INFECTION PREVENTION
complacency will potentially cost lives. The risk facing healthcare is quite clear – a return to the pre-penicillin age. The second challenge in the fight against sepsis is as crucially important to overcome as multidrug resistance – the protection of vulnerable patients who are at risk from secondary infection. However, this is a considerably easier enemy to vanquish. Patients, as outlined earlier, are at risk when they are exposed to infection at a time when they should be in a safe environment such as an ICU. The current treatment with antibiotics only increases the risk of multidrug- resistant bacteria, so a preventative strategy is clearly required.
‘Prevention better than cure’ The adage ‘prevention is better than cure’ could not be more appropriate than in the case of sepsis as a hospital-acquired infection. If post-operative recovery patients are at risk, and 39% or more deaths in ICUs are caused by secondary bacterial, fungal, or viral infections, it makes absolute logical sense to mitigate that risk by removing the cause via a disinfection regime. In a paper looking at infection control across the UK healthcare sector, Perry et al3
observed
that after many decades of becoming comfortable with antibiotic drugs, we must now consider future strategies, with infection control professionals playing a key role in strict adherence to disinfection protocols. It is not a giant leap of faith to agree that a robust strategy of disinfection in the healthcare environment will decrease the frequency of sepsis cases; the question at this point is: ‘Which is the most efficient disinfection process to use?’
Available infection control options? As discussed, the battle to minimise cases of sepsis in hospitals must centre on effective infection control, crucially through the use of biocides. There are various technologies that will administer a host of these agents, but many are unsuitable for healthcare environments due to post-treatment toxicity and lengthy clean-up requirements. Formaldehyde in gaseous form is still used as a highly effective biocide, but not typically in healthcare, as it and its decomposition products are carcinogenic and mutagenic, among a host of other human exposure risks, including ALS. Other gases such as chlorine dioxide and ethylene oxide pose significant risks to patients and personnel, requiring high levels of security when used to avoid leakage from the area being disinfected. Processes leaving strong odours, even when non-toxic, are not ideal in a healthcare setting, so any process which causes odours should be avoided if possible.
Enzyme indicators operate in the same way as biological indicators, and give the same quality of results, but do not require an incubation time.
Bioburden reduction Bioburden reduction is usually accomplished by removal of pathogens from surfaces, either manually, or by using semi, or fully automated biocide generators, with any airborne particulates being cleaned up by ventilation or HVAC. Indeed, build-up of surface contamination over time comes from the air and human contact, so good management of both air quality and personal hygiene, and use of gloves and masks, are important aspects of HAI control.
It is generally accepted that, for an appropriate degree of disinfection to be accomplished, colony-forming units (CFU) of fungal or bacterial species must be reduced by at least 99.9999%, or 6 log on all surfaces. Any disinfection protocol not achieving this level of kill will expose the risk of rapid pathogen revival, resulting in patient risk. It is possible to sterilise an area, i.e. to completely remove all viable species, but this requires such extreme processing – high-pressure
steam or gamma irradiation for example – that it is totally impracticable for hospital rooms, and in any case, by nature hospital environments are exposed to particles – viable and non-viable – from human activity. Reducing CFUs by 6 log will reduce risk substantially, but there will then be a gradual build-up of pathogens over a prolonged period, so repeated cycling of room decontaminations is essential in mitigating risk. The frequency of such cycling is dependent upon variables such as patient and personnel traffic, and exposure to ‘dirty’ areas – if kept under positive pressure, ingress of airborne particulates is minimised.
A constant threat
Recognition of the need to reduce bioburden, or ‘kill bugs’, can be dated back to Dr John Snow in his pioneering work of 1854, says Howorth.
Whichever of the various technologies available is utilised, it must be understood that, in an inherently infectious arena such as healthcare, the war is never over, with risk of patient complications such as sepsis constantly a threat. Manual cleaning, typically by spray and wipe, but also mop and bucket, is perceived to be cheap, and is popular in healthcare, but efficacy is highly variable, and is very much dependent on how operators apply and wipe off the biocide ‘cocktail’. Any guarantee of even low log reduction on surfaces is poor, given the ‘hit and miss nature’ of the technique. Manual techniques are impossible to properly validate, leaving uncertainty as to the effectiveness of disinfection. There is also a requirement for PPE to be used when handling biocides in open containers, or in spray or wipe form, and repeated actions required when processing can lead to RSI. This method of disinfection carries a large amount of assumption that the area being treated is clean. A major survey from the American Journal of Infection Control4 concluded that ‘Currently, there is a narrow focus on assessing the efficacy of (spray and wipe) products used for cleaning and disinfecting, with limited assessment of infection prevention effectiveness in actual health care settings’.
October 2018 Health Estate Journal 69
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