Disinfection of vascular catheter connectors that are protected by antiseptic caps is unnecessary

OBJECTIVE

Determination of whether vascular catheter disinfecting antiseptic-containing caps alone are effective at decreasing microbial colonization of connectors compared to antiseptic-containing caps plus a 5-second alcohol manual disinfection.

SETTING

The study was conducted in a 718-bed, tertiary-care, academic hospital.

PATIENTS

A convenience sample of adult patients across intensive care units and acute care wards with peripheral and central venous catheters covered with antiseptic-containing caps.

METHODS

Quality improvement study completed over 5 days. The standard-of-care group consisted of catheter connectors with antiseptic-containing caps cleaned with a 5-second alcohol wipe scrub prior to culture. The comparison group consisted of catheter connectors with antiseptic-containing caps without a 5-second alcohol wipe scrub prior to culture. The connectors were pressed directly onto blood agar plates and incubated. Plates were assessed for growth after 48-72 hours.

RESULTS

In total, 356 catheter connectors were cultured: 165 in the standard-of-care group, 165 in the comparison group, and 26 catheters connectors without an antiseptic-containing cap, which were designated as controls. Overall, 18 catheter connectors (5.06%) yielded microbial growth. Of the 18 connectors with microbial growth, 2 (1.21%) were from the comparison group, 1 (0.61%) was from the standard-of-care group, and 15 were controls without an antiseptic-containing cap.

CONCLUSIONS

Bacterial colonization rates were similar between the catheter connectors cultured with antiseptic-containing caps alone and catheter connectors with antiseptic-containing caps cultured after a 5-second scrub with alcohol. This finding suggests that the use of antiseptic-containing caps precludes the need for additional disinfection.

132. Assessment of the Long-Term Effects of Training Consultant Pharmacists to Promote Antimicrobial Stewardship in Long-Term Care Facilities

Background

We implemented a one-year antimicrobial stewardship training program that lasted through 2018 where we assisted 9 long-term care facility (LTCF) consultant pharmacists in promoting antibiotic stewardship programs (ASP) in 32 LTCF (Figure 1). Surveys were conducted during and after the training program to assess performance.

Methods

Infection Preventionists (IP), Directors of Nursing (DON) and Medical Directors (MD) of the LTCF received mail surveys in 2018 and online surveys in 2019. It included questions assessing the respondents’ perceptions of their ASP, barriers to ASP implementation and stewardship related knowledge, and the skills and contributions of their consultant pharmacists. Qualitative analyses categorized reported barriers into common themes. Fisher exact test compared perceptions of consultant pharmacists’ performance and frequently reported barriers during training and after the intervention was completed.

Results

Representatives (IP, DON and/or MD) of 18 facilities responded to the surveys at both time points of the study, with 34 individual surveys in 2018 and 25 in 2019. Most rated their consultant pharmacists as knowledgeable and helpful who regularly provided feedback and suggestions both during and after the training (Table 1). Fifty-six percent of facilities reported that their consultant pharmacists were similarly involved, and 12% felt they were more involved, in ASP implementation in 2019 compared to 2018. Top 3 reported barriers to ASP implementations were the same during 2018 and 2019 (Table 2). Overall, 84% of facilities in 2019 believed that the consultant pharmacists “definitely helped” their ASP efforts, and 80% of facilities desired to continue the partnership into the future.

Table 1. Comparison of Consultant Pharmacists’ Performance Evaluations During (2018) and After (2019) Completion of Training

Figure 3. Barriers to ASP implementation reported during (2018) and after (2019) training.

Conclusion

This study demonstrates that training consultant pharmacists resulted in meaningful actions and prolonged engagement in ASP activities. Efforts should be directed on making similar training programs available nationwide for consultant pharmacists working in LTCF.

Disclosures

Muhammad Salman Ashraf, MBBS, Merck & Co. Inc (Grant/Research Support)

Microbial colonization of intravascular catheter connectors in hospitalized patients

BACKGROUND

Central line-associated bloodstream infections may be due to catheter connector colonization and intraluminal migration of pathogens. We assessed the colonization of the split septum catheter connector system, and subsequently the luer lock catheter connector system.

METHODS

This was a prospective, 2 phase, quality improvement study at a tertiary referral center. Each phase of the study was performed over 3 consecutive days in hospitalized patients receiving an active infusion; first with a split septum lever lock connector and second with a luer lock connector and alcohol port protector. The connectors were inoculated onto blood agar plates and incubated. Plates were assessed for microbial growth after 48-72 hours.

RESULTS

In phase I, 98 (41.9%) of 234 split septum connectors yielded microbial growth. In phase II, 56 (23.1%) of 243 luer lock connectors yielded microbial growth. In phase II only, there was a significant increased rate of contamination in peripheral catheters compared with all other catheters, and the rate of contamination on the acute care wards was significantly higher when compared with the intensive care units.

CONCLUSIONS

Bacterial colonization of the lever lock system was unacceptably high among all catheter types and hospital locations. Transition to luer lock catheter connectors and alcohol port protectors decreased the colonization; however, colonization still remained substantial. Causation of colonization cannot be determined with these results.

Reduction in Blood Culture Contamination Through Use of Initial Specimen Diversion Device

Background

Blood culture contamination is a clinically significant problem that results in patient harm and excess cost.

Methods

In a prospective, controlled trial at an academic center Emergency Department, a device that diverts and sequesters the initial 1.5-2 mL portion of blood (which presumably carries contaminating skin cells and microbes) was tested against standard phlebotomy procedures in patients requiring blood cultures due to clinical suspicion of serious infection.

Results

In sum, 971 subjects granted informed consent and were enrolled resulting in 904 nonduplicative subjects with 1808 blood cultures. Blood culture contamination was significantly reduced through use of the initial specimen diversion device™ (ISDD) compared to standard procedure: (2/904 [0.22%] ISDD vs 16/904 [1.78%] standard practice, P = .001). Sensitivity was not compromised: true bacteremia was noted in 65/904 (7.2%) ISDD vs 69/904 (7.6%) standard procedure, P = .41. No needlestick injuries or potential bloodborne pathogen exposures were reported. The monthly rate of blood culture contamination for all nurse-drawn and phlebotomist-drawn blood cultures was modeled using Poisson regression to compare the 12-month intervention period to the 6 month before and after periods. Phlebotomists (used the ISDD) experienced a significant decrease in blood culture contamination while the nurses (did not use the ISDD) did not. In sum, 73% of phlebotomists completed a post-study anonymous survey and widespread user satisfaction was noted.

Conclusions

Use of the ISDD was associated with a significant decrease in blood culture contamination in patients undergoing blood cultures in an Emergency Department setting.

Clinical Trials Registration

NCT02102087.

Adequate Disinfection of a Split-Septum Needleless Intravascular Connector with a 5-Second Alcohol Scrub

Objective.

Define optimum vascular catheter connector valve disinfection practices under laboratory and clinical conditions.

Design.

Prospective observational clinical survey and laboratory assessment of disinfection procedures.

Setting.

All adult inpatients at an academic healthcare center.

Methods.

In the clinical setting, contamination of needleless connectors was assessed in 6 weekly prevalence surveys in which the connector valves from central venous catheters (CVCs) in situ were cultured by pressing the connector diaphragm to an agar plate. Before culture, valves were disinfected by scrubbing the diaphragm with a 70% isopropyl alcohol pledget for 0, 5, 10, 15, or 30 seconds. In the laboratory, the diaphragms on 150 unused sterile connector valves were inoculated with 103, 105, or 108colony-forming units ofStaphylococcus epidermidisand allowed to dry. After disinfection of the diaphragms by scrubbing with a 70% isopropyl alcohol pledget for 0, 5, 10, 15, or 30 seconds, the valves were sampled by pressing the diaphragm to an agar plate.

Results.

In the clinical setting, 363 connector valves from patients with CVCs were sampled, and 66.7% of nondisinfected valves revealed bacterial contamination. After 5-second disinfection with an alcohol pledget, only 1 (1.4%) of 71 yielded microbial growth (P< .005). In the laboratory, at the 103and 105inoculum, all connector valves yielded sterile cultures when scrubbed for 5 or more seconds (P< .001). At the 108inoculum, 2 (20%) of 10 connector valves yielded minimal growth ofS. epidermidis.

Conclusions.

A 5-second scrub with a 70% isopropyl alcohol pledget yields adequate disinfection of a split-septum intravascular catheter connector valve under clinical and laboratory conditions.

Optimum outlier model for potential improvement of environmental cleaning and disinfection

The effectiveness and efficiency of 17 housekeepers in terminal cleaning 292 hospital rooms was evaluated through adenosine triphosphate detection. A subgroup of housekeepers was identified who were significantly more effective and efficient than their coworkers. These optimum outliers may be used in performance improvement to optimize environmental cleaning.

Impact of adenosine triphosphate detection and feedback on hospital room cleaning

OBJECTIVE

To assess the effect of adenosine triphosphate (ATP) device measurement of hospital room cleaning and feedback of pooled results to environmental service workers (EVS) to improve cleaning efficacy.

DESIGN

Nonrandomized controlled trial conducted over 20 months.

SETTING

Three hospitals of varying size.

PARTICIPANTS

EVS workers, randomly selected on the basis of convenience sample of rooms.

INTERVENTIONS

Environmental cleanliness composite scores were combined with layered educational interventions and used to provide feedback to EVS workers on specific hospital units. Trends in cleaning efficacy were observed after the interventions.

RESULTS

Cleaning efficacy improved significantly with each intervention (P < .01) and decreased during the washout period.

CONCLUSIONS

The ATP detection device combined with educational feedback for EVS workers resulted in significant improvement in cleaning efficacy of the hospital room environment.

Hospital Basins Used to Administer Chlorhexidine Baths Are Unlikely Microbial Reservoirs

Basins, commonly used to bathe patients who are unable to bathe themselves, frequently become contaminated with potential pathogens and may serve as a source for nosocomial transmission. Chlorhexidine (CHG) has bactericidal activity against a broad spectrum of pathogens and is increasingly used in antiseptic patient baths. The purpose of this study was to ascertain whether basins used to administer CHG bed baths are likely to become contaminated.

Bed bath conditions were simulated by mixing 30 mL of a 4% CHG product or soap preparation to 1 L of warm (37°C) tap water in a 6-L plastic basin (Medical Action Industries). Two commercial brands of CHG (Hibiclens, Molnlycke Health Care [hereafter, CHG-A], or Scrub Care, Cardinal Health [hereafter, CHG-B]) and 1 brand of soap (SensiCare SeptiSoft, ConvaTec) were used. Basins were inoculated with 108 colony-forming units (CFUs) of 1 species of bacteria, mixed for 30 seconds, incubated for 20 minutes at room temperature, emptied, and allowed to dry for 1 hour. A 100-cm2 area on the bottom of the basin was sampled for 10 seconds in 2 directions with a cotton swab premoistened with normal saline. Swab tips were placed in 2 mL of trypticase soy broth (Difco) and vortex-mixed for 30 seconds, and the solution was quantitatively cultured on sheep blood agar (Remel). Cultures were incubated at 37°C for 24 hours, and colonies were counted and expressed as CFUs per square centimeter. Tap water with and without a bacterial inoculum served as positive and negative controls, respectively.

Effect of hospital-wide chlorhexidine patient bathing on healthcare-associated infections

BACKGROUND

Chlorhexidine gluconate (CHG) bathing has been used primarily in critical care to prevent central line-associated bloodstream infections and infections due to multidrug-resistant organisms. The objective was to determine the effect of hospital-wide CHG patient bathing on healthcare-associated infections (HAIs).

DESIGN

Quasi-experimental, staged, dose-escalation study for 19 months followed by a 4-month washout period, in 3 cohorts.

SETTING

Academic medical center.

PATIENTS

All patients except neonates and infants.

INTERVENTION AND MEASUREMENTS

CHG bathing in the form of bed basin baths or showers administered 3 days per week or daily. CHG bathing compliance was monitored, and the rate of HAIs was measured.

RESULTS

Over 188,859 patient-days, 68,302 CHG baths were administered. Adherence to CHG bathing in the adult critical care units (90%) was better than that observed in other units (57.7%, [Formula: see text]). A significant decrease in infections due to Clostridium difficile was observed in all cohorts of patients during the intervention period, followed by a significant rise during the washout period. For all cohorts, the relative risk of C. difficile infection compared to baseline was 0.71 (95% confidence interval [CI], 0.57-0.89; [Formula: see text]) for 3-days-per-week CHG bathing and 0.41 (95% CI, 0.29-0.59; [Formula: see text]) for daily CHG bathing. During the washout period, the relative risk of infection was 1.85 (95% CI, 1.38-2.53; [Formula: see text]), compared to that with daily CHG bathing. A consistent effect of CHG bathing on other HAIs was not observed. No adverse events related to CHG bathing were reported.

CONCLUSIONS

CHG bathing was well tolerated and was associated with a significant decrease in C. difficile infections in hospitalized patients.

Genetic counseling in an extended attenauted familial adenomatous polyposis kindred

OBJECTIVES

To provide DNA-based genetic counseling to family members in the direct genetic lineage of a family fulfilling phenotypical criteria for the autosomal, dominantly inherited, attenuated familial adenomatous polyp (AFAP) syndrome. This enabled highly targeted cancer risk estimation based on cancer phenotype in concert with the presence or absence of the adenomatous polyposis coli (APC) germline mutation. Management recommendations could then be fully responsive to this syndrome's natural history.

METHODS

Detailed family history with pathology verification of colonic polyps and cancer was performed on an extended AFAP kindred. Endoscopic gastrointestinal examinations enabled detailed knowledge of the syndrome's upper and lower gastrointestinal tract phenotype. Molecular genetic evaluation of DNA led to the identification of the APC germline mutation which co-segregated with the phenotype.

RESULTS

Forty-two members of this extended AFAP family underwent DNA testing, wherein 27 were found to harbor the APC germline mutation,thereby enabling precision in their genetic counseling. Anecdotal examples of this counseling experience, with particular attention to psychological reactions, as well as concerns about such issues as insurance and employer discrimination, have been described.

CONCLUSIONS

When DNA-based testing is offered to AFAP family members, genetic counselors must compassionately consider patients' psychological concerns when providing detailed risk status and available surveillance and management programs.

Surveillance in Lynch syndrome: how aggressive?

OBJECTIVE

To identify colorectal cancers occurring after colonoscopic screening in patients at risk for Lynch syndrome.

METHODS

All cancers in Lynch syndrome families on file at the Creighton University Hereditary Cancer Institute were reviewed for history of prior colonoscopy.

RESULTS

Of 225 individuals with 313 colon cancers, six patients from different families had colon cancers arising within 4 1/2 yr of colonoscopic surveillance. Another 17 patients had metachronous colon cancers within 5 yr of resection of their first colon cancer.

CONCLUSION

Of 225 colorectal cancer patients from Lynch syndrome families, 10.2% of patients had colorectal cancer within 5 yr of colonoscopy or colon resection. In Lynch syndrome, the potential for interval neoplasms and the malignant potential of missed diminutive adenomas may differ from cases in the general population.

Adenoma follow-up in at-risk Lynch syndrome family members

Persons at 50% risk of Lynch Syndrome were screened with colonoscopy at six or twelve month intervals. On initial exam, eight of fifty-five patients had adenomas. Follow-up was available in 27 patients (mean 35.5 months). Estimated time to finding new adenomas was 58 months for patients clear on first colonoscopy and 16 months for patients who had adenomas on first exam (p < 0.01). One adenocarcinoma has been found, arising in a tubulovillous adenoma. The short-term risk of colorectal cancer in Lynch syndrome relatives without adenomas is low, as is the risk in those who had all adenomas removed.

Genetics, natural history, tumor spectrum, and pathology of hereditary nonpolyposis colorectal cancer: an updated review

Hereditary nonpolyposis colorectal cancer (HNPCC) dates to Warthin's description of family G, which he began studying in 1895. Warthin's observations were not fully appreciated until 1966 when two families with an autosomal dominant inheritance pattern of nonpolyposis colorectal cancer (CRC) and endometrial cancer were described. This condition was first termed the "cancer family syndrome" and was later renamed HNPCC. Some have proposed that HNPCC consists of at least two syndromes: Lynch syndrome I, with hereditary predisposition for CRC having early (approximately 44 years) age of onset, a proclivity (70%) for the proximal colon, and an excess of synchronous and metachronous colonic cancers and Lynch syndrome II, featuring a similar colonic phenotype accompanied by a high risk for carcinoma of the endometrium. Transitional cell carcinoma of the ureter and renal pelvis and carcinomas of the stomach, small bowel, ovary, and pancreas also afflict some families. Current estimates indicate that HNPCC may account for as much as 6% of the total CRC burden. There are no known premonitory phenotypic signs or biomarkers of cancer susceptibility in the Lynch syndromes. This report will summarize current knowledge, with emphasis on the manner in which this knowledge can be employed effectively for diagnosis and management of HNPCC.

Natural history of at-risk Lynch syndrome family members with respect to adenomas

Our goal is to determine colon cancer surveillance strategy in patients at risk for Lynch's syndrome. Asymptomatic persons at 50% risk of having Lynch syndrome (age 25-70 years) were enrolled in colonoscopic screening. Those without adenomas were asked to return in one year. Those with adenomas were asked to return in six months because of concern for rapid malignant degeneration.

RESULTS

Twenty-five males and thirty females participated. On initial exam, eight of fifty-five patients (14.5%) had adenomas. Logistic regression showed a significant effect of age on the probability of finding adenomas at initial examination (p < 0.02). Followup was available in 27 patients (mean 35.5 months). Kaplan-Meier estimation of time to finding new or previously missed adenomas was 58 months for patients clear on first colonoscopy and 16 months for patients who had adenomas on first exam (p < 0.01). One adenocarcinoma has been found arising in a tubulovillous adenoma.

CONCLUSION

The short-term risk of colorectal cancer in Lynch syndrome relatives without adenomas is low, as is the risk in those who have had all visualized adenomas removed.

Colon cancer genetics

The terms "hereditary," "sporadic," and "familial" colorectal cancer (CRC) suggest a knowledge of causation; however, current understanding of CRC does not permit categorization of differing CRC risks in accord with their cause per se. Despite these serious shortcomings, these terms are defined operationally on the basis of a family history of cancer, and when available, additional phenotypic information. The sporadic type occurs in the absence of a family history of CRC in a first-degree relative. The familial type occurs when at least one first-degree relative has CRC. Both these categories require the exclusion of hereditary CRC. In the case of hereditary CRC, this type is defined as a family history of CRC occurring in a pattern that indicates autosomal-dominant inheritance, which also may involve certain phenotypic signs (depending on the specific disorder, i.e., florid adenomatous polyps, benign and malignant extracolonic lesions, cancer of unusually early onset, and multiple primary cancer, particularly synchronous and metachronous CRC). Although this operational classification does not produce etiologically homogeneous groups, it is believed to have pragmatic utility with respect to planning targeted surveillance and management strategies. Because of the distinctive natural history of CRC in hereditary syndromes, it is of paramount clinical importance to identify hereditary CRC when it does occur. Even in patients with no evidence of hereditary CRC syndrome, their family history may be second only to age in determining the best CRC screening program for those who are asymptomatic. In an attempt to provide a perspective on the clinical evaluation of CRC risk, research was reviewed on pathologic features and biomarkers that may be related to CRC causes, especially the genetic basis of CRC susceptibility. The long-term objective of studies on the genetic epidemiology of CRC is primary and secondary prevention through development of targeted management and surveillance recommendations (based on an understanding of CRC causation) that is relevant to hereditary, familial, and sporadic CRC.

Gynecologic cancer clues to Lynch syndrome II diagnosis: a family report

Lynch syndrome II was diagnosed when two sisters manifested early-onset synchronous carcinomas of the ovary and endometrium and a third sister was found to have Duke's A carcinoma of the cecum. A detailed cancer family history indicated paternal transmission of the deleterious genotype. The pattern of carcinoma of the colorectum and extracolonic sites throughout the extended family was then found to be consonant with this hereditary cancer-prone disorder. Lynch syndrome II may be exceedingly difficult to diagnose due to an absence of premonitory clinical signs or biomarkers of genotypic susceptibility. Its recognition is therefore dependent on a detailed cancer family history (all anatomic sites), coupled with knowledge of the pattern of the cancer spectrum, distribution, and natural history, as manifested in this hereditary disorder. We describe the decision logic that was involved in the diagnosis of Lynch syndrome II in this family and indicate the important role of the gynecologists in this process.

Variable gastrointestinal and urologic cancers in a Lynch syndrome II kindred

There are no premonitory physical signs or biomarkers which can identify the genotypic status in Lynch syndrome II. Diagnosis is therefore dependent on the pedigree, with attention to cancer of all anatomic sites, inclusive of those cardinal features of its natural history. The tumor spectrum in Lynch syndrome II has continued to expand commensurately with increasing interest in this disorder. We report a family showing the constant cancer features of this syndrome but, in addition, occurrences of carcinoma of the bile duct, urologic system, and extremely early-onset carcinoma of the pancreas, in patients in the direct genetic lineage who were considered to be candidates for having inherited the deleterious genotype. Diagnosis of Lynch syndrome II is crucial in targeting its surveillance and management.