Knowledge, awareness, and risk practices related to bacterial contamination of antiseptics, disinfectants, and hand hygiene products among healthcare workers in sub-saharan Africa: a cross-sectional survey in three tertiary care hospitals (Benin, Burkina Faso, and DR Congo)

BACKGROUND

Antiseptics, disinfectants, and hand hygiene products can be contaminated with bacteria and cause healthcare-associated infections, which are underreported from low- and middle-income countries. To better understand the user-related risk factors, we conducted a knowledge, awareness, and practice survey among hospital staff in sub-Saharan Africa.

METHODS

Self-administered questionnaire distributed among healthcare workers in three tertiary care hospitals (Burkina Faso, Benin, Democratic Republic of the Congo).

RESULTS

617 healthcare workers (85.3% (para)medical and 14.7% auxiliary staff) participated. Less than half (45.5%) had been trained in Infection Prevention & Control (IPC), and only 15.7% were trained < 1 year ago. Near two-thirds (64.2%) preferred liquid soap for hand hygiene, versus 33.1% for alcohol-based hand rub (ABHR). Most (58.3%) expressed confidence in the locally available products. Knowledge of product categories, storage conditions and shelf-life was inadequate: eosin was considered as an antiseptic (47.5% of (para)medical staff), the shelf life and storage conditions (non-transparent container) of freshly prepared chlorine 0.5% were known by only 42.6% and 34.8% of participants, respectively. Approximately one-third of participants approved using tap water for preparation of chlorine 0.5% and liquid soap. Most participants (> 80%) disapproved recycling soft-drink bottles as liquid soap containers. Nearly two-thirds (65.0%) declared that bacteria may be resistant to and survive in ABHR, versus 51.0% and 37.4% for povidone iodine and chlorine 0.5%, respectively. Depicted risk practices (n = 4) were ignored by 30 to 40% of participants: they included touching the rim or content of stock containers with compresses or small containers, storing of cotton balls soaked in an antiseptic, and hand-touching the spout of pump dispenser. Filling containers by topping-up was considered good practice by 18.3% of participants. Half (52.1%) of participants acknowledged indefinite reuse of containers. Besides small differences, the findings were similar across the study sites and professional groups. Among IPC-trained staff, proportions recognizing all 4 risk practices were higher compared to non-trained staff (35.9% versus 23.8%, p < 0.0001).

CONCLUSIONS

The present findings can guide tailored training and IPC implementation at the healthcare facility and national levels, and sensitize stakeholders' and funders' interest.

Growth of Gram-Negative Bacteria in Antiseptics, Disinfectants and Hand Hygiene Products in Two Tertiary Care Hospitals in West Africa-A Cross-Sectional Survey

Antiseptics, disinfectants, and hand hygiene products can act as reservoirs of Gram-negative bacteria causing healthcare-associated infections. This problem is rarely documented in low- and middle-income countries, particularly in sub-Saharan Africa. In a cross-sectional survey, we assessed the bacterial contamination of antiseptics, disinfectants, and hand hygiene products in two university hospitals in Burkina Faso and Benin. During ward visits and staff interviews, in-use products were cultured for the presence of Gram-negative bacteria. The growth of Gram-negative bacteria was absent or rare in alcohol-based products, povidone iodine, and Dakin solution. Contamination was highest (73.9% (51/69)) for liquid soap products (versus antiseptic/disinfectants (4.5%, 7/157) (p < 0.0001)), mostly used in high-risk areas and associated with high total bacterial counts (>10,000 colony-forming units/mL). Contaminating flora (105 isolates) included Enterobacterales and the Vibrio non-cholerae/Aeromonas group (17.1%) and non-fermentative Gram-negative rods (82.8%). Multidrug resistance was present among 9/16 Enterobacterales (Klebsiella and Enterobacter spp.) and 3/12 Acinetobacter spp., including carbapenem resistance (Acinetobacter baumannii: NDM, Pseudomonas stutzeri: VIM). The risk factors for contamination included the type of product (cleaning grade and in-house prepared liquid soap), use of recycled disposable containers and soft drink bottles, absence of labeling, topping-up of containers, dilution with tap water (pharmacy and ward), and poor-quality management (procurement, stock management, expiry dates, and period after opening).

Baseline and seasonal trends of Bacillus cereus and Bacillus subtilis from clinical samples in Japan

Background

Outbreaks of Bacillus cereus bloodstream infections (BSIs) are a concern in Japanese medical settings.

Aim

This study determined baseline values for B. cereus detection in clinical samples that are useful as reference values for hospitals when assessing the need for intervention.

Method

A retrospective analysis of B. cereus detection in the Japan Nosocomial Infections Surveillance data from 2008 to 2014 was performed; it included 950 individual hospitals across the country.

Findings

Bacillus spp. were detected in 0.54% of the clinical specimens submitted for bacteriological testing. Specimens positive for Bacillus spp. were mainly blood (24.6%), stool (26.5%), and respiratory specimens (23.3%). Identification of Bacillus spp. at the species level (i.e., B. cereus or B. subtilis) was reported in 55.3%, 14.7%, and 15.4% of cases, of which 88.9%, 48.3%, and 33.1% were B. cereus in blood, stool, and respiratory specimens, respectively. Of the 4105 hospital-years, 75.7% had blood specimens with Bacillus spp., with a median of 0.85 blood specimens/100 beds annually (interquartile range, 0.17-2.10). The B. cereus detection showed significant summer seasonality, regardless of specimen type or geographic distribution. The B. subtilis detection did not show seasonality, and its detection remained constant throughout the year. The seasonality of Bacillus spp. reflects the high proportion of B. cereus.

Conclusions

The increased detection rate of Bacillus spp. during summer should be interpreted as a risk factor for B. cereus BSIs. A post-summer decrease in Bacillus spp. should not be interpreted as an effect of interventions.

Investigation of a cluster of Bacillus cereus bacteremia in neonatal care units

BACKGROUND

Bacillus cereus is a well-known pathogen for self-limited foodborne illness, and rarely an opportunistic pathogen associated with invasive infections among immunocompromised patients. Nosocomial outbreaks have been rarely reported.

METHODS

Between August and November 2019, four preterm neonates in neonatal care units of a medical center developed late-onset B. cereus bacteremia. An investigation was carried out. Forty-eight environmental specimens were obtained from these neonatal units, skin surface and environmental objects of Patient 4 for the detection of this organism 19 days after the onset of illness of Patient 4. B. cereus isolates from Patient 4, five unrelated patients and environmental objects if identified were further characterized by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST).

RESULTS

All four infants survived after vancomycin-containing treatment. Patient 4 developed diffuse cerebritis, brain abscess with severe neurologic sequelae. Of the 48 environmental samplings, 26 specimens showed positive for B. cereus, with one major clone (sequence type 365) accounting for 73%. The isolate from Patient 4 (ST427) was identical to one isolate collected from environmental objects in the same unit. After extensive cleaning of the environment and re-institution of the sterilization procedure of hospital linens, which was ceased since two months before the outbreak, no more cases was identified in these units for at least one year.

CONCLUSIONS

We documented a cluster of B. cereus bacteremia involving four preterm infants, which might be associated with cessation of the procedure for linen sterilization and was successfully controlled by re-institution of this procedure.

Measurement of drug concentration and bacterial contamination after diluting morphine for intrathecal administration: an experimental study

Background

Low concentrations of morphine are required for safe dosing for intrathecal injections. Sometimes, manual dilution of morphine is performed to achieve these low concentrations, but risks dilution errors and bacterial contamination. The primary goal was to compare the concentrations of morphine and bupivacaine between four groups of syringes. The secondary goal was to investigate the difference in contamination rate between these groups.

Methods

Twenty-five experienced anesthesia providers were asked to prepare a mixture of bupivacaine 2.0 mg/ml and morphine 60 μg/ml using 3 different methods as clean and precise as possible. The fourth method used was the aspiration of ampoules prepared by the pharmacy. The concentrations of morphine and bupivacaine were measured by High-Pressure Liquid Chromatography (HPLC). The medication was cultured for bacterial contamination.

Results

Group 1 (median 60 μg/ml; 95% CI: 59–110 μg/ml) yielded 3 outliers above 180 μg/ml morphine concentration. Group 2 (76 μg/ml; 95% CI: 72–80 μg/ml) and 3 (69 μg/ml; 95% CI: 66–71 μg/ml) were consistently higher than the target concentration of 60 μg. The group “pharmacy” was precise and accurate (59 μg/ml; 95% CI: 59–59 μg/ml). Group 2 and “pharmacy” had one contaminated sample with a spore-forming aerobic gram-positive rod.

Conclusion

Manually diluted morphine is at risk for deviating concentrations, which could lead to increased side-effects. Medication produced by the hospital pharmacy was highly accurate. Furthermore, even when precautions are undertaken, contamination of the medication is a serious risk and appeared to be unrelated to the dilution process.

Characterization of Ba813 harbouring Bacillus cereus in patients with haematological malignancy and hospital environments at a medical centre in Japan

Introduction. Bacillus cereus harbouring Ba813, a specific chromosomal marker of Bacillus anthtacis, is found in patients with severe manifestations and causes nosocomial outbreaks.Aim. We assessed the genetic characteristics and virulence of Ba813(+) B. cereus in a hospital setting.Methodology. Three neutropenic patients with haematological malignancy developed B. cereus bacteraemia within a short period. Fifteen B. cereus were isolated from different sites in a haematology ward. A total of 18 isolates were evaluated for Ba813- and B. anthracis-related virulence, food poisoning-related virulence, genetic diversity, bacteria motility and biofilm formation.Results. Ba813(+) B. cereus was detected in 33 % (1/3) of patients and 66 % (9/15) of the hospital environment. The 18 strains were divided into 2 major clusters (clade 1 and clade 2), and 14 strains were classified into clade 1. All Ba813(+) strains, including four sequence types, were classified into clade 1/the cereus III lineage, which is most closely related to the anthracis lineage. Two strains belonging to clade 1/non-cereus III carried the B. anthracis-associated cap gene, but not Ba813. B. cereus, including Ba813(+) strains, had significantly lower prevalence of enterotoxin genes than clade 2 strains. In clade 1, B. cereus, Ba813(+) strains showed significantly higher swimming motility and biofilm formation ability than Ba813(-) strains.Conclusion. Ba813(+) B. cereus, which are genetically closely related to B. anthracis, were abundant in a haematological ward. Ba813(+) B. cereus with high motility and biofilm formation abilities may spread easily in hospital environments, and could become a hospital-acquired infection.

The cereus matter of Bacillus endophthalmitis

Bacillus cereus (B. cereus) endophthalmitis is a devastating intraocular infection primarily associated with post-traumatic injuries. The majority of these infections result in substantial vision loss, if not loss of the eye itself, within 12-48 h. Multifactorial mechanisms that lead to the innate intraocular inflammatory response during this disease include the combination of robust bacterial replication, migration of the organism throughout the eye, and toxin production by the organism. Therefore, the window of therapeutic intervention in B. cereus endophthalmitis is quite narrow compared to that of other pathogens which cause this disease. Understanding the interaction of bacterial and host factors is critical in understanding the disease and formulating more rational therapeutics for salvaging vision. In this review, we will discuss clinical and research findings related to B. cereus endophthalmitis in terms of the organism's virulence and inflammogenic potential, and strategies for improving of current therapeutic regimens for this blinding disease.

Extended drip infusion of peripheral parental nutrition containing amino acids might be associated with Bacillus cereus bloodstream infection

In some Japanese hospitals, patients using infusion bags for parenteral nutrition containing amino acids have developed Bacillus cereus bloodstream infections. We considered that proliferation of contaminated B cereus in the bag during prolonged drip infusion might be one of the causes of infection. This study indicated that 8 h is the maximum appropriate drip infusion time for peripheral parental nutrition containing amino acids to prevent B cereus bloodstream infections.

Bacillus species pseudo-outbreak: construction works and collateral damage

We describe the investigation and management of a pseudo-outbreak of Bacillus spp. bacteraemia associated with construction work in an emergency department (ED). During the pseudo-outbreak period 59 out of 3469 (1.7%) blood cultures yielded Bacillus spp. versus 24 out of 7628 (0.31%) in 2012. Material, surfaces, and air samples showed environmental contamination. Cases rapidly declined following the implementation of infection control measures and the end of construction. Construction works at the ED caused environmental contamination that most probably led to the pseudo-outbreak of Bacillus bacteraemia. In hospital settings, the lack of correctly implemented effective barriers during construction may place patients and healthcare providers at risk as well as lead to pseudo-outbreaks.

APIC position paper: Safe injection, infusion, and medication vial practices in health care

The transmission of bloodborne viruses and other microbial pathogens to patients during routine health care procedures continues to occur because of the use of improper injection, infusion, medication vial, and point-of-care testing practices by health care personnel. These unsafe practices occur in various clinical settings and result in unacceptable and devastating events for patients. This document updates the Association for Professionals in Infection Control and Epidemiology 2010 position paper on safe injection, infusion, and medication vial practices in health care.

CXCL1, but not IL-6, significantly impacts intraocular inflammation during infection

During intraocular bacterial infections, the primary innate responders are neutrophils, which may cause bystander damage to the retina or perturb the clarity of the visual axis. We hypothesized that cytokine IL-6 and chemokine CXCL1 contributed to rapid neutrophil recruitment during Bacillus cereus endophthalmitis, a severe form of intraocular infection that is characterized by explosive inflammation and retinal damage that often leads to rapid vision loss. To test this hypothesis, we compared endophthalmitis pathogenesis in C57BL/6J, IL-6^-/-, and CXCL1^-/- mice. Bacterial growth in eyes of CXCL1^-/-, IL-6^-/-, and C67BL/6J mice was similar. Retinal function retention was greater in eyes of IL-6^-/- and CXCL1^-/- mice compared with that of C57BL/6J, despite these eyes having similar bacterial burdens. Neutrophil influx into eyes of CXCL1^-/- mice was reduced to a greater degree compared with that of eyes of IL6^-/- mice. Histology confirmed significantly less inflammation in eyes of CXCL1^-/- mice, but similar degrees of inflammation in IL6^-/- and C57BL/6J eyes. Because inflammation was reduced in eyes of infected CXCL1^-/- mice, we tested the efficacy of anti-CXCL1 in B. cereus endophthalmitis. Retinal function was retained to a greater degree and there was less overall inflammation in eyes treated with anti-CXCL1, which suggested that anti-CXCL1 may have therapeutic efficacy in limiting inflammation during B. cereus endophthalmitis. Taken together, our results indicate that absence of IL-6 did not affect overall pathogenesis of endophthalmitis. In contrast, absence of CXCL1, in CXCL1^-/- mice or after anti-CXCL1 treatment, led to an improved clinical outcome. Our findings suggest a potential benefit in targeting CXCL1 to control inflammation during B. cereus and perhaps other types of intraocular infections.

Bacillus cereus in personal care products: risk to consumers

Bacillus cereus is ubiquitous in nature and thus occurs naturally in a wide range of raw materials and foodstuffs. B. cereus spores are resistant to desiccation and heat and able to survive dry storage and cooking. Vegetative cells produce several toxins which on ingestion in sufficient numbers can cause vomiting and/or diarrhoea depending on the toxins produced. Gastrointestinal disease is commonly associated with reheated or inadequately cooked foods. In addition to being a rare cause of several acute infections (e.g. pneumonia and septicaemia), B. cereus can also cause localized infection of post-surgical or trauma wounds and is a rare but significant pathogen of the eye where it may result in severe endophthalmitis often leading to loss of vision. Key risk factors in such cases are trauma to the eye and retained contaminated intraocular foreign bodies. In addition, rare cases of B. cereus-associated keratitis (inflammation of the cornea) have been linked to contact lens use. Bacillus cereus is therefore a microbial contaminant that could adversely affect product safety of cosmetic and facial toiletries and pose a threat to the user if other key risk factors are also present. The infective dose in the human eye is unknown, but as few as 100 cfu has been reported to initiate infection in a susceptible animal model. However, we are not aware of any reports in the literature of B. cereus infections in any body site linked with use of personal care products. Low levels of B. cereus spores may on occasion be present in near-eye cosmetics, and these products have been used by consumers for many years. In addition, exposure to B. cereus is more likely to occur through other routes (e.g. dustborne contamination) due to its ubiquity and resistance properties of spores. The organism has been recovered from the eyes of healthy individuals. Therefore, although there may be a perceived hazard, the risk of severe eye infections as a consequence of exposure through contaminated near-eye cosmetics is judged to be vanishingly small. It is unlikely that more stringent microbiological standards for near-eye cosmetics will have any impact on the risk of severe eye infections caused by B. cereus, as these are not linked to use of personal care products.

Role of TLR5 and flagella in bacillus intraocular infection

B. cereus possesses flagella which allow the organism to migrate within the eye during a blinding form of intraocular infection called endophthalmitis. Because flagella is a ligand for Toll-like receptor 5 (TLR5), we hypothesized that TLR5 contributed to endophthalmitis pathogenesis. Endophthalmitis was induced in C57BL/6J and TLR5−/− mice by injecting 100 CFU of B. cereus into the mid-vitreous. Eyes were analyzed for intraocular bacterial growth, retinal function, and inflammation by published methods. Purified B. cereus flagellin was also injected into the mid-vitreous of wild type C57BL/6J mice and inflammation was analyzed. TLR5 activation by B. cereus flagellin was also analyzed in vitro. B. cereus grew rapidly and at similar rates in infected eyes of C57BL/6J and TLR5−/− mice. A significant loss in retinal function in both groups of mice was observed at 8 and 12 hours postinfection. Retinal architecture disruption and acute inflammation (neutrophil infiltration and proinflammatory cytokine concentrations) increased and were significant at 8 and 12 hours postinfection. Acute inflammation was comparable in TLR5−/− and C57BL/6J mice. Physiological concentrations of purified B. cereus flagellin caused significant inflammation in C57BL/6J mouse eyes, but not to the extent of that observed during active infection. Purified B. cereus flagellin was a weak agonist for TLR5 in vitro. These results demonstrated that the absence of TLR5 did not have a significant effect on the evolution of B. cereus endophthalmitis. This disparity may be due to sequence differences in important TLR5 binding domains in B. cereus flagellin or the lack of flagellin monomers in the eye to activate TLR5 during infection. Taken together, these results suggest a limited role for flagellin/TLR5 interactions in B. cereus endophthalmitis. Based on this and previous data, the importance of flagella in this disease lies in its contribution to the motility of the organism within the eye during infection.

Bacillus cereus and severe intestinal infections in preterm neonates: Putative role of pooled breast milk

BACKGROUND

Bacillus cereus is an environmental pathogen whose spores resist the usual cleaning procedure applied by the food industry and hospitals. We reported a cluster of severe intestinal infections due to B cereus in 2 very low birth weight neonates from a neonatal intensive care unit.

METHODS

Environmental sampling and bacteriological analysis of pooled breast milk (PBM) were performed. Practices for preparation and administration of milk were observed and additional laboratory experiments performed. Strains were typed using M13-polymerase chain reaction and their virulence tested using cellular and insect models.

RESULTS

B cereus strains were exclusively isolated from intestinal tracts and PBM. No environmental culture yielded any viable B cereus. Although genotypically diverse, both clinical and food strains exhibited high virulence potency. These findings pointed out the pathogenic potency of B cereus in neonates; the putative role of PBM as a reservoir for pathogenic B cereus and the triggered effect of a defective care procedure, which allowed the growth of bacteria in pasteurized PBM. Well described from dried formula, the presence of pathogenic B cereus strains in PBM was not previously reported.

CONCLUSIONS

Careful monitoring of conditions during collection, conservation, and administration of PBM should be implemented in high-risk populations such as premature neonates.