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Influenza


 Mode of Transmission

The influenza virus can be acquired through droplet transmission from an infected person, and direct or indirect contact with contaminated surfaces.

 Hospital Reservoirs

Patients, staff and visitors who are incubating or are infected with influenza (contagious period ranges from 1 day before symptom onset to 5-7 days after being sick1) can introduce the virus into healthcare settings.

1. Centers for Disease Control. (2016). Clinical signs and symptoms of Influenza.
Retrieved from: https://www.cdc.gov/immigrantrefugeehealth/pdf/seasonal-flu/contamination_cleaning_english_508.pdf

 Survival in Hospital Environment

The influenza virus can survive on non-porous surfaces for 24-48 hrs

1. Salgado CD, Farr BM, Hall KK, Hayden FG. (2002). Influenza in the acute hospital setting. The Lancet Infectious Diseases (2), pp145-55.

 Disease

Influenza illness is characterized by the following signs and symptoms:
  • Fever
  • Headache
  • Myalgia
  • Cough
  • Sore throat
  • Runny nose.

 Prevention

Preventing the transmission of influenza in the hospital environment requires the prompt detection and isolation of patients with new respiratory symptoms.

Staff and visitors that are sick should stay home so they do not expose vulnerable persons in the hospital.

Vaccinating patients and staff is a good way to prevent sickness and/or reduce severity of illness.

In conjunction with additional precautions (e.g. isolation, use of PPE), strong routine practices, or standard precautions , are important to prevent transmission of influenza. This includes good hand hygiene, and adherence to cleaning protocols.

1. Bridges CB, Kuehnert MJ, Hall CB. (2003). Transmission of Influenza: Implications for control in health care settings. Clinical Infectious Diseases. (37), pp1094-1101.

 Effective Cleaning

Routine cleaning and disinfection of surfaces in the hospital environment is important for reducing the risk of influenza transmission. Strong adherence to hospital and/or manufacturers protocols for cleaning is advised. All potential hospital-approved disinfectants should be verified for influenza virus kill claims.

Products containing the following chemicals can kill influenza1:
  • Chlorine
  • Hydrogen peroxide
  • Iodophors
  • Alcohols
See the following link to EPA website for listing of agents proven to kill influenza:
https://www.epa.gov/pesticide-registration/list-m-registered-antimicrobial-products-label-claims-avian-bird-flu

1. Centres for Disease Control (2010). Influenza (Flu), Cleaning to Prevent the Flu.
Retrieved from : https://www.cdc.gov/immigrantrefugeehealth/pdf/seasonal-flu/contamination_cleaning_english_508.pdf.

MRSA

Methicillin-resistant Staphylococcus aureus

 Mode of Transmission

MRSA can be acquired through direct contact with a person who has MRSA, or indirect contact with contaminated surfaces.

 Hospital Reservoirs

Patients who carry MRSA, or have an infection with the bacteria, serve as hospital reservoirs. When a healthcare provider has cared for a patient with MRSA but does not effectively clean their hands afterwards, then there is risk for MRSA transmission. Similarly, when equipment comes into contact with MRSA positive patients and is not effectively cleaned afterwards, then there is risk for MRSA transmission.

 Survival in Hospital Environment

MRSA can survive on a variety of hospital surfaces for various amounts of time. MRSA has been found on hospital curtains, over-bed tables, bed-railings, patient charts, and healthcare provider uniforms, to name a few.

Studies of MRSA survival rates on fabrics indicate that MRSA can survive anywhere from 4-21 days on cotton and 2-14 days on terrycloth, depending on the size of inoculum. Survival rate on polyester was anywhere from 1-40 days.

1. Chen KH, Chen LR, Wang YK. (2014). Contamination of medical charts: An important source of potential infection in hospitals. PLoS One, 18;9(2):e78512

2. Hardy KJ, Oppenheim BA, Gossain S, Gao F, Hawkey PM. (2006). A study of the relationship between environmental contamination with Methicillin-Resistant Staphylococcus aureus (MRSA) and patient’s acquisition of MRSA. Infection Control and Hospital Epidemiology, 27(2), pp127-32.

3. Neely AN, Maley MP. (2000). Survival of Enterococci and Staphylococci on hospital fabrics and plastic. Journal of Clinical Microbiology, (38)(2), pp724-6.

 Disease

People who have MRSA but display no signs or symptoms are said to be colonized. Colonization is a risk factor for clinical infection.

Clinical infections with MRSA can be serious, and in some cases result in death.

MRSA infections include, but are not limited to:
  • Skin infections
  • Pneumonia
  • Blood Stream Infections
  • Sepsis.

 Prevention

Preventing the transmission of MRSA in the hospital environment includes good hand hygiene practices, adherence to cleaning protocols, the appropriate use of personal protective equipment and applying additional precautions as required (e.g. isolation). Some of these measures are known as routine practices , or standard precautions.

 Effective Cleaning

Routine cleaning and disinfection of surfaces in the hospital environment is critical to reducing the risk of MRSA transmission. Strong adherence to hospital and/or manufacturers protocols for cleaning is advised. All potential hospital-approved disinfectants should be verified for MRSA kill claims.

See the following link to EPA website for listing of agents proven to kill MRSA: https://www.epa.gov/pesticide-registration/list-h-epas-registered-products-effective-against-methicillin-resistant

VRE

Vancomycin-resistant Enterococcus

 Mode of Transmission

VRE can be acquired through direct contact with a person who has VRE, or indirect contact with contaminated surfaces.

 Hospital Reservoirs

Patients who carry VRE, or have an infection with the bacteria, serve as hospital reservoirs. When equipment and spaces are not effectively cleaned following contact with a VRE positive patient, then there is risk for VRE transmission. Similarly, when a healthcare provider has cared for a patient with VRE but does not effectively clean their hands afterwards, then there is risk for VRE transmission.

 Survival in Hospital Environment

VRE can survive for long periods of time on a variety of hospital surfaces. VRE has been found on medical equipment, bed rails and door knobs.

Studies of VRE survival rates on fabrics indicate that VRE can survive for days to months on cotton (E. faecalis = 18-22 days, E. faecium = 62-90 days), depending on the size of inoculum. VRE survival rates on polyester ranged from 73-80 days for E. faecalis, and 80-90 days for E. faecium.

1. Arias CA, Murray BE. (2012). The rise of Enterococcus: beyond vancomycin resistance. Nature, v10, pp266-78.

2. Neely AN, Maley MP. (2000). Survival of Enterococci and Staphylococci on hospital fabrics and plastic. Journal of Clinical Microbiology, (38)(2), pp724-6.

 Disease

People who have VRE but display no signs or symptoms are said to be colonized. Colonization can contribute to the risk of developing a clinical infection.

Clinical infections with VRE can be serious, and in some cases result in death.

VRE infections include, but are not limited to:
  • Urinary tract infections
  • Wound/surgical infections
  • Blood stream infections
  • Sepsis

 Prevention

Preventing the transmission of VRE in the hospital environment includes good hand hygiene practices, adherence to cleaning protocols, the appropriate use of personal protective equipment and applying additional precautions as required (e.g. isolation). Some of these measures are known as routine practices , or standard precautions.

 Effective Cleaning

Routine cleaning and disinfection of surfaces in the hospital environment is critical to reducing the risk of VRE transmission. Strong adherence to hospital and/or manufacturers protocols for cleaning is advised. All potential hospital-approved disinfectants should be verified for VRE kill claims.

See the following link to EPA website for listing of agents proven to kill VRE:
https://www.epa.gov/pesticide-registration/list-h-epas-registered-products-effective-against-methicillin-resistant

Tuberculosis

Mycobacterium tuberculosis

 Mode of Transmission

Tuberculosis is acquired through Airborne transmission from patients who have pulmonary Tuberculosis (TB).

 Hospital Reservoirs

Patients admitted to hospital who are unrecognized for having pulmonary TB are the most significant contributors to transmission in healthcare settings.

1. Ogunremi T, Menzies D, Embil J. (2014). Chapter 15: The Prevention and Control of Tuberculosis Transmission in Health Care and Other Settings. Canadian Tuberculosis Standards, 7th ED. Public Health Agency of Canada.
Retrieved from: http://www.phac-aspc.gc.ca/tbpc-latb/pubs/tb-canada-7/assets/pdf/tb-standards-tb-normes-ch15-eng.pdf

 Survival in Hospital Environment

Tuberculosis is contagious through airborne transmission, and therefore must be inhaled to cause disease. The bacteria are propelled into the air by talking, breathing, coughing, and through other aerosol-generating procedures performed in healthcare settings (e.g. intubation, sputum induction, etc.). TB can remain suspended in indoor air for long periods of time, but engineering controls effectively remove this bacteria from healthcare settings; Airborne Infection Isolation Rooms (AIIRs) employ negative pressure to direct air, and all infectious particles contained within it, out of the facility.

 Disease

Common symptoms of pulmonary TB include, but are not limited, to the following1:
  • Cough – lasting 3 weeks or longer
  • Hemoptysis
  • Weight loss
  • Night sweats
  • Weakness/fatigue
  • Reduced appetite
  • Chills
  • Chest pain

1. Centres for Disease Control. (2016). Tuberculosis – Signs & Symptoms.
Retrieved from: https://www.cdc.gov/tb/topic/basics/signsandsymptoms.htm

 Prevention

Preventing the transmission of TB in the hospital environment requires the prompt detection and isolation of patients who are suspected or confirmed for pulmonary TB. Hospitals must also ensure that their Airborne Infection Isolation Rooms (AIIRs) are meeting the minimum required negative pressure.

 Effective Cleaning

EPA-registered tuberculocidal disinfectant will kill TB.

See the following link to EPA website for listing of agents proven to kill TB:
https://www.epa.gov/pesticide-registration/list-b-epas-registered-tuberculocide-products-effective-against-mycobacterium

C.difficile

Clostridium difficile

 Mode of Transmission

C.difficile bacteria can be acquired through direct contact with a person who has C.difficile, or indirect contact with contaminated surfaces.

 Hospital Reservoirs

Patients who carry C.difficile or have a C.difficile infection, serve as hospital reservoirs1. Hospital equipment and contaminated surfaces can become reservoirs when they are not cleaned effectively. When equipment comes into contact with C.difficile positive patients and is not effectively cleaned afterwards, then there is risk for C.difficile transmission When a healthcare provider has cared for a patient with C.difficile but does not effectively clean their hands afterwards, then there is risk for C.difficile transmission.

1. Furuya-Kanamori L, Marquess J, Yakob L, Riley TV, Paterson DL, Foster NF, Huber CA, Clements ACA. (2015). Asymptomatic Clostridium difficile colonization: epidemiology and clinical implications. BMC Infectious Diseases. 15(516), pp1-11.

 Survival in Hospital Environment

C.difficile is difficult to eradicate from healthcare environments because it can survive in its vegetative state, called a spore, for up to 5 months on hard surfaces1. C.difficile easily contaminates the immediate patient environment, and even the greater medical ward. The bacteria has been detected on a variety of surfaces including, but not limited to, over-bed tables, bulletin boards, patient televisions/screens, nursing stations, computer keyboards, and in kitchenettes/nutrition stations2.

1. Association for Professionals in Infection Control & Epidemiology. (2013). Guide to prevention Clostridium difficile infections. Pp 50-66.
Retrieved from: www.apic.org.

2. Faires MC, Pearl DL, Berke O, Reid-Smith RJ, Weese JS. (2013). BMC Infectious Diseases, (13)342.

 Disease

Some people are colonized with C.difficile, but only after exposure to healthcare interventions, like receiving antibiotics, do they develop an infection1. A C.difficile infection can range in symptoms that include the following:
  • Abdominal pain/ distension
  • Diarrhea
  • Nausea
  • Fever
  • Dehydration
  • Loss of appetite

Severe cases can result in a condition called toxic megacolon, and can lead to death.

1. Lin HJ, Hung YP, Liu HC, Lee JC, Lee CI, Wu YH, Tsai PJ, Ko WC. (2015). Risk factors for Clostridium difficile-associated diarrhea among hospitalized adults with fecal toxigenic C.difficile colonization. Journal of Microbiology, Immunology and Infection, (48), pp 183-9.

 Prevention

Preventing the transmission of C.difficile in the hospital environment includes good hand hygiene practices, the use of additional precautions (e.g. isolation, personal protective equipment ) and enhanced cleaning with agents proven effective against C.difficile spores. As always, routine practices , or standard precautions apply.

 Effective Cleaning

Routine cleaning and disinfection of surfaces in the hospital environment is critical to reducing the risk of C.difficile transmission. Targeted cleaning with agents proven effective against C.difficile spores should be directed towards spaces where patients with known or suspected C.difficile infection (CDI) currently occupy or have previously occupied. Likewise, equipment that has come into contact with a patient who has or is suspected of CDI should be cleaned with an agent proven effective against C.difficile spores.

See the following link for listing of agents proven to kill C.difficile:
https://www.epa.gov/pesticide-registration/list-k-epas-registered-antimicrobial-products-effective-against-clostridium

ESBL & CPE

Extended Spectrum Beta-Lactamases & Carbapenem-Producing Enterobacteriaceae

 Mode of Transmission

ESBLs and CPEs are a variety of bacteria that have acquired antibiotic resistance mechanisms. The bacteria are spread through direct contact with a person who has an ESBL or CPE, or indirect contact with contaminated surfaces.

 Hospital Reservoirs

Patients who carry an ESBL or CPE, or have an infection with the bacteria, can serve as hospital reservoirs. The hospital environment, however, has also been found to play a role in the transmission of ESBL-equipped bacteria. Contaminated sinks and drains have both been implicated with outbreaks in Intensive Care Units (ICUs).

As with other antibiotic-resistant organisms (AROs), hands and equipment can become contaminated with ESBL and CPE bacteria and serve as vehicles for transmission if they are not effectively sanitized.

1. Roux D, Aubier B, Cochard H, Quentin R, van der Mee-Marquet N. (2013). Contaminated sinks in intensive care units: an underestimated source of extended-spectrum beta-lactamase-producing Enterobacteriaceae in the patient environment. Journal of Hospital Infection Control (85), pp106-11.

2. Lowe C, Willey B, O’Shaughnessy A, Lee W, Lum M, Pike K, Larocque C, Dedier H, Dales L, Moore C, McGeer A. (2012). Outbreak of Extended-Specrum -Lactamase-producing Klebsiella oxytoca Infection Associated with Contaminated Handwashing Sinks. Emerging Infectious Diseases (18)8, pp1242-7.

 Survival in Hospital Environment

Survival in the hospital environment is variable for ESBLs and CPE and is highly dependent on the type of bacteria that has acquired the resistance. The genetic elements that make it possible for antibiotic resistance are, in many cases, at the expense of fitness to the organism, which means that they do not survive as well as antibiotic sensitive strains.

1. Andersson DI, Hughes D. (2010). Antibiotic resistance and its cost: is it possible to reverse resistant? Nature (8), pp260-71.

 Disease

People who have an ESBL or CPE but display no signs or symptoms are said to be colonized. Colonization can contribute to the risk of developing a clinical infection.

Clinical infections with ESBLs and CPE can be serious, and in some cases result in death.

ESBLs and CPE cause the same infections that other bacteria can cause and include, but are not limited to, urinary tract infections, skin/soft tissue infections, pneumonia, blood stream infections, and sepsis.

 Prevention

Preventing the transmission of ESBLs & CPE in the hospital environment includes good hand hand hygiene , adherence to cleaning protocols, the appropriate use of personal protective equipment and applying additional precautions as required (e.g. isolation). Some of these measures are known as routine practices , or standard precautions.

 Effective Cleaning

Routine cleaning and disinfection of surfaces with hospital-approved disinfectant is critical to reducing the risk of ESBL and CPE transmission. Strong adherence to hospital and/or manufacturers protocols for cleaning is advised.

Content created by Claudia Crussell-Balogh, CIC, MHSc.