Nosocomial infection primary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Primary Prevention

Hospitals have sanitation protocols regarding uniforms, equipment sterilization, washing, and other preventive measures. Thorough hand washing and/or use of alcohol rubs by all medical personnel before and after each patient contact is one of the most effective ways to combat nosocomial infections. More careful use of antimicrobial agents, such as antibiotics, is also considered vital.

Despite sanitation protocol, patients cannot be entirely isolated from infectious agents. Furthermore, patients are often prescribed antibiotics and other antimicrobial drugs to help treat illness; this may increase the selection pressure for the emergence of resistant strains.

Sterilization

Sterilization goes further than just sanitizing. It kills all microorganisms on equipment and surfaces through exposure to chemicals, ionizing radiation, dry heat, or steam under pressure.

Isolation

Isolation precautions are designed to prevent transmission of microorganisms by common routes in hospitals. Because agent and host factors are more difficult to control, interruption of transfer of microorganisms is directed primarily at transmission.

Handwashing and Gloving

Handwashing frequently is called the single most important measure to reduce the risks of transmitting skin microorganisms from one person to another or from one site to another on the same patient. Washing hands as promptly and thoroughly as possible between patient contacts and after contact with blood, body fluids,secretions, excretions, and equipment or articles contaminated by them is an important component of infection control and isolation precautions. The spread of nosocomial infections, among immunocompromised patients is connected with health care workers' hand contamination in almost 40% of cases, and is a challenging problem in the modern hospitals. The best way for workers to overcome this problem is conducting correct hand-hygiene procedures; this is why the WHO launched in 2005 the GLOBAL Patient Safety Challenge. Two categories of micro-organisms can be present on health care workers' hands: transient flora and resident flora. The first is represented by the micro-organisms taken by workers from the environment, and the bacteria in it are capable of surviving on the human skin and sometimes to grow. The second group is represented by the permanent micro-organisms living on the skin surface (on the stratum corneum or immediately under it). They are capable of surviving on the human skin and to grow freely on it. They have low pathogenicity and infection rate, and they create a kind of protection from the colonization from other more pathogenic bacteria. The skin of workers is colonized by 3.9 x 10⁴ – 4.6 x 10⁶ cfu/cm². The microbes comprising the resident flora are: Staphylococcus epidermidis, S. hominis, and Microccocus,Propionibacterium, Corynebacterium, Dermobacterium, and Pitosporum spp., while in the transitional could be found S. aureus, and Klebsiella pneumoniae, andAcinetobacter, Enterobacter and Candida spp. The goal of hand hygiene is to eliminate the transient flora with a careful and proper performance of hand washing, using different kinds of soap, (normal and antiseptic), and alcohol-based gels. The main problems found in the practice of hand hygiene is connected with the lack of available sinks and time-consuming performance of hand washing. An easy way to resolve this problem could be the use of alcohol-based hand rubs, because of faster application compared to correct hand washing.

Although handwashing may seem like a simple process, it is often performed incorrectly. Healthcare settings must continuously remind practitioners and visitors on the proper procedure to comply with responsible handwashing. Simple programs such as Henry the Hand, and the use of handwashing signals can assist healthcare facilities in the prevention of nosocomial infections.

All visitors must follow the same procedures as hospital staff to adequately control the spread of infections. Visitors and healthcare personnel are equally to blame in transmitting infections. Moreover, multidrug-resistant infections can leave the hospital and become part of the community flora if steps are not taken to stop this transmission.

In addition to handwashing, gloves play an important role in reducing the risks of transmission of microorganisms. Gloves are worn for three important reasons in hospitals. First, they are worn to provide a protective barrier and to prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin. In the USA, the Occupational Safety and Health Administration has mandated wearing gloves to reduce the risk of bloodborne pathogen infections. Second, gloves are worn to reduce the likelihood microorganisms present on the hands of personnel will be transmitted to patients during invasive or other patient-care procedures that involve touching a patient's mucous membranes and nonintact skin. Third, they are worn to reduce the likelihood the hands of personnel contaminated with micro-organisms from a patient or a fomite can be transmitted to another patient. In this situation, gloves must be changed between patient contacts, and hands should be washed after gloves are removed.

Wearing gloves does not replace the need for handwashing, because gloves may have small, inapparent defects or may be torn during use, and hands can become contaminated during removal of gloves. Failure to change gloves between patient contacts is an infection control hazard.

Surface Sanitation

Sanitizing surfaces is an often overlooked, yet crucial, component of breaking the cycle of infection in health care environments. Modern sanitizing methods such as NAV-CO2have been effective against gastroenteritis, MRSA, and influenza agents. Use of hydrogen peroxide vapor has been clinically proven to reduce infection rates and risk of acquisition. Hydrogen peroxide is effective against endospore-forming bacteria, such as Clostridium difficile, where alcohol has been shown to be ineffective.

Antimicrobial Surfaces

Micro-organisms are known to survive on inanimate ‘touch’ surfaces for extended periods of time. This can be especially troublesome in hospital environments where patients with immunodeficiencies are at enhanced risk for contracting nosocomial infections.

Touch surfaces commonly found in hospital rooms, such as bed rails, call buttons, touch plates, chairs, door handles, light switches, grab rails, intravenous poles, dispensers (alcohol gel, paper towel, soap), dressing trolleys, and counter and table tops are known to be contaminated with Staphylococcus, MRSA (one of the most virulent strains of antibiotic-resistant bacteria) and vancomycin-resistant Enterococcus (VRE). Objects in closest proximity to patients have the highest levels of MRSA and VRE. This is why touch surfaces in hospital rooms can serve as sources, or reservoirs, for the spread of bacteria from the hands of healthcare workers and visitors to patients.

Copper alloy surfaces have intrinsic properties to destroy a wide range of micro-organisms. In the interest of protecting public health, especially in heathcare environments with their susceptible patient populations, an abundance of peer-reviewed antimicrobial efficacy studies have been and continue to be conducted around the world regarding copper’s efficacy to destroy E. coli O157:H7, methicillin-resistant Staphylococcus aureus (MRSA), Staphylococcus, Clostridium difficile, influenza A virus, adenovirus, and fungi.

Much of this antimicrobial efficacy work has been or is currently being conducted at the University of Southampton and Northumbria University (United Kingdom),University of Stellenbosch (South Africa), Panjab University (India), University of Chile (Chile), Kitasato University (Japan), the Instituto do Mar and University of Coimbra (Portugal), and the University of Nebraska and Arizona State University (USA). A summary of the antimicrobial copper touch surfaces clinical trials to date is available.

In 2007, U.S. Department of Defense’s Telemedicine and Advanced Technologies Research Center began to study the antimicrobial properties of copper alloys in a multisite clinical hospital trial conducted at the Memorial Sloan-Kettering Cancer Center (New York City), the Medical University of South Carolina, and the Ralph H. Johnson VA Medical Center (South Carolina). Commonly touched items, such as bed rails, over-the-bed tray tables, chair arms, nurse's call buttons, IV poles, etc. were retrofitted with antimicrobial copper alloys in certain patient rooms (i.e., the “coppered” rooms) in the intensive care units (ICUs). Early results disclosed in 2011 indicated the coppered rooms demonstrated a 97% reduction in surface pathogensversus the control rooms. This reduction is the same level achieved by “terminal” cleaning regimens conducted after patients vacated their rooms. Furthermore, of critical importance to health care professionals, the preliminary results indicated the patients in the coppered ICUs had a 40.4% lower risk of contracting a hospital-acquired infection versus patients in the control ICUs. The US Department of Defense investigation contract, which is ongoing, will also evaluate the effectiveness of copper alloy touch surfaces to prevent the transfer of microbes to patients and the transfer of microbes from patients to touch surfaces, as well as the potential efficacy of copper alloy-based components to improve indoor air quality.

In the US, the Environmental Protection Agency (EPA) regulates the registration of antimicrobial products. After extensive antimicrobial testing according to the agency’s stringent test protocols, 355 copper alloys, including many brasses, were found to kill more than 99.9% of MRSA, E. coli O157:H7, Pseudomonas aeruginosa, S. aureus, Enterobacter aerogenes, and VRE within two hours of contact. Normal tarnishing was found to not impair antimicrobial effectiveness.

On February 29, 2008, the EPA granted its first registrations of five different groups of copper alloys as “antimicrobial materials” with public health benefits. The registrations granted antimicrobial copper as "a supplement to and not a substitute for standard infection control practices." Subsequent registration approvals of additional copper alloys have been granted. The results of the EPA-supervised antimicrobial studies, demonstrating copper's strong antimicrobial efficacies across a wide range of alloys, have been published. These copper alloys are the only solid surface materials to be granted “antimicrobial public health claims” status by EPA.

The EPA registrations state laboratory testing has shown, when cleaned regularly:

• Antimicrobial copper alloy surfaces (ACAs) continuously reduce bacterial contamination, achieving 99.9% reduction within two hours of exposure.
• ACAs kill greater than 99.9% of Gram-negative and Gram-positive bacteria within two hours of exposure.
• ACAs deliver continuous and ongoing antibacterial action, remaining effective in killing greater than 99% of bacteria within two hours, and continue even after repeated contamination.
• ACAs help inhibit the buildup and growth of bacteria within two hours of exposure between routine cleaning and sanitizing steps.
• Testing demonstrates effective antibacterial activity against S. aureus, E. aerogenes, MRSA, E. coli O157:H7, and Pseudomonas aeruginosa.

The registrations state, "antimicrobial copper alloys may be used in hospitals, other healthcare facilities, and various public, commercial and residential buildings".

Aprons

Wearing an apron during patient care reduces the risk of infection. The apron should either be disposable or be used only when caring for a specific patient.

Mitigation

The most effective technique for controlling nosocomial infection is to strategically implement QA/QC measures to the health care sectors, and evidence-based management can be a feasible approach. For those with ventilator-associated or hospital-acquired pneumonia, controlling and monitoring hospital indoor air quality needs to be on agenda in management, whereas for nosocomial rotavirus infection, a hand hygiene protocol has to be enforced. Other areas needing management include ambulance transport.