Standard Precautions

 by Gillian Robinson

Are your staff increasing risk of cross infection?

Cardigans – a potential vector of infection?

Each winter cardigans or long sleeved tops under uniform tunics appear as part of clothing worn by carers, nurses and other staff providing resident care.  Does this practice increase the risk of cross infection?

There are certainly studies that demonstrate that uniforms become contaminated with potential pathogenic organisms including Staphylococcus aureus, Clostridium difficile and Norovirus[1]. It is more difficult to find evidence that links contaminated uniforms with the transmission of pathogens to patients and residents.

Most contamination occurs in areas of greatest hand contact such as pockets and cuffs[2], which may the cause the wearer to re-contaminate their cleaned hands. Long sleeves may also become contaminated with bodily fluids, which then directly contaminate another resident through direct hands on care. This would be a great way to spread around those multi-drug resistant organisms that live in the bowel, such as ESBL, VRE and CRE!

The biggest risk of wearing long sleeves when delivering care involving patient contact is that hand hygiene cannot be carried out effectively. Anyone who has been taught hand washing using the Glitterbug gel and UV light will remember how the wrists were often left glowing, demonstrating that your wrists also get contaminated and need cleaning. In many healthcare facilities across the world, a ‘Bare Below the Elbows’ policy is used to ensure that effective hand hygiene is undertaken. This applies to the use of an alcohol based hand rub or gel, as well as washing with soap and water.

So the next time that you put your cardigan on or come to work with a long-sleeved top, remember that, prior to any patient contact remove the cardigan or roll up your sleeves and perform hand hygiene.

[1] Mitchell et al. Role of healthcare apparel and other healthcare textiles in the transmission of pathogens: a review of the literature. Journal of Hospital Infection, 2015 Aug;90(4):285-92

[2]Loh et al. Bacterial flora on the white coats of medical students. Journal of Hospital Infection,  2000 May;45(1):65-8.

 

Contributed by:

Ruth Barratt

Infection Prevention & Control Advisor

infectprevent@gmail.com

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 by Gillian Robinson

MRSA or ESBL positive staff or residents – what to do, changing times

MRSA was first isolated in NZ in 1975, remained at extremely low levels over the next 10 years (0.05% of 2077 surveyed Staphylococcus aureus isolates nationally in 1982). But from the 1990’s onwards the incidence of various strains of MRSA has steadily increased in both hospitals, rest homes and the community.

Most of us carry Staph aureus as part of our normal skin flora.  When we have a cut, wound  or other compromised skin integrity (e.g. infected dermatitis/eczema) some of our normal flora can increase in numbers to cause what we recognise as a clinical infection.

i.e. we catch this Staph aureus infection from our own normal flora

Community laboratory data now shows that 5 out of every 100  Staph aureus  infections in the South Island,  12 out of every 100 in the Auckland region,  are now MRSA

i.e. MRSA is now endemic in the population,  so trying to isolate those with MRSA or remove it from those who are carriers by ‘decolonisation’ (e.g. chlorhexidine body washes and mupiricin) is a wasted effort, and can in fact be counterproductive – toxicity, promotes antibiotic resistance, stigmatisation, isolating residents is generally shown to produce worse clinical outcomes.  Isolation is required for some infectious diseases which MRSA is not.

Resident/patient with MRSA – use good Standard Precautions (hand hygiene).  Cover any infected cuts or wounds as per normal.  Plus Contact Precautions (glove/gown) as you normally would if providing wound care and splashing or direct skin or uniform contact possible.

Staff member with MRSA – again no special precautions are generally required and ‘decolonisation’ is not indicated.  Good Standard Precautions (hand hygiene – alcohol hand rubs or liquid soap and water both work well).

We should always aim to prevent any cross infections of any organisms, susceptible or resistant.

Good ongoing environmental and equipment cleaning and hygiene should be maintained routinely in the facility, regardless of any known MRSA or other resistant organisms  (e.g. ESBL).

Additional Facts

  • Our total combined use of antibiotics has bred or created these resistant bacteria – are we doing all we can to reduce any over use of antibiotics? g. UTI’s are commonly ‘over treated’ on a positive dipstick result rather than clear clinical symptoms
  • Any known positive MRSA (or ESBL) only represents the tip of the iceberg – a known positive person is an indicator only of a much larger issue, there will be many more unknowns. So, like blood and body fluids, it is best to think any one of us – staff residents and patients – could be positive at any time because we not uncommonly will be but seldom be aware of it
  • MRSA, ESBL, VRE carriers – the good news is 9 times out of 10 we spontaneously lose our carriage or colonisation of these resistant bacteria in 1-12 months when we happen to be carriers and do not use antimicrobials, and usually we will not know when we are carriers, but temporary carriage is likely on staff several times over in a 5-10 year period
  • ESBL (extended spectrum beta lactamase) is increasing similarly to MRSA, but started a few years later. Its primary reservoir source is the bowel not the skin
  • Staph aureus itself (the susceptible form MSSA and the more resistant form MRSA) generally have equal pathogenic potential but are generally normal flora also
  • Each one of us is made up of 10 trillion tissue cells and 90 trillion bacteria  e. ‘your bugs are my bugs’ – we cannot but help share our microbes by touch, shedding skin, etc but we must actively reduce this sharing by good Standard Precautions on all by all

Our combined total use of antibiotics continues to create ever more microbial resistance.

Good hand hygiene and cough containment Standard Precaution practice coupled with thorough cleaning of equipment and the environment will ensure there is a lower risk of transmission and environmental contamination of our shared microbes – the resistant and susceptible forms.

Article shared with the kind permission of:

Author: Ben Harris – Microbiologist – Southern Community Laboratories (2015) 

 

 

 

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