This is the third post of a six-part blog series, Infections Inside Out, by Dr. Kelly Cawcutt. Read part two here.

Biofilms play an important role in the development of hospital-acquired infections (HAIs). In my line of work, I’m often reminded of their presence when handlining central venous catheters or endotracheal tubes, but biofilms can also be present on any environmental surfaces. Biofilms are defined as a complex collection of microorganisms that attach to a surface and create a surface specific ecosystemic on that surface (known as an extracellular polymeric substance [EPS]). Given the complexity, and strong adherence to surfaces, biofilms result in a perpetual conglomerate of microorganisms that may be impossible to fully eradicate, resulting in a difficult, albeit often underestimated cause of infections in healthcare.

Given the increase usage of ventilators for the treatment of severe COVID patients, I thought now was a particularly good time to drive awareness about this complex, Jello-like matrix filled with microorganisms such as bacteria.

Biofilms contribute to many infectious diseases. Some classic examples are endocarditis, prosthetic joint infections and Clostridiodes difficile (C. diff) along with device-related infections such as central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs) and ventilator-associated pneumonia (VAP), among others. In the era of COVID-19, the impact of biofilms on HAIs may be more prominent due to the high device utilization in the intensive care units (ICUs) and long length of stays.

Considering the impact of biofilms, there are many details to keep in mind. First, given the capacity for biofilms to form on any surface, preventing microorganisms from attaching to a surface is a key intervention. The prevention of infection is multifaceted, and echoes the importance of infection control measures such as hand hygiene, device stewardship, aseptic technique, maintenance of devices and equipment, and environmental cleaning. Beyond this, patients may have additional risk factors that contribute to their likelihood of biofilm development which can include diabetes, kidney disease and immunosuppression. The risk factors are associated with decreased innate immune responses that normally fight the development of biofilms, so when a disease impacting the innate immune system is present, there is less of our individual capacity to prevent the build-up of that "gunk" on my patient’s endotracheal tube. Recognizing the role comorbid conditions, especially those that are very common (like diabetes and kidney disease) may play in such infections is essential as we strive to beat biofilms and prevent HAIs.

There are many human pathogens that are described to comprise, and grow within, biofilms can result in infection, including, but not limited to, Staphylococcus aureus, Pseudomonas aeruginosa and Legionella pneumophila. Candida species, including both Candida albicans and Candida auris (C. auris), are known to also cause biofilms. The known presence of these organisms has resulted in innovative devices, such as central venous catheters, impregnated with antimicrobial agents to prevent microbial attachment to the catheter, and therefore biofilm development. Such catheters have demonstrated decreases in HAIs, specifically in this scenario, CLABSI.

Although individual patient infection control measures must be followed, environmental sources of biofilm cannot be ignored. One specific rising concern in the infection control world is C. auris, which was first detected in 2009, and subsequently has spread throughout the world. Infections secondary to C. auris are significant due the life-threatening nature of these infections, combined with both the resistance to several antifungal medications and the capacity to spread within healthcare facilities. C. auris has been described to cause surface biofilms in patient rooms that may be difficult to eradicate, therefore be a conduit for infections. C. auris may be contracted from a patient, or their environment (including equipment that may be used for multiple patients), in as little as 4 hours, therefore effective disinfection is critical. Chlorhexidine-based regimens for patient asepsis may not be as effective as povidone iodine and environmental disinfectants, such as ethyl alcohol and quaternary ammonium, may be less effective than hydrogen peroxide or sodium hypochlorite. We must understand which infection control strategies, including the chemicals used, are effective against pathogens, or we will miss the opportunity to prevent HAIs!

Beyond the patient and physical environment, biofilms with infectious pathogens (such as Pseudomonas aeruginosa and Legionella pneumophilia) can form in water sources and clear guidance exists from the CDC on how to assess, and decrease the risk, of water-based biofilm as a source for transmission of infection within hospitals. Examples of where such biofilms could occur is within faucets, ice machines, showers, toilets and drains.

Given the near impossibility of eradicating biofilms, further research into prevention of biofilms is of paramount importance. Specifically, the roles of antimicrobial impregnated devices and surfaces (such as the central venous catheter device mentioned above),  and optimal patient asepsis and environmental disinfection. Our best offense continues to be adherence  to infection control practices and engaging the entire healthcare team in the one-two punch required to beat biofilms. Our patients are depending on us!

Kelly Cawcutt, MD, MS, FACP is a paid consultant for Clorox Healthcare. 

This is the second post of a six-part blog series, Infections Inside Out, by Dr. Kelly Cawcutt. Read part one here.

Hospital-acquired infections (HAIs) are infections acquired during medical care and are often directly related to the use of medical devices or procedures, along with lapses in critical infection control practices such hand hygiene, and appropriate cleaning and disinfection. Every day in the U.S., approximately 1 in 31 patients will suffer from a HAI. These infections can include central line associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), surgical site infections (SSIs), ventilator-associated pneumonia (VAP) and development of Clostridiodes difficile infection (CDI). The Centers for Disease Control and Prevention (CDC), along with State and county health departments, along with individual hospitals, monitor these closely via reports to the National Healthcare Safety Network, which assesses outbreaks and monitors progress towards future prevention efforts — with a goal of elimination of HAIs in the future of medicine.

The impact of COVID-19 on HAIs may ultimately be profound due to the use of antibiotics for possible bacterial co-infection and prolonged ICU stays, including the use of multiple invasive devices placing these vulnerable patients at risk for CLABSI, CAUTI, VAP, CDI. Additional factors clearly impacting HAIs during this pandemic include lack of appropriate resources and supply chain issues (such as personal protective equipment and testing supplies), combined with varying rates of infected healthcare workers and risk of burnout impacting the available workforce. Finally, there is ongoing concern that fear amidst this pandemic may negatively impact adherence to infection control practices. Never has prevention of HAIs been more critical given the burden of COVID-19 on healthcare around the world. 

Prevention of HAIs

Prevention of HAIs is comprised of several key concepts: avoid both device placement and antibiotic use unless clearly indicated, remove devices and stop antibiotics as soon as possible, and follow infection control measures for the healthcare workers and environment (such as standard and transmission-based precautions, hand hygiene and environmental and equipment cleaning).

With the clear impact of HAIs, there are several different guidelines focusing on how to prevent HAIs. A few critical recommendations and guidelines are:

Anyone within the healthcare field, including the patient, is accountable to help prevent HAIs. This is truly a multidisciplinary effort!

Patient’s Role

In the end, we are all patients and, as mentioned above, can play a role in prevention of HAIs. There are several key actions anyone can take to keep ourselves, and our loved ones, safe from these infections. Practicing excellent hand hygiene, watching closely for signs of developing infection, remembering to only take antibiotics when your healthcare team feels it is necessary and remaining an advocate for safety throughout your hospital stay (such as reminding healthcare workers to perform hand hygiene). (Here is a quick video on five tips to prevent HAIs as a patient.)

Device-Related Risks

There are many invasive devices that are frequently used for patient care, and once they are in place for at least 48 hours, those devices carry the risk for a possible reportable HAI to develop. Some patients require infusions of medications or frequent access to blood draws and monitoring, therefore may have a central venous catheter placed, thereby creating a simultaneous risk for developing CLABSI. Certain patients will have trouble urinating, or need very close monitoring of urine output due to impaired kidney, so an indwelling urinary catheter is inserted and, with that, the risk for CAUTI arises. Patients with severe lung disease, such as those with respiratory failure from COVID-19, may require invasive mechanical ventilation, as provided via an endotracheal tube. Much like the two catheters listed above, with insertion and use of the endotracheal tube, the risk for development of VAP evolves.

In essence, all of these devices are inserted through a potential non-sterile source and therefore carry a risk for bacteria to create a biofilm on the external surface of the catheter, or have bacterial inoculated on the internal surface during cares, increasing the risk of a possible life-threatening HAI. Understanding appropriate indications, insertion techniques, maintenance and prompt removal, once no longer indicated,  is of paramount importance.

Environmental Cleaning

Infections can spread within the healthcare setting, including based on inadequate environmental cleaning. CDI is one such infection, which is highlighted below. Additionally, there are many aspects of the environment to consider, such as the high touch surfaces at risk for contamination based on lack of hand hygiene. Air-based contamination are based on infectious aerosols (which may additionally occur via coughing, sneezing, flushing a toilet, procedures for a patient that may generate aerosols such as suctional or intubation) or mold secondary to construction or other damage. Water-based contamination can be found in ice machines, faucets, drains and with equipment that utilizes water but is not maintained or cleaned via manufacturer instructions-for-use (IFUs).

All of these simple components around us can serve as conduits for infection. Although this may be top of mind for many during this pandemic and tempt us to focus only on COVID-19, the more ‘mundane’ aspects of environment infection control are just as important in 2020 as they were each year prior. It’s critical that healthcare team members, including nurses, doctors, technicians and  EVS staff  responsible for cleaning equipment, or the environment, use products that are EPA-registered to be effective against these HAIs.

Seeing C. diff Differently – What Has Changed in Prevention?

CDI is the most common cause of HAIs in the U.S., with specific guidelines for infection prevention given its prevalence from national societies (Infectious Diseases Society of America and the Society of Healthcare Epidemiology of America) and from the CDC. There are several key steps to preventing CDI as a HAI:

Despite all the efforts on COVID-19, as frontline healthcare teams, we must all pitch in to continue the fight against HAIs. Our patients are depending on us.

Kelly Cawcutt, MD, MS, FACP is a paid consultant for Clorox Healthcare. 

This is the first post of a six-part blog series, Infections Inside Out.

Infectious diseases remain a critical cause of morbidity, mortality and cost in all healthcare facilities including outpatient clinics, long-term care facilities and acute care facilities, such as hospitals. Infections can come from two main places – inside the hospital walls and from outside within a community. A patient can develop a community-acquired infection prior to arrival in any healthcare setting, which often is what prompted the patient to seek care. The most recent example of this is COVID-19 (SARS-CoV-2). This virus is impacting healthcare facilities around the world with increased patient burdens and human-to-human spread in which infected patients are transmitting the infection to other patients, visitors  and healthcare workers.

There are also many healthcare-associated infections (HAIs) that patients in both acute and long-term care settings are at specific risk for based on multiple factors such as: having chronic medical problems that increase possible risks (such as requiring dialysis or conditions causing weakened immune systems), prior admission to healthcare facilities or receipt of antibiotics (placing patients at increased risk of acquisition of antibiotic-resistant (AR) infections or Clostridiodes difficle (C.diff) infection, the use of invasive devices (such as a ventilator in the setting of respiratory failure), and any procedures (such as surgery) needed for medical care. Lapses in infection control practices such as hand hygiene and cleaning and disinfection are another HAI risk factor. Going forward, we will specifically focus on HAIs in acute healthcare settings.

The primary reported infections under the umbrella of HAIs include central line associated bloodstream infections (CLABSI), catheter associated urinary tract infections (CAUTI), and surgical site infections (SSIs) and ventilator associated pneumonia (VAP), and C. diff gastroenteritis (actually the leading cause of HAI). These HAIs are reported and tracked nationally by the National Healthcare Safety Network (NHSN). However, it is important to note that these infections can be caused by both antibiotic-susceptible and AR pathogens. According to the CDC, each year in the U.S., there are over 2.8 million infectious causes by AR pathogens. This results in over 35,000 deaths. Microorganisms that are frequently also discussed in this category include C. diff infections and detection of AR bacteria, such as Carbapenem-resistant Enterobacteriaceae (CRE) or Methicillin-resistant Staphylococcus aureus (MRSA).  Prevention of these infections is clearly of paramount importance and infection control practices such as adherence to guidance for hand hygiene, isolation practices, when to wear gloves and gowns and environmental cleaning, to prevent spread throughout the hospital. Additional infection control expert guidance is available through many organizations including the CDC,  Society for Healthcare Epidemiology of America (SHEA) and the Association for Professionals in Infection Control and Epidemiology (APIC).

The toll that infections can have on patients, and healthcare facilities as a whole, can be daunting when you consider the needs for ongoing surveillance, diagnosis, management and complex infection prevention strategies. Strategies for the prevention of HAIs nearly all start with maintaining excellent hand hygiene, minimizing unnecessary invasive devices, prudent and correct use of antibiotics, employing appropriate precautions to prevent spread of infection within a facility and correct and thorough environmental and equipment cleaning and disinfecting to help eliminate pathogens. In many ways, the strategies are easier said than done; however, they are important to helping prevent the spread of the pathogens that cause infection, especially when you consider the substantial cost, they have on patient health and hospital cost.

Over the next posts, we will break down some of the key aspects of infectious diseases and prevention in the acute healthcare setting, including AR, HAIs, biofilms, multi-drug resistant organisms and challenges of infection prevention. Together, we can all strive to better understand and improve infection prevention thereby improving patient safety and care.

Kelly Cawcutt, MD, MS, FACP is a paid consultant for Clorox Healthcare. 

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