1. Cleaning in the ICU: strong evidence, strong convictions and a dose of reality? Cleaning in the ICU: strong evidence, strong convictions and a dose of reality ? APR Wilson, G Moore, D Smyth, R Jackson, J Singleton, E James, V Gant, S Shaw, M Singer G Bellingan University College London Hospitals Royal Free Hospital

2. What do we know about MRSA transmission? How it is MRSA transmitted – Hands? Airbourne? How effective is isolation of MRSA patients? Why don’t some patients get MRSA? Where are patients colonised?

4. Evidence MRSA can be controlled Yap, Gomersall et al. (Hong Kong) Clin Infect Dis 2004; 39: 511 Observational report of MRSA incidence on ICU 100% compliance with contact precautions during SARS 8 fold INCREASE in MRSA during this period Returned to baseline after return to normal precautions Souweine (France 2000) Retrospective: contact, surveillance, isolation, mupiricin One year pre and one year post introduction MRSA rates fell from 4/1000 pt days to 2.2/1000 Jernigan (Charlottesville 1996) Prospective, Neonatal ICU 4.8% colonised/infected – single strain Contact, cohort, surveillance staff + patients Transmission ratesIsolation 0.009/day Not isolated0.14/day p<0.0001

6. Isolation No Isolation

7. Air Communal Surfaces Patient Carrier of pathogen known or unknown Near patient surfaces Hands of staff and visitors

8. Hospital acquired pathogens Transmitted by unwashed hands, air or environment or other? Transmitted by unwashed hands, air or environment or other? In ICU hand hygiene more important than physical segregation?? In ICU hand hygiene more important than physical segregation?? Towards Cleaner Hospitals, Matrons Charter, linked to 50% MRSA reduction target Towards Cleaner Hospitals, Matrons Charter, linked to 50% MRSA reduction target

9. Cleaning ICU patient susceptible to repeated contamination ICU patient susceptible to repeated contamination Microfibre removes 99% of surface bacteria Microfibre removes 99% of surface bacteria Near patient equipment cleaned by unsupervised nurses not domestics Near patient equipment cleaned by unsupervised nurses not domestics

10. Aims Compare standard cleaning and intensively monitored enhanced cleaning Compare standard cleaning and intensively monitored enhanced cleaning Effect on local contamination rates Effect on local contamination rates Effect on colonisation of patients Effect on colonisation of patients Effect on hospital acquired infection Effect on hospital acquired infection

11. Two month phases Apr 07-Mar 08 Randomised standard or enhanced cleaning with one week washout Randomised standard or enhanced cleaning with one week washout Standard – existing practices plus nurses clean equipment Standard – existing practices plus nurses clean equipment Enhanced – microfibre monitored by ATP bioluminescence. Enhanced – microfibre monitored by ATP bioluminescence. MRSA screening on admission and weekly MRSA screening on admission and weekly

12. Methods Normal domestic staff routine cleaning beds, floors and walls Nursing staff bedside equipment Enhanced – team of technicians used colour coded microfibre cloths, 15 min per bed area

13. Methods Sampling daily - 20% of beds i.e. 12 bed days each ICU each week, total 1152 bed days, 20736 samples Sampling daily - 20% of beds i.e. 12 bed days each ICU each week, total 1152 bed days, 20736 samples 1:4 MRSA bed 1:4 MRSA bed Air and environmental samples, patient and general areas Air and environmental samples, patient and general areas Hourly sampling 1 day each phase Hourly sampling 1 day each phase

14. Methods Sites: drawer, bed rail, syringe driver, nurse hands, monitor and keyboard/chart Three times each sampling day Communal sites: apron dispenser, doctors hands, telephone, air

15. Methods Both ICU screened for MRSA on admission and 1-2 times/week Both ICU screened for MRSA on admission and 1-2 times/week 90% chance of detecting 50% reduction in contaminated bed areas 90% chance of detecting 50% reduction in contaminated bed areas 67% chance of detecting 50% reduction in rate of acquisition of MRSA 67% chance of detecting 50% reduction in rate of acquisition of MRSA

16. Expected Outcome Show if enhanced cleaning beneficial for environmental contamination and acquisition of hospital pathogens Show if enhanced cleaning beneficial for environmental contamination and acquisition of hospital pathogens Acquisition of pathogens is/is not related to level of contamination in environment Acquisition of pathogens is/is not related to level of contamination in environment

17. Monitoring Steering Group meeting every 3-4 weeks Steering Group meeting every 3-4 weeks Daily supervision of staff by investigators Daily supervision of staff by investigators

18. Typical Clean Trace Audit

19. Hand hygiene audits Used Pittet criteria Used Pittet criteria Compliance in enhanced phases: UCH 50% RFH 58% Compliance in enhanced phases: UCH 50% RFH 58% Compliance in standard phases: UCH 53% RFH 50% Compliance in standard phases: UCH 53% RFH 50%

20. Patients A EnhA StdB EnhB Std Patients799863453468 >48h346379222242 Median APACHE171617 Median age61.261.358.159.0

21. Patients A EnhA StdB EnhB Std Female %41.946.442.441.2 ICU stay (IQR)1-6 1-11 % pts MRSA positive o/a 8.56.510.88.3

22. Enhanced Cleaning reduced MRSA in the environment

23. MRSA in environment Bedspaces with MRSA Samples tested Odd ratio Standard165 1.6% 10141 Enhanced70 0.7% 100680.45 0.34, 0.61

24. Repeated sampling 12h

25. MRSA sites %

26. Enhanced cleaning reduced MRSA at all sites in patient environment

27. Hands MRSA reduced on doctors’ hands (OR 0.26 [0.07, 0.95]) during enhanced cleaning Nurse hands trend (OR 0.6 [0.29, 1.08])

28. Enhanced Cleaning had no measurable effect on MRSA acquisition or infections A EnhA StdB EnhB Std % pts MRSA positive o/a 8.56.510.88.3 MRSA acquisitions 12 1.5% 10 1.2% 18 4.0% 24 5.1% MRSA new infection 8413

29. Patient acquisition of MRSA OR95% CI Enhanced vs. standard 0.98(0.58, 1.65)

30. Acquisition of other pathogens – too low EnhStdEnhStd Patients799863453468 Acinetobacter2029 ESBL4573 VRE1100 C difficile2682

31. Conclusions Enhanced cleaning reduced MRSA load in environment 40% Enhanced cleaning reduced bacterial load on nurse/doctor hands No significant reduction in acquisition or infection Bed rails highly touched and contaminated – texture effect

32. Origin MRSA 7 of 64 cases MRSA in environment preceded isolation from patient of a strain indistinguishable by PFGE Further typing to establish chains of transmission

33. Airborne Spread Why is MRSA commonly detected in the nose? Can detect distant MRSA in the air after: – –physiotherapy or NIV for non-intubated patients with MRSA pneumonia, – –bed linen changes from colonised patients Would expect the isolation study to have shown a difference

34. The gut as a source of colonisation? Silvestri et al. – –oropharyngeal carriage in up to 80% of cases during an outbreak – –33% in the absence of an outbreak. Oral vancomycin – –significantly reduced colonisation, – –reduce MRSA nosocomial pneumonia and – –contained an MRSA outbreak. No vancomycin resistant enterococci (VRE) or intermediate sensitivity S. aureus (VISA) found Did not screen for topical MRSA - incidence of skin with gut carriage unknown

35. Local variations in MRSA incidence in ICU’s in the UK London Teaching Hospitals with >1000 admissions/year Hospital a) no bacteraemias in 6 months Hospital b)1 bacteraemia in 14 months Hospital c)12 bacteraemias in 12 months

36. Local variations in MRSA incidence in ICU’s in the UK Hospital a) chlorhexidine wash daily for all, CVC bundles, no 3 way taps, rapid screening, isolation, linezolid for specific cases, standard plus precautions for all. Hospital b)chlorhexidine wash daily for all, CVC bundle, full gowns, rapid screening, no isolation. Hospital c)rapid screening and chlorhexidine for positive cases, CVC bundles, no 3 way taps, isolation, standard plus precautions for all.

37. The evidence We could not identify a major source for environmental transmission of MRSA. Enhanced cleaning may not reduce colonisation or infection Isolation may not reduce colonisation or infection Clearly a broad “attack” on the environment, the patient and ICU processes can reduce MRSA rates Does it matter that we don’t know which of these are effective…??? It would be great if infection control techniques could be based on evidence rather than conjecture.