The importance of preventive washing in intensive care units as part of COVID-19 management
By Thomas OH, Ph.D., Medical & Scientific Affairs for ASIA PACIFIC (Schülke & Mayr)
As coronavirus disease 2019 (COVID-19) spreads across the globe, critical care units (CCU) are at the forefront of managing patients severely affected by the disease. Workflows have been streamlined to ensure rapid diagnosis and appropriate management to cope with COVID-19 cases. Infection prevention has always been a critical part of this process to help protect both patients and healthcare workers from nosocomial infection. With the increasing hospitalisation from COVID-19, the focus on infection control to reduce healthcare-associated infection (HAI) is even more prudent now to reduce the impact on the healthcare system.
The latest available data up to 1st May 2020 from the Intensive Care National Audit & Research Centre (ICNARC) shows 9,801 patients have been admitted for critical care with confirmed COVID-19 in England, Wales and Northern Ireland. In patients with COVID-19, the most common complication is acute respiratory distress syndrome (ARDS) which has been recorded in 60–70% of patients admitted to CCU. [Phua, 2020] Unlike the annually circulating flu strains (e.g. influenza A(H1N1), A(H3N2) and B viruses), there is no existing immunity in humans against SARS-CoV-2 rendering everyone susceptible to the virus regardless of age, gender, ethnicity and social status. The situation is made more critical with the high transmissibility of the virus (e.g. via asymptomatic route) resulting in rapid spread in a non-immune population posing significant challenges to critical care.
Rigorous infection prevention precautions need to be taken in CCUs to minimise the risk of nosocomial infection. Latest guidance from NHS England emphasises the role of the Infection Prevention & Control team, particularly in hospital areas which have been repurposed for critical care. However, it is not only the SARS-CoV-2 virus which poses an immediate risk but also other commonly recognised pathogens associated with HAIs. A patient’s potential recovery may be severely compromised if they develop a nosocomial infection.
The prevalence of HAIs in hospitals in England is estimated to be about 6.4%. [NICE, 2014] The most common types of HAIs include respiratory infections particularly pneumonia and infections of the lower respiratory tract. [NICE, 2014] The common infections include those caused by methicillin-resistant Staphylococcus aureus (MRSA), methicillin-sensitive Staphylococcus aureus (MSSA), Clostridium difficile (C. diff) and Escherichia coli (E. coli). [NICE, 2014] Despite seeing a decrease in the incidence rate of all reported MRSA bacteraemia, bacteraemia by E. coli has continued to increase each year and so has MSSA bacteraemia. [Public Health England, 219]. The latter is significant as a reasonable proportion of the United Kingdom population (25% to 30%) is positive for skin or nasal carriage of Staphylococcus. [Jeans, 2018]
One measure to help prevent HAIs is patient decontamination with an antimicrobial body wash. A number of studies have evaluated the cost effectiveness of screening and decontamination strategies in the control of MRSA in ICUs. Patients may be screened for MRSA on admission and positive patients then undergo a decontamination regime including the use of a body wash and nasal gel. Alternatively, a programme of universal decontamination may be implemented in ICUs, in which all admitted patients undergo decontamination.
Evidence from a 2011 study concluded that all decontamination strategies in ICU improved health outcomes as well as cutting costs of healthcare provision. It was found that universal decontamination was the most cost effective in an ICU setting. [Robotham, 2011] Another investigation of decontamination strategies in ICUs found that universal decontamination provided both lower intervention costs and lower total ICU costs than either screening and isolation or targeted decontamination. Compared with screening and isolation, universal decolonization was estimated to save $171,000 and prevented 9 additional bloodstream infections for every 1,000 ICU admissions. [Huang, 2014]
Compared to alternative methods, such as screening and isolation or screening plus selective decontamination, the strategy of universal decontamination is independent of the patient’s microbial status and has been shown to be more effective and efficient. A study examining over 74,000 patients showed that universal decontamination in adult ICU led to a 37% reduction in risk of an MRSA clinical isolate and a 44% reduction in risk of bloodstream infections due to all pathogens. [Huang, 2013]
To date, the evidence on the effectiveness of decontamination to reduce nosocomial infections is apparent, but the choices of antimicrobial actives available for this purpose is limited. Chlorhexidine remains the main active used in many countries. However, heavy reliance on a single active has raised concerns about microbial resistance, particularly in the backdrop of global antibiotic resistance and the increasing evidence of tolerances of microbes towards chlorhexidine. [Hardy, 2018] The other molecule available is octenidine, a broad spectrum antimicrobial that is less susceptible to bacterial resistance and also with promising effectiveness reported in ICUs to lower HAIs.
Available clinical evidences on the use of an octenidine-based antimicrobial for routine patient washing includes a two year retrospective pilot study in a mixed medical and surgical ICU / high dependency unit. The study showed a 76% reduction in the acquisition of multi-drug resistant organisms. [Spencer, 2013] The effectiveness of octenidine as a preventive body wash in ICU in an observational study involving 29, 532 ICU patients in Germany reported a significant reduction in ICU-acquired blood-stream infections and MRSA in medical ICUs after implementation of octenidine-based antimicrobial for decontamination. [Gastmeier, 2016]
A recent study involving the outbreak of Vancomycin-resistant enterococcus (VRE) nosocomial cases in a 32 bed ICU clearly demonstrated that the introduction of preventive body washing with an octenidine-based antimicrobial can be an effective add-on strategy for infection control. The initial implementation of a heightened hand hygiene and surface disinfection regime did not reduce acquisition of VRE. A significant reduction was only observed after the introduction of mandatory body washing with an octenidine-based antimicrobial wash. Nosocomial incidence density of 7.55 (pre-intervention) was reduced to 2.61 (post-intervention) per 1000 patient days. Furthermore, the number of nosocomial infections was significantly reduced from 13 to 1 cases after intervention. [Messler, 2019]
To date, the evidence for preventive body washing of patients on critical care units appears to be very much in favour of the practice. If universally adopted across CCUs for all patients, the principle of keeping the microbial bioburden down via decontamination has the potential to synergise the existing infection control measures to reduce nosocomial infections in healthcare institutions. Given the current demands on the healthcare system by the COVID-19 situation, any reasonable steps which may help reduce infection rates should be worth considering.
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References
Gastmeier et al, (2016) An observational study of the universal use of octenidine to decrease nosocomial bloodstream infections and MDR organisms, J Anti Chemo, 71, pp. 2569-76
Huang S et al, (2013) Targeted versus Universal Decolonization to Prevent ICU Infection, N Engl J Med 2013.
Huang S et al, Cost Savings of Universal Decolonization to Prevent Intensive Care Unit Infection: Implications of the REDUCE MRSA Trial, Infect Control Hosp Epidemiol, 2014 Oct;35 Suppl 3:S23-31
Hardy et al (2018), Increased usage of antiseptics is associated with reduced susceptibility in clinical isolates of staphylococcus aureus, mBio 9:e00894-18
ICNARC report on COVID-19 in critical care, 01 May 2020
Jeans E et al, MSSA screening and decolonisation in elective hip and knee arthroplasty. Journal of Infection, 77 (2018) 405–409
Messler et al Reduction of nosocomial vancomycin-resistant enterococcus faecium (VRE) colonisation on an intensive care unit after the introduction of antiseptic (octenidine-based) bathing, J Hosp Infect. 2019 Mar;101(3):264-271
NICE, Infection prevention and control Quality Standard [QS61], April 2014
Phua J, et al, Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations, Lancet Respir Med 2020, Published Online April 6, 2020
Public Health England, MRSA, MSSA, Gram-negative bacteraemia and CDI: quarterly report, 2019
Robotham JV et al, Screening, isolation, and decolonisation strategies in the control of methicillin resistant Staphylococcus aureus in intensive care units: cost effectiveness evaluation, BMJ 2011;343:d5694
Spencer et al, Daily bathing with octenidine on an intensive care unit is associated with a lower carriage rate of methicillin-resistant Staphylococcus aureus, Journal of Hospital Infection 83 (2013) 156-159
