A pseudo-outbreak of Mycobacterium lentiflavum occurred that contaminated the tap water at the sputum collection booth in our hospital. M. lentiflavum was detected from 81 patients, but the infectious patients were not recognized. M. lentiflavum was cultured from 6 of 103 hospital tap water samples excluding the sputum collection booth. Twenty two isolates (14 clinical isolates, 3 isolates from the sputum collection booth, and 5 isolates from hospital tap water) were classified into profiles A–E by automated repetitive sequence-based PCR. The clinical isolates and the environment isolates included both profiles C and D. The similarity percentages were more than 95%.
To prevent transmission of multidrug-resistant organisms (MDROs), establishment of both contact precaution and environmental measures is recommended. However, adherence to these measures in clinical practice has not been evaluated in Japanese health-care institutions. The present study evaluated how health-care personnel follow the contact precaution protocols recommended by the CDC guidelines during care for patients colonized and/or infected with MDROs in Japanese acute-care facilities. Data related to adherence to contact precautions was collected at five tertiary care hospitals by direct observation by certified nurses in infection control (CNIC), who evaluated hand hygiene, wearing gown and gloves immediately before room entry of patients colonized/ infected with MDROs, discarding gown and gloves when leaving, followed by hand hygiene. In addition, the CNIC asked each member of staff in charge of the patients with MRDOs how environmental measures are followed. The Ethic Review Boards of International University of Health and Welfare as well as five tertiary care hospitals approved this study. A total of 1468 scenes were observed. Overall adherence rates to contact precautions at five hospitals were as follows: 52.8% for hand hygiene before room entry; 68.9% for glove wearing; 65.8% for glove disposal; 78.7% for gown wearing; 75.1% for gown disposal; and 75.5% for hand hygiene when leaving the patient's room. Adherence rates for hand hygiene before room entry were significantly greater in the ICU and ER, compared to other units (46.0%, p<0.001). Adherence rates of physicians for all contact precaution protocols were significantly lower than for other health-care personnel (31.5%–60.8%, p<0.001). The averages of adherence rates of cleaning measures for high-frequency contact surface points in the patient's environment at the five hospitals were 85.9% to 100%. Based on the findings of this study, we could conclude that recommended environmental measures required for patients colonized/ infected with MRDOs were fully followed by health-care personnel. However, we found that the adherence rate to hand hygiene by health-care personnel who wore gloves before room entry was low. To increase adherence to the contact precautions recommended by the CDC guidelines, systems for regular monitoring of contact precautions and feedback are essential.
The department of hematology/oncology in our hospital has a bone marrow transplantation (BMT) unit with 31 cleanrooms and associated clean areas. Air cleanliness of the whole unit is maintained at class 7 based on ISO 14644–1, which is equivalent to class 10,000 based on the US Federal Standard 209E. The floor has not only private rooms but also a staff station, lounge, laundry room, etc.; the same arrangement as a normal ward. There are few facilities where the whole floor is kept at class 7 in Japan. The unit is a closed space and environmental management is important for the floor, so we decided to enforce large-scale cleaning in the same way as the operating rooms and ICU under ICT supervision. However, there are no guidelines about cleaning of wards in Japan. Cleaning presents the problem of environmental pollution during the cleaning, and elapsed time before patients can return to their rooms after the cleaning. To evaluate actual contamination status during and after cleaning, the number of microparticles were measured using a particle counter and the colonies counted on the agar plates. The number of microparticles was increased the most after drying of a corridor with a blower after waxing and after moving several beds from the cleanroom to a corridor. The quantity of microparticles stabilized at less than two columns at approximately 30 minutes after cleaning. Multiple colonies of bacteria, yeasts, and fungi were recovered from several samples during the cleaning, but only a few colonies were recovered from samples after cleaning. Most colonies were identified as environmental microorganisms. Therefore, patients should not enter a cleanroom after completion of cleaning for 30–60 minutes. If several cleanrooms are cleaned at the same time, a barrier should be positioned in the corridor to prevent contamination of other areas.
Alcohol-based hand rubs are recommended for use by healthcare staff worldwide. In addition to gel and liquid rubs, ethanol-based foam is available for hand hygiene. Ethanol-based foam was launched as the first alcohol-based foaming hand rub available in Japan in June 2011. Ethanol-based foam has gained attention among healthcare staff because ethanol-based foam does not drip from the hands, and allows good visual coverage. This study compared the effectiveness of ethanol-based gel and foam for bacterial removal and the percentage of areas covered with gel or foam. The Parm-Stamp Test was used to prove that ethanol-based foam has the same efficacy against bacteria as gel. To examine if the hands were fully covered with gel or foam, we used the Black Lights device and fluorescence powder. The results showed that the ethanol-based foam provided significantly improved coverage compared with the gel. According to the questionnaire results, ethanol-based foam has a lot of unique benefits, such as no dripping, easy spreading, good visual coverage, and no sticky feeling. Due to the effective cleaning with excellent skin feel during and after use, ethanol-based hand rub foam is very useful in the clinical setting for hand hygiene among healthcare workers.
Hematopoietic stem cell transplantation is a standard therapy for patients with blood disease, and central venous catheter (CVC) insertion is essential for the treatment. However, Central Line-Associated Bloodstream Infection (CLABSI) may occur due to catheter insertion, and is the main cause of death after transplant surgery. To prevent CLABSI during catheter insertion, maximal sterile barrier precautions (wearing of mask, cap, sterilized gloves, and sterilized gown, and using a drape big enough to cover the patient's body) are recommended based on the known efficacy of these precautions. Many studies have investigated the correlations between care of the CVC insertion site and the incidence of CLABSI, but no study has compared the methods used at the time of dressing change. In this study, dressing change was performed at the CVC insertion site of patients who received hematopoietic stem cell transplantation by three methods; using unsterilized gloves in 14 subjects, using sterilized gloves in 11 subjects, and taking maximal sterile barrier precautions in 9 subjects, and verified which methods are effective in reducing CLABSIs. Thirteen of the 34 patients had confirmed infections. The incidence of CLABSIs per 1,000 catheter-days was 7.5 with maximal sterile barrier precautions, 9.5 with unsterilized gloves, and 10.1 with sterilized gloves. However, there was no statistically significant difference between the three methods.
This study aimed to evaluate blood or body fluid exposure and self-reported compliance with personal protective equipment (PPE) use among midwives. The anonymous questionnaires were mailed to 314 birth centers in Japan, and were returned from 139 birth centers (return rate 42.1%). The total experiences of exposure among midwives were 125 (90.0%). Exposure to the face was the most common (77.6%), followed by the upper extremity (75.2%) and hands (67.2%). The number of midwives who had experience of birth assistance with the bare hands in the last year was 25 (18.0%). Moreover, five of those midwives (5/25) answered that this was routine practice. On the other hand, wearing a gown and gloves during birth assistance was most common (57.6%), followed by only gloves (30.2%). During birth assistance, only one of the midwives wore a mask, goggle, gloves, and gown (all required PPE), whereas 52 midwives (40.3%) answered that they cannot understand the need for PPE. The reason for not wearing appropriate PPE was that the mother did not have any infectious disease (78.4%). This study indicated that present wearing of PPE by midwives during the birth is not adequate. Despite exposure of the face being the most common incident, few midwives wore a mask and goggles. The requirements for appropriate infection control practice and educational approaches for midwives, based on the characteristics of the birth center, should be promoted.
Cooperation in infection control has been implemented in the HOKUSHIN region, the northern area of Nagano prefecture, since 2007. The health insurance systems have required inter-hospital cooperation before additional charges can be accepted since 2012, so we examined the effects of this change on infection control activities in each hospital in our network. Twenty five of the 37 hospitals in our region (67.6%) replied to our questionnaires about acceptance of additional charges and the state of cooperation. Acceptance of additional charges had increased remarkably in middle size hospitals, and future acceptance was indicated in many small size hospitals. However, the actual costs for infection control activities will increase in the future in many hospitals. We recommend continuous expansion of our regional network and the development of cooperative activities for infection control in Hokushin.