Download The Missing Step: Natural Behavior of Pathogenic

The Missing Step: Natural Behavior of Pathogenic Organisms Via Shoe Sole Contamination That Can Lead to Infection in a Health Care Facility: Systematic Review Christopher P. Griffith (May 2016) ABSTRACT: Health Care Associated Infections (HAIs) are a cause for preventable death in the US and globally, thus have sounded the alarm for change! Health care executives and Infection Control (IC) specialists throughout the medical industry have been forced to implement new IC programs and strategies to combat the organisms that are causing the problem. Between acute care hospitals and elderly care facilities there are between 5-­‐6 million infections that lead to nearly 500,000 deaths annually. Although new technologies and stringent interventions have been developed and implemented to combat many known reservoirs of pathogenic presence, there is still an enormous gap that has been left virtually untouched and literally stepped around. Shoe soles are proven to have an overwhelmingly dense pathogenic load, often the highest levels anywhere in the particular environment. There is still very little if any protocols, tools or technology in place to directly prevent shoe sole pathogens from spreading and causing infection in health care. This review examines how pathogens on shoe soles through natural environmental behavior can pose a threat to human infection in health care. It also asks why in other industries such as pharmaceuticals, biotech, veterinarian and food processing/packaging there are interventions in place to stop the spread of dangerous organisms via shoe soles, however in human health care where people are most vulnerable, there is still a major missing piece of the IC puzzle? Of the many, proven, high risk locations for the presence of nosocomial pathogens which lead to Healthcare Associated Infections (HAI’s), shoe soles are the largest reservoir of alert bacteria and other organisms found in a healthcare setting .1 Shoe soles, especially those in high risk infection areas of healthcare facilities, present a potential source for infection.2 Objects such as stethoscopes and the hands of medical staff members, both commonly found in healthcare facilities, are recognized to be highly contaminated and appropriately have Infection Control (IC) program protocol in place, to manage cleaning policies of these high-­‐risk vectors of infection. Unfortunately, the soles of shoes are the dirtiest reservoir of infectious pathogens in healthcare and remain uncontrolled and untreated! A clinical poster presentation at the American Society of Microbiology meeting in 2015, states that in a hospital, shoe-­‐bottom surfaces can be highly contaminated with pathogenic bacteria from diverse sources.3 Many published studies have proven that unacceptable high levels of infectious pathogenic organism are present on the shoe bottoms of staff, patients, and visitors walking into healthcare facilities. The study referenced here took place at a large Texas hospital and revealed positive culture of C-­‐Diff on 45% of shoes sampled, 100% of them positive for C-­‐Perfringens, and 90% were positive for VRE. This data is closely replicated in other clinically published environmental studies pertaining to 39.7% of C-­‐Diff positive cultures on 63 shoe soles samples in houses and throughout community environs.4,5 Shoe soles can host pathogens that can lead to infection through both cross-­‐contamination and pathogen migration (from one area to another). Another clinical study proved that the shoe soles of physicians during their rounds had a 56% contamination presence before rounds and a 65% contamination presence after rounds. (MRSA, HLAR, saprophytic flora, saprophytic aerobic bacilli, coagulase-­‐negative Staphylococcus, acinetobacter baumanii and Escherichia coli were found). Shoe sole contamination levels significantly increase as the workday progresses in healthcare facilities. Some of the same bacteria were also found on swabs taken from hands before (16%) and after (28%) rounds. Although the results from hands should be considered unsatisfactory, results of examination of swabs collected from soles of shoes before and after doctor’s rounds are very bad.1 Contamination on shoe bottoms continues to increase and spread throughout HC environments, both on surfaces (lateral transmission) and in the air (airborne transmission), over time. There are high transfer rates of infectious organisms from shoe bottoms to both clean and dirty floors. Organisms are picked up by shoe soles or theatre over shoes and re-­‐deposited to areas that may not have been contaminated prior.6 Once pathogens are transferred onto any floor type, they can become re-­‐suspended, as aerosols, through activities such as walking, moving equipment, HVAC systems, sweeping, vacuuming or mopping. Floor bacteria in hospitals has been shown to account for up to 15% of airborne colony forming units (CFUs) with walking contributing to their redispersal from floor to air.2 The aerosols generated from a contaminated floor can reach breathing height, are within respirable size range, and could transmit infection.7 Findings from operating room studies also prove that the presence of pathogenic bacterial species, such as Staphylococci on all shoe types, is responsible for postoperative wound infection. Outdoor shoes worn by theater staff in the OR were found to have the most contamination present (98%), followed by dedicated morning theatre shoes (68%), and finally dedicated end-­‐of-­‐day theatre shoes (56%). The major cause of deep postoperative wound sepsis is contamination from airborne colony forming units (CFUs), with the CFUs in the operating theatre shown to be proportional to the activity and number of people present.2 Other known effects of these organisms, once aerosolized, can be but are not limited to, landing on people (open wounds, surgical sites) or equipment, suspending and or redistributing through air currents and then resettling on all environmental surfaces and floors. Furthermore, floors that have been terminally cleaned in healthcare facilities show strong evidence that they return to contaminated pretreatment levels in just a few hours or less. This, unfortunately, is when and where the process starts over and repeats itself (Table 1) Table 1 Although many published medical studies strongly recommend healthcare IC protocols to clean the shoes of healthcare staff members daily,8 healthcare IC departments have very limited, if any at all, protocols, programs or technologies currently managing the spread and control of pathogens via shoe bottoms. This is of severe concern for the healthcare industry as most IC specialists consider HAIs to be at epidemic levels. Nearly 2 million HAIs from acute-­‐care hospitals and 3.8 million infections from elderly care facilities, combine for a total of almost 500,000 deaths per year, in the United States alone! HAIs are responsible for an estimated direct medical costs ranging from between $35 and $45 billion annually. The total direct, indirect and nonmedical social costs of HAIs are estimated to be at $96 to $147 billion annually, including loss of work, legal costs, family distress, suffering, reoccurring long-­‐term complications and other patient factors. Why would those in the healthcare environment not insist on the management and control of shoe borne pathogens in order to kill and remove these organisms from the HAI equation altogether? Other industries such as those related to food processing/packaging, biotech, pharmaceuticals, veterinarian and more, have stringent policies and standards for the control of shoe borne or shoe sole pathogens that lead to contamination and infection. The healthcare environment is where both young and old, immune deficient and the most vulnerable patients are cared for. Much more needs to be done to control deadly pathogens from spreading throughout healthcare facilities and other environments which can then cause further injury or death due to infection. INFECTION CONTROL
AREAS OF CONCERN
Areas related to HAIs currently being addressed through
bundling protocols. Lowering the overall microbial load is
directly related to lowering infection rates and creates a much
safer healthcare environment!
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WHAT AREA HAVE WE MISSED?
RAPID
TESTING
vs
CULTURE
SURGICAL
EQUIPMENT
SHOE
SOLES
HARD
SURFACES
AIR
SOFT TEXTURED
SURFACES
WATER
HAND
HYGIENE
MOUTH
PPE
PPE
Infection control staff members should strongly consider adding a shoe sole decontamination system to their existing IC program to lower the overall microbial burden, which consequently lead to HAIs in their facilities. Until now, there has never been a cost effective, chemical free, hands free, low maintenance and highly effective option to significantly lower the overall microbial load from this major source (shoe bottoms) within a healthcare or any other environment. References: 1 Paduszynska, K.; Gagis, L.; Rucinska, M.; Pomorski, L. “Physicians as an infective vector at a department of surgery.” 2014 2
Amirfeyz R.; Tasker A.; Ali S.; Bowker K. Blom A. :Theatre shoes – a link in the common pathway of
postoperative wound infection?” The Royal College of Surgeons of England 2007; 89: 605-608
3 M
Jahangir Alam, Jacob K McPherson, Julie Miranda, Sangeetha S Fernando, Lynn Le, Jonathan
Amadio, Kevin W Garey (2015) Prevalence and characteristics of toxigenic Clostridium difficile, C.
perfringens and Enterococcus on shoe-bottoms from a hospital system In: American Society for
Microbiology (ASM) Texas Branch Fall Meeting, (poster presentation) Oct 29-31, 2015 (SAM
HOUSTON STATE UNIVERSITY, HUNTSVILLE, TX)
4
Alam M.J.; Anu A.; Walk S.T.; Garey K.W. “Investigation of potentially pathogenic Clostridium difficile
contamination in household environs.” Anaerobe 27 (2014) 31-33
5
Alam M.J.; Anu A.; Wattanapaisal D.; Lu L.; Kallarackal V.; Nguyen K.; Jones D.; Hoang E.; Garey
K.W. Prevalence of Clostridium difficile and their characteristics in and around various public environs:
(poster presentation)
6
Copp G.; Slezak L.; Didley N.; Mailhot C.B. “Footwear Practices and Operating Room
Contamination.” Nov/Dec 1987 vol. 36 no.6
7
Paton S.; Thompson K.; Parks S.R.; Bennett A.M. “Reaerosolization of Spores from Flooring
Surfaces To Assess the Risk of Dissemination and Transmission of Infections.” Applied and
Environmental Microbiology Aug 2015 Vol. 81 Number 15
8
Agarwal M.; Hamilton-Stewert P.; Dixon R.A. “Contaminated operating room boots: The potential for
infection.” Association for Professionals in Infection Control and Epidemiology 2002
Christopher P. Griffith