bundle