Significant reduction in vancomycin-resistant enterococcus colonization and bacteraemia after introduction of a bleach-based cleaning–disinfection programme
Introduction
Colonization and disease due to vancomycin-resistant enterococci (VRE), particularly vanB Enterococcus faecium, has increased substantially in many Australian and some European hospitals during the past 5–7 years, including a recent clonal outbreak of ST-203 vanB E. faecium.1, 2, 3 At our institution, a tertiary hospital in Melbourne, the annual number of patients colonized on active screening of ‘high-risk’ wards (HRWs: intensive care unit, renal, liver transplant, and haematology–oncology units) and with VRE bacteraemia throughout the entire hospital increased markedly from 2007/8.2 This occurred despite reinforcement of the US Centers for Disease Control and Prevention (CDC) Guidelines, an active hand hygiene programme (based on the World Health Organization ‘My Five Moments of Hand Hygiene’ programme), a decline in nosocomial meticillin-resistant Staphylococcus aureus bacteraemia, and a longstanding antimicrobial stewardship programme.4, 5, 6 Reasons for this increase potentially relate to inherent delays in identification of VRE colonization due to reliance on culture-based detection methods, limited sensitivity of rectal swabs compared with faecal culture, incomplete hospital cleaning–disinfection, potential healthcare worker (HCW) fatigue with strict adherence to the appropriate use of prescribed personal protective equipment (PPE) and possible adaptation of new VRE strains to the hospital environment.3, 7, 8
Based on a successful pilot programme in our busy haemodialysis unit we instituted a similar, but hospital-wide, multi-modal bleach-based culture-change cleaning–disinfection programme (‘Bleach-Clean’) and assessed the efficacy of the programme on detection of VRE colonization, disease and environmental contamination before and after implementation.
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Bleach-Clean intervention
The new multi-modal Bleach-Clean intervention was implemented collaboratively by staff from the hospital infection control, infectious diseases and microbiology departments, environmental services, and senior hospital executive staff (Table I). It was rolled out during the six months from 1 August 2009 to 31 January 2010 (‘implementation period’) and evaluated by comparing the six-month period pre implementation (‘period A’, 1 February 2009 to 31 July 2009) to the two consecutive six-month
VRE colonization
VRE colonization outcome data for periods A, B1 and B2 in HRWs are shown in Table II. Adherence to the weekly VRE screening programme by healthcare workers improved significantly between the pre- and post-intervention periods [68.1% (period A) vs 73.1% (period B); P < 0.001], although the improvement was greater in period B1 than B2 (Table II). Despite increases in HRW activity (mean inpatients per week for periods A, B1 and B2: 219, 226 and 230, respectively) and overall improved screening
Discussion
Our multi-modal Bleach-Clean programme appears to have been associated with a significant reduction in newly recognized VRE colonization among inpatients in HRWs, as well as a hospital-wide reduction in VRE disease, especially VRE bacteraemia. The stable frequency of VSE bacteraemia during this time is consistent with its association with community-onset urosepsis and suggests that the reduction in VRE bacteraemia was related to a decrease in healthcare-associated infection.14, 15 The total
Acknowledgements
The authors are grateful to nursing, medical, laboratory and cleaning staff of the hospital who contributed to the success of the programme.
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