1. Removal of sinks from ICU Patient rooms
& the effect on gram negative colonisation rates
Alma Tostmann, PhD EPIET (C2009) – EAN Vice President
Dept of Primary and Community Care
Radboud university medical centre
Nijmegen/ Netherlands

2. HCAI at intensive care units
HCAI at Intensive Care Unit  morbidity and mortality
Environmental contamination: potential source transmission
Hand washing sinks : best practice of ICU design (hygiene)
But: source of trouble reported since 1970’s.
Ayliffe, et al, The Lancet, 1974
Edmonds, et al, Applied Microbiology, 1972
Teres, et al, The Lancet, 1973
EAN Mini Module HCAI 2017

3. Outbreaks multidrug-resistant gram-negative bacilli (MDR-GNB) intensive care units, including paediatric and neonatal ICUs sinks
EAN Mini Module HCAI 2017

4. Intensive Care Unit Radboudumc
Radboudumc: 953 beds
IC: 50 single rooms
Selective digestive tract decontamination (SDD)1
Low MRSA and VRE prevalence (in Netherlands)
All patients: contact isolation at ICU
Increase antibiotic resistance (gram negative rods)
2 outbreaks related to sinks
Klebsiella pneumoniae ESBL
Enterobacter cloacae ESBL
EAN Mini Module HCAI 2017
1N Engl J Med 2009; 360: , may 2009

5. Outbreak at ICU Enterobacter cloacae ESBL spring 2014.
Routine SDD cultures.
Related? Outbreak?
Same genotype
Clustering in time and space (1 IC unit)
Transmission between patients (genotype)
Same pathogen found in the patient room sinks
EAN Mini Module HCAI 2017

6. What happened next?
Hand washing sinks removed from all patient rooms Summer 2014.
Research: effect on colonization gram negative pathogens?
EAN Mini Module HCAI 2017

7. Design Environmental (ecological) intervention study
intervention = removal of sinks.
Data source: routine SDD cultures
Time period: 1 year before vs. 1 year after sink removal
Outcome 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

8. When comparing ‘mean rate’ pre – post:
1: mean rate seems higher after intervention
2: mean rate seems lower after intervention
In reality: no effect, just existing trend. 2 1
EAN Mini Module HCAI 2017

9. https://academic.oup.com/ije/article/46/1/348/2622842/Interrupted-time-series-regression-for-the
EAN Mini Module HCAI 2017

10. Results Before 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

11. In conclusion Removal sinks from patients rooms ICU
Reduced colonisation ICU-acquired gram negative pathogens, incl multidrug resistant pathogens
No difference in Candida colonisation
Larger effect in patients with longer duration of admission
Increased likehood of ICU-acquired colonization
No alternative explanations
Patient population pre / post
Hand hygiene compliance
Cleaning and disinfection practice
EAN Mini Module HCAI 2017

12. ICU-rooms pre  post
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13. Implementation Round table discussion with Doctors Nurses
Care assistants
EAN Mini Module HCAI 2017

14. Discussion Remove all hand washing sinks? Depends on the setting
What is the effect in hospitals with high gram negative pathogen sepsis?
Hospitals with no SDD on ICUs
Low income countries
Hospitals with frequent Clostridium difficile
Effective method to ‘work around behavioural change’
Worth considering
EAN Mini Module HCAI 2017

15. SOCO ;-)
Sinks can be a source of transmission in hospitals
Especially gram negative pathogens (water)
When implementing such a drastic measure,
input and engagement of personell is essential
Alma Tostmann
Joost Hopman, head Hygiene Infection Control unit
Many thanks!
Acknowlegdements:
- Medical Microbiology, Radboudumc: Prof. Andreas Voss, Eva Kolwijck, Rita Bos
- ICU, Radboudumc: Prof. Hans van der Hoeven, prof. Peter Pickkers
Medical Microbiology, Laurentius hospital Roermond: Patrick Sturm
Paper sinks:
General info ITS:
EAN Mini Module HCAI 2017