Rhea Vidrine, MD
Elizabeth H. Mack, MD, MS
Hospital-acquired infections are associated with increased morbidity, mortality, and patient care costs.1 These have led to the formation of networks such as the Children’s Hospitals’ Solutions for Patient Safety (SPS), a network of more than 140 institutions whose mission is to eliminate serious harm across all children’s hospitals through the implementation of prevention bundles.2 From its inception in 2012 through January 2019, SPS has prevented 13,952 children from experiencing serious harm, with an estimated cost savings of $294 million.3 Methods for preventing hospital-acquired infections are multifactorial and include the implementation of prevention bundles, antibiotic stewardship, and transmission prevention strategies. Here we describe emerging strategies in preventing hospital-acquired infections, inspired by a talk given at the Society of Critical Care Medicine’s (SCCM) 2019 Pediatric Current Concepts Course and the accompanying textbook chapter.
Chlorhexidine Gluconate Bathing
Chlorhexidine gluconate (CHG) bathing or treatment is a commonly used method to prevent healthcare-acquired infections by reducing skin bacterial colonization and therefore decreasing the risk of contamination at catheter sites.4,5 In their systemic review and meta-analysis, Musuuza et al found that CHG patient treatments are associated with a statistically significant reduction in hospital-acquired central line-associated bloodstream infections (CLABSIs). They also showed that CHG treatments affected all microorganisms that are most commonly associated with CLABSIs.5 The Pediatric Scrubbing with Chlorhexidine Reduces Unwanted Bacteria (SCRUB) trial examined the effect of daily CHG treatments in critically ill pediatric patients and found a 36% reduction of bacteremia in patients bathed daily with CHG.4
In the Centers for Disease Control and Prevention Guidelines for the Prevention of Intravascular Catheter-Related Infections, daily CHG baths are included as a category 2 recommendation.6 The SPS CLABSI prevention bundle also includes daily CHG treatments for all patients with central venous catheters.7
While it is known that CHG can cause skin irritation and anaphylaxis, only 1% of patients in the SCRUB trial withdrew due to skin irritation.4 However, patient factors such as smell of the bathing wipes, comfort during the bath, and residue after the bath are important aspects of patient adherence with the daily baths, especially in noncritically ill patients.5 A new surfactant colloidal silver technology cleansing formula has recently been introduced and found to be noninferior to 4% CHG wipes.8 This new technology is associated with a fresher smell and less of a sticky residue after the bath, which may address some of the issues with poor patient adherence.
Environmental Surface Cleaning
Studies support environmental cleaning and disinfection as a way to control hospital-acquired infections, specifically for multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Clostridium difficile, and norovirus.9 While there is consensus on the use of environmental cleaning, disagreement remains on the best method. Traditional cleaning methods have been shown to be suboptimal due to both personnel-related issues and the type of surfaces being cleaned.10 Failure to properly clean a patient room can lead to increased risk of hospital-acquired infections with resistant pathogens; therefore, new technologies to improve disinfection are being studied.10 There are many new technologies, such as new disinfectants, new methods for applying disinfectants, and photocatalytic disinfection. We describe here self-disinfecting surfaces, ultraviolet light devices, and hydrogen peroxide vapor.
Heavy metals such as silver and copper have antimicrobial properties that may decrease the bacterial load on surfaces.10 Coating surfaces with these heavy metals allows for continuous antimicrobial activity for weeks or months and therefore proper cleaning is not reliant on human behaviors. Silver is bactericidal by binding to disulfide and sulfhydryl groups in the cell wall.10,11 Silver has been integrated into several medical devices such as central venous lines (CVLs), wound dressings, and indwelling catheters. CVLs impregnated with silver sulfadiazine were associated with a lower rate of colonization when compared to standard catheters.12 While a silver-based surface spray has been to shown to eliminate S aureus, Pseudomonas aeruginosa, and VRE, no current studies have shown decreased incidence of hospital-acquired infections.11
Copper is thought to be antimicrobial by its ability to form free radicals that are toxic to cells.10,11 Copper has been shown to kill many pathogens associated with hospital-acquired infections such as MRSA, Enterococcus, Escherichia coli, Klebsiella pneumoniae, Acinetobacter, P aeruginosa, and Mycobacterium tuberculosis.11 Salgado et al examined the incidence of hospital-acquired infections and/or colonization with MRSA or VRE in patients in ICU rooms that had copper alloy surfaces. They found a decreased incidence of both in patients in rooms with copper alloy surfaces.13
Ultraviolet Light Devices
Automated mobile ultraviolet (UV) light devices are another method of surface cleaning. They continuously emit UVC light that kills common pathogens associated with hospital-acquired infections, such as VRE, MRSA, and C difficile.10,14 UV light breaks down molecular bonds in DNA, which destroys the organism’s replication abilities.15 The Benefits of Enhanced Terminal Room (BETR) Disinfection study showed that adding UVC light disinfection to standard cleaning methods resulted in a significantly decreased risk of hospital-acquired infections with C difficile.14 UV light devices are mobile, user friendly, require minimal training, and can be used without having to seal off the room.10
Hydrogen Peroxide Vapor
Hydrogen peroxide vapor (HPV) has a broad range of germicidal abilities and has been shown to eliminate MRSA, VRE, C difficile, and Acinetobacter on surfaces.16 HPV has been used in combination with traditional decontamination methods to eradicate Serratia in a neonatal ICU and a multidrug- resistant gram-negative rod outbreak in an ICU.17,18 HPV has even been used to decontaminate isolation rooms after a patient with Ebola was in it.19 While HPV has been shown to be effective in eliminating pathogens that commonly cause nosocomial infections, it is not commonly used in hospitals due to cost concerns and long treatment times, although treatments are becoming more efficient.10
Blood Sample Collection Site
CLABSIs are now widely recognized as a source of preventable harm. There has been a significant decrease in CLABSIs since the implementation of prevention bundles. However, there is no standard on how to decrease line entries or from where to collect blood samples when a patient with a central line has a fever. Studies have shown that up to half of positive blood cultures are false positives, likely due to contamination, and that blood cultures from samples that were collected from central lines have a high rate of false positivity.20
Boyce et al showed significant improvement in their blood culture contamination rates by instituting a policy of drawing blood samples by venipuncture instead of through the central line. Whenever blood samples could not be obtained through venipuncture, a specialized procedure was used to obtain the sample from the central line to reduce the risk of contamination.21
Woods-Hill et al created a clinical practice guideline for blood sample collection in the pediatric ICU. This tiered guideline helped physicians determine whether a blood culture was necessary and from where the blood sample should be collected, with an emphasis on peripheral collection. They showed a reduction in blood sample collection rate and a reduction in blood samples collected from central lines without an increase in missed sepsis cases.22 Given the increased rate of false-positive blood cultures from samples that were collected from central lines, blood samples should be collected though venipuncture when possible.
The implementation of prevention bundles, hand hygiene, and antimicrobial stewardship have led to significant improvements in reducing hospital-acquired infections, but these infections still remain a major source of morbidity, mortality, and cost. CHG treatments, environmental surface cleaning, and strategic blood sample collection are emerging strategies for the prevention of healthcare-acquired infections.
- 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013. Rockville, MD: Agency for Healthcare Research and Quality; October 2015 AHRQ Publication No. 16-0006-EF.
- Children’s Hospitals’ Solutions For Patient Safety. Our Mission. https://www.solutionsforpatientsafety.org/about-us/our-mission/. Accessed October 17, 2019.
- Children’s Hospitals’ Solutions For Patient Safety. Our Results. https://www.solutionsforpatientsafety.org/our-results/. Accessed October 17, 2019.
- Milstone AM, Elward A, Song X, et al; Pediatric SCRUB Trial Study Group. Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: a multicenter, cluster-randomised, crossover trial. Lancet. 2013 Mar 30;381(9872)1099-1106.
- Musuuza JS, Guru PK, O’Horo JC, et al. The impact of chlorhexidine bathing on hospital-acquired bloodstream infections: a systematic review and meta-analysis. BMC Infect. Dis. 2019 May 14;19(1):416.
- O’Grady NP, Alexander M, Burns LA, et al; Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011 May;52(9):e162-e193.
- Children’s Hospitals’ Solutions for Patient Safety. SPS Prevention Bundles. May 2019. https://www.solutionsforpatientsafety.org/wp-content/uploads/SPS-Prevention-Bundles.pdf. Accessed October 17, 2019.
- Paulson DS, Topp R, Boykin RE, Schultz G, Yang Q. Efficacy and safety of a novel skin cleansing formulation versus chlorhexidine gluconate. Am J Infect Control. 2018 Nov;46(11):1262-1265.
- Donskey CJ. Does improving surface cleaning and disinfection reduce health care-associated infections? Am J Infect Control. 2013 May;41(5 Suppl):S12-S19.
- Boyce JM. Modern technologies for improving cleaning and disinfection of environmental surfaces in hospitals. Antimicrob Resist Infect Control. 2016 Apr 11;5:10.
- Weber DJ, Rutala WA. Self-disinfecting surfaces: review of current methodologies and future prospects. Am J Infect Control. 2013 May;41(5 Suppl):S31-S35.
- Wang H, Huang T, Jing J, et al. Effectiveness of different central venous catheters for catheter-related infections: a network meta-analysis. J Hosp Infect. 2010 Sep;76(1):1-11.
- Salgado CD, Sepkowitz KA, John JF, et al. Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit. Infect Control Hosp Epidemiol. 2013 May;34(5):479-486.
- Anderson DJ, Chen LF, Weber DJ, et al; CDC Prevention Epicenters Program. Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study. Lancet. 2017 Feb 25;389(10071):805-814.
- Rutala W A, Weber DJ. Monitoring and improving the effectiveness of surface cleaning and disinfection. Am J Infect Control. 2016 May 2;44(5 Suppl):e69-e76.
- Otter JA, French GL. Survival of nosocomial bacteria and spores on surfaces and inactivation by hydrogen peroxide vapor. J Clin Microbiol. 2009 Jan;47(1):205-207.
- Bates CJ, Pearse R. Use of hydrogen peroxide vapour for environmental control during a Serratia outbreak in a neonatal intensive care unit. J Hosp Infect. 2005 Dec;61(4):364-366.
- Otter JA, Yezil S, Schouten MA, van Zanten AR, Houmes-Zielman G, Nohlmans-Paulssen MK. Hydrogen peroxide vapor decontamination of an intensive care unit to remove environmental reservoirs of multidrug-resistant gram-negative rods during an outbreak. Am J Infect Control. 2010 Nov;38(9):754-756.
- Otter JA, Mepham S, Athan B, et al. Terminal decontamination of the Royal Free London’s high-level isolation unit after a case of Ebola virus disease using hydrogen peroxide vapor. Am J Infect Control. 2016 Feb;44(2):233-235.
- Shafazand S, Weinacker AB. Blood cultures in the critical care unit: improving utilization and yield. Chest. 2002 Nov;122(5):1727-1736.
- Boyce JM, Nadeau J, Dumigan D, et al. Obtaining blood cultures by venipuncture versus from central lines: impact on blood culture contamination rates and potential effect on central line-associated bloodstream infection reporting. Infect Control Hosp Epidemiol. 2013 Oct;34(10):1042-1047.
- Woods-Hill CZ, Fackler J, Nelson McMillan K, et al. Association of a clinical practice guideline with blood culture use in critically ill children. JAMA Pediatr. 2017 Feb 1;171(2):157-164.