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Thursday, July 25, 2013

Hot Tubs - A Cornucopia of Critters

There are some topics that I think are worth repeating, especially when the "culprit" can be found in acute care facilities, long term care facilities, hotels, spas, cruise ships, gyms and even our own homes. Regardless of the name you know it by - Hot Tub, Whirlpool, Foot Spa Bath - the fact of the matter is any reservoir that holds water and has the ability for water to recirculate (and pool in out of sight places) has the potential to cause harm.  I should likely also add - may have more than one user at any given time any of whom may have questionable personal hygiene practices, may have open sores or may have a communicable disease.

In August 2012, Lee and I wrote two blogs "Are their Monsters in Your Drain" and "Life Slime - the stuff nightmares are made of" both of which focused on outbreaks associated with biofilms found in sink drains, Hot Tubs and the like.  A Class Action Law Suit recently filed, claims that Hot Tubs are infested with dangerous, flesh-eating bacteria.  The Law Suit claims that the cesspools (I mean Hot Tubs) are not limited to one (1) ship, but have been associated with infections on different ships at different times.  One complainant claims he contracted "hot tub folliculitis" in December of 2011 from a cruise ship whirlpool and that the severe infection resulted in spending a week in the hospital, $70,000 in medical bills and nearly cost him his leg. While it remains to be proven, there could be an additional 50 people or more who were also infected on this voyage.  The suit, further alleges that a May 2012 cruise on a different ship resulted in at least two (2) passengers becoming infected with MRSA and Staphylococcus aureus

I think many of us have heard in the media more than once about a cruise ship being struck with Norovirus, but I would hazard a bet that most of you did not stop to consider the perils of taking that dip in the warm, inviting hot tub.  The Vessel Sanitation Program (VSP) at the CDC regulates the cruise industry with a mandate to prevent and control the introduction, transmission, and spread of gastrointestinal (GI) illnesses on cruise ships (e.g. Norovirus).  Perhaps they should add to their mandate, to prevent and control the transmission and spread of hot tub folliculitis. VSP does have an Operations Manual that details a sanitation programs to minimize the risk for acute gastroenteritis within which there is a section on Recreational Water Facilities (aka hot tubs).   In accordance to the Operations Manual there are very specific requirements with regards to water quality, recirculation etc, etc.  One would intuitively think that if the requirements specified were followed such an occurrence would be hard pressed to happen.

As both Lee & I stressed in our earlier blogs, having established procedures that detail how to clean and disinfect and with what frequency to disinfect areas that are harbingers of biofilm will help stop their growth and development. I guess we should have further specified that you MUST follow the maintenance, cleaning and sanitation procedures. 

Bugging Off!


Friday, July 19, 2013

Book Review: Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out

Summer has arrived and with it I hope many of you have had or are about to enjoy some vacation time.  Being an avid reader, summer vacations sitting on the dock enjoying the view of the river and devouring a good book are some of my most prized moments.

This book is a story of a simple device, a checklist, that the authors suggest can make healthcare safer.  Written by Peter Pronovost, an anaesthesiologist and critical care specialist and Eric Vohr a communications executive, together they build a convincing case for urgent and radical change of western healthcare systems. Using personal accounts of two deaths, Pronovost illustrates perfectly how adept modern health systems are in harming patients unnecessarily.  Throughout the book, the narrative continues with an array of true stories of preventable error and how through the use of the checklist, he has been able to successfully address these events.

With the development, implementation and measurement of interventions using the checklist; Pronovost stands alongside a handful of pioneers who have truly transformed patient safety and infection prevention.  This book provides a fascinating insight into how it all happened, who was involved in the collaborative development of the checklist and what might happen next.  He talks about the checklist as a life saving device which adds an interesting angle to the story, and should challenge every reader to reconsider how we position the things we do, the tools we use, the approaches we take in our day to day work in infection prevention and the language we use.  At first the reader might be forgiven for thinking this is a little exuberant - I mean is the checklist really equivalent to the discovery of penicillin?  However, given the fact that the checklist if implemented successfully and consistently could save lives on a monumental scale, the language might even be underselling the device as Pronovost believes its use could eradicate 1 million cases of central line associated blood stream infections and save 50, 000 lives.  Something I think we can all agree is worth doing!

The book emphasizes how the checklist revolution can only be achieved alongside a parallel cultural revolution in our healthcare systems.  The checklist effect is predicated on a collaborative culture and the need for a radical shift in the status of the physician.  Pushing the boundaries of convention throughout, Pronovost is clear that success requires the status quo to be transformed beyond recognition.

Being a list maker myself, I know firsthand a successful grocery shopping trip or errand run only occurs if I have made my list, checked it twice and checked it off as I go along.   If the success rate of simple tasks like grocery shopping can be improved, I'm all for using checklist to improve infection prevention and patient safety.  You never you when you'll be a patient and Pronovost's checklist could save your life.

Bugging off!


Sunday, July 14, 2013

The Dissenter & Father of Hand Hygiene Ignaz Semmelweiss turns 195!

It's true, I'm not always known to be a conformist.  I can be difficult and occasionally disagree in matters of opinion (the definition of a dissenter).  The next time someone comments about my lack of conformity, I'll quote Professor Cass Sunstein from the University of Chicago "Dissenters benefit others while conformists benefit themselves." 

Semmelweiss was the quintessential dissenter.  He challenged the conformists' accepted wisdom and sought answers to problems that, in his mind, had not be suitably explained.  But for challenging the norm, he was ostracized, condemned, and driven to a state of near insanity that led to an early death.  July 1st marked what would have been Ignaz Semmelweiss' 195th birthday.  His legacy of positive dissent, benefited patients not just in his lifetime, but has been essential to patient safety ever since.  It seems fitting to pay homage to the man who, through his "difficult" manner and positive dissent from accepted wisdom in the introduction of antiseptic hand hygiene, has saved the lives of millions of patients.

The General Hospital of Vienna boasted quite favorable conditions for its time.  Unlike its contemporaries of the early part of the 19th century who often had 3 or 4 patients/bed, the General Hospital of Vienna's policy was 1 patient/bed.  They further segregated patient care by class: a section for the wealthy, a section for patients who were able to pay a small sum for care and a third section and certainly the largest for those who were unable to pay.  The indigent patients were permitted free care with the understanding that some of that care would be seen to by medical students and midwives in training.

In the indigent section of the hospital there were two maternity clinics that admitted patients to one or the other on alternate days.  One clinic was largely for training of midwives while the second was for training of doctors.  When Semmelweiss was appointed assistant to the Professor of the First Obstetrical Clinic some of his first observations were of women desperately weeping and begging to be admitted to the Second Obstetrical Clinic rather than the First and for a very good reason, the First clinic had a deadly reputation.

In the First Clinic, maternal mortality rates due to Childbed Fever (a form of septicemia) rarely dipped below 10% of admissions and in some months climbed as high as 30%.  Conversely, in the Second Clinic where the midwives were in training, the mortality rate rarely climbed above 2%.  Physicians and governmental authorities were more than aware of the ravages of Childbed Fever to the point that they were often referred to as "houses of death", but causes were most often attributed to miasmas (foul air), improper diet, strong liquors or violent mental emotions.

Haunted by the higher rates of Childbed Fever in the First Clinic, Semmelweiss was unwilling to accept the conformist view.  The only difference between the two clinics were the people working there.  After eliminating all factor that were consistent between the two clinics he eventually concluded that the medical students were carrying "cadaverous particles" (e.g. microbes) on their person to the First Clinic after performing autopsies of patients who had died from Childbed Fever.  When his best friend and fellow physician died after being cut by a student during an autopsy he was compelled to act.  He was convinced the cause of transmission was from contaminated hands of physicians and students.

Semmelweiss demanded that all students and physicians clean their hands with a chlorinated lye solution before attending patients in the First Clinic in order to remove or destroy the invisible cadaverous particles.  The strategy worked and deaths attributable to Childbed Fever rapidly dropped to below that of the Second Clinic where the midwives had always kept their hands clean and did not attend autopsies.  Unfortunately, rather than celebrations and change in practice the culture of conformity triumphed and Semmelweiss was forced to resign his position and subsequently the mortality rates in the First Clinic returned to pre-intervention levels.

As we know, Semmelweiss' ideas were eventually accepted and he has become widely recognized as the "Father of Hand Hygiene".  In celebration of his 195th birthday, I hope the next time you sing "Happy Birthday" while washing your hands, you'll remember Ignaz Semmelweiss!

Bugging Off!

Friday, July 5, 2013

Disinfectant Chemistry Report Card #15 - Parachlorometaxylenol (PCMX) - Many formats, many uses, but at what cost?

 PCMX is an antimicrobial chemical compound used as a preservative to control bacteria, algae, and fungi in adhesives, emulsions, paints, cooling fluids, glue, cosmetics, hygiene products such as hair conditioners and deodorants, topical medications, urinary antiseptics and metal working fluids.  Liquid PCMX solutions are used for cleaning and disinfecting wounds, abrasions and abscesses while creams are used for cuts, scratches, insect bites, and burns. Powders are used to treat problems of the feet and skin inflammations.

PCMX is used in 0.5% to 4% in antiseptic formulations and has low level of antimicrobial activity. Its effectiveness is also very formulation dependant in terms of use along with other active agents.  Disruption of cell membrane potentials is the main mechanism by which PCMX prevents pathogenic activity. 

Resistance among pathogens to PCMX have been reported, with biofilm generating pathogens being the most resistant.  Bacteria sourced from industrial locations such as, P. stutzeri and A. johnsonii, have been shown to be more resistant to PCMX family of disinfectants.  Many virus types have been found to be resistant to pure forms of PCMX in low concentrations; however when formulated with other active ingredients can overcome the resistance.

Acute oral toxicity of pure PCMX has been reported for mice with LD50 of 1g/kg of body weight; however it imposes very low to no toxicity in low dilutions. It is a mild skin irritant and may trigger allergic reactions in some individuals.  Various forms of dermatitis have been reported when using PCMX on skin surfaces.

Long term biodegradation may produce hazardous by-products; however the degradation products are as hazardous as PCMX itself.  Biodegradation in activated sludge is slow, with only 40% of a 10 ppm solution taking 7 days to decompose.  Bioaccumulation in aquatic organisms’ body is moderate, however still posing adverse effects.

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

• Speed of Disinfection – B

o Contact times will be dependent upon concentration and formulation
o Hand Sanitizing formulations generally carry a  30 second sanitizing claims

• Spectrum of Kill – B to C

o Efficacy against bacteria, viruses and fungi has been shown but is dependent upon formulation and concentration

• Cleaning Effectiveness – C

o Cleaning efficacy of PCMX comes from the addition of surfactants to formulations

• Safety Profile – B

o PCMX not significantly toxic to humans and other mammals, is practically non-toxic to birds.
o  It is a mild skin irritant and may trigger allergic reactions in some individuals

• Environmental Profile – D

o Bioaccumulative in the environment and reacts to form more toxic by-products
o Moderately toxic to freshwater invertebrates and highly toxic to fish

• 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!