Bare skin or sleeved garments-which is better when it comes to preventing the spread of infectious pathogens between patients and healthcare workers (HCW)?

Bare below the elbows (BBE) is an infection prevention approach meant to limit patient contact with potentially infectious agents on contaminated HCW clothing. Critics, however, cite limited evidence that bare skin is less contaminated than sleeves of garments.

In a study presented at IDWeek 2019, investigators with Virginia Commonwealth University Health System compared then flora and bioburden between BBE and sleeved HCW within 2 progressive care units.

Participating clinician HCWs submitted to swab sampling of their dominant wrist/forearm and agreed to participate in informed consent and a survey on bathing and laundering.

Hand hygiene was not performed prior to sampling. Investigators inoculated the swabs into TSA broths and incubated for 24 hours at 37°C.

“Colonies consistent with possible Staphylococcus spp were tested with latex agglutination, and positive isolates were plated on CHROMagarTM MSSA/MRSA,” the research team reported. “Fisher’s exact/Wilcoxon rank sum tests were used to compare the categorical/numerical data between BBE and sleeved providers using SAS version 9.4.”

Results included swabs from 63 HCWs-30 BBE and 33 sleeved. Bacterial growth was morphologically consistent with skin flora, and no gram-negative rods grew. There were no differences in bioburden estimates or presence of S aureus between the groups (p-value = 0.099 and 0.325, respectively).

HCW survey results indicated BBE clinicians were more likely to be working in garments that were freshly laundered (p-value < 0.0001), and 3 sleeved HCW could not recall the last time the garments they were wearing were laundered.

“HCW laundering practices remain suboptimal, particularly among sleeved HCW,” investigators concluded. “The potential impact of hand hygiene on comparative bioburden between sleeved and BBE HCWs remains unknown and is the focus of future investigations.”

The study, Bare Below the Elbows versus Sleeved Attire: A Pilot Study Comparing Microbial Flora of Healthcare Workers, will be presented in an oral abstract session on Friday, October 4, 2019, at IDWeek in Washington, DC.

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The Great ‘Bare Below the Elbows’ Debate: Are Healthcare Workers Better Off With Sleeves or Bare Skin?

Gloves and gowns are common intensive care unit (ICU) fomites that are frequently contaminated with antibiotic-resistant bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA). Guidelines recommend use of contact precautions for healthcare personnel (HCP) when dealing with patients infected with MRSA, but the efficacy of these standards are unclear.

In a study presented at IDWeek 2019, investigators with the University of Maryland, Weill Cornell Medicine, and Harbor UCLA sought to determine which patients are more likely to transfer MRSA to HCP gloves or gowns and to identify HCP interactions more likely to lead to glove or gown contamination.

The study comprised a total of 402 MRSA-colonized patients and 3982 HCP interactions. The research team cultured HCP gloves and gowns following patient interaction but before doffing. They also sampled patients’ anterior nares, perianal area, chest, and arms to assess the association between bacterial burden and contamination.

HCP gloves and gowns were contaminated with MRSA in 14.3% and 5.9% of interactions, respectively. Contamination of either gloves or gowns occurred in 16.2% of interactions.

In terms of HCP types associated with the highest rates of contamination, occupational/physical therapists were at high risk (odds ratio [OR]: 6.96 [95% confidence interval [CI]: 3.51-13.79]), followed by respiratory therapists (OR: 5.34 [95% CI: 3.04-9.39]), when compared with the “other” category.

Naturally, HCP who have to physically touch patients are more at risk of contamination (OR: 2.59 [95% CI: 1.04-6.51]) when compared with HCP who touch nothing in a patient’s room. Furthermore, HCP who touched only the environment were not at risk of contamination (OR: 1.13 [95% CI: 0.43, 3.00]) when compared with touching nothing.

Investigators also identified an association between increasing bacterial burden in the patient’s nares, perianal area, and chest skin and glove or gown contamination.

“Contamination of HCP gloves and gowns with MRSA occurs frequently when caring for ICU patients,” investigators concluded. “Hospitals may consider optimizing contact precautions by using less precautions for low-risk interactions and more precautions for high-risk interactions.”

The study, Considerations for a Targeted Approach to Contact Precautions for Patients with MRSA in Hospitals: A Multicenter Cohort Study to Identify High-Risk Patient Characteristics and Healthcare Personnel Interactions, will be presented in an oral abstract session on Friday, October 4, 2019, at IDWeek in Washington, DC.

Certain Healthcare Personnel Patient Interactions Carry Higher Risk of MRSA Transmission

Candida auris is an emerging scourge in healthcare facilities, including long-term acute care hospitals (LTACHs) and skilled nursing facilities with ventilator units (VSNFs). Patients in either of these facilities are at risk for C auris colonization, which can lead to invasive disease in 5-10% of patients and carry a mortality rate of >45%.

An LTACH-affiliated laboratory in California began enhanced surveillance of C auris in September 2018 to monitor rates of colonization and transmission. In February 2019, a case was identified in Orange County in a patient who had not traveled outside the region, indicating local acquisition.

An interdisciplinary team from US Centers for Disease Control and Prevention, California Department of Public Health, and Orange County Health Care Agency performed point prevalence surveys (PPS) and infection prevention assessments at all LTACH and VSNF subacute units in Orange County to record all C auris colonization and control the spread of the emerging pathogen.

The team’s findings were presented at IDWeek 2019.

Investigators collected composite axilla and groin swabs for C auris polymerase chain reaction testing and reflex culture from all assenting patients at facilities between March and August 2019 and performed PPS. Facilities with >1 C auris-colonized patient received a repeat PPS every 2 weeks to monitor new transmissions. The research team used whole-genome sequencing to evaluate the relationships of isolates and also analyzed infection prevention measures such as hand hygiene adherence, access to alcohol-based hand rubs, and cleaning of high-touch surfaces.

The first PPS included 3 Orange County LTACHs and 14 VSNFs. A total of 45 C auris-colonized patients were reported in 3 (100%) LTACHs and 6 (43%) VSNFs. That number increased to 124 colonized patients in the repeat PPS. Most of the patients (70%) were at 2 facilities.

Investigators completed whole-genome sequencing for isolates from 48 patients, which revealed that all of the samples were highly related (< 11 single nucleotide polymorphisms) in the African clade.

When it came to infection prevention measures, 5 of the 9 facilities with C auris displayed hand hygiene adherence < 50%, 3 had limited access to alcohol-based hand rubs, and < 60% of assessed high-touch surfaces were clean.

“Our investigation, prompted by enhanced surveillance, identified C auris at 9 [Orange County] facilities. [Whole-genome sequencing] indicated a single introduction and local transmission,” investigators concluded. “Early detection, followed by rapid county-wide investigation and [infection preventionist] support, enabled containment efforts for C auris in [Orange County].”

The study, Regional assessment and containment of Candida auris transmission in post-acute care settings - Orange County, California, 2019, was presented as a late breaking oral abstract on Thursday, October 3, 2019, at IDWeek in Washington, DC.

Early Detection and Quick Infection Prevention Support Key to Tackling Candida Auris

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today. Each column explores the Bug of the Month's etiology, the infections it can cause, the modes of transmission, and ways to fight its spread. The pathogen profiles will span bacterial, viral, fungal and parasitic species. We encourage you to use Bug of the Month as a teaching tool to help educate healthcare personnel and start a dialogue about microbiology-related imperatives.

ICT Oct 01, 2019 Vol 23 No 08

The Great ‘Bare Below the Elbows’ Debate: Are Healthcare Workers Better Off With Sleeves or Bare Skin?

Certain Healthcare Personnel Patient Interactions Carry Higher Risk of MRSA Transmission

Early Detection and Quick Infection Prevention Support Key to Tackling Candida Auris

October 2019 Bug of the Month