January 28, 2021

A quick look at the pros and cons of four effective options.

PHOTO CREDIT: Pamela Bevelhymer, RN, BSN, CNOR
BARE NARES When used properly, nasal decolonization regimens can greatly reduce the risk of surgical site infections.

Preoperative nasal decolonization has become a widely used, viable tool for preventing surgical site infections (SSIs). This relatively inexpensive practice addresses the most common gathering site of infectious materials such as S. aureus. However, there remains a lack of consensus on the most effective and reliable nasal decolonization regimen.

The peer-reviewed literature that has developed around this topic identified four effective treatments. Edward Septimus, MD, an infectious disease specialist and professor of internal medicine at Texas A&M College of Medicine in Houston, discusses the options:

• Mupirocin. Dr. Septimus calls this "the classic treatment" with the highest volume of supporting literature, but it presents a strong patient compliance challenge. "Mupirocin use requires screening patients at least a week in advance, and then patients must strictly follow the application regimen at home for five days," he says. Concern is also growing about mupirocin resistance, due to its wide use over many years. "Mupirocin's colonization eradication rate typically is extremely high (93% to 95%), but if there's high-level mupirocin resistance, you often get no reduction in colonization," explains Dr. Septimus. "With intermediate or low-level resistance, there may be a transient reduction in the number of organisms, but a quick rebound takes place at the end of the first week. In terms of surgical prophylaxis, we still don't know if a transient reduction is good enough." While there hasn't been a major shift away from mupirocin, he says the trend is to identify something better and easier to use.
• Povidone-iodine (PI). One advantage of PI is that no resistance to S. aureus has been reported, says Dr. Septimus, but a greater one lies in this regimen's design. "You don't need to worry about screening patients days in advance," he says. "You simply administer PI in the pre-op area before surgery with two applications in each nostril twice. It's a much simpler regimen that's especially attractive to outpatient surgery centers." While PI lacks mupirocin's volume of evidence, the literature around it is growing. Dr. Septimus warns, however, that all PI isn't created equal, as products specifically indicated for intranasal use contain chemicals that help the agent attach better to the nasal mucosa. These specialized preparations are multiple times more expensive than generic swabs, according to Dr. Septimus. "Stick with the intranasal preparation until someone proves over-the-counter versions are more effective," he advises. "Sure, it's more expensive than a generic formulation, but it's not nearly as expensive as an SSI."
• Alcohol-based antiseptic. At least one peer-reviewed study confirms the potential efficacy of alcohol-based swabs, says Dr. Septimus. "The mitigating issue with alcohol is that it has a very short duration of action," he explains. "It must be applied multiple times a day, which leads to compliance issues."
• Photodynamic therapy. Dr. Septimus calls this emerging regimen developing in Canada "fascinating." Not yet FDA-approved, it carries no compliance concerns, as it's applied just before surgery. "You place a material in the nose, generally methylene blue," says Dr. Septimus. "Then you deliver a wavelength of photodynamic therapy that combines with the methylene blue to eradicate bacteria very safely." Although U.S. centers can't yet employ this method, Dr. Septimus says it's worth monitoring.

"The nasal decolonization picture will likely become clearer in the next couple of years," says Dr. Septimus. "It's too early to say which is the best. For now, the important thing is to fully understand how each agent works, and follow related evidence-based protocols to the letter."

Precleaning instruments at the point of use relieves some stress for reprocessing techs and enhances operational efficiencies.

PHOTO CREDIT: Pamela Bevelhymer, RN, BSN, CNOR
NO-CAKE ZONE By precleaning and pretreating instruments after cases, OR staff help eliminate bottlenecks in sterile processing.

The busier your surgery center, the more your sterile processing department (SPD) could use a hand from the OR staff. "With increasing caseloads, more instrumentation needed for complex procedures and a constant emphasis on maintaining overall efficiencies, instrument care has never been harder," says William DeLuca, CRCST, CHL, CIS, associate director of the sterile processing department at Mount Sinai West in New York City.

Mr. DeLuca says OR staff can make life much easier for SPD by precleaning used instruments before sending them for reprocessing. "They can wipe down dirty instruments with sterile water or treat them with an enzymatic spray to prevent blood, fat or tissue from developing into a layer of bioburden that's difficult to remove," he says, pointing to industry guidelines.

By precleaning instruments so bioburden doesn't get caked on, reprocessing techs can turn around pristine trays and send them back to ORs more quickly, without wasting time and effort trying to remove dried-up gook manually. Obviously, this supports operational efficiencies and enhances patient safety, but there are additional benefits. "The proper cleaning of instruments helps to reduce the cost of instrument upkeep," says Mr. DeLuca. "If your reprocessing techs consistently perform a lackluster job cleaning and sterilizing instruments, surfaces will become stained. That can lead to pitting and rust, and the tools will eventually break." That's especially crucial because, he notes, the instruments that present the most difficult cleaning challenges tend to be more expensive.

Although everyone can agree that precleaning instruments is a good thing, the challenge is ensuring it's actually done consistently and effectively. Mr. DeLuca calls for interdepartmental cooperation. "OR directors and sterile processing managers need to develop a good working relationship," he says. "They both need to understand how long it takes to reprocess instrument trays, the steps involved and why cutting corners at any point in the process can negatively affect patient care. They also need to understand the risks involved if reprocessing steps are skipped."

The fruits of that relationship, says Mr. DeLuca, should lead to a better understanding among OR staff about how long it takes to reprocess trays, how the job can't be rushed, and how precleaning can help both SPD and the OR keep better pace with the surgical schedule. "Strong surgical leaders who understand what goes into reprocessing instrument trays will likely pass this knowledge along to the rest of the OR staff," he says.

Learn how antimicrobial disposable linens can help reduce the risk of cross-contamination and improve patient safety.

Credit: Ansell STAT-BLOC^™

Now, more than ever, critical infection prevention efforts are being implemented into the high-risk hospital environment. To prevent the transmission of infectious agents in the healthcare setting, the CDC recommends the use of disposable in acute care areas.¹

Environmental surfaces continue to harbor viruses and act as a reservoir for bacterial proliferation. Organisms have the unique ability to survive and multiply in the cracks, crevices and microscopic holes of table mattresses, gurneys and beds. Inadequate disinfection or cleaning have the potential to lead to harboring harmful pathogens which put both the patient and healthcare worker at risk for acquiring infections. In one study, the FDA received 700 reports that mattress covers failed to prevent blood and body fluids from leaking into the mattress, exposing patients to harmful pathogens and bacteria.²

The Risks of Reusable Linens

Reusable cotton linens do not maintain acceptable barrier properties. Reusable textiles show serious faults, impairing functionality and exposing patients to pathogens and bacteria, being harbored in the O.R. mattress. A recent study showed insufficient removal of bacterial contaminates after laundering, with 93% of towels containing E. coli and Klebsiella.³

Many facilities have now transitioned to disposable, impervious table sheets, however even with this barrier protection, significant bacterial transfer still occurs from a contaminated operating room table to the patient contact surface.

Ansell is the only provider of disposable, antimicrobial linens that offer complete protection against bacterial migration and strike-through contamination. STAT-BLOC^™ Linens are 99.9% effective against E.coli, MRSA and CRE and now show efficacy against COVID-19. In a time when the fight against cross-contamination is critical, these disposable, antimicrobial linens are an infection prevention tool that every healthcare facility should have on hand.

APIC shares crucial information on protecting providers during the pandemic.

Surface disinfection, air filtration, hand hygiene, proper donning and doffing of PPE — there's been a lot of talk about these areas of infection prevention during the pandemic. But what about your staff's eyes? How can these portals of entry for COVID-19 be best protected against potentially infectious splashes, sprays and droplets?

The Association for Professionals in Infection Control and Epidemiology (APIC) last month released its collected guidance on the issue. Here are the key components:

• Proper eye protection. Eyewear such as face shields and goggles should protect the eyes from all sides. As a result, regular eyeglasses and contact lenses do not offer suitable protection.
• Staff distribution. All patient-facing staff, including anyone who comes within six feet of a patient, should wear eye protection regardless of whether the patient has COVID-19. This means eye protection should always be worn in intake areas, patient bays, procedure rooms and, in many cases, visitor areas.
• Safe use and removal. Never touch eyewear during use; if you need to remove it, leave the patient care area. Always consider the front of the eyewear contaminated. To remove wraparound face shields, grasp from the back and remove carefully. To remove goggles that sit above the ears, remove them as you would a pair of eyeglasses, using the side pieces and being careful not to touch the front. In all cases, perform hand hygiene immediately afterward.
• Cleaning and disinfection. If you're reusing eyewear, always clean and disinfect it with an appropriate solution or hot soapy water when soiled or after use; follow the manufacturer's instructions for use or your facility's protocol. Perform hand hygiene afterward. Fully dry the eyewear using air or clean absorbent towels. Sterilization is generally not necessary.
• Extended use. Eye protection can be worn for repeated encounters with different patients if it is not removed between patients.

APIC presents this information in a two-page PDF you can download here.

Keeping the issue at the forefront can help maintain proper handwashing practices.

A new study bolsters the theory that continual education, training and auditing is necessary to ensure proper hand hygiene practices are followed in hospitals, even during the worst pandemic of our lives.

The examination of hand hygiene performance (HHP) was published this month in the American Journal of Infection Control. Through automated monitoring of more than 35 million hand hygiene opportunities at nine U.S. hospitals from January 2020 to May 2020, researchers found HHP initially increased at the outset of the pandemic, as initial awareness and sensitivity was extremely high. As the year went on, however, the early performance improvements were not fully sustained.

Researchers used the monitoring data to estimate HHP rates in the 10 weeks leading up to COVID-19-related local school closures, and the 10 weeks after. They found average HHP rates increased from 46% to 56% in the months preceding school closures, rising to 62% when the school closures occurred and awareness was heightened. HHP rates remained over 60% for four weeks before declining to 54% at the end of the 20-week study period. Although HHP rates at Week 20 were higher than the rates during the first eight weeks of the study, "they were lower than the peak performance rate which occurred two weeks after the week of school closures," the researchers noted.

The researchers flatly state, "Even during pandemic conditions, it appears to be difficult to sustain improvements in hand hygiene performance." They hope further study in this area will include analysis of data over an extended period of time "to determine if increased hand hygiene will become the new normal or resemble a campaign that drives an increase, but is not sustained due to lack of a multimodal, long-term program."

According to the researchers, the key take-home point for administrators is that continuous monitoring and reinforcement of hand hygiene protocols is crucial to maintain compliance. They note that automated monitoring systems can aid in this effort by providing useful compliance data for administrators to present to their staffs.