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Global Consensus Conference: Final recommendations
Global Consensus Conference: Final recommendations AIMS AND GOALS The overall purpose of this conference was to achieve consensus on infection control practice across health care settings and international boundaries related to caring for patients with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE). The aim was to examine the infection control problems associated with these antibioticresistant organisms (AROs) and consider possible solutions. Global, pertaining to the whole world, was the perspective the organizers of this conference envisioned. Thus, despite not all countries being represented at this conference, MRSA and VRE are not limited by geographic boundaries and represent universal infection control challenges. The goal of this consensus conference was to focus on specific issues that come under the direct influence of infection control professionals (ICPs). These issues include, but are not limited to, use of barriers to prevent ARO transmission, hand hygiene, and issues such as appropriate application of antiseptics and disinfectants. Delegates recognized that as a person moves across the continuum of care and from developed to developing countries, available resources (eg, barrier materials, antimicrobial-containing products, germicides, personnel, and logistics of material distribution) will vary considerably in availability and accessibility. Practical limitations exist that will determine local decisions regarding priorities for application of available resources. New information and scientific investigation will therefore require that the recommendations from this conference be reviewed and revised over time. The delegates acknowledge that other AROs, for instance, extended spectrum β-lactamase-producing Reprint requests: APIC, 1275 K St NW, Suite 1000, Washington, DC 20005-4006. Published simultaneously in AJIC: American Journal of Infection Control (1999;27:503-13), Canadian Journal of Infection Control (in press, Winter 1999), and British Journal of Infection Control. Copyright © 1999 by the Association for Professionals in Infection Control and Epidemiology, Inc, Community and Hospital Infection Control Association—Canada, and Infection Control Nurses Association. 0196-6553/99/$8.00 + 0
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Enterobacteriaceae, penicillin-resistant Streptococcus pneumoniae, and Acinetobacter baumannii, are also difficult pathogens to treat/control; however, these AROs were not specifically addressed at this conference. Even so, some of the recommendations that emerged might be more widely applicable to other AROs. The conference presented a major opportunity for professionals and scientists in the infection prevention and control field to discuss trends and develop strategies for best practice. CONFERENCE ORGANIZERS This conference was coordinated by infection control professional organizations in the United States, Canada, and the United Kingdom. These organizations are: • The Association for Professionals in Infection Control and Epidemiology, Inc (APIC) • The Community and Hospital Infection Control Association—Canada (CHICA) • The Infection Control Nurses Association (ICNA) DELEGATES Delegates were invited experts from the fields of health care epidemiology, clinical/medical microbiology, infectious diseases, industry, and infection control. They included physicians, microbiologists, medical technologists, nurses, other health care personnel, and corporate sponsor representatives. Participation was by invitation only. (See list of delegates in the Appendix.) FORMAT The Scientific Committee organized a series of plenary sessions to present the important issues involving MRSA and VRE. Three workshops, Barriers, Skin, and Environment, then provided opportunities for delegates to contribute their own views to the proceedings and develop recommendations to answer specific questions assigned to each. The recommendations from the workshops were presented in a final session, and consensus recommendations were arrived at by using electronic voting. The definition of consensus based on tallied votes was as follows: 1. 90% or more of delegates voting for a recommendation = consensus 2. 75%-<90% of delegates voting for a recommenda503
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504 Global Consensus Conference tion = consensus as long as no delegate strongly disagreed with the recommendation 3. <75% of delegates voting for a recommendation = no consensus Only recommendations reaching consensus are outlined under each workshop heading. WORKSHOPS • Barriers: barrier precautions/patient isolation/ screening • Skin: hand hygiene, including skin decontamination, cleansing, and antisepsis • Environment: decontamination and disinfection— the role of the environment and equipment INTRODUCTION All conference participants acknowledged that antibiotic resistance is a global public health crisis with potential for adversely affecting health and leading, potentially, to a “post-antibiotic era.” A global perspective and action are urgently needed. By illustration, a traveler can spread a clonal strain relatively easily over long distances with modern air travel and unintentionally serve as a source of spread of MRSA through several health care facilities around the globe.1,2 Despite significant progress against morbidity and mortality associated with infectious diseases, 5 of the 10 leading causes of death are communicable diseases or perinatal disorders.3 In the previous few decades, trends in the United States demonstrated a significant decline in infectious disease mortality. However, this trend was reversed with the emergence of HIV,4 a reminder that the microbial ecosystem is unpredictable and dynamic. Against this background, there is growing recognition that microorganisms play a wider role as contributors to chronic, noninfectious diseases.5 Preliminary reports that antibiotics might be able to prevent progression of atherosclerosis or prevent myocardial infarction are further evidence of the need to maintain antibiotic effectiveness.6,7 The progression of antibiotic resistance has been unrelenting among hospitalized patients.8 In the United States alone, there has been a 20-fold increase in the frequency of VRE as nosocomial pathogens.9 Antibiotic resistance knows no boundaries and is observed in industrialized countries, developing countries, the community, and across the spectrum of care delivery.10-15 Trends by country/region for the prevalence of VRE and MRSA are summarized in Table 1. What is apparent is that the frequency of MRSA and VRE varies considerably among countries and also within geographic locations. There are examples of successful control through screening and isolation precautions and nationwide
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decrease in consumption of certain antibiotics that can reverse antibiotic resistance.16-19 However, juxtaposed against some positive interventions are more recent reports of emergence of even more challenging microbes, such as vancomycin-resistant S aureus.20,21 One estimate places the direct cost of nosocomial infections caused by 6 different strains of AROs to be minimally $1.3 billion (1992 US dollars)/year in the United States.22 A reversal of trends highlighted previously is needed. This reversal will require joint efforts on the part of physicians and other health care providers, as well as the ICP and, ultimately, the consumer.23 CONFERENCE GUIDING PRINCIPLE Prudent use of antimicrobials is of paramount importance in the prevention and control of AROs. The fundamental and perhaps ultimate control of AROs depends on addressing the root cause for the emergence of most of these strains: inappropriate use of antibiotics. Whereas it is acknowledged that development of antibiotic resistance is multifactorial, 2 key factors are the prevalence of resistance genes and the extent of antibiotic use in humans and animals. Selective pressure from widespread use of antibiotics often gives rise to AROs; there have been numerous examples of a causal association between antibiotic consumption and emergence of AROs.24 Levy suggests maintenance of antibiotic use below a threshold (sufficient amount to treat infections within a hospital or community but not encourage propagation of resistant strains).25 Therefore, the delegates reinforce as fundamental to control and prevention of AROs the prudent use of not only antibiotics, but also more broadly, antimicrobials. However, use of antibiotics was not the focus of this conference. WORKSHOP PREAMBLES, GUIDING PRINCIPLES, ASSUMPTIONS, AND FINAL RECOMMENDATIONS Please note: Workshop recommendations are published in the order in which they were presented for consensus voting. As such there is no intentional or implied hierarchical or rank order to the recommendations that follow. Barriers Workshop—Preamble The Barriers Workshop participants believed strongly that their recommendations need to be recognized as general in scope so that countries and practice settings interpret and tailor interventions based on the local epidemiology of MRSA and VRE. Access to essential medications in developing nations is limited, and the same may apply to the items needed for application of isolation precautions.26 In addition, risk of transmission will likely vary from one patient care setting to another. Brennen and others monitored potential for spread of
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Table 1. Examples of frequency of MRSA and VRE by country/region Source
Country/location
MRSA prevalence
VRE prevalence
Voss A, et al. Eur J Clin Microbiol Infect Dis 1994;13:50-5.
Denmark
0.1%
Voss A, et al. Eur J Clin Microbiol Infect Dis 1994;13:50-5 (MRSA); Boisivon A, et al. Clin Microbiol Infect 1996;3:175-9 (VRE)
France
33.8%
Struelens MJ, et al. Infect Control Hosp Epidemiol 1996;17:503-8.
Belgium
1.6%-62.4%
Martone WJ. Infect Control Hosp Epidemiol 1998;19:539-45.
US, ICUs, NNIS Hospitals
Voss A, et al. Eur J Clin Microbiol Infect Dis 1994;13:50-5. Folorunso AB, et al. Infect Control Hosp Epidemiol 1997;18:765-7.
Spain, Italy 1500-bed teaching hospital, Hong Kong, China
>30% 0.24–14.88 per 100 discharges
Canadian Nosocomial Infection Surveillance Program.
Canada
3.4% (range 0%-18%, 1995-1998)
Duse A. GCC Conference; 1999.
S Africa
21%
Dornbusch K, et al. Scand J Infect Dis 1998;30:281-8.
North, Central, and Southern Europe (blood isolates only)
0.8% (North) 14% (Central) 41% (South)
Torvaldsen S, et al. Infect Control Hosp Epidemiol 1999;20:133-5.
Western Australia
12.0/10 (1993) 27.0/105 (1995) 55.7/105 (1997)
VRE among long-term care patients and found that patient-to-patient spread was infrequent.15 In contrast, an intensive care unit may elect to extend the practice of precautions to universal application of gowns/aprons and gloves to improve adherence by health care personnel with isolation precautions.27 Another issue to be considered when developing strategies for containment of AROs includes the level of endemic rates. Austin and Anderson have recently applied observational data to develop models for the dynamics of transmission of MRSA and VRE, which can be used for designing interventional and programmatic changes.28 This is an example of application of local epidemiologic data to counter further spread of MRSA and VRE. Other variables that impinge on the success of infection prevention and control include an understanding of the behavior that motivates health care personnel and variation in the epidemiology between MRSA and VRE. Adherence by personnel to hand hygiene, the fundamental procedure to prevent the spread of resistant and susceptible microorganisms, is variable and usually suboptimal. Even application of behavioral theory to improve on this adherence has not met with sustained success.29 Thus education, monitoring of adherence, and availability of adequate personnel are part of strategies to control AROs. Last, an assessment of the published evidence that uses scoring methods in combina-
tion with local knowledge will result in improved decision support and action. Two areas this workshop did not address were efficacy of empiric precautions and procedures for transfer of patients through the continuum of care. Barriers Workshop—Questions asked to address: 1. When and what kind of spatial separation is needed? 2. When are physical barriers needed and what are they? 3. How do we identify patients who need spatial or physical barriers? 4. Should we identify colonized staff and under what circumstances?
2% (colonization)
0.4% (1989) 13.6% (1994) 23.2% (1997)
5% (North) 3% (Central) N/A (South)
Barriers Workshop—Final Recommendations 1. Use spatial separation between patients known to be infected or colonized with MRSA or VRE and patients who are not known to be infected or colonized. 2. For placement of patients known to be infected or colonized with MRSA or VRE: i. a single room, preferably with a self-contained bathroom, is the first choice. ii. room sharing by or cohorting of patients infected or colonized with the same organism (MRSA or VRE) is a second choice. iii. room or ward sharing with noninfected or noncolonized patient(s) is the third choice.
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506 Global Consensus Conference The priority for a single room or choice of roommate(s) is determined by a risk assessment of the patient population taking into consideration: i. likelihood of MRSA/VRE transmission from the source patient. ii. risk and consequences of the noninfected or colonized roommate(s) becoming colonized or infected. iii. the setting in which care is provided. 3. Maintain appropriate staffing levels to provide adequate patient care for whatever means of placement is chosen. 4. Use physical barriers appropriately to reduce the risk of transmission of MRSA/VRE among patients. 5. Wear clean, nonsterile gloves when touching the patient or a potentially contaminated environmental source: • Change gloves between patients. Change gloves between tasks on the same patient when contamination has occurred. • When glove supply is limited, use gloves for touching draining body fluids, wound sites, or stool. • Wash hands after removing gloves. 6. Use gowns or plastic aprons to protect the skin or clothing from gross contamination. 7. There is insufficient evidence to make recommendations for or against the routine use of gowns or aprons in preventing the transmission of MRSA/VRE. 8. There is insufficient evidence to make recommendations for or against the use of masks or eye or mucous membrane protection to prevent the transmission of MRSA/VRE. 9. Shoe covers and hair covers are not recommended. 10. Where resources for physical barriers are limited, establish glove use as the first priority. 11. Information describing the need for and type of physical barriers appropriate for a given patient must be readily accessible and communicated. 12. Assess the impact of physical barriers on psychologic, cultural, and care needs of the patient. • Seek interventions to minimize the negative impacts without increasing the risk of transmission. 13. The need for continuation of spatial separation or physical barriers should be reassessed periodically. • Discontinue as soon as feasible. • Determinants for discontinuation must be individualized. 14. The goal of screening of patients for MRSA or VRE must be identified before screening is undertaken. 15. Before screening is undertaken: • cost-effectiveness must be considered. • appropriate laboratory support must be available.
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16. Situations in which a strong recommendation for screening may be made include: • exposed patients in an outbreak situation in which identification of colonized patients is an adjunct in outbreak control. • in evaluation of the effectiveness of an intervention. No consensus could be reached about the use of screening in other specific situations beyond those in recommendation 16. 17. Do not screen staff unless they are epidemiologically linked to ongoing transmission. Skin Workshop—Preamble Participants in this workshop started with the premise that the ultimate goal of cleansing the skin of care providers, regardless of specific product used, is to prevent the transmission of infection, including AROs, from their hands. Incumbent in this goal are some basic principles and underlying assumptions: i. Soap/detergent and water removes soil and some transient microbes from the skin but does not destroy microbes such as MRSA and VRE. ii. Antiseptic/detergent products remove soil and remove and destroy microbes on the skin. iii. Antiseptic products formulated for use without water do not remove soil, but do remove and destroy microbes on skin. iv. Visible soiling must first be removed by some means before the use of an antiseptic agent that does not remove soil. v. There is no evidence that AROs are less susceptible to soap/detergent products or antiseptic agents when compared with antibiotic-susceptible organisms. vi. Currently, there is no evidence for resistance of AROs to antiseptic agents at recommended concentrations. Antiseptic agents act in a nonspecific manner and at multiple target sites in/on microorganisms. The Skin Workshop also developed the following guiding principles relating to hand hygiene and AROs. A. National or local guidelines outlining hand hygiene shall be followed. B. Because adherence to hand hygiene guidelines has been shown to be inadequate, particular efforts to improve hand hygiene practices in high-risk areas, with high-risk patients, and with patients known to have AROs are warranted. C. Efforts must be made to protect the integrity and health of care providers’ hands. D. Product use and storage must take into account national and local guidelines and manufacturer’s instructions, as well as available scientific information.
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E. Antiseptic products selected for use shall meet national/international criteria for safety and efficacy. Skin Workshop—Questions asked to address: 1. Do you need to do anything differently when you have AROs? 2. When do you need antimicrobial agents? 3. Where there is no water, what should be done? 4. What antimicrobial agents can be used? Skin Workshop—Final Recommendations 1. Hand hygiene is the single most important procedure for preventing the transmission of AROs. 2. Whereas research data from randomized controlled trials showing that use of antiseptic products will actually reduce infections is lacking, evidence suggests that the removal of ARO’s from hands with soap/detergent and water is less effective than with the application of an antiseptic product. An antiseptic agent should be readily available and accessible to care providers working in any setting. 3. An antiseptic product shall be used in high-risk areas, with high-risk patients, and with known ARO patients. • High-risk areas may include, but are not limited to: a. intensive care units b. transplant units c. burn units d. hematology/oncology units e. hemodialysis units • Patients at high risk of acquisition/transmission of AROs may include but are not limited to those: a. receiving multiple antibiotics or receiving repeated treatments with antibiotics b. with prolonged hospital stay c. with frequent admissions d. transferred from other health care facilities or units with a high endemic rate of AROs • Use of antiseptics with known ARO patients shall include, but is not limited to: a. acute care b. long-term care in which more than residential care is provided c. community settings in which care providers move from home to home 4. High-risk areas and high-risk patients shall be identified by regular assessment at local and institutional levels. 5. The risk assessment for acquisition/transmission of AROs may include patient surveillance cultures as directed by infection control personnel. 6. A. In the absence of sufficient or adequate handwashing facilities and where there is no visible soil, an antiseptic product formulated for use without water shall be used.
Global Consensus Conference 507 B. In the absence of sufficient or adequate handwashing facilities and where there is visible soil, soil must first be removed by some means (eg, rinsing, mechanical rubbing, and wipes) before use of an antiseptic product formulated for use without water. Environment Workshop—Preamble Several studies have demonstrated that VRE can survive in the environment for prolonged periods, and outbreaks involving an environmental reservoir have been reported.30 However, environmental survival of resistant and susceptible enterococci are similar.31 In addition, AROs may simply be highlighting problems with the infrastructure of care delivery such as decreased support or time for cleaning of the environment.32 Last, there is no evidence that pathogens such as VRE and MRSA are more resistant to disinfectants applied to inanimate surfaces when used at proper dilution and with sufficient contact time.33,34 The following assumptions were developed by this workshop and should be considered when reviewing the recommendations. i. Housekeeping practices in health care facilities have deteriorated. ii. MRSA and VRE are becoming endemic in many areas. iii. The role of air in transmission of MRSA and VRE has not been elucidated and therefore was not dealt with by this workshop. iv. MRSA and VRE are no more resistant to inactivation by germicides than sensitive isolates. v. There is insufficient evidence to fully assess the role of the environment in transmission of infection. vi. We recognize that the environment is only one factor in the risk of transmission of VRE and MRSA. vii. Agents used in environmental cleaning differ between North America (detergent-disinfectant) and Europe (detergent). viii. The Spaulding Classification (not used in all parts of Europe or the United Kingdom) was used as the basis for discussion (see “Glossary”). Environment Workshop—Questions asked to address: 1. Do you need to do anything differently when you have AORs? If yes, at what frequency? 2. When do you need disinfectants/detergents for environmental (surfaces, noncritical) cleaning? 3. Where there is no water or use of water is not appropriate (eg, monitors and pumps), what should be done? Environment Workshop—Guiding Principles A. Recommendations must consider safety of humans, animals, and the environment.
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B. We will generally not qualify statements as minimum requirements. C. Evidence-based recommendations were developed, where possible, but when lacking, good judgment should prevail. Environment Workshop—Final Recommendations 1.
Routine culturing of the environment or air is discouraged. 2. Culturing of the environment is acceptable when epidemiologically indicated and for research and educational purposes. 3. Each facility should use a method to validate compliance with their cleaning, disinfecting, and sterilization practices. 4. Each facility should assign responsibility for implementation of these practices. 5. Cleaning procedures need to be defined and shall be applied consistently. 6. Surfaces and equipment should be easily cleanable. 7. Adequate staffing and sufficient effort must be put into physical cleaning of the environment. 8. Products should be used according to national or local guidelines, manufacturer’s instructions, and available scientific information; ensure product contact with all surfaces being treated. Acute care delivery area 9. Where detergents-disinfectants are used for environmental cleaning, no additional or different products are required in the presence of MRSA/VRE. 10. Non–hand-contact (infrequently touched) environmental surfaces should be cleaned when visibly soiled and as required to maintain an aesthetically pleasing environment. Cleaning with detergent is sufficient. Facilities may choose to use a detergent-disinfectant for convenience. 11. Hand-contact environmental surfaces should undergo at least daily thorough cleaning. Where detergents are routinely used, a detergent-disinfectant should be used for MRSA and VRE. 12. Noncritical equipment used for MRSA and VRE patients should be dedicated where possible. 13. When dedicated equipment is not possible, shared noncritical items will be cleaned and disinfected between patient use. 14. Limit quantity of disposable items taken into room or designated space of VRE/MRSA patient to what would be reasonably used for that patient. 15. Consider discarding unused disposable items that cannot be cleaned or disinfected after MRSA/VRE patient discharge. Broad application: not necessarily limited to acute care setting 16. Under special circumstances for example out-
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break, hyperendemic situations, additional procedures may be implemented at the discretion and direction of facility’s infection control program director or according to current guidelines. 17. Terminal cleaning (when patient is discharged from the room or when isolation is discontinued) is to be done as an opportunity to clean areas not routinely accessible and in accordance with previously stated recommendations. 18. Use currently accepted guidelines for disinfection and sterilization of critical and semicritical items. 19. No additional procedures are required for cleaning, disinfecting, and sterilizing critical and semicritical items in the presence of MRSA/VRE. Nonacute care delivery areas 20. Under usual circumstances, no additional or different practices are required in the presence of MRSA/VRE. 21. Non–hand-contact environmental surfaces should be cleaned when visibly soiled and as required to maintain aesthetics. 22. Hand-contact environmental surfaces should undergo regular thorough cleaning; there is insufficient evidence to make a recommendation on the frequency of cleaning. 23. Cleaning with a detergent is sufficient. 24. There is insufficient evidence to make a recommendation on using detergent versus detergentdisinfectant. Home care delivery setting 25. Equipment used in the home care environment by health care personnel is handled the same as in acute care facilities. 26. Family members should be provided common sense information about cleaning of the home. Nonwater immersible items (NWII) 27. Environmental cleaning products should be chosen on the basis of efficacy and safety. 28. NWII should be cleaned and where necessary decontaminated with a method compatible with the item. 29. Items not easily cleaned (eg, computer keyboards) but easily contaminated—cover with plastic and clean regularly. Water inaccessible area/location 30. Facilities should be prepared for situations where water is inaccessible (eg, planned water disruptions, storm warnings, and disaster situations). 31. Select acceptable ready-to-use disinfecting products, which do not require rinsing. Decolonization therapy 32. Decolonization is not recommended unless there is epidemiologic evidence that the colonized person is spreading the organism.
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Research agenda (areas in need of further scientific investigation) 1. Impact of disinfectant use on emergence of antimicrobial resistance in MRSA/VRE 2. Role of air in transmission of MRSA 3. Define techniques to minimize transmission of MRSA/VRE from environment 4. Detergents versus disinfectants for environmental cleaning GLOSSARY Note: Some of the terms included in this glossary were developed and provided by some of the workshops during their deliberations. Other terms were abstracted from published resources and are included to assist the reader. Therefore, these were not distributed to all workshops before their sessions. The GCC Organizing and Scientific Committees would like to thank and acknowledge those persons who contributed to this glossary. Acute care—A pattern of health care in which a patient is treated for a brief but severe episode of illness, for the sequelae of an accident or other trauma, or during recovery from surgery. Ambulatory care—Health services provided on an outpatient basis to persons who visit a facility for care and depart on the same day. Antibiotic—A naturally occurring or synthetic organic substance that inhibits or destroys selective bacteria or other microorganisms. Antimicrobial agent—A product that destroys or inhibits the growth of microorganisms. Antimicrobial soap—A soap containing an ingredient with in vitro and in vivo activity against skin flora. Antiseptic—A chemical germicide or product that destroys or inhibits growth of microorganisms formulated for use on skin or tissue and should not be used to decontaminate inanimate objects. Examples include isopropyl alcohol, chlorhexidine gluconate, and tincture of iodine. Biocide—A chemical agent, usually broad spectrum, that destroys microorganisms. Chemical sterilant—Liquid chemical used to destroy all forms of microbial life, including fungal and bacterial spores. Often used for high-level disinfection when used for shorter exposure periods (eg, device immersed in 2% glutaraldehyde for ≥20 minutes). Cleaning—Removal, usually with detergent or enzymatic products, mechanical action, and water, of all foreign material (eg, blood, soil, and organic material) from objects or surfaces. Commensals—Microorganisms living with, on, or in a person without causing infection, inflammation, or injury. An example pertaining to skin is resident flora.
Global Consensus Conference 509 Community health nursing—A field of nursing that is a blend of primary health care and nursing practice with public health nursing. Critical items—Items that enter sterile tissue or the vascular system must be sterile. High risk of infection if contaminated with any microorganism, including bacterial spores. Examples include devices that enter the vascular system or sterile tissue (eg, surgical instruments, intravascular catheters, implantable devices, biopsy forceps, and needles). Detergent—Any of a group of water-soluble cleaning agents that have wetting and emulsifying properties. Any cleaning agent, including soap. Disinfection—A process that eliminates many or all pathogenic microorganisms, with the exception of bacterial spores, from inanimate objects. Germicide—An agent that destroys microorganisms, particularly pathogenic organisms (“germs”). Other agents designated by words with the suffix “-cide” (eg, virucide, fungicide, bactericide, sporicide, and tuberculocide) destroy the microorganisms identified by the prefix. Hand-contact surfaces—Frequently touched vertical or horizontal fixed surfaces (eg, bedside rails, overbed table, and medical equipment display panel [monitor]). Hand antisepsis—A process for the removal or destruction of transient microorganisms from the hands. Hand hygiene—Measures used to prevent person-toperson transfer of microorganisms via the hands. Handrub—Process for application of an antimicrobial agent to the hands. Usually a waterless, alcohol-based product (ethyl, isopropyl, or n-propyl alcohol) provided in either a rub, gel, or wipe. It is useful for situations when potable water is not readily available. Alcohols are not good cleaning agents and therefore are not recommended if the hands are physically soiled with substances such as dirt and possibly organic material. Handwash(ing)—A process for the removal of dirt, organic material, and transient flora on hands (eg, soap/detergent and running water). High-level disinfection—Destruction of all microorganisms, with the exception of high numbers of bacterial spores. Used for semicritical devices (see Spaulding Classification). Examples of liquid chemicals used for this include 2% or greater glutaraldehyde, 7.5% hydrogen peroxide, 0.08% peracetic acid plus 1.0% hydrogen peroxide, 0.2% peracetic acid, 0.55% orthophthalaldehyde, and 0.35% peracetic acid. Home care—Health service provided in the patient’s place of residence for the purpose of promoting, maintaining, or restoring health or minimizing the effects of illness and disability. Intermediate-level disinfection—Inactivates Myco-
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510 Global Consensus Conference bacterium tuberculosis, vegetative bacteria, most viruses, and most fungi but does not necessarily kill bacterial spores. Used for some specific types of semicritical devices (eg, oral thermometer and hydrotherapy tank), and noncritical devices or surfaces (see Spaulding Classification). Long-term care—The provision of health, social, and personal care and housing services on a recurring or continuing basis to persons of all ages with chronic health and mental conditions that limit their ability to carry out normal daily activities without assistance. Encompasses care in institutions, community-based settings, and private homes. Low-level disinfection—Can kill most bacteria, some viruses, and some fungi but cannot be relied on to kill resistant microorganisms such as tubercle bacilli or bacterial spores. Used for noncritical devices or surfaces (see Spaulding Classification). Noncritical items—Come in contact with intact skin. Examples include sphygmomanometer, stethoscope, bed rails, linen, and bedside table. Non–hand-contact surfaces—Infrequently touched vertical or horizontal, fixed surfaces (eg, ceilings, walls, and underside of beds). Plain (bland) or nonantimicrobial soap— Detergent-based cleansers in any form (bar, liquid, leaflet, or powder) used for the primary purpose of physical removal of dirt and contaminating microorganisms. Resident flora—Microorganisms persistently isolated from the skin of most persons. (Also termed “colonizing flora” or commensals.) Semicritical items—Items that come in contact with mucous membranes or skin that is not intact. Such items should be free of all microorganisms, with exception of high numbers of bacterial spores. Underlying rationale is that mucous membranes are less susceptible to infection with spores but can be susceptible to infection with microbes such as tubercle bacilli and certain viruses. Examples include flexible, fiberoptic endoscopes, laryngoscope blades, and endocavitary ultrasound probe. Spaulding classification—A process classification scheme developed by Dr Earle H. Spaulding in 1968 based on the premise that the type of disinfection or sterilization needed for a device or instrument in between each patient use be based on degree of risk of infection involved in the use of the item/device. Devices were therefore categorized by Spaulding into 3 classes, critical, semicritical, and noncritical. (See definitions for each in this glossary.) Note: The Spaulding Classification is used primarily in North America. Other countries such as the United Kingdom may not use this approach. For example, in the United Kingdom, detergents are routinely used for clean-
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ing of floors. In the United States, by contrast, a germicidal detergent such as a quaternary ammonium compound (ie, surface-active agent) is often used for this purpose. Sterilization—Complete elimination or destruction of all forms of microbial life. Used for devices classified as critical (see Spaulding Classification). Accomplished typically by heat (eg, steam or hot air), low-temperature method (eg, ethylene oxide, ion gas plasma, or liquid chemical sterilant). Skilled nursing facility—An institution or part of an institution that provides skilled nursing care that might include rehabilitation and various nursing and medical procedures. Subacute care—A level of treatment that is between chronic and acute. Transient flora—Microorganisms isolated from the skin but not demonstrated to be consistently present in the majority of persons. Such flora generally are considered to be transient but are of concern because of ready transmission by hands. (Also termed “contaminating or noncolonizing flora.”)
References 1. Roman RS, Smith J, Walker M, et al. Rapid geographic spread of a methicillin-resistant Staphylococcus aureus strain. Clin Infect Dis 1997;25:698-705. 2. Nicolle LE, Dyck B, Thompson G, et al. Regional dissemination and control of epidemic methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol 1999;20:202-5. 3. Murray CJL, Lopez AD. Mortality by cause for eight regions of the world: global burden of disease study. Lancet 1997;349:1269-76. 4. Armstrong GL, Conn LA, Pinner RW. Trends in infectious disease mortality in the United States during the 20th century. JAMA 1999;281:61-6. 5. Lorber B. Are all diseases infectious? Ann Intern Med 1996;125:844-51. 6. Meier CR, Derby LE, Jick SS, et al. Antibiotics and risk of subsequent first-time acute myocardial infarction. JAMA 1999;281:427-31. 7. Bachmaier K, Neu N, de la Maza LM, et al. Chlamydia infections and heart disease linked through antigenic mimicry. Science 1999;283:1335-9. 8. Struelens MJ. The epidemiology of antimicrobial resistance in hospital acquired infections: problems and possible solutions. Br Med J 1998;317:652-4. 9. Gold HS, Moellering RC. Antimicrobial-drug resistance. N Engl J Med 1996;335:1445-3. 10. Archibald L, Phillips L, Monnet D, et al. Antimicrobial resistance in isolates from inpatients and outpatients in the United States: increasing importance of the intensive care unit. Clin Infect Dis 1997;24:211-5. 11. Hart CA, Kariuki S. Antimicrobial resistance in developing countries. Br Med J 1998;317:647-50. 12. Maguire GP, Arthur AD, Boustead PJ, et al. Emerging epidemic of community-acquired methicillin-resistant Staphylococcus aureus infection in the Northern Territory. Med J Austr 1996;164:721-23. 13. Rahal K, Wang F, Schindler J, et al. Reports on surveillance of antimicrobial resistance in individual countries. Clin Infect Dis 1997;24(Suppl 1):S169-75. 14. Tucci V, Haran MA, Isenberg HD. Epidemiology and control of
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vancomycin-resistant enterococci in an adult and children’s hospital. AJIC Am J Infect Control 1997;25:371-6. Brennen C, Wagener MM, Muder RR. Vancomycin-resistant Enterococcus faecium in a long-term care facility. J Am Geriatr Soc 1998;46:157-60. Vandenbroucke-Grauls C. Management of methicillin-resistant Staphylococcus aureus in the Netherlands. Rev Med Microbiol 1998;9:109-16. Seppala H, Klaukka T, Vuopio-Varkila J, et al. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. N Engl J Med 1997;337:441-6. Jernigan JA, Titus MG, Groschel DHM, et al. Effectiveness of contact isolation during a hospital outbreak of methicillin-resistant Staphylococcus aureus. Am J Epidemiol 1996;143:496-504. Quale J, Landman D, Saurina G, et al. Manipulation of a hospital antimicrobial formulary to control an outbreak of vancomycinresistant enterococci. Clin Infect Dis 1996;23:1020-5. Smith TL, Pearson ML, Wilcox KR, et al. Emergence of vancomycin resistance in Staphylococcus aureus. N Engl J Med 1999;340:493-501. Sieradzki K, Roberts RB, Haber SW, Tomasz A. The development of vancomycin resistance in a patient with methicillin-resistant Staphylococcus aureus infection. N Engl J Med 1999;340:517-23. US Congress, Office of Technology Assessment. Impacts of Antibiotic-Resistant Bacteria. OTA-H-629. Washington (DC): US Government Printing Office; 1995 Sept. Gonzales R, Steiner JF, Merle SA. Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA 1997;278:901-04. Shlaes DM, Gerding DN, John JF Jr, et al. Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Infect Control Hosp Epidemiol 1997;18:275-91. Levy SB. The challenge of antibiotic resistance. Sci Am 1998;278(3):46-53. Pecoul B, Chirac P, Trouiller P, et al. Access to essential drugs in poor countries. A lost battle? JAMA 1999;281:361-7. Slaughter S, Hayden MK, Nathan C, et al. A comparison of the effect of universal use of gloves and gowns with that of glove use alone on acquisition of vancomycin-resistant enterococci in a medical intensive care unit. Ann Intern Med 1996;125:448-56. Austin DJ, Anderson RM. Transmission dynamics of epidemic methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci in England and Wales. J Infect Dis 1999;179:88391. Larson EL, Bryan JL, Adler LM, et al. A multifaceted approach to changing handwashing behavior. AJIC Am J Infect Control 1997;25:3-10. Livornese LL, Dias S, Samel C, et al. Hospital-acquired infection with vancomycin-resistant Enterococcus faecium transmitted by electronic thermometers. Ann Intern Med 1992;117:112-6. Wendt C, Wiesenthal B, Dietz E, et al. Survival of vancomycinresistant and vancomycin-susceptible enterococci on dry surfaces. J Clin Microbiol 1998;36:3734-6. Smith TL, Iwen PC, Olson SB, et al. Environmental contamination with vancomycin-resistant enterococci in an outpatient setting. Infect Control Hosp Epidemiol 1998;19:515-8. Rutala WA, Stiegel MM, Sarubbi FA, et al. Susceptibility of antibiotic-susceptible and antibiotic-resistant hospital bacteria to disinfectants. Infect Control Hosp Epidemiol 1997;18:417-21. Anderson RL, Carr JH, Bond WW, et al. Susceptibility of vancomycin-resistant enterococci to environmental disinfectants. Infect Control Hosp Epidemiol 1997;18:195-9.
Bibliography Barrier Precautions and Isolation Report of a combined Working Party of the British Society for Antimicrobial Chemotherapy and Hospital Infection Society. Guidelines on the control of methicillin-resistant Staphylococcus aureus in the community. J Hosp Infect 1995;31:1-12. Commonwealth Department of Health and Family Services [Australia]. Antibiotic resistance. Available: http://www.health.gov.au/pubhlth/strateg/communic/antibiot.htm; accessed 4/19/99. Health Canada. Controlling antimicrobial resistance: an integrated action plan for Canadians. CCDR 1997; 23S7:1-32. Available: http://www.hc-sc.gc.ca/main/lcdc/web/dpg_e.html; accessed 4/19/99. Health Canada. Preventing the spread of vancomycin resistant enterococci (VRE) in Canada. CCDR 1997;23S8:1-1-11, 1-16. Available: http://www.hc-sc.gc.ca/main/lcdc/web/dpg_e.html; accessed 4/19/99. Garner JS, Hospital Infection Control Practices Advisory Committee (HICPAC). Guideline for isolation precautions in hospitals. Part I. Evolution of isolation precautions. AJIC Am J Infect Control 1996;24:24-31. Hospital Infection Control Practices Advisory Committee (HICPAC). Guideline for isolation precautions in hospitals. Part II. Recommendations for isolation precautions in hospitals. AJIC Am J Infect Control 1996;24:32-52. Report of a combined Working Party of the British Society for Antimicrobial Chemotherapy, the Hospital Infection Society, and the Infection Control Nurses Association. Revised guidelines for the control of methicillin-resistant Staphylococcus aureus infection in hospitals. J Hosp Infect 1998;39:253-90. Available at: http://www.hbuk.co.uk/hb/journals/hi/hi98/hi98.toc/039004t.htm; accessed, 4/19/99. Hospital Infection Control Practices Advisory Committee (HICPAC). Recommendations for preventing the spread of vancomycin resistance: recommendations of the HICPAC. AJIC Am J Infect Control 1995;23:87-94. Infection Control Nurses Association. Guidelines for hand hygiene. Bathgate, Scotland: Fitwise; 1999. Shlaes DM, Gerding DN, John JF Jr, et al. Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Infect Control Hosp Epidemiol 1997;18:275-91. Smith PW, Rusnak PG. Infection prevention and control in the longterm-care facility. AJIC Am J Infect Control 1997;25:488-512. Standing Medical Advisory Committee Sub-group on Antimicrobial Resistance. The path of least resistance: summary and recommendations. London: Department of Health; 1998.
Skin Cleansing and Antisepsis Garner JS, Favero MS. CDC guideline for handwashing and hospital environment control, 1985. Infect Control 1986;7:231-5. Larson EL, 1992, 1993, and 1994 APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. AJIC Am J Infect Control 1995;23:251-69. Health Canada. Hand washing, cleaning, disinfection and sterilization in health care. CCDR 1998; 24S8:1-55. Available: http://www.hc-sc.gc.ca/main/lcdc/web/dpg_e.html; accessed, 4/19/99.
Decontamination and Disinfection of the Environment and Equipment American Association of Medical Instrumentation. Safe handling and biological decontamination of medical devices in health care facilities and in nonclinical settings. American Association of Medical Instrumentation; 1996. i-ix, p. 1-40.
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512 Global Consensus Conference Rutala WA, 1994, 1995, and 1996 APIC Guidelines Committee. APIC guideline for selection and use of disinfectants. AJIC Am J Infect Control 1996;24:313-42. Health Canada. Hand washing, cleaning, disinfection and sterilization in health care. CCDR 1998;24S8:1-55. Available: http://www.hc-sc.gc.ca/main/lcdc/web/dpg_e.html; accessed 4/19/99.
APPENDIX Organizing Committee Georgia Dash (APIC) Candace Friedman, Chair (APIC) Dee May (ICNA) Pat Piaskowski (CHICA-Canada) Scientific Committee Carla Alvarado Elena Bourganskaia Georgia Dash—Chair Candace Friedman Stewart Gibson Karen Green Anne Griffiths-Jones Barbara Gruendemann Lee Hanna Mary LeBlanc Dee May Janet McCulloch Pearl Orenstein Shirley Paton Pat Piaskowski Jeanne Pfieffer Speakers Jose Cruz (US) Adriano Duse (South Africa) Julie Gerberding (US) Allison McGeer (Canada) Dominique Monnet (Denmark) Andrew Simor (Canada) Marjorie Underwood (US) Chief Facilitator Gilles Delage (Canada) LISTING OF DELEGATES BY WORKSHOP GROUP Barriers Anne Augustin (Canada) Adriano Duse (S Africa) John Gammon (UK) Julia Garner (US) Karen Green (Canada) Terri Goodman, Johnson & Johnson (US) Seto Wing Hong (China) Marguerite Jackson (US)
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Catherine Mallaghan (UK) Allison McGeer (Canada) Mark Miller (Canada) Dominique Monnet (Denmark) Lindsay Nicolle—Facilitator (Canada) Fernando Otaiza (Chile) Gopal Rao (UK) Jay Sommers, Kimberly-Clark (US) Bob Spencer (UK) Hayden Williams, Regent (UK) Skin Liz Bowley, deb (UK) RPD Cooke (UK) Ann Cote, Kimberly-Clark (US) Eilish Creamer (Ireland) Evonne Curran (Scotland) Donna Holton—Facilitator (Canada) Barry Farr (US) Stewart Gibson, Reckitt & Colman (UK) Dinah Gould (UK) Stefan Grosek (Slovenia) Anita Hanrahan (Canada) Sandra Harrison, Johnson & Johnson (US) Elaine Larson (US) Susan MacMillan (Canada) Rita McCormick (US) Folashade Tolulope Ogunsola (Nigeria) David Mullis, Regent (US) Mike Muschett, deb (Canada) Roger Olson, 3M Health Care (US) Laurie O’Neill (Canada) Denise Pretzer, STERIS (US) Manfred Rotter (Austria) Environment Michelle Alfa (Canada) Nancy Alfieri (Canada) Carla Alvarado (US) Roy Browning (Scotland) Jacqueline Daley, 3M Health Care (Canada) Martin Favero (US) Adam Fraise (UK) Carol Goldman (Canada) Hilary Humphreys (Ireland) Lynn Johnston—Facilitator (Canada) Paul Malchesky, STERIS (US) Cathryn Murphy (Australia) Frank Rhame (US) Joe Rubino, Reckitt & Colman (US) William Rutala (US) Syed Sattar (Canada) Mark Wilcox (UK)
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Association Representatives
Corporate Sponsors
Ginette Hebert, President, Community and Hospital Infection Control Association— Canada Susan MacQueen, Chair, Infection Control Nurses Association Janet Franck, President, Association for Professionals in Infection Control and Epidemiology, Inc.
3M Health Care Deb-Canada & U.K. Johnson & Johnson Medical Kimberly-Clark Reckitt & Colman Regent Medical STERIS
Endorsements Laboratory Centre for Disease Control (LCDC)— Health Canada International Federation of Infection Control (IFIC) National Center for Infectious Diseases, US Centers for Disease Control and Prevention (CDC)
Editor—Conference Proceedings Russell Olmsted
17/52/102609
Enterobacteriaceae, penicillin-resistant Streptococcus pneumoniae, and Acinetobacter baumannii, are also difficult pathogens to treat/control; however, these AROs were not specifically addressed at this conference. Even so, some of the recommendations that emerged might be more widely applicable to other AROs. The conference presented a major opportunity for professionals and scientists in the infection prevention and control field to discuss trends and develop strategies for best practice. CONFERENCE ORGANIZERS This conference was coordinated by infection control professional organizations in the United States, Canada, and the United Kingdom. These organizations are: • The Association for Professionals in Infection Control and Epidemiology, Inc (APIC) • The Community and Hospital Infection Control Association—Canada (CHICA) • The Infection Control Nurses Association (ICNA) DELEGATES Delegates were invited experts from the fields of health care epidemiology, clinical/medical microbiology, infectious diseases, industry, and infection control. They included physicians, microbiologists, medical technologists, nurses, other health care personnel, and corporate sponsor representatives. Participation was by invitation only. (See list of delegates in the Appendix.) FORMAT The Scientific Committee organized a series of plenary sessions to present the important issues involving MRSA and VRE. Three workshops, Barriers, Skin, and Environment, then provided opportunities for delegates to contribute their own views to the proceedings and develop recommendations to answer specific questions assigned to each. The recommendations from the workshops were presented in a final session, and consensus recommendations were arrived at by using electronic voting. The definition of consensus based on tallied votes was as follows: 1. 90% or more of delegates voting for a recommendation = consensus 2. 75%-<90% of delegates voting for a recommenda503
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504 Global Consensus Conference tion = consensus as long as no delegate strongly disagreed with the recommendation 3. <75% of delegates voting for a recommendation = no consensus Only recommendations reaching consensus are outlined under each workshop heading. WORKSHOPS • Barriers: barrier precautions/patient isolation/ screening • Skin: hand hygiene, including skin decontamination, cleansing, and antisepsis • Environment: decontamination and disinfection— the role of the environment and equipment INTRODUCTION All conference participants acknowledged that antibiotic resistance is a global public health crisis with potential for adversely affecting health and leading, potentially, to a “post-antibiotic era.” A global perspective and action are urgently needed. By illustration, a traveler can spread a clonal strain relatively easily over long distances with modern air travel and unintentionally serve as a source of spread of MRSA through several health care facilities around the globe.1,2 Despite significant progress against morbidity and mortality associated with infectious diseases, 5 of the 10 leading causes of death are communicable diseases or perinatal disorders.3 In the previous few decades, trends in the United States demonstrated a significant decline in infectious disease mortality. However, this trend was reversed with the emergence of HIV,4 a reminder that the microbial ecosystem is unpredictable and dynamic. Against this background, there is growing recognition that microorganisms play a wider role as contributors to chronic, noninfectious diseases.5 Preliminary reports that antibiotics might be able to prevent progression of atherosclerosis or prevent myocardial infarction are further evidence of the need to maintain antibiotic effectiveness.6,7 The progression of antibiotic resistance has been unrelenting among hospitalized patients.8 In the United States alone, there has been a 20-fold increase in the frequency of VRE as nosocomial pathogens.9 Antibiotic resistance knows no boundaries and is observed in industrialized countries, developing countries, the community, and across the spectrum of care delivery.10-15 Trends by country/region for the prevalence of VRE and MRSA are summarized in Table 1. What is apparent is that the frequency of MRSA and VRE varies considerably among countries and also within geographic locations. There are examples of successful control through screening and isolation precautions and nationwide
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decrease in consumption of certain antibiotics that can reverse antibiotic resistance.16-19 However, juxtaposed against some positive interventions are more recent reports of emergence of even more challenging microbes, such as vancomycin-resistant S aureus.20,21 One estimate places the direct cost of nosocomial infections caused by 6 different strains of AROs to be minimally $1.3 billion (1992 US dollars)/year in the United States.22 A reversal of trends highlighted previously is needed. This reversal will require joint efforts on the part of physicians and other health care providers, as well as the ICP and, ultimately, the consumer.23 CONFERENCE GUIDING PRINCIPLE Prudent use of antimicrobials is of paramount importance in the prevention and control of AROs. The fundamental and perhaps ultimate control of AROs depends on addressing the root cause for the emergence of most of these strains: inappropriate use of antibiotics. Whereas it is acknowledged that development of antibiotic resistance is multifactorial, 2 key factors are the prevalence of resistance genes and the extent of antibiotic use in humans and animals. Selective pressure from widespread use of antibiotics often gives rise to AROs; there have been numerous examples of a causal association between antibiotic consumption and emergence of AROs.24 Levy suggests maintenance of antibiotic use below a threshold (sufficient amount to treat infections within a hospital or community but not encourage propagation of resistant strains).25 Therefore, the delegates reinforce as fundamental to control and prevention of AROs the prudent use of not only antibiotics, but also more broadly, antimicrobials. However, use of antibiotics was not the focus of this conference. WORKSHOP PREAMBLES, GUIDING PRINCIPLES, ASSUMPTIONS, AND FINAL RECOMMENDATIONS Please note: Workshop recommendations are published in the order in which they were presented for consensus voting. As such there is no intentional or implied hierarchical or rank order to the recommendations that follow. Barriers Workshop—Preamble The Barriers Workshop participants believed strongly that their recommendations need to be recognized as general in scope so that countries and practice settings interpret and tailor interventions based on the local epidemiology of MRSA and VRE. Access to essential medications in developing nations is limited, and the same may apply to the items needed for application of isolation precautions.26 In addition, risk of transmission will likely vary from one patient care setting to another. Brennen and others monitored potential for spread of
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Table 1. Examples of frequency of MRSA and VRE by country/region Source
Country/location
MRSA prevalence
VRE prevalence
Voss A, et al. Eur J Clin Microbiol Infect Dis 1994;13:50-5.
Denmark
0.1%
Voss A, et al. Eur J Clin Microbiol Infect Dis 1994;13:50-5 (MRSA); Boisivon A, et al. Clin Microbiol Infect 1996;3:175-9 (VRE)
France
33.8%
Struelens MJ, et al. Infect Control Hosp Epidemiol 1996;17:503-8.
Belgium
1.6%-62.4%
Martone WJ. Infect Control Hosp Epidemiol 1998;19:539-45.
US, ICUs, NNIS Hospitals
Voss A, et al. Eur J Clin Microbiol Infect Dis 1994;13:50-5. Folorunso AB, et al. Infect Control Hosp Epidemiol 1997;18:765-7.
Spain, Italy 1500-bed teaching hospital, Hong Kong, China
>30% 0.24–14.88 per 100 discharges
Canadian Nosocomial Infection Surveillance Program.
Canada
3.4% (range 0%-18%, 1995-1998)
Duse A. GCC Conference; 1999.
S Africa
21%
Dornbusch K, et al. Scand J Infect Dis 1998;30:281-8.
North, Central, and Southern Europe (blood isolates only)
0.8% (North) 14% (Central) 41% (South)
Torvaldsen S, et al. Infect Control Hosp Epidemiol 1999;20:133-5.
Western Australia
12.0/10 (1993) 27.0/105 (1995) 55.7/105 (1997)
VRE among long-term care patients and found that patient-to-patient spread was infrequent.15 In contrast, an intensive care unit may elect to extend the practice of precautions to universal application of gowns/aprons and gloves to improve adherence by health care personnel with isolation precautions.27 Another issue to be considered when developing strategies for containment of AROs includes the level of endemic rates. Austin and Anderson have recently applied observational data to develop models for the dynamics of transmission of MRSA and VRE, which can be used for designing interventional and programmatic changes.28 This is an example of application of local epidemiologic data to counter further spread of MRSA and VRE. Other variables that impinge on the success of infection prevention and control include an understanding of the behavior that motivates health care personnel and variation in the epidemiology between MRSA and VRE. Adherence by personnel to hand hygiene, the fundamental procedure to prevent the spread of resistant and susceptible microorganisms, is variable and usually suboptimal. Even application of behavioral theory to improve on this adherence has not met with sustained success.29 Thus education, monitoring of adherence, and availability of adequate personnel are part of strategies to control AROs. Last, an assessment of the published evidence that uses scoring methods in combina-
tion with local knowledge will result in improved decision support and action. Two areas this workshop did not address were efficacy of empiric precautions and procedures for transfer of patients through the continuum of care. Barriers Workshop—Questions asked to address: 1. When and what kind of spatial separation is needed? 2. When are physical barriers needed and what are they? 3. How do we identify patients who need spatial or physical barriers? 4. Should we identify colonized staff and under what circumstances?
2% (colonization)
0.4% (1989) 13.6% (1994) 23.2% (1997)
5% (North) 3% (Central) N/A (South)
Barriers Workshop—Final Recommendations 1. Use spatial separation between patients known to be infected or colonized with MRSA or VRE and patients who are not known to be infected or colonized. 2. For placement of patients known to be infected or colonized with MRSA or VRE: i. a single room, preferably with a self-contained bathroom, is the first choice. ii. room sharing by or cohorting of patients infected or colonized with the same organism (MRSA or VRE) is a second choice. iii. room or ward sharing with noninfected or noncolonized patient(s) is the third choice.
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506 Global Consensus Conference The priority for a single room or choice of roommate(s) is determined by a risk assessment of the patient population taking into consideration: i. likelihood of MRSA/VRE transmission from the source patient. ii. risk and consequences of the noninfected or colonized roommate(s) becoming colonized or infected. iii. the setting in which care is provided. 3. Maintain appropriate staffing levels to provide adequate patient care for whatever means of placement is chosen. 4. Use physical barriers appropriately to reduce the risk of transmission of MRSA/VRE among patients. 5. Wear clean, nonsterile gloves when touching the patient or a potentially contaminated environmental source: • Change gloves between patients. Change gloves between tasks on the same patient when contamination has occurred. • When glove supply is limited, use gloves for touching draining body fluids, wound sites, or stool. • Wash hands after removing gloves. 6. Use gowns or plastic aprons to protect the skin or clothing from gross contamination. 7. There is insufficient evidence to make recommendations for or against the routine use of gowns or aprons in preventing the transmission of MRSA/VRE. 8. There is insufficient evidence to make recommendations for or against the use of masks or eye or mucous membrane protection to prevent the transmission of MRSA/VRE. 9. Shoe covers and hair covers are not recommended. 10. Where resources for physical barriers are limited, establish glove use as the first priority. 11. Information describing the need for and type of physical barriers appropriate for a given patient must be readily accessible and communicated. 12. Assess the impact of physical barriers on psychologic, cultural, and care needs of the patient. • Seek interventions to minimize the negative impacts without increasing the risk of transmission. 13. The need for continuation of spatial separation or physical barriers should be reassessed periodically. • Discontinue as soon as feasible. • Determinants for discontinuation must be individualized. 14. The goal of screening of patients for MRSA or VRE must be identified before screening is undertaken. 15. Before screening is undertaken: • cost-effectiveness must be considered. • appropriate laboratory support must be available.
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16. Situations in which a strong recommendation for screening may be made include: • exposed patients in an outbreak situation in which identification of colonized patients is an adjunct in outbreak control. • in evaluation of the effectiveness of an intervention. No consensus could be reached about the use of screening in other specific situations beyond those in recommendation 16. 17. Do not screen staff unless they are epidemiologically linked to ongoing transmission. Skin Workshop—Preamble Participants in this workshop started with the premise that the ultimate goal of cleansing the skin of care providers, regardless of specific product used, is to prevent the transmission of infection, including AROs, from their hands. Incumbent in this goal are some basic principles and underlying assumptions: i. Soap/detergent and water removes soil and some transient microbes from the skin but does not destroy microbes such as MRSA and VRE. ii. Antiseptic/detergent products remove soil and remove and destroy microbes on the skin. iii. Antiseptic products formulated for use without water do not remove soil, but do remove and destroy microbes on skin. iv. Visible soiling must first be removed by some means before the use of an antiseptic agent that does not remove soil. v. There is no evidence that AROs are less susceptible to soap/detergent products or antiseptic agents when compared with antibiotic-susceptible organisms. vi. Currently, there is no evidence for resistance of AROs to antiseptic agents at recommended concentrations. Antiseptic agents act in a nonspecific manner and at multiple target sites in/on microorganisms. The Skin Workshop also developed the following guiding principles relating to hand hygiene and AROs. A. National or local guidelines outlining hand hygiene shall be followed. B. Because adherence to hand hygiene guidelines has been shown to be inadequate, particular efforts to improve hand hygiene practices in high-risk areas, with high-risk patients, and with patients known to have AROs are warranted. C. Efforts must be made to protect the integrity and health of care providers’ hands. D. Product use and storage must take into account national and local guidelines and manufacturer’s instructions, as well as available scientific information.
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E. Antiseptic products selected for use shall meet national/international criteria for safety and efficacy. Skin Workshop—Questions asked to address: 1. Do you need to do anything differently when you have AROs? 2. When do you need antimicrobial agents? 3. Where there is no water, what should be done? 4. What antimicrobial agents can be used? Skin Workshop—Final Recommendations 1. Hand hygiene is the single most important procedure for preventing the transmission of AROs. 2. Whereas research data from randomized controlled trials showing that use of antiseptic products will actually reduce infections is lacking, evidence suggests that the removal of ARO’s from hands with soap/detergent and water is less effective than with the application of an antiseptic product. An antiseptic agent should be readily available and accessible to care providers working in any setting. 3. An antiseptic product shall be used in high-risk areas, with high-risk patients, and with known ARO patients. • High-risk areas may include, but are not limited to: a. intensive care units b. transplant units c. burn units d. hematology/oncology units e. hemodialysis units • Patients at high risk of acquisition/transmission of AROs may include but are not limited to those: a. receiving multiple antibiotics or receiving repeated treatments with antibiotics b. with prolonged hospital stay c. with frequent admissions d. transferred from other health care facilities or units with a high endemic rate of AROs • Use of antiseptics with known ARO patients shall include, but is not limited to: a. acute care b. long-term care in which more than residential care is provided c. community settings in which care providers move from home to home 4. High-risk areas and high-risk patients shall be identified by regular assessment at local and institutional levels. 5. The risk assessment for acquisition/transmission of AROs may include patient surveillance cultures as directed by infection control personnel. 6. A. In the absence of sufficient or adequate handwashing facilities and where there is no visible soil, an antiseptic product formulated for use without water shall be used.
Global Consensus Conference 507 B. In the absence of sufficient or adequate handwashing facilities and where there is visible soil, soil must first be removed by some means (eg, rinsing, mechanical rubbing, and wipes) before use of an antiseptic product formulated for use without water. Environment Workshop—Preamble Several studies have demonstrated that VRE can survive in the environment for prolonged periods, and outbreaks involving an environmental reservoir have been reported.30 However, environmental survival of resistant and susceptible enterococci are similar.31 In addition, AROs may simply be highlighting problems with the infrastructure of care delivery such as decreased support or time for cleaning of the environment.32 Last, there is no evidence that pathogens such as VRE and MRSA are more resistant to disinfectants applied to inanimate surfaces when used at proper dilution and with sufficient contact time.33,34 The following assumptions were developed by this workshop and should be considered when reviewing the recommendations. i. Housekeeping practices in health care facilities have deteriorated. ii. MRSA and VRE are becoming endemic in many areas. iii. The role of air in transmission of MRSA and VRE has not been elucidated and therefore was not dealt with by this workshop. iv. MRSA and VRE are no more resistant to inactivation by germicides than sensitive isolates. v. There is insufficient evidence to fully assess the role of the environment in transmission of infection. vi. We recognize that the environment is only one factor in the risk of transmission of VRE and MRSA. vii. Agents used in environmental cleaning differ between North America (detergent-disinfectant) and Europe (detergent). viii. The Spaulding Classification (not used in all parts of Europe or the United Kingdom) was used as the basis for discussion (see “Glossary”). Environment Workshop—Questions asked to address: 1. Do you need to do anything differently when you have AORs? If yes, at what frequency? 2. When do you need disinfectants/detergents for environmental (surfaces, noncritical) cleaning? 3. Where there is no water or use of water is not appropriate (eg, monitors and pumps), what should be done? Environment Workshop—Guiding Principles A. Recommendations must consider safety of humans, animals, and the environment.
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B. We will generally not qualify statements as minimum requirements. C. Evidence-based recommendations were developed, where possible, but when lacking, good judgment should prevail. Environment Workshop—Final Recommendations 1.
Routine culturing of the environment or air is discouraged. 2. Culturing of the environment is acceptable when epidemiologically indicated and for research and educational purposes. 3. Each facility should use a method to validate compliance with their cleaning, disinfecting, and sterilization practices. 4. Each facility should assign responsibility for implementation of these practices. 5. Cleaning procedures need to be defined and shall be applied consistently. 6. Surfaces and equipment should be easily cleanable. 7. Adequate staffing and sufficient effort must be put into physical cleaning of the environment. 8. Products should be used according to national or local guidelines, manufacturer’s instructions, and available scientific information; ensure product contact with all surfaces being treated. Acute care delivery area 9. Where detergents-disinfectants are used for environmental cleaning, no additional or different products are required in the presence of MRSA/VRE. 10. Non–hand-contact (infrequently touched) environmental surfaces should be cleaned when visibly soiled and as required to maintain an aesthetically pleasing environment. Cleaning with detergent is sufficient. Facilities may choose to use a detergent-disinfectant for convenience. 11. Hand-contact environmental surfaces should undergo at least daily thorough cleaning. Where detergents are routinely used, a detergent-disinfectant should be used for MRSA and VRE. 12. Noncritical equipment used for MRSA and VRE patients should be dedicated where possible. 13. When dedicated equipment is not possible, shared noncritical items will be cleaned and disinfected between patient use. 14. Limit quantity of disposable items taken into room or designated space of VRE/MRSA patient to what would be reasonably used for that patient. 15. Consider discarding unused disposable items that cannot be cleaned or disinfected after MRSA/VRE patient discharge. Broad application: not necessarily limited to acute care setting 16. Under special circumstances for example out-
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break, hyperendemic situations, additional procedures may be implemented at the discretion and direction of facility’s infection control program director or according to current guidelines. 17. Terminal cleaning (when patient is discharged from the room or when isolation is discontinued) is to be done as an opportunity to clean areas not routinely accessible and in accordance with previously stated recommendations. 18. Use currently accepted guidelines for disinfection and sterilization of critical and semicritical items. 19. No additional procedures are required for cleaning, disinfecting, and sterilizing critical and semicritical items in the presence of MRSA/VRE. Nonacute care delivery areas 20. Under usual circumstances, no additional or different practices are required in the presence of MRSA/VRE. 21. Non–hand-contact environmental surfaces should be cleaned when visibly soiled and as required to maintain aesthetics. 22. Hand-contact environmental surfaces should undergo regular thorough cleaning; there is insufficient evidence to make a recommendation on the frequency of cleaning. 23. Cleaning with a detergent is sufficient. 24. There is insufficient evidence to make a recommendation on using detergent versus detergentdisinfectant. Home care delivery setting 25. Equipment used in the home care environment by health care personnel is handled the same as in acute care facilities. 26. Family members should be provided common sense information about cleaning of the home. Nonwater immersible items (NWII) 27. Environmental cleaning products should be chosen on the basis of efficacy and safety. 28. NWII should be cleaned and where necessary decontaminated with a method compatible with the item. 29. Items not easily cleaned (eg, computer keyboards) but easily contaminated—cover with plastic and clean regularly. Water inaccessible area/location 30. Facilities should be prepared for situations where water is inaccessible (eg, planned water disruptions, storm warnings, and disaster situations). 31. Select acceptable ready-to-use disinfecting products, which do not require rinsing. Decolonization therapy 32. Decolonization is not recommended unless there is epidemiologic evidence that the colonized person is spreading the organism.
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Research agenda (areas in need of further scientific investigation) 1. Impact of disinfectant use on emergence of antimicrobial resistance in MRSA/VRE 2. Role of air in transmission of MRSA 3. Define techniques to minimize transmission of MRSA/VRE from environment 4. Detergents versus disinfectants for environmental cleaning GLOSSARY Note: Some of the terms included in this glossary were developed and provided by some of the workshops during their deliberations. Other terms were abstracted from published resources and are included to assist the reader. Therefore, these were not distributed to all workshops before their sessions. The GCC Organizing and Scientific Committees would like to thank and acknowledge those persons who contributed to this glossary. Acute care—A pattern of health care in which a patient is treated for a brief but severe episode of illness, for the sequelae of an accident or other trauma, or during recovery from surgery. Ambulatory care—Health services provided on an outpatient basis to persons who visit a facility for care and depart on the same day. Antibiotic—A naturally occurring or synthetic organic substance that inhibits or destroys selective bacteria or other microorganisms. Antimicrobial agent—A product that destroys or inhibits the growth of microorganisms. Antimicrobial soap—A soap containing an ingredient with in vitro and in vivo activity against skin flora. Antiseptic—A chemical germicide or product that destroys or inhibits growth of microorganisms formulated for use on skin or tissue and should not be used to decontaminate inanimate objects. Examples include isopropyl alcohol, chlorhexidine gluconate, and tincture of iodine. Biocide—A chemical agent, usually broad spectrum, that destroys microorganisms. Chemical sterilant—Liquid chemical used to destroy all forms of microbial life, including fungal and bacterial spores. Often used for high-level disinfection when used for shorter exposure periods (eg, device immersed in 2% glutaraldehyde for ≥20 minutes). Cleaning—Removal, usually with detergent or enzymatic products, mechanical action, and water, of all foreign material (eg, blood, soil, and organic material) from objects or surfaces. Commensals—Microorganisms living with, on, or in a person without causing infection, inflammation, or injury. An example pertaining to skin is resident flora.
Global Consensus Conference 509 Community health nursing—A field of nursing that is a blend of primary health care and nursing practice with public health nursing. Critical items—Items that enter sterile tissue or the vascular system must be sterile. High risk of infection if contaminated with any microorganism, including bacterial spores. Examples include devices that enter the vascular system or sterile tissue (eg, surgical instruments, intravascular catheters, implantable devices, biopsy forceps, and needles). Detergent—Any of a group of water-soluble cleaning agents that have wetting and emulsifying properties. Any cleaning agent, including soap. Disinfection—A process that eliminates many or all pathogenic microorganisms, with the exception of bacterial spores, from inanimate objects. Germicide—An agent that destroys microorganisms, particularly pathogenic organisms (“germs”). Other agents designated by words with the suffix “-cide” (eg, virucide, fungicide, bactericide, sporicide, and tuberculocide) destroy the microorganisms identified by the prefix. Hand-contact surfaces—Frequently touched vertical or horizontal fixed surfaces (eg, bedside rails, overbed table, and medical equipment display panel [monitor]). Hand antisepsis—A process for the removal or destruction of transient microorganisms from the hands. Hand hygiene—Measures used to prevent person-toperson transfer of microorganisms via the hands. Handrub—Process for application of an antimicrobial agent to the hands. Usually a waterless, alcohol-based product (ethyl, isopropyl, or n-propyl alcohol) provided in either a rub, gel, or wipe. It is useful for situations when potable water is not readily available. Alcohols are not good cleaning agents and therefore are not recommended if the hands are physically soiled with substances such as dirt and possibly organic material. Handwash(ing)—A process for the removal of dirt, organic material, and transient flora on hands (eg, soap/detergent and running water). High-level disinfection—Destruction of all microorganisms, with the exception of high numbers of bacterial spores. Used for semicritical devices (see Spaulding Classification). Examples of liquid chemicals used for this include 2% or greater glutaraldehyde, 7.5% hydrogen peroxide, 0.08% peracetic acid plus 1.0% hydrogen peroxide, 0.2% peracetic acid, 0.55% orthophthalaldehyde, and 0.35% peracetic acid. Home care—Health service provided in the patient’s place of residence for the purpose of promoting, maintaining, or restoring health or minimizing the effects of illness and disability. Intermediate-level disinfection—Inactivates Myco-
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510 Global Consensus Conference bacterium tuberculosis, vegetative bacteria, most viruses, and most fungi but does not necessarily kill bacterial spores. Used for some specific types of semicritical devices (eg, oral thermometer and hydrotherapy tank), and noncritical devices or surfaces (see Spaulding Classification). Long-term care—The provision of health, social, and personal care and housing services on a recurring or continuing basis to persons of all ages with chronic health and mental conditions that limit their ability to carry out normal daily activities without assistance. Encompasses care in institutions, community-based settings, and private homes. Low-level disinfection—Can kill most bacteria, some viruses, and some fungi but cannot be relied on to kill resistant microorganisms such as tubercle bacilli or bacterial spores. Used for noncritical devices or surfaces (see Spaulding Classification). Noncritical items—Come in contact with intact skin. Examples include sphygmomanometer, stethoscope, bed rails, linen, and bedside table. Non–hand-contact surfaces—Infrequently touched vertical or horizontal, fixed surfaces (eg, ceilings, walls, and underside of beds). Plain (bland) or nonantimicrobial soap— Detergent-based cleansers in any form (bar, liquid, leaflet, or powder) used for the primary purpose of physical removal of dirt and contaminating microorganisms. Resident flora—Microorganisms persistently isolated from the skin of most persons. (Also termed “colonizing flora” or commensals.) Semicritical items—Items that come in contact with mucous membranes or skin that is not intact. Such items should be free of all microorganisms, with exception of high numbers of bacterial spores. Underlying rationale is that mucous membranes are less susceptible to infection with spores but can be susceptible to infection with microbes such as tubercle bacilli and certain viruses. Examples include flexible, fiberoptic endoscopes, laryngoscope blades, and endocavitary ultrasound probe. Spaulding classification—A process classification scheme developed by Dr Earle H. Spaulding in 1968 based on the premise that the type of disinfection or sterilization needed for a device or instrument in between each patient use be based on degree of risk of infection involved in the use of the item/device. Devices were therefore categorized by Spaulding into 3 classes, critical, semicritical, and noncritical. (See definitions for each in this glossary.) Note: The Spaulding Classification is used primarily in North America. Other countries such as the United Kingdom may not use this approach. For example, in the United Kingdom, detergents are routinely used for clean-
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ing of floors. In the United States, by contrast, a germicidal detergent such as a quaternary ammonium compound (ie, surface-active agent) is often used for this purpose. Sterilization—Complete elimination or destruction of all forms of microbial life. Used for devices classified as critical (see Spaulding Classification). Accomplished typically by heat (eg, steam or hot air), low-temperature method (eg, ethylene oxide, ion gas plasma, or liquid chemical sterilant). Skilled nursing facility—An institution or part of an institution that provides skilled nursing care that might include rehabilitation and various nursing and medical procedures. Subacute care—A level of treatment that is between chronic and acute. Transient flora—Microorganisms isolated from the skin but not demonstrated to be consistently present in the majority of persons. Such flora generally are considered to be transient but are of concern because of ready transmission by hands. (Also termed “contaminating or noncolonizing flora.”)
References 1. Roman RS, Smith J, Walker M, et al. Rapid geographic spread of a methicillin-resistant Staphylococcus aureus strain. Clin Infect Dis 1997;25:698-705. 2. Nicolle LE, Dyck B, Thompson G, et al. Regional dissemination and control of epidemic methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol 1999;20:202-5. 3. Murray CJL, Lopez AD. Mortality by cause for eight regions of the world: global burden of disease study. Lancet 1997;349:1269-76. 4. Armstrong GL, Conn LA, Pinner RW. Trends in infectious disease mortality in the United States during the 20th century. JAMA 1999;281:61-6. 5. Lorber B. Are all diseases infectious? Ann Intern Med 1996;125:844-51. 6. Meier CR, Derby LE, Jick SS, et al. Antibiotics and risk of subsequent first-time acute myocardial infarction. JAMA 1999;281:427-31. 7. Bachmaier K, Neu N, de la Maza LM, et al. Chlamydia infections and heart disease linked through antigenic mimicry. Science 1999;283:1335-9. 8. Struelens MJ. The epidemiology of antimicrobial resistance in hospital acquired infections: problems and possible solutions. Br Med J 1998;317:652-4. 9. Gold HS, Moellering RC. Antimicrobial-drug resistance. N Engl J Med 1996;335:1445-3. 10. Archibald L, Phillips L, Monnet D, et al. Antimicrobial resistance in isolates from inpatients and outpatients in the United States: increasing importance of the intensive care unit. Clin Infect Dis 1997;24:211-5. 11. Hart CA, Kariuki S. Antimicrobial resistance in developing countries. Br Med J 1998;317:647-50. 12. Maguire GP, Arthur AD, Boustead PJ, et al. Emerging epidemic of community-acquired methicillin-resistant Staphylococcus aureus infection in the Northern Territory. Med J Austr 1996;164:721-23. 13. Rahal K, Wang F, Schindler J, et al. Reports on surveillance of antimicrobial resistance in individual countries. Clin Infect Dis 1997;24(Suppl 1):S169-75. 14. Tucci V, Haran MA, Isenberg HD. Epidemiology and control of
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vancomycin-resistant enterococci in an adult and children’s hospital. AJIC Am J Infect Control 1997;25:371-6. Brennen C, Wagener MM, Muder RR. Vancomycin-resistant Enterococcus faecium in a long-term care facility. J Am Geriatr Soc 1998;46:157-60. Vandenbroucke-Grauls C. Management of methicillin-resistant Staphylococcus aureus in the Netherlands. Rev Med Microbiol 1998;9:109-16. Seppala H, Klaukka T, Vuopio-Varkila J, et al. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. N Engl J Med 1997;337:441-6. Jernigan JA, Titus MG, Groschel DHM, et al. Effectiveness of contact isolation during a hospital outbreak of methicillin-resistant Staphylococcus aureus. Am J Epidemiol 1996;143:496-504. Quale J, Landman D, Saurina G, et al. Manipulation of a hospital antimicrobial formulary to control an outbreak of vancomycinresistant enterococci. Clin Infect Dis 1996;23:1020-5. Smith TL, Pearson ML, Wilcox KR, et al. Emergence of vancomycin resistance in Staphylococcus aureus. N Engl J Med 1999;340:493-501. Sieradzki K, Roberts RB, Haber SW, Tomasz A. The development of vancomycin resistance in a patient with methicillin-resistant Staphylococcus aureus infection. N Engl J Med 1999;340:517-23. US Congress, Office of Technology Assessment. Impacts of Antibiotic-Resistant Bacteria. OTA-H-629. Washington (DC): US Government Printing Office; 1995 Sept. Gonzales R, Steiner JF, Merle SA. Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA 1997;278:901-04. Shlaes DM, Gerding DN, John JF Jr, et al. Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Infect Control Hosp Epidemiol 1997;18:275-91. Levy SB. The challenge of antibiotic resistance. Sci Am 1998;278(3):46-53. Pecoul B, Chirac P, Trouiller P, et al. Access to essential drugs in poor countries. A lost battle? JAMA 1999;281:361-7. Slaughter S, Hayden MK, Nathan C, et al. A comparison of the effect of universal use of gloves and gowns with that of glove use alone on acquisition of vancomycin-resistant enterococci in a medical intensive care unit. Ann Intern Med 1996;125:448-56. Austin DJ, Anderson RM. Transmission dynamics of epidemic methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci in England and Wales. J Infect Dis 1999;179:88391. Larson EL, Bryan JL, Adler LM, et al. A multifaceted approach to changing handwashing behavior. AJIC Am J Infect Control 1997;25:3-10. Livornese LL, Dias S, Samel C, et al. Hospital-acquired infection with vancomycin-resistant Enterococcus faecium transmitted by electronic thermometers. Ann Intern Med 1992;117:112-6. Wendt C, Wiesenthal B, Dietz E, et al. Survival of vancomycinresistant and vancomycin-susceptible enterococci on dry surfaces. J Clin Microbiol 1998;36:3734-6. Smith TL, Iwen PC, Olson SB, et al. Environmental contamination with vancomycin-resistant enterococci in an outpatient setting. Infect Control Hosp Epidemiol 1998;19:515-8. Rutala WA, Stiegel MM, Sarubbi FA, et al. Susceptibility of antibiotic-susceptible and antibiotic-resistant hospital bacteria to disinfectants. Infect Control Hosp Epidemiol 1997;18:417-21. Anderson RL, Carr JH, Bond WW, et al. Susceptibility of vancomycin-resistant enterococci to environmental disinfectants. Infect Control Hosp Epidemiol 1997;18:195-9.
Bibliography Barrier Precautions and Isolation Report of a combined Working Party of the British Society for Antimicrobial Chemotherapy and Hospital Infection Society. Guidelines on the control of methicillin-resistant Staphylococcus aureus in the community. J Hosp Infect 1995;31:1-12. Commonwealth Department of Health and Family Services [Australia]. Antibiotic resistance. Available: http://www.health.gov.au/pubhlth/strateg/communic/antibiot.htm; accessed 4/19/99. Health Canada. Controlling antimicrobial resistance: an integrated action plan for Canadians. CCDR 1997; 23S7:1-32. Available: http://www.hc-sc.gc.ca/main/lcdc/web/dpg_e.html; accessed 4/19/99. Health Canada. Preventing the spread of vancomycin resistant enterococci (VRE) in Canada. CCDR 1997;23S8:1-1-11, 1-16. Available: http://www.hc-sc.gc.ca/main/lcdc/web/dpg_e.html; accessed 4/19/99. Garner JS, Hospital Infection Control Practices Advisory Committee (HICPAC). Guideline for isolation precautions in hospitals. Part I. Evolution of isolation precautions. AJIC Am J Infect Control 1996;24:24-31. Hospital Infection Control Practices Advisory Committee (HICPAC). Guideline for isolation precautions in hospitals. Part II. Recommendations for isolation precautions in hospitals. AJIC Am J Infect Control 1996;24:32-52. Report of a combined Working Party of the British Society for Antimicrobial Chemotherapy, the Hospital Infection Society, and the Infection Control Nurses Association. Revised guidelines for the control of methicillin-resistant Staphylococcus aureus infection in hospitals. J Hosp Infect 1998;39:253-90. Available at: http://www.hbuk.co.uk/hb/journals/hi/hi98/hi98.toc/039004t.htm; accessed, 4/19/99. Hospital Infection Control Practices Advisory Committee (HICPAC). Recommendations for preventing the spread of vancomycin resistance: recommendations of the HICPAC. AJIC Am J Infect Control 1995;23:87-94. Infection Control Nurses Association. Guidelines for hand hygiene. Bathgate, Scotland: Fitwise; 1999. Shlaes DM, Gerding DN, John JF Jr, et al. Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Infect Control Hosp Epidemiol 1997;18:275-91. Smith PW, Rusnak PG. Infection prevention and control in the longterm-care facility. AJIC Am J Infect Control 1997;25:488-512. Standing Medical Advisory Committee Sub-group on Antimicrobial Resistance. The path of least resistance: summary and recommendations. London: Department of Health; 1998.
Skin Cleansing and Antisepsis Garner JS, Favero MS. CDC guideline for handwashing and hospital environment control, 1985. Infect Control 1986;7:231-5. Larson EL, 1992, 1993, and 1994 APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. AJIC Am J Infect Control 1995;23:251-69. Health Canada. Hand washing, cleaning, disinfection and sterilization in health care. CCDR 1998; 24S8:1-55. Available: http://www.hc-sc.gc.ca/main/lcdc/web/dpg_e.html; accessed, 4/19/99.
Decontamination and Disinfection of the Environment and Equipment American Association of Medical Instrumentation. Safe handling and biological decontamination of medical devices in health care facilities and in nonclinical settings. American Association of Medical Instrumentation; 1996. i-ix, p. 1-40.
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512 Global Consensus Conference Rutala WA, 1994, 1995, and 1996 APIC Guidelines Committee. APIC guideline for selection and use of disinfectants. AJIC Am J Infect Control 1996;24:313-42. Health Canada. Hand washing, cleaning, disinfection and sterilization in health care. CCDR 1998;24S8:1-55. Available: http://www.hc-sc.gc.ca/main/lcdc/web/dpg_e.html; accessed 4/19/99.
APPENDIX Organizing Committee Georgia Dash (APIC) Candace Friedman, Chair (APIC) Dee May (ICNA) Pat Piaskowski (CHICA-Canada) Scientific Committee Carla Alvarado Elena Bourganskaia Georgia Dash—Chair Candace Friedman Stewart Gibson Karen Green Anne Griffiths-Jones Barbara Gruendemann Lee Hanna Mary LeBlanc Dee May Janet McCulloch Pearl Orenstein Shirley Paton Pat Piaskowski Jeanne Pfieffer Speakers Jose Cruz (US) Adriano Duse (South Africa) Julie Gerberding (US) Allison McGeer (Canada) Dominique Monnet (Denmark) Andrew Simor (Canada) Marjorie Underwood (US) Chief Facilitator Gilles Delage (Canada) LISTING OF DELEGATES BY WORKSHOP GROUP Barriers Anne Augustin (Canada) Adriano Duse (S Africa) John Gammon (UK) Julia Garner (US) Karen Green (Canada) Terri Goodman, Johnson & Johnson (US) Seto Wing Hong (China) Marguerite Jackson (US)
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Catherine Mallaghan (UK) Allison McGeer (Canada) Mark Miller (Canada) Dominique Monnet (Denmark) Lindsay Nicolle—Facilitator (Canada) Fernando Otaiza (Chile) Gopal Rao (UK) Jay Sommers, Kimberly-Clark (US) Bob Spencer (UK) Hayden Williams, Regent (UK) Skin Liz Bowley, deb (UK) RPD Cooke (UK) Ann Cote, Kimberly-Clark (US) Eilish Creamer (Ireland) Evonne Curran (Scotland) Donna Holton—Facilitator (Canada) Barry Farr (US) Stewart Gibson, Reckitt & Colman (UK) Dinah Gould (UK) Stefan Grosek (Slovenia) Anita Hanrahan (Canada) Sandra Harrison, Johnson & Johnson (US) Elaine Larson (US) Susan MacMillan (Canada) Rita McCormick (US) Folashade Tolulope Ogunsola (Nigeria) David Mullis, Regent (US) Mike Muschett, deb (Canada) Roger Olson, 3M Health Care (US) Laurie O’Neill (Canada) Denise Pretzer, STERIS (US) Manfred Rotter (Austria) Environment Michelle Alfa (Canada) Nancy Alfieri (Canada) Carla Alvarado (US) Roy Browning (Scotland) Jacqueline Daley, 3M Health Care (Canada) Martin Favero (US) Adam Fraise (UK) Carol Goldman (Canada) Hilary Humphreys (Ireland) Lynn Johnston—Facilitator (Canada) Paul Malchesky, STERIS (US) Cathryn Murphy (Australia) Frank Rhame (US) Joe Rubino, Reckitt & Colman (US) William Rutala (US) Syed Sattar (Canada) Mark Wilcox (UK)
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Association Representatives
Corporate Sponsors
Ginette Hebert, President, Community and Hospital Infection Control Association— Canada Susan MacQueen, Chair, Infection Control Nurses Association Janet Franck, President, Association for Professionals in Infection Control and Epidemiology, Inc.
3M Health Care Deb-Canada & U.K. Johnson & Johnson Medical Kimberly-Clark Reckitt & Colman Regent Medical STERIS
Endorsements Laboratory Centre for Disease Control (LCDC)— Health Canada International Federation of Infection Control (IFIC) National Center for Infectious Diseases, US Centers for Disease Control and Prevention (CDC)
Editor—Conference Proceedings Russell Olmsted