Cleaning in the ICU: strong evidence, strong convictions and a dose of reality ? APR Wilson, G Moore, D Smyth, R Jackson, J Singleton, E James, V Gant, S Shaw, M Singer G Bellingan University College London Hospitals Royal Free Hospital What do we know about MRSA transmission? How it is MRSA transmitted – Hands? Airbourne? Why don’t some patients get MRSA? Where are patients colonised? How effective is isolation of MRSA patients? Evidence MRSA can be controlled 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 Yap, Gomersall et al. (Hong Kong) Clin Infect Dis 2004; 39: 511 Observational report of MRSA incidence on ICU 100% compliance with contact precautions during SARS 8 fold INCREASE in MRSA during this period Returned to baseline after return to normal precautions Isolation No Isolation Air Communal Surfaces Carrier of pathogen known or unknown Patient Hands of staff and visitors Near patient surfaces Hospital acquired pathogens Transmitted by unwashed hands, air or environment or other? In ICU hand hygiene more important than physical segregation?? Towards Cleaner Hospitals, Matrons Charter, linked to 50% MRSA reduction target Cleaning ICU patient susceptible to repeated contamination Microfibre removes 99% of surface bacteria Near patient equipment cleaned by unsupervised nurses not domestics Aims Compare standard cleaning and intensively monitored enhanced cleaning Effect on local contamination rates Effect on colonisation of patients Effect on hospital acquired infection Two month phases Apr 07-Mar 08 Randomised standard or enhanced cleaning with one week washout Standard – existing practices plus nurses clean equipment Enhanced – microfibre monitored by ATP bioluminescence. MRSA screening on admission and weekly 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 Methods Sampling daily - 20% of beds i.e. 12 bed days each ICU each week, total 1152 bed days, 20736 samples 1:4 MRSA bed Air and environmental samples, patient and general areas Hourly 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 admission and 1-2 times/week 90% chance of detecting 50% reduction in contaminated bed areas 67% chance of detecting 50% reduction in rate of acquisition of MRSA Expected Outcome Show if enhanced cleaning beneficial for environmental contamination and acquisition of hospital pathogens Acquisition of pathogens is/is not related to level of contamination in environment Monitoring Steering Group meeting every 3-4 weeks Daily supervision of staff by investigators k Ve eyb oa nt il a rd to rf M on aci a i to Dr rf aw ac ia er To ha nd p of le dr aw er s co ts id e sy rin Co F ge ts oo ide to fb Sh co ed nt el ro fu lp nd an er el ve nt i la to r Relative light units Typical Clean Trace Audit ATP audit Phase 5 2000 1500 1000 500 0 ATP pre clean ATP post clean Hand hygiene audits Used Pittet criteria Compliance in enhanced phases: UCH 50% RFH 58% Compliance in standard phases: 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 61.3 58.1 59.0 61.2 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 Number of bed areas contaminated with MRSA Enhanced Cleaning reduced MRSA in the environment 90 80 70 60 50 40 30 20 10 0 standard cleaning enhanced cleaning MRSA in environment Bedspaces Samples with MRSA tested Standard Enhanced 165 1.6% 70 0.7% Odd ratio 10141 10068 0.45 0.34, 0.61 Repeated sampling 12h Median Total Viable Count 20 enhanced A 15 enhanced B 10 standard A standard B 5 20 :0 0 18 :0 0 16 :0 0 14 :0 0 12 :0 0 10 :0 0 0 08 :0 0 Median CFU/contact slide 25 MRSA sites 7 6 5 % 4 3 2 1 0 Drawer handle Chart Keyboard Bed rail Syringe driver Nurse's hand Monitor Apron dispenser Air Doctor hand Telephone Number of sites contaminated with MRSA Enhanced cleaning reduced MRSA at all sites in patient environment 70 60 50 40 30 20 10 0 chart or keyboard bed rail syringe driver standard cleaning draw er handle monitor enhanced cleaning nurse's hand 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 % pts MRSA positive o/a MRSA acquisitions MRSA new infection A Enh A Std B Enh B Std 8.5 6.5 10.8 8.3 12 1.5% 8 10 1.2% 4 18 4.0% 1 24 5.1% 3 Patient acquisition of MRSA Enhanced vs. standard OR 95% CI 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.