1150 infection control & hospital epidemiology october 2017, vol. 38, no. 10 table 2. Environmental Contamination Observed During 120 Shifts in the ASCOT Trial
Control (N=40),
All sites Bed rails Bed
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Median CFU (IQR) 159.6 (61.5–304.2)
65.0 (25.0–145.5) 43.0 (15.0–157.3) 9.5 (3.5–20.7)
Median CFU (IQR)a 138.5 (62.5–278.6)
Scrub 1 (N=40),
67.0 (27.3–123.3) 44.5 (14.0–142.5) 10.0 (5.8–20.6)
Median CFU (IQR)b 115.9 (43.8–235.4)
Scrub 2 (n=40),
47.7 (19.4–113.3) 31.0 (12.8–97.0) 7.5 (4.8–14.8)
NOTE. CFU, total number of colony-forming units defined as sum of colony-forming units from each cultured high
touch surface; IQR, interquartile range. aScrubs contained a complex element compound with embedded silver-alloy. bScrubs impregnated with an organosilane-based quaternary ammonium and a hydrophobic fluoroacrylate copolymer emulsion.
−3.0 to 191.0) in the control arm, 73.0 (IQR, −107.0 to 194.0) in the Scrub 1 arm, and 54.5 (IQR, −60.0 to 215.0) in the Scrub 2 arm. Nurses’ sleeves and clothing covering their abdomens showed the greatest increase in contamination during the shift. Scrub type was not associated with a change in HCP cloth-
ing contamination in multivariable linear regression that accounted for shift order, nurse crossover/clustering, pre-shift contamination, patient characteristics, and environmental contamination (overall P=.70). Mean difference estimates were 0.118 for the Scrub 1 arm (95% CI, −0.206 to 0.441; P=.48) and 0.009 for the Scrub 2 arm (95% CI, −0.323 to 0.342; P=.96).
Evaluation of Acquisition and Transmission Events
We identified acquisition events during 39 (33%) of the 120 shifts (Table 4), including 20 (17%) environmental acquisi- tions and 19 (16%) acquisitions on HCP clothing. Of all HCP clothing acquisitions, 3 (16%) occurred while caring for patients on contact precautions. The organisms most com- monly involved in acquisition events were MSSA (n=11, 9%), Acinetobacter (n=10, 8%), and MRSA (n=8, 7%). Moreover, 23 of the acquisition events (59%) were confirmed transmis- sion events from another member of the transmission triangle. The number of acquisition and transmission events were generally similar across study arms (Table 4). Of the 19 HCP clothing acquisition events, 12 (63%) were
perceptions of scrub types are provided in the Supplementary Material.
discussion
Transmission of microorganisms involves 3 elements: a source, a susceptible host with a portal of entry receptive to the agent, and a mode of transmission.17 In the healthcare setting, these elements culminate in pathogen movement between the patient, healthcare providers (HCP), and the environment, known as the “transmission triangle.” When transmission in this triangle leads to patient acquisition, healthcare-associated infections (HAIs) can follow.1 Our randomized controlled trial focused on the use of antimicrobial-impregnated scrubs as a strategy to decrease pathogen movement in the transmission triangle. Our results demonstrated that bacterial contamina- tion of HCP clothing was not decreased when HCPs wore the antimicrobial-impregnated scrubs used in this study compared to standard (control) scrubs. We did, however, confirm that HCP clothing frequently became contaminated during routine clinical care, and pathogens were frequently acquired from the patient care environment. Strategies to decrease pathogen movement in the transmis-
confirmed transmission events: 7 from the patient, 3 from environmental contamination, and 2 from the patient and/or the environment (i.e., both the patient and environment were contaminated with target organism during the same shift) (Figure 1). Of these confirmed transmission events, 1 (8%) occurred while the patient was on contact precautions. Sta- phylococcus aureus was involved in the most HCP transmission events (n=6: 3 MRSA and 3 MSSA). Of the 20 environmental acquisition events, 11 (55%) were
confirmed transmission events. All 11 were transmitted from the patient. We did not identify any MDROs on HCP clothing at the beginning of a shift. Clothing from 3 HCP (7.5%) were contaminated with MSSA. No transmissions from HCP-to- patient or HCP-to-environment were observed. Finally, nurse
sion triangle can be generally categorized by the points of the triangle. Interventions can focus on the patient (eg, decoloni- zation or source control), the environment (eg, enhanced disinfection, antimicrobial surfaces or textiles), or the health- care provider (eg, hand hygiene, gowns and gloves, antimicrobial-impregnated clothing). Growing evidence sug- gests that contaminated healthcare textiles may be a source for transmission of epidemiologically important pathogens and HAIs.4 Preclinical data suggested that antimicrobial- impregnated textiles are efficacious at reducing bacterial burden,8–10 but data to support the use of antimicrobial- impregnated scrubs in clinical practice are limited. To date, 4 other trials have examined antimicrobial-impregnated scrubs, with conflicting results.12–15 Bearman et al12 performed a blinded, crossover, randomized controlled trial comparing antimicrobial-impregnated surgical scrubs to standard surgical scrubs. Use of antimicrobial-impregnated scrubs led to a>4 log10 reduction in the burden of MRSA on
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