ICU Patient rooms amp the effect on gram negative colonisation rates Alma Tostmann PhD EPIET C2009 EAN Vice President Dept of Primary and Community Care ID: 796412
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Removal of sinks from ICU Patient rooms& the effect on gram negative colonisation rates
Alma Tostmann, PhD EPIET (C2009) – EAN Vice PresidentDept of Primary and Community CareRadboud university medical centreNijmegen/ Netherlands
Slide2HCAI at intensive care unitsHCAI at Intensive Care Unit morbidity and mortality Environmental contamination: potential source transmissionHand washing sinks : best practice of ICU design (hygiene) But: source of trouble reported since 1970’s. EAN Mini Module HCAI 2017 2
Edmonds, et al, Applied Microbiology, 1972Teres, et al, The Lancet, 1973Ayliffe, et al, The Lancet, 1974
Slide3Outbreaks multidrug-resistant gram-negative bacilli (MDR-GNB)intensive care units, including paediatric and neonatal ICUs sinks3
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Slide4Intensive Care Unit RadboudumcRadboudumc: 953 bedsIC: 50 single roomsSelective digestive tract decontamination (SDD)
1Low MRSA and VRE prevalence (in Netherlands) All patients: contact isolation at ICUIncrease antibiotic
resistance (gram negative rods
)
2
outbreaks
related
to
sinks
Klebsiella
pneumoniae
ESBL
Enterobacter
cloacae
ESBL
4
1
N
Engl
J Med 2009; 360:2138-2141, may 2009
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Slide5Outbreak at ICUEnterobacter cloacae ESBL spring 2014. Routine SDD cultures.Related? Outbreak? Same genotypeClustering in time and space (1 IC unit)Transmission between patients (genotype) Same pathogen found in the patient room sinksEAN Mini Module HCAI 2017 5
Slide6What happened next?Hand washing sinks removed from all patient rooms Summer 2014. Research: effect on colonization gram negative pathogens? EAN Mini Module HCAI 2017 6
Slide7Design Environmental (ecological) intervention study intervention = removal of sinks. Data source: routine SDD culturesTime period: 1 year before vs. 1 year after sink removalOutcome measure: gram negative colonisation rate / 1000 admission days.Sensitivity analysis
: longer duration admission First GN+ culture ≥2, ≥5, ≥7, ≥10, ≥14 days. ‘negative control’: Candida colonisation (routine SDD cultures) Interrupted time series analysis (ITS) EAN Mini Module HCAI 2017 7
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When comparing ‘mean rate’ pre – post:1: mean rate seems higher after intervention2: mean rate seems lower after interventionIn
reality: no effect, just existing trend.
Slide9EAN Mini Module HCAI 2017 9https://academic.oup.com/ije/article/46/1/348/2622842/Interrupted-time-series-regression-for-the
Slide10ResultsBefore intervention: 1496 patients (9153 admission days) After intervention : 1444 patients (9044 admission days)Segmented regression analysis: after removal sinks stat. sign. Reduction in gram negative colonisation rate. Effect more pronounced in sensitivity analysis Largest effect among patients with longer duration admission (2-3x less)EAN Mini Module HCAI 2017 10
Slide11In conclusion Removal sinks from patients rooms ICUReduced colonisation ICU-acquired gram negative pathogens, incl multidrug resistant pathogensNo difference in Candida colonisation Larger effect in patients with longer duration of admissionIncreased likehood of
ICU-acquired colonization No alternative explanationsPatient population pre / postHand hygiene compliance Cleaning and disinfection practiceEAN Mini Module HCAI 2017 11
Slide12ICU-rooms pre post12EAN Mini Module HCAI 2017
Slide13Implementation Round table discussion withDoctorsNursesCare assistantsEAN Mini Module HCAI 2017 13
Slide14Discussion Remove all hand washing sinks?Depends on the settingWhat is the effect in hospitals with high gram negative pathogen sepsis?Hospitals with no SDD on ICUsLow income countriesHospitals with frequent Clostridium difficileEffective method to ‘work around behavioural change’Worth consideringEAN Mini Module HCAI 2017 14
Slide15SOCO ;-)Sinks can be a source of transmission in hospitalsEspecially gram negative pathogens (water) When implementing such a drastic measure, input and engagement of personell is essentialAlma Tostmann [Alma.Tostmann@Radboudumc.nl]
Joost Hopman, head Hygiene Infection Control unit [Joost.Hopman@radboudumc.nl]Many thanks! Acknowlegdements: - Medical Microbiology
, Radboudumc: Prof. Andreas Voss, Eva Kolwijck, Rita Bos- ICU, Radboudumc: Prof. Hans van der Hoeven, prof. Peter PickkersMedical Microbiology,
Laurentius hospital
Roermond
: Patrick Sturm
Paper
sinks
:
https://aricjournal.biomedcentral.com/articles/10.1186/s13756-017-0213-0
General info ITS
:
https://academic.oup.com/ije/article/46/1/348/2622842/Interrupted-time-series-regression-for-the
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