CRE are important emerging threat to public health

CRECRE, which stands for Carbapenem-resistant Enterobacteriaceae, are a family of germs that are difficult to treat because they have high levels of resistance to antibiotics. CRE are an important emerging threat to public health.

The United States, Australia and Canada all have issued a series of guidelines for dealing with CRE. While many points overlap, among them promoting proper hand hygiene, taking contact precautions, screening those at high risk and promoting antimicrobial stewardship, it is worthwhile to peruse what each country suggests and how they arrived at their guidelines. The links are:

Here’s a bit more CRE-related information:

  • Common Enterobacteriaceae includeKlebsiella species and Escherichia coli (E. coli). These germs are found in normal human intestines (gut). Sometimes these bacteria can spread outside the gut and cause serious infections, such as urinary tract infections, bloodstream infections, wound infections, and pneumonia. Enterobacteriaceae can cause infections in people in both healthcare and community settings.
  • Carbapenems are a group of antibiotics that are usually reserved to treat serious infections, particularly when these infections are caused by germs that are highly resistant to antibiotics. Sometimes carbapenems are considered antibiotics of last resort for some infections. Some Enterobacteriaceae can no longer be treated with carbapenems because they have developed resistance to these antibiotics (i.e., CRE); resistance makes the antibiotics ineffective in killing the resistant germ. Resistance to carbapenems can be due to a few different mechanisms. One of the more common ways that Enterobacteriaceae become resistant to carbapenems is due to production ofKlebsiella pneumoniae carbapenemase (KPC). KPC is an enzyme that is produced by some CRE that was first identified in the United States around 2001. KPC breaks down carbapenems making them ineffective.  Other enzymes, in addition to KPC, can breakdown carbapenems and lead to the development of CRE, but they are uncommon in the United States.

U.S., Africa agree to plan to advance public health across Africa

african cdcThe world medical community has had some wake-up calls the past couple years: the botched handling of the Ebola epidemic and the ongoing issues with MERS, to name a couple. When added to the already pressing issues tied to antimicrobial resistance, some folks are beginning to take notice.

So we applaud the move to form and fund an African CDC organization as reported on the University of Minnesota website. Tom Frieden, MD, MPH, director of the U.S. CDC, said in a statement that West Africa’s Ebola outbreak reaffirmed the need for a public health institute to support African health ministries and other groups in preventing, detecting, and responding to disease outbreaks. “This memorandum solidifies the commitment by the United States to advance public health across Africa and global health security,” he said.

Under the terms of the memorandum of cooperation (MOC), the U.S. CDC will provide technical expertise and assist with planning for future African CDC development. Two U.S. CDC experts will be located at the African Union to serve as long-term technical advisors to the African CDC, and the U.S. CDC will support fellowships for 10 African epidemiologists to help at the main and regional African CDC offices.

It will launch later this year with the formation of an African Surveillance and Response Unit, which will include an emergency operations center and the capacity to organize a force that can be deployed to serve member states during future health emergencies.


Hand hygiene is key component in reducing absenteeism among school children

kids hand washSchool children are at a higher risk for infection because of their immature immune systems and more frequent social mixing. Gastrointestinal and respiratory infections are the most commonly occurring illnesses among schoolchildren because of their poor hand hygiene.

The American Journal of Infection Control published a study (Comparative efficacy of a simplified hand washing program for improvement in hand hygiene and reduction of school absenteeism among children with intellectual disability.) The setting was a Hong Kong school for children with special needs. A simplified, five-step hand washing technique used was modified from the seven-step version put forth by the World Health Organization.

The simplified 5-step technique combines steps 1 and 3, rubbing palms and fingers together (palm-to-palm and palm-to-palm with fingers interlaced steps), and omits the wrist-rubbing procedure. The simplified 5-step technique is as follows: (1) between fingers, (2) backs of hands, (3) backs of fingers, (4) finger tips, and (5) thumbs. This reduces the spread of microorganisms because water can wet children’s clothes, especially when they are wearing long-sleeved shirts in winter. Wet sleeves serve as a reservoir for microbes that can be transferred to the hands by direct contact, therefore providing a habitat for infectious disease transmission.

The intervention group experienced a significant increase in the rating of their hand washing quality in both hands from pre- to post-test: left dorsum (+1.05, P < .001); right dorsum (+1.00, P < .001); left palm (+0.98, P < .001); and right palm (+1.09, P < .001). The pre- to post-test difference in the intervention group (+1.03, P < .001) was significantly greater than the difference in the control group (+0.34, P = .001). There were no differences between the post-test and the sustainability assessment in the intervention group. The intervention school experienced a significantly lower absenteeism rate (0.0167) than the control group in the same year (0.028, P = .04). Students in this study showed better performance in simplified hand washing techniques and experienced lower absenteeism than those using usual practice in special education school settings.

The researchers concluded: It is very important in the public health agenda to standardize a hand washing program for school teachers and school nurses to teach vulnerable high-risk groups about hand washing procedures and ultimately to prevent the spread of germs in the school community. Therefore, it is hoped that these simplified 5-step hand washing techniques will be adopted by the Centre for Health Protection and Ministry of Health through collaboration and wide adoption by school nurses and school teachers in both special education schools and mainstream schools because the world has been moving toward the integration of children with special education needs into mainstream schools.

Researchers find leaving hospital staff to clean uniforms at home is an unhealthy practice

Doctor with Mask & Stethoscope arms foldedMany hospitals leave their staff to handle their own uniform cleaning at home, and at least one group of researchers has found that to be an unhealthy practice. Typical home laundry processes simply won’t remove bacteria from clothing.

Researchers at DeMontfort University in Leicester, England, surveyed 265 hospital staff workers at four hospitals to learn more about their uniform washing habits. They asked staff how often they washed their uniforms, the temperatures they wash them at and whether uniforms were washed separately from other clothing.

The results showed 49 percent of those surveyed did not wash their uniforms at a recommended temperature of 60°C while 40 percent also washed their uniforms with other clothing, risking cross-contamination and spread of illness. A total of 74 percent of respondents said they washed their uniforms after every shift, which means the remaining 26 percent potentially were carrying bacteria-contaminated clothing into another shift.

The report authors – DMU microbiologist Katie Laird , PhD student Kate Riley and Principal Lecturer John Williams, from the university’s School of Fashion and Textiles – have called for national guidelines to be introduced and have also recommended washing of hospital uniforms is moved back in-house.

It is common for staff to launder their uniforms at home as it reduces NHS costs and is more convenient. But as we’ve noted, the cost-cutting and convenience comes at an unacceptable cost. The report writers have suggested that moving uniform cleaning back in-house would rule out any possibilities of not meeting a national standard.

In this piece, Enteric Virus Survival during Household Laundering and Impact of Disinfection with Sodium Hypochlorite, it was found that washing with detergent alone was not found to be effective for the removal or inactivation of enteric viruses, as significant concentrations of virus were found on the swatches (reductions of 92 to 99%). It was also demonstrated that viruses are readily transferred from contaminated cloths to uncontaminated clothes. The use of sodium hypochlorite reduced the number of infectious viruses on the swatches after washing and drying by at least 99.99%. Laundering practices in common use in the United States do not eliminate enteric and respiratory viruses from clothes. The use of bleach can further reduce the numbers of enteric viruses in laundry.

Sanitation of Low Temperature Home Laundry experiments with a procedure that was developed to closely simulate the home laundry process. It measured the ability of the entire laundry process to remove bacteria from fabrics, including the mechanical action of washing, rinsing and tumble drying. It finds:

  • The use of detergent alone was not effective in sanitizing fabrics when water of low temperature was used in the laundry.
  • Detergent concentration had no effect on the numbers of bacteria surviving treatment.
  • The nonionic non-phosphate detergent resulted in lower bacterial counts when used on the terry cloth, whereas the anionic phosphate detergent was slightly more effective on the polyester/cotton sheeting.
  • The number of bacteria surviving treatment was reduced slightly by raising the wash water temperature from 65°F to 105°F.
  • Use of a disinfectant significantly reduced bacteria counts.
  • Increasing the disinfectant concentration reduced bacteria survival with the medium concentration providing an acceptable level of reduction.
  • Drying at 160° F yielded lower counts than drying at 80°F.

Monitoring and ensuring air quality is a critical but often overlooked piece of the infection control puzzle

MRSA 2Indoor air quality matters everywhere, but probably no place more than in hospitals. Poor air quality can lead to a host of issues for patients and healthcare workers alike, including HAIs and occupational diseases. Monitoring and ensuring air quality is a critical but often overlooked piece of the infection control puzzle. Without a surface to air strategy, no infection control plan can be comprehensive.

Indoor air quality levels in a University Hospital in the Eastern Province of Saudi Arabia aimed to assess IAQ inside a large University hospital at Al-Khobar City in the Eastern Province of Saudi Arabia. Levels of particulate matter (both PM10 and TSP) were found to be higher than the Air Quality Guidelines (AQGs). The highest concentrations of the fungal species recorded were Cladosporium and Penicillium. Education of occupants of health care facilities on IAQ is critical. They must be informed about the sources and effects of contaminants and the proper operation of the ventilation system.

Some notable takeaways from the study:

  • IAQ is also influenced by the indoor sources of pollution, including the characteristics of the building and the habits of the residents. Thus, levels of the indoor pollutants differ from one location to another according to the type and number of activities carried out in each location.
  • Nosocomial infections transmitted by the airborne route, especially fungal infection such as aspergillosis, are a major source of morbidity and mortality in immunocompromised patients. Bio-aerosols, of which fungal spores are one of the major types of microorganisms, can be present in all hospital environments, and may be transmitted through indoor and outdoor air, visitors, patients, and air conditioners.
  • Levels of PM (both PM10and TSP) were higher than the AQG. The highest concentrations of different fungal species recorded were Cladosporium, followed by Penicillium. Education of occupants of HCFs on IAQ is critical. They should be provided with information on the sources and effects of contaminants and the proper operation of ventilation systems. In addition, the location of the healthcare facilities should be carefully selected, so that they are removed from any direct sources of noise or air pollution such as roads or industrial areas.
  • All Chrome-agar positive colonies were tested by coagulase test to confirm theStaphylococcus aureus identity as MRSA. In the selected hospital, the highest isolation rate was at the ER department where it was 7.5 ± 6.51, followed by the OPD at 5.4 ± 6.51, followed by the burn reception area (corridor) at 3.6 ± 7.67. The lowest concentration was in the kitchen, laboratory, and pediatric intensive care isolation unit (0.3 ± 0.5). These results were in accord with Kim et al.[43] Mean concentrations of airborne bacteria and fungi were the highest in main lobby, followed by the surgical ward, ICU, and biomedical laboratory. The predominant genera of airborne bacteria identified in the general hospital were Staphylococcus  (50%).

Older sewer systems can send waterborne pathogens back into your tap water

sewer systemsWaterborne pathogens are a source of infection, and your city’s infrastructure might just impact your exposure to them. As the accompanying graphic from an article in Environmental Health Perspectives shows, more updated sewer systems route sewage to a treatment plant through one pipe and untreated storm runoff into a body of water through another. However, less modern systems route sewage and storm water to a treatment plant through the same pipe.

There’s a reason newer systems separate the two. When it rains heavily and the combined system becomes overloaded, water utilities must discharge the excess – known as combined sewer overflow (CSO) – into nearby bodies of waters. Those waters often might be a source of local drinking water. The catch here is that bacteria, viruses and protozoa in these releases can cause waterborne diseases when it makes it back into your tap water, according to the EHP article written by Carol Potera.

Some interesting observations from the study discussed in the article:

For the current study, investigators utilized data on daily visits to emergency rooms for GI illnesses after extreme rainfall events in Massachusetts from 2003 to 2007. They assessed three study areas. The first included 11 towns with combined sewer systems that discharged into the Merrimack River, a source of drinking water for all 11 towns. The second included 24 towns with combined sewer systems whose overflow ran into Boston Harbor, which is used largely for recreation. The third included 9 towns with modern “separate” sewer systems that transported sewage independently of storm runoff.

During the study period, 18 extreme rainfalls occurred, defined as the 99th percentile or greater—this equated to 1.33, 1.60, and 1.97 inches of rain per event at the three sites, respectively. In towns where CSOs flowed into the Merrimack River emergency room visits increased by an average 13% for all ages and an average 32% for people older than 65 years about a week after extreme rainfalls. In comparison, no unusual rise in visits occurred at hospitals in towns that did not have combined sewer systems or where CSOs were discharged into recreational waters.

You can bank on paper money being friendly to pathogens

It’s been said that money is the root of all evil. That depends on your perspective. But what it quite possibly might be, in addition to something that can be exchanged for goods worldwide, is an effective vehicle for pathogens to travel. Could money be a vector for pathogMoneyenic disease? We will show below a few studies we’ve come across that are worth taking a look at and that might help to answer this question.

  • Comparison of Aerobic and E. Coli Colony-Forming Units Isolated From Circulating Paper and Plastic $20 Canadian Banknotes. This piece submitted to The British Columbia Institute of Technology by Ryan Oliver says that contamination rates vary greatly and while the majority of bills had relatively low contamination rates, a select few had extremely high contamination rates.
  • Microbial load and safety of paper currencies from some food vendors in Jimma Town, Southwest Ethiopia. The combination of the widespread use (of paper money) and constant exchange make paper currency make it a likely agent for disease transmission. The aim of this study was to evaluate the microbial load and safety of Ethiopian paper currencies collected from some food vendors in Jimma town. All 100 paper currency samples evaluated in the study were contaminated with different microbial groups. In agreement to several studies[2632], the predominant bacteria encountered among aerobic mesophilic bacteria in this study were Staphylococcus  (34.06%) followed byBacillus spp. (31.88%), and Enterobacteraceae (13.39%).
  • Public health implications of contamination of Franc CFA (XAF) circulating in Buea (Cameroon) with drug resistant pathogens. This study concludes that the CFA franc circulating in Buea could serve as a vehicle for transmission of drug resistant pathogenic or potential organisms and contamination could be due to currency usage and handling as mint notes were not contaminated. Hygiene practices during or after handling currency is greatly encouraged to prevent infection.
  • Screening currency notes for microbial pathogens and antibiotic resistance genes using a shotgun metagenomic approach. Fomites are a well-known source of microbial infections and previous studies have provided insights into the sojourning microbiome of fomites from various sources. Paper currency notes are one of the most commonly exchanged objects and its potential to transmit pathogenic organisms has been well recognized. … (The study) identified 78 pathogens including Staphylococcus aureus, Corynebacterium glutamicum, Enterococcus faecalis, and 75 cellulose degrading organisms including Acidothermus cellulolyticus, Cellulomonas flavigena and Ruminococcus albus. Additionally, 78 antibiotic resistance genes were identified and 18 of these were found in all the samples. Furthermore, six out of 78 pathogens harbored at least one of the 18 common antibiotic resistance genes.

Contaminated ambulances illustrate infection control must begin before arriving at hospital

inside of an very used greek ambulance

The chain of infection can begin even before a patient reaches a hospital in some cases. Studies show those transported by ambulance might well be put at risk even before arriving at a primary care facility.

Not unexpectedly, most sites inside the vehicles are contaminated before cleaning. Perhaps less expected, however, is that many sites inside ambulances not only remain contaminated after cleaning but previously uncontaminated areas became contaminated during the cleaning process, according to one study. The results indicate that the cleaning protocol based on fumigation with a hydrogen peroxide system is insufficient and should be revisited and improved because of the risk of infection.

A dissertation that addresses ambulance infection control in an emergency medical service in a South African district indicates similar problems. It found that “contamination of ambulances was widespread throughout the district under study, with 13 species of micro-organisms being identified, 10 of which were potentially pathogenic. Many respondents were unaware of policies and procedures. IC knowledge, cleaning practices and procedures were generally poor, personal protective equipment was frequently unavailable and staff immunization was inadequate. Challenges were insufficient time and cleaning resources. Patient body fluid exposures had occurred in 67 (54.9%) of the respondents.”

It goes on to conclude that “ambulances have an unacceptable level of pathogenic micro-organism contamination, and may be a reservoir in the transmission of potentially serious infections to patients and staff. There is a need for the development and implementation of evidence-based ambulance IC guidelines. These findings should be carefully considered and all attempts must be made to tackle the problem of ambulance cleanliness and infection control.”

Ambulance hygiene is a concerning issue and cleaning methods and protocols should be improved, reviewed and tested for efficacy to prevent them from adding to the risk of infection.

No magic bullet in HAI fight; comprehensive plan requires team approach to address all surfaces, air

Defending against HAIs that cause death and suffering daily throughout the world is a complex fight that cannot be easily won. While we need logo for annalsto focus on immediate solutions, we at the same time must understand it will be on ongoing struggle because new bugs will emerge and existing bugs will adapt. Final solutions will be layered because there are no silver bullets that will put an end to HAIs.

Each time we talk to infection control professionals, they invariably tell us they are looking for the product that does everything. That would be great in a perfect world. Unfortunately, it doesn’t exist. Looking for the invisible flying tank is not the way to fight this battle. We need an interdisciplinary approach make headway. We need engineers, pharmacists, janitors, facility managers, microbiologists, nurses, physicians to come together to communicate and develop a strong, consistent team approach. We need to share successful strategies, as well as those that aren’t, if we are to enjoy any long-term success is this critically important fight.

Members of the University of Pennsylvania School of Medicine published a new systematic overview recently in the Annals of Internal Medicine that points to several promising cleaning tactics of “high-touch” surfaces such as tray tables, light switches, bed rails and toilets. The study, however, is limited in scope because it does not address transmission through air or laundry.

Consider this, from the study’s lead author, Jennifer Han, M.D., M.S.C.E.: “The cleaning of hard surfaces in hospital rooms is critical for reducing healthcare-associated infections. We found that the research to date does provide a good overall picture of the before and after results of particular cleaning agents and approaches to monitoring cleanliness. Researchers now need to take the next step and compare the various ways of cleaning these surfaces and monitoring their cleanliness in order to determine which are the most effective in driving down the rate of hospital-acquired infections.”

She is absolutely correct about the next steps that need be taken as it relates to hard surfaces. But we would contend that focusing on a single area at the expense of a more comprehensive plan to include air and laundry (bed sheets, privacy curtains, uniforms, et. al.) is destined to fall short. We need intensive research and studies in these areas, too. There won’t be a single, narrowly-focused solution that ends the HAI fight.

Here are a couple of other related pieces worth taking a look at:

White House offers up series of important goals in national plan to fight antibiotic-resistant bacteria

white house logoFar too often swept under the proverbial rug, the growing number of illnesses and deaths resulting from resistance to antibiotics is a very real and pressing issue. It doesn’t get the attention of sexier causes, though it should. It truly is one of the more important challenges that governments throughout the world face. Preventable illness and death related to infections caused by antibiotic resistant bacteria is made more troublesome because our ability to combat them is compromised by their ability to not only survive but thrive in the face of increasingly less effective antibiotics assaults.

Dr. Tom Frieden, MD, MPH, Director U.S. Centers for Disease Control and Prevention, sums up quite nicely the peril of inaction when he says: Every day we don’t act to better protect antibiotics will make it harder and more expensive to address drug resistance in the future. Drug resistance can undermine both our ability to fight infectious diseases and much of modern medicine. Patients undergoing chemotherapy for cancer, dialysis for renal failure, and increasingly common treatments for diseases such as arthritis depend on antibiotics so common infectious complications can be treated effectively.

The White House unveiled the National Strategy for Combating Antibiotic-Resistant Bacteria in September 2014. The stated vision: The United States will work domestically and internationally to prevent, detect, and control illness and death related to infections caused by antibiotic- resistant bacteria by implementing measures to mitigate the emergence and spread of antibiotic resistance and ensuring the continued availability of therapeutics for the treatment of bacterial infections. The United States joins the World Health Organization (see previous blog), Australia and the European Union in developing strategies to combat antimicrobial resistance.

Specifically, five interrelated goals were outlined:

  1. Slow the Emergence of Resistant Bacteria and Prevent the Spread of Resistant Infections.
  2. Strengthen National One-Health Surveillance Efforts to Combat Resistance.
  3. Advance Development and Use of Rapid and Innovative Diagnostic Tests for Identification and Characterization of Resistant Bacteria.
  4. Accelerate Basic and Applied Research and Development for New Antibiotics, Other Therapeutics, and Vaccines.
  5. Improve International Collaboration and Capacities for Antibiotic Resistance Prevention, Surveillance, Control, and Antibiotic Research and Development.

To read the report in detail, visit the link provided above in this story.