Decontamination
microbiomes are interconnected, he explained. “This interaction is what it is all about,” commented Joost, highlighting both a paper and editorial on microbiomes in the hospital environment. The paper, ‘Cartography of opportunistic pathogens and antibiotic resistance genes in a tertiary hospital environment’, by Chng et al, reported that quasi-metagenomics with nanopore sequencing provided thousands of high-contiguity genomes, phage and plasmid sequences (>60% novel), enabling characterisation of resistome and mobilome diversity and dynamic architectures in hospital environments. Phylogenetics identified multidrug-resistant
strains as being widely distributed and stably colonising across sites. Comparisons with clinical isolates indicated that such microbes could persist in hospitals for extended periods (>8 years), to opportunistically infect patients. These findings highlighted the importance of characterising antibiotic resistance reservoirs in hospitals and established the feasibility of systematic surveys to target resources for preventing infections.4 Haak & Wiersinga also penned an
editorial within the journal, Nature Medicine, underscoring the pervasive and long-lasting presence of antimicrobial resistance genes within hospital environments.5 Joost went on to further highlight the risks in healthcare settings. He explained that he was asked by the CDC to undertake analysis of neonatal units in LMICs, as part of a project funded by the Bill & Melinda Gates Foundation. IP&C gaps were identified and summarised into four main categories: facility policies such as prioritising a patient safety culture and maintaining facility capacity, general healthcare worker behaviours such as hand hygiene and proper device insertion and maintenance, specialty healthcare worker behaviours such as cleaning and reprocessing of medical equipment, and infrastructural considerations such as adequate medical equipment and hand hygiene supplies.6 In terms of infrastructure, Joost pointed out
that having partitions between incubators is important as it creates a separation between infants and helps to interrupt transmission by stopping staff from moving freely between incubators. It provides a ‘threshold’ and therefore encourages hand hygiene between interactions as they have to walk from one area to another. “The fact that you change the infrastructure
to change the behaviour is important,” Joost commented. He showed a series of photos of neonatal
facilities, from high income to LMICs, to demonstrate the challenges around infrastructure and facility design (from an IP&C perspective), across both settings. An investigation of an infection outbreak at a neonatal hospital in Haiti, resulting in 100% mortality, identified that incubators were too close together and there were issues with contamination from the ventilation. Droplets could be felt in the air, due to condensation, so Joost cultured the droplets from the air- conditioning and was able to link this to the infection outbreak. The same microorganisms were also found in the sinks. Interventions included introducing partitions, taking out sinks and going waterless (to remove the exposure
In the future the aim is to use Virtual Reality to visualise which surfaces have been touched, enabling staff to focus cleaning on those areas. Even better, if you had a robot in the room, it could clean the surfaces immediately
after they have been touched. Joost Hopman, Radboud University Medical Centre, Netherlands.
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route), and changing the ventilation. These interventions drove down the mortality rates significantly. He showed a photo of a new neonatal facility in the Netherlands which are now single rooms only and the rooms are waterless. He pointed out that the benefits of single rooms are lost if sinks are located within the room. Knowledge transfer between high-, medium-
and low-income countries is important and Joost learnt a great deal from his time when dealing with the Ebola outbreak, and through the development of guidelines in 2014. One key factor he observed during the outbreak, was the set-up of isolation rooms. It was oberved that the healthcare professional would enter the anteroom, see the patient at the back, then exit on the other side. The ‘dirty’ exit room concept eliminates dangerous backtracking of contamination within the facility and this approach has now been adopted within high- income settings, to improve IP&C measures, Joost reported. Other simple interventions can also be implemented in high resource settings, in addition to more high-tech interventions. Simple solutions include the use of coloured lines on the floor to indicate red for ‘dirty’, orange for ‘intermediate’, and green for ‘clean’. A ‘buddy’ constantly observes the healthcare worker, while they are taking care of the patient with Ebola, using cameras and audio.
Water-based contamination Water in healthcare facilities also poses a significant potential risk of infection and Joost highlighted an investigation into a global outbreak of severe Mycobacterium chimaera disease after cardiac surgery, associated with heater-cooler devices (HCDs) used during
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