As pathogens have adapted and become more resistant to antibiotics, multidrug-resistant organisms (MDRO), commonly known as, “Super Bugs,” have emerged. To combat the advancement of MDRO infections, the nation has launched antibiotic stewardship programs across the realm of healthcare. While appropriate prescribing of antibiotics is of the utmost importance in our war against MDRO infections, we must remain vigilant in our work practices to prevent the spread of infections in the physical environment.
Hand Hygiene
Clean hands prevent the spread of germs, including those that are resistant to antibiotics. Yes, we have all heard this for years, but lack of hand hygiene remains healthcare’s biggest challenge in the battle against MDRO infections. According to the CDC, most MDRO transmissions occur through contaminated hands [1]. When contaminated hands touch surfaces and patients, the chain of MDRO infections grows. While this simple concept is not new, we must begin and end every patient care process with hand hygiene. There are two methods for hand hygiene – alcohol-based hand sanitizer and washing with soap and water. Hand sanitizers need to contain at least 60% alcohol to effectively sanitize. According to the CDC, alcohol-based hand sanitizer is the preferred method to clean hands in most clinical situations However, there is an exception: C. difficile forms spores which are not killed by alcohol-based hand sanitizer; therefore, effective hand washing with soap and water is a must.
Clean hands prevent the spread of germs, including those that are resistant to antibiotics. Yes, we have all heard this for years, but lack of hand hygiene remains healthcare’s biggest challenge in the battle against MDRO infections. According to the CDC, most MDRO transmissions occur through contaminated hands [1]. When contaminated hands touch surfaces and patients, the chain of MDRO infections grows. While this simple concept is not new, we must begin and end every patient care process with hand hygiene. There are two methods for hand hygiene – alcohol-based hand sanitizer and washing with soap and water. Hand sanitizers need to contain at least 60% alcohol to effectively sanitize. According to the CDC, alcohol-based hand sanitizer is the preferred method to clean hands in most clinical situations However, there is an exception: C. difficile forms spores which are not killed by alcohol-based hand sanitizer; therefore, effective hand washing with soap and water is a must.
Technique matters! Failure to adequately perform hand hygiene does not kill pathogens causing MDRO infections. Thumbs, fingertips, and between fingers are often missed [7]. Therefore, enough sanitizer must be used to fully cover your hands, including fingers and thumbs, and rub until dry. When using either hand sanitizer or soap and water, it should take at least 15 to 20 seconds [2].
Personal Protective Equipment (PPE)
Bacteria, including methicillin-resistant Staphylococcus Aureus (MRSA) and Vancomycin-resistant enterococci (VRE), can survive on clothing. Yes, this includes lab coats and scrubs! [5] To prevent contamination of clothing, contact isolation precautions with a gown and gloves need to be worn during all interactions involving contact with the patient and/or the patient’s environment. Additionally, the sequence for donning PPE upon room entry and properly doffing before exiting the patient room controls the spread of MDRO contamination. Immediately after removal of PPE, be sure to perform hand hygiene.
Bacteria, including methicillin-resistant Staphylococcus Aureus (MRSA) and Vancomycin-resistant enterococci (VRE), can survive on clothing. Yes, this includes lab coats and scrubs! [5] To prevent contamination of clothing, contact isolation precautions with a gown and gloves need to be worn during all interactions involving contact with the patient and/or the patient’s environment. Additionally, the sequence for donning PPE upon room entry and properly doffing before exiting the patient room controls the spread of MDRO contamination. Immediately after removal of PPE, be sure to perform hand hygiene.
Surface Disinfection
MRSA can remain viable on surfaces for up to seven months and VRE can remain viable on surfaces for up to four months [4] The CDC states environmental contamination due to the lack of following facility procedures for cleaning and disinfection can be a common cause of MDRO transmission [1]. To eliminate MDRO infections on surfaces, start by selecting the best disinfectant to kill the targeted pathogen. A list of EPA-registered products which are active against MDRO can be found in Selected EPA-Registered Disinfectants Lists. MRSA and VRE are susceptible to several EPA-registered low and intermediate-level disinfectants from List H: EPA-registered Antimicrobial Products Effective Against MRSA and / or VRE [6]. Stronger solutions are not better! Due to the growing resistance to antibiotics by these organisms, the use of stronger solutions of disinfectants for inactivation is not recommended [3]. For more information, a full list of EPA-registered disinfectants can be found on the EPA website.
MRSA can remain viable on surfaces for up to seven months and VRE can remain viable on surfaces for up to four months [4] The CDC states environmental contamination due to the lack of following facility procedures for cleaning and disinfection can be a common cause of MDRO transmission [1]. To eliminate MDRO infections on surfaces, start by selecting the best disinfectant to kill the targeted pathogen. A list of EPA-registered products which are active against MDRO can be found in Selected EPA-Registered Disinfectants Lists. MRSA and VRE are susceptible to several EPA-registered low and intermediate-level disinfectants from List H: EPA-registered Antimicrobial Products Effective Against MRSA and / or VRE [6]. Stronger solutions are not better! Due to the growing resistance to antibiotics by these organisms, the use of stronger solutions of disinfectants for inactivation is not recommended [3]. For more information, a full list of EPA-registered disinfectants can be found on the EPA website.
A discussion of disinfectants would not be complete without stressing the importance of wet contact time. As the saying goes – “If it is worth doing, it is worth doing right!” Wet contact time is the time the surface should remain wet for a disinfectant to effectively kill the pathogens. If the disinfectant dries before the wet contact time is met, the disinfectant must be reapplied to the surface.
Policies and Procedures Hospital policies should define the methods, frequency of cleaning, and the products required to disinfect. A risk-assessment can help identify high-touched surfaces which include bed rails, IV poles, overbed tables, doorknobs, light switches, etc. High-touched surfaces need to be cleaned and disinfected more frequently than other surfaces [3]. Implementation of cleaning checklists can be a beneficial tool to assure that items are not missed. Check product labels for inactivation claims, indications for use, and instructions. Cleaning and disinfecting procedures need to address the wet contact time as indicated by the manufacturer’s instructions for use for the specific product being used to kill the specific pathogen. Lastly, incorporate the personal protective equipment (PPE) required as instructed by the product’s safety data sheet.
Once cleaning and disinfection procedures are established, staff need to be trained and deemed competent. Remember, technique matters! Staff should be able to articulate and demonstrate proper cleaning techniques.
Surveillance
After education and training, continuous vigilance extends to leadership. An effective infection prevention and control program must have strategies in place to monitor hand hygiene compliance, adherence to isolation precautions, and cleaning and disinfecting the environment. There are various methods of surveillance. While it can be time-consuming, direct observation can provide opportunities for real-time education and stress the importance of correct technique. Some may argue that direct observation imposes the Hawthorne effect which is a term given when staff behavior is influenced because they know someone is watching. While compliance data is valuable, don’t get bogged down in the numbers – the ultimate goal is to reduce transmission of MDRO infections. When conducting surveillance, it is important to include standardized training and data collection tools to produce reliable data. Regardless of the surveillance method you choose, be sure to evaluate all shifts and different types of staff.
After education and training, continuous vigilance extends to leadership. An effective infection prevention and control program must have strategies in place to monitor hand hygiene compliance, adherence to isolation precautions, and cleaning and disinfecting the environment. There are various methods of surveillance. While it can be time-consuming, direct observation can provide opportunities for real-time education and stress the importance of correct technique. Some may argue that direct observation imposes the Hawthorne effect which is a term given when staff behavior is influenced because they know someone is watching. While compliance data is valuable, don’t get bogged down in the numbers – the ultimate goal is to reduce transmission of MDRO infections. When conducting surveillance, it is important to include standardized training and data collection tools to produce reliable data. Regardless of the surveillance method you choose, be sure to evaluate all shifts and different types of staff.
Final Note
The spread of MDRO infections occurs mostly through contact with contaminated hands and surfaces. The best way to prevent the spread is to perform proper hand hygiene, follow contact precautions, and effectively disinfecting environmental surfaces. Observe technique, provide real-time education, and stay vigilant in preventing MDRO infections in the environment.
The spread of MDRO infections occurs mostly through contact with contaminated hands and surfaces. The best way to prevent the spread is to perform proper hand hygiene, follow contact precautions, and effectively disinfecting environmental surfaces. Observe technique, provide real-time education, and stay vigilant in preventing MDRO infections in the environment.
References:
1. Centers for Disease Control and Prevention. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007. Updated May 2022.
1. Centers for Disease Control and Prevention. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007. Updated May 2022.
2. Centers for Disease Control and Prevention. Hand Hygiene in Healthcare Settings. Updated November, 2019.
3. Centers for Disease Control and Prevention. Healthcare Infection Control Practices Advisory Committee. Guidelines for Environmental Infection Control in Health-Care Facilities, 2004. Updated July 2019.
4. Kramer, A., Schwebke, I., & Kampf, G. (2006). How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infectious Diseases, 6, 130.
5. Neely, A. N., & Maley, M. P. (2000). Survival of enterococci and staphylococci on hospital fabrics and plastic. Journal of clinical microbiology, 38(2), 724–726.
6. U.S. Environmental Protection Agency. (2022). Antimicrobial Products Registered with EPA for Claims Against Common Pathogens.
7. Widmer, A. F., Dangel, M., & RN. (2004). Alcohol-based hand rub: evaluation of technique and microbiological efficacy with international infection control professionals. Infection Control and Hospital Epidemiology, 25(3), 207-209.