Welcome to Professional and Technical Services (PTS) – experts in chemical disinfection for infection prevention. Our goal is to educate and provide you the latest resources related to cleaning and disinfection of environmental surfaces, medical devices and hands. As specialists in disinfectant chemistries, microbiology, environmental cleaning and disinfection, facility assessments and policy and procedure creation we are dedicated to helping any person or facility who uses chemical disinfectants.

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Friday, May 31, 2013

Can I borrow your pen?

A study I recently came across by Halten et al of the University of Houston investigated the potential of writing pens as a source of transmission, which could be significant for hospital infection control practices when you consider the ubiquity of the instruments in healthcare facilities.  As this is tradeshow season where sharing of pens is a virtual second by second occurrence, I was curious to find out just how contaminated pens could get.

For the study, the clinical investigators responsible for enrolling patients into a study investigating antibiotic associated diarrhea were given a new writing pen each day.  They were then randomly assigned each day to clean the pen between patient visits while the non-intervention group did not clean the pens. After using the pen for the entire day to enroll patients, the investigators put the pen in a sterile labeled bag.  The pens were then immediately transported to the laboratory. Four unused writing pens were used as controls to assure that pens were not previously contaminated with microorganisms.

Unfortunately the sample size in the study was quite small, just 23 pens (10 in the intervention group, and 13 in the non-intervention group), in addition to the four control pens. For each group, between 2 and 11 patients touched each pen, along with the assigned investigator.  In the non-intervention group 12 of 13 pens showed bacterial growth compared with 4 of 10 pens in the intervention group. No growth was observed on control pens.

No Gram-negative bacilli, such as Pseudomonas spp.or E. coli, were identified in either group, which tells me that the investigators were being fastidious hand washers at least for the duration of the test.  There was however a significant difference in the Gram-positive cocci, presumptively identified as Staphylococcus spp. and Enterococcus spp. in the intervention compared with the non-intervention group.

The study showed that cleaning/sanitizing the pens can significantly reduce the level of potential pathogenic bacteria.  This is an important finding indicating that the risk of transmission of healthcare-associated pathogens can be decreased with the use of a sanitizing agent for wiping fomites such as writing pens between patients.  The ability of bacteria to survive on pens for long durations of time emphasizes the need to clean equipment (i.e. pens) after patient contact.

Seeing as I head to the CHICA-Canada conference this Sunday, I think perhaps I'll pack extra pens and be sure NOT to share mine.  I have a nasty habit of putting my pen in my mouth and I can't trust that everyone will be as fastidious in their hand washing as the clinical investigators in this study....

Hasta la vista!


aka “The Germinator”

Friday, May 24, 2013

Disinfectant Chemistry Report Card #14 - Chlorhexidine - Safe for Humans, But At What Risk To the Environment?

Chlorhexidine or Chlorhexidine Gluconate, is one of the most widely used antiseptics for oral rinses or mouthwashes to reduce dental plaque and oral bacteria. It is also used for skin cleaners for surgical scrubs and preoperative skin preparations.

Chlorhexidine is a broad-spectrum antiseptic that is considered to have rapid action, residual activity and is active in the presence of organic matter. The positive charge carried by the chlorhexidine molecule reacts with the cell surface of bacteria which is negatively charged and destroys the cell membrane. It is effective on both gram-positive and gram-negative bacteria, although it is less effective with some gram-negative bacteria. It has also shown to have some virucidal efficacy and to inhibit spores and fungi. Depending on the level of kill (e.g. sanitizing vs. disinfection), Chlorhexidine is effective in contact times of 30-seconds to 2 minutes against vegetative bacteria.

Chlorhexidine is non-flammable.  At high concentrations Chlorhexidine is harmful, however at the low concentrations typically used for oral rinses and skin cleaners it can be safely used. Despite Chlorhexidine being relatively non-toxic at low concentrations, there have been incidences of anaphylactic reactions. In fact, in the UK, a patient safety alert on the risk of anaphylactic reactions from the use of medical devices and medicinal products containing chlorhexidine has been issued with recommendations that if a patient experienced an unexplained reaction that healthcare providers check whether chlorhexidine was used or was impregnated in a medical device that was used.

From an environmental perspective, the by-products that chlorhexidine degrades into are reported to be more toxic that chlorhexidine itself.  Further, chlorhexidine can accumulate in the bodies of aquatic creatures and thus increases the toxic effects caused by long-term exposure.

Here’s how we would score Chlorhexidine on the key decision making criteria:

• Speed of Disinfection – A to B

o Contact times will be dependent upon concentration and level of kill required and range from 30 seconds to 2 minutes

• Spectrum of Kill – B to C

o Achieves disinfection against all microorganisms; bacteria, viruses and fungi but efficacy is concentration dependent

• Cleaning Effectiveness – C

o Some cleaning studies have shown that Chlorhexidine is not an effective cleaning agent

• Safety Profile – B

o Is considered safe to humans at the concentrations used for oral rinses and skin cleaners
o Anaphylactic reactions are well documented

• Environmental Profile – D

o Bioaccumulative in the environment and reacts  to form more toxic by-products
o Concerns with Aquatic Toxicity

• Cost Effectiveness – B to C

o Products are available from a number of suppliers

**For more in-depth scientific information about Alcohol and other disinfectant chemistries, stay tuned to www.infectionpreventionresource.com.

Bugging off!


Friday, May 17, 2013

SARS - Was Round 2 ten years in the making?

I'll admit to a little media sensationalism in the title.  Everyone knows about SARS thanks to the 2003 global outbreak.  Not everyone knows that SARS was caused by a Coronavirus and face it - had I started off with Novel Corona Virus (one of our latest viral threats) eyes would glaze over and you may not have read this post!

Similar to the H7N9 Influenza virus that many of us are following closely, the Novel Coronavirus (nCoV) or as it is now officially known  as "Middle East Respiratory Syndrome Coronavirus" (MERS-CoV) is believed to have caused the death of at least 18 people in the Middle East and Europe is cause for concern.  While 18 deaths may not seem significant this in actual fact is roughly half of the laboratory confirmed cases - basically a flip of a coin in deciding life over death. 

It's important to understand, that MERS-CoV is not SARS.  They are both from the same family of viruses and the fact that they are related is certainly a certain in trying to predict the future.  MERS-CoV has been infecting people in the Middle East (Jordan, Qatar, Saudi Arabia and United Arab Emirates) and Europe (UK, Germany and France), however, at this time we still do not know where the virus stems from.  Similar to SARS Coronavirus we saw in 2003, many of people who have become infected develop severe pneumonia.  Of interest with nCoV, many of those that have been infected to date have been older men with underlying medical conditions. 

What we can say is that the clusters that have been seen so far support the fact that person-to-person transmission with close contact with an infected person is occurring.  Transmission does seem to be limited to close contact within small clusters with no indication that the virus has the capacity to sustain generalized transmission within communities.  Nor do we know if other people have or are developing a mild infection and therefore have not had to seek medical attention. 

Most concerning are the questions we have yet to answer such as how people getting infected (from animals? from surfaces? from people through droplet or contact transmission?) and what are the main risk factors?  Genetic testing of MERS-CoV is showing that the virus is similar to bat viruses BUT this similarity does not imply that bats are the reservoir or that direct exposure to bats or bat poop are responsible for infection.   Further, researchers have yet to find MERS-CoV in an animal.

From an infection prevention perspective we do know that Coronaviruses are enveloped viruses meaning in the hierarchy of susceptibility to disinfectants they are among the easiest pathogens to kill.  Ensuring we have a robust cleaning and disinfection program for environmental surfaces and shared patient care equipment and medical devices will help mitigate environmental transmission.  Standard Precautions (Routine Practices) including hand hygiene and the use of Personal Protective Equipment (gloves, goggles, gowns, masks) are of course a cornerstone to any infection control program.  The WHO has developed an Interim Guidance Document for Infection Prevention and control during healthcare for probable or confirmed cases of Novel Coronavirus (nCoV) infection and I know that many of our National and Regional Public Health agencies across North America have been developing and circulating similar guidance documents, screening tools and check lists.

When it comes to our understanding of MERS-CoV there certainly are gaps in our knowledge that will inevitably take time to fill in.  Those who want to keep abreast of the latest findings can do so by following the Global Alert Response (GAR) Updates on the WHO website.  For those of use lucky enough to travel, the next time your seatmate coughs you may want to ask where they've travelled to lately - just don't lean in too close.....

Bugging Off!


Friday, May 10, 2013

Do You Sweat the Small Stuff? Dispelling the Myth of Efficacy Claims

Often we allow ourselves to get all worked up about things that, upon closer examination, aren't really that big a deal. We focus on little problems and blow them out of proportion.  In the world of infection prevention and control we see this time and time again. 

Infection prevention and control is not black and white nor is it one size fits all.  It would certainly make our lives easier if it were, but the truth of the matter is that the environmental hygiene processes used to prevent infections will differ from region to region and facility to facility depending on the patient population and underlying disease or pathogen prevalence.  As such the selection and use of liquid chemical disinfectants is largely a matter of judgement based on the facilities needs.

Example #1 Sweating over a TB claim
One common misconception with respect to label claims is the purpose of a tuberculocidal claim.  Historically, tuberculocidal claims have been used as the benchmark of a product's ability to inactivate a broad-spectrum of pathogens including the far less resistant bloodborne pathogens (e.g. Hepatitis B or C and HIV).   It is this broad-spectrum capability that was the original basis for OSHA's regulations for bloodborne pathogens. However OSHA revised its stance in 1991 to specify that disinfectant products that carry efficacy claims against HIV and Hepatitis B (HBV) are indeed appropriate for managing blood and body fluid spills.

EPA registered disinfectants with efficacy claims against HIV and HBV or appropriate for use in cleaning and disinfecting surface that are contaminated with blood and body fluid.  Bloodborne pathogens we are concerned with are enveloped EASY TO KILL viruses.  EPA registered disinfectant labels include explicit directions for how they can be used against bloodborne pathogens on their EPA approved label. 

Example #2 Sweating over Multiple Contact Times
Varying times listed on a disinfectant's label for efficacy against various bacteria, viruses, fungi, and mycobacteria causes angst within the Infection Prevention and Control community because it is believed by some that the longest kill time on the product as the required wet/contact kill time. The truth is that surfaces contaminated with organisms such as Candida, non-tuberculosis mycobacteria and other fungi have rarely, if ever, been shown to be a risk factor for healthcare-associated infections.  Products with Fungicidal claims can be relevant when supporting a claim for broad-spectrum disinfection and can be of interest in situations such as mold or fungal remediation, however, their relevance to infection prevention and environmental transmission of disease is minimal. 

The CDC Guideline for Disinfection and Sterilization in Healthcare Facilities refers to the time necessary to kill bacteria on surfaces (i.e., 1 minute) not the kill time for more difficult to inactivate pathogens such as Mycobacterium tuberculosis which doesn’t even have an environmental surface mode of transmission. When it comes to disease prevalence, experts all agree that the primarily causative organisms are either bacteria or viruses and that the pathogens of concern moving forward will continue to be bacteria or viruses.  Vegetative bacteria such as S. aureus, Enterococcus, Eschericihia coli, coagulase-negative Staphylococcus, Pseudomonas aeruginosa, Klebsiella spp, Enterobacter spp, etc and viruses such as Influenza and the more difficult to kill Norovirus are the pathogens that cause the vast majority of healthcare-associated infections.  In fact studies have shown these organisms to cause upwards of 85-90% of HAIs. (Rutala  2012)

When choosing a disinfectant product, ask yourself: what is relevant to my facility and my patients?  If your surveillance and outbreak data reflects the fact that 90% of your concerns are due to vegetative bacteria and viruses, focus your attention on a disinfectant formulation that provides you with a responsible balance between effectiveness - broad spectrum coverage against gram negative and gram positive vegetative bacteria and both enveloped and non-enveloped viruses; and minimal toxicity – results in greater user compliance.  

Bugging Off!


Thursday, May 2, 2013

A+ or F? What's your Hand Hygiene knowledge grade?

Last week I attended a dinner event put on by the Royal Canadian Institute.  Each table had a "theme" with which to base our conversation on.  The theme for our table was "First Do No Harm: Healthcare Culture and Patient Safety".  Dr. Michael Gardam (a past Talk Clean To Me guest blogger and current  Director of Infection Prevention and Control at the University Health Network in Toronto) was the table host and started off the night with the concept of positive deviance (PD) by asking what we would do to ensure that each and every patient we saw was given a hospital acquired infection (HAI).

For those of your who are unfamiliar with PD, it is a strength-based, problem-solving approach for behavior and social change that finds uncommon but successful behaviors or strategies that enable someone to find better solutions to a problem than their peers.  In healthcare (and in life) we often look at how we can solve or fix the problem.  Taking the view of how we can create the problem sometime leads to finding a "better" solution.   As expected, not washing ones hands was the first idea that came out as being "the way" to ensure we spread diseases.

As mentioned last week - May 5th is the global SAVE LIVES: Clean Your Hands campaign organized by the WHO.  I had challenged you to ensuring you washed your hands when appropriate and to point out other peoples oversights in an effort to stop the transmission of HAIs.

This week I'm challenging you to be positively deviant....take the following hand hygiene quiz, BUT, the objective is to answer based on how NOT to follow hand hygiene best practices.   Can you score an A+ and ensure that by following the wrong practices you can spread diseases?

1. How long should you scrub your hands together when washing with soap and water?
a. 2 minutes
b. 15 seconds
c. Just long enough to rinse the soap off

2. How often should you clean your hands after touching an environmental surface, for example a bedrail?
a. After each and every time I touch a surface
b. One if the surface is noticeably dirty
c. Never

3. Use of artificial nails by healthcare workers should be promoted because pretty hands mean clean hands.
a. True
b. False

4. What is the primary purpose of hand hygiene?
a. Reduce microorganisms on the hands
b. To keep hands clean
c. To keep nails clean
d. None of the Above

5. Which is the preferred method for drying hands in a healthcare setting?
a. Paper Towel
b. Air Hand Dryer
c. Using the seat of my pants

6. It's important to wash your hands:
a. After you use the restroom
b. Before you start preparing food
c. After petting an animal
d. None of the Above
e. All of the Above

7. What supplies do you need for hand washing?
a. Warm water, soap, something clean to dry your hands with
b. Alcohol-based Hand Sanitizer
c. Nothing because there is no scientific evidence to support the importance of hand hygiene
d. A or B

8. A co-worker who examines a patient with VRE, then borrows my pen without cleaning his/her hands is likely to contaminate my pen with VRE?
a. True
b. False

I hope you're as positively deviant as I am!  Give yourself an A+ if you answered 1-c, 2-c, 3-a, 4-d, 5-c, 6-d, 7-d, 8-b.  Your Hand Hygiene practices suck! 

Now that we know what not to do, can you think outside of the box to come up with a solution of how to ensure Healthcare workers wash their hands 100% of the time?

Bugging Off!