Significant reduction in vancomycin-resistant enterococcus colonization and bacteraemia after introduction of a bleach-based cleaning–disinfection programme

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Summary

Background

Vancomycin-resistant enterococcus (VRE) colonization and infection have increased at our hospital, despite adherence to standard VRE control guidelines.

Aim

We implemented a multi-modal, hospital-wide improvement programme including a bleach-based cleaning–disinfection programme (‘Bleach-Clean’). VRE colonization, infection and environmental contamination were compared pre and post implementation.

Methods

The programme included a new product (sodium hypochlorite 1000 ppm + detergent), standardized cleaning–disinfection practices, employment of cleaning supervisors, and modified protocols to rely on alcohol-based hand hygiene and sleeveless aprons instead of long-sleeved gowns and gloves. VRE was isolated using chromogenic agar and/or routine laboratory methods. Outcomes were assessed during the 6 months pre and 12 months post implementation, including proportions (per 100 patients screened) of VRE colonization in high-risk wards (HRWs: intensive care, liver transplant, renal, haematology/oncology); proportions of environmental contamination; and episodes of VRE bacteraemia throughout the entire hospital.

Findings

Significant reductions in newly recognized VRE colonizations (208/1948 patients screened vs 324/4035, a 24.8% reduction, P = 0.001) and environmental contamination (66.4% reduction, P = 0.012) were observed, but the proportion of patients colonized on admission was stable. The total burden of inpatients with VRE in the HRWs also declined (median percentage of colonized inpatients per week, 19.4% vs 17.3%, P = 0.016). Hospital-wide VRE bacteraemia declined from 14/2935 patients investigated to 5/6194 (83.1% reduction; P < 0.001), but there was no change in vancomycin-susceptible enterococcal bacteraemia (P = 0.54).

Conclusion

The Bleach-Clean programme was associated with marked reductions in new VRE colonizations in high-risk patients, and VRE bacteraemia across the entire hospital. These findings have important implications for VRE control in endemic healthcare settings.

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.

Section snippets

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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