[Glenys Harrington]

Hi Sony,

Other bodies that send email alerts are the CDC and FDA

CDC email updates there are a number of things you can subscribe to at this site

http://www.cdc.gov/Other/emailupdates/

http://www.fda.gov/Safety/MedWatch/

http://service.govdelivery.com/service/subscribe.html?codeUSFDA_46

regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Hi Sony

The regulatory body in Australia that issues clinical product and medication alerts in the TGA (Therapeutic Goods Administration). They have an email alert subscription service that was recently posted on this list.

http://www.tga.gov.au/newsroom/subscribe.htm

Hope this is what you are asking for.

Cheers

Michael

Michael Wishart

Infection Control Coordinator

Holy Spirit Northside Private Hospital

627 Rode Road, Chermside, Qld 4032

t: (07) 3326 3068 | f: (07) 3607 2226

e: Michael.Wishart@svha.org.au

w: http://www.holyspiritnorthside.org.au

Please consider the environment before printing this email

http://www.interactivejam.com.au/images/ACIPC-conference.jpg

Dear All,

We would like to know, in Australia, which government agent/department is responsible for the captioned issue.

This issue is raised because we would like to monitor the captioned issue (not only just for Aus. products but also other products i.e. global monitoring), and to notify our management and local users timely, if incident occurs.

Yours sincerely,

Sony SO

Nursing Officer, Infection Control Branch (Team 2)

Centre for Health Protection, HONG KONG SAR, CHINA

http://www.chp.gov.hk/tc/cindex.html

office phone: +852 2125-2922; fax: +852 3523-0752

HA email sony@ha.org.hk; DH email no_icb4@dh.gov.hk

Please consider the environment before printing this e-mail

_____

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[Glenys Harrington]

Hi Rachel,

With the evidence for environmental cleaning and disinfection the main
outcome if you were using any new infection control strategy would be a
decrease in the acquisition of MROs (i.e. MRSA, VRE and Acinetobacter &
Clostridium difficile).

Haven’t heard of any decrease in MROs acquisitions at site/s where it is
being used (although happy to be corrected) and as per the abstract
previously posted this strategy may not have good activity against
C.difficile. This would be a problem in the setting of hospital
transmission.

It seems this microfiber (used daily) steam (used only on discharge) is
primarily a “facility lead cleaning program” rather than a targeted
infection control strategy. The cost and time savings associate with this
strategy primarily relate to savings generated as a result of replacing
2-step cleaning and disinfection program.

There was a nice publication from the Geelong ICT which showed that 2-step
cleaning and disinfection was not necessary – have included the abstract for
those who may not have seen it.

Am J Infect Control. 2013
Mar;41(3):227-31. doi: 10.1016/j.ajic.2012.03.021. Epub 2012 Sep 13.

The effectiveness of a single-stage versus traditional three-staged protocol
of hospital disinfection at eradicating vancomycin-resistant Enterococci
from frequently touched surfaces.

Friedman ND1,
Walton AL,
Boyd S,
Tremonti C,
Low J,
Styles K,
Harris O,
Alfredson D,
Athan E.

Author information

Abstract

BACKGROUND:

Environmental contamination is a reservoir for vancomycin-resistant
enterococcus (VRE) in hospitals.

METHODS:

Environmental sampling of surfaces was undertaken anytime before
disinfection and 1 hour after disinfection utilizing a sodium
dichloroisocyanurate-based, 3-staged protocol (phase 1) or benzalkonium
chloride-based, single-stage clean (phase 2). VRE colonization and infection
rates are presented from 2010 to 2011, and audits of cleaning completeness
were also analyzed.

RESULTS:

Environmental samples collected before disinfection were significantly more
likely to be contaminated with VRE during phase 1 than phase 2: 25.2% versus
4.6%, respectively; odds ratio (OR), 7.01 (P < .01). Environmental samples
collected after disinfection were also significantly more likely to yield
VRE during phase 1 compared with phase 2: 11.2% versus 1.1%, respectively;
OR, 11.73 (P < .01). Rates of VRE colonization were higher during 2010 than
2011. Cleaning audits showed similar results over both time periods.

CONCLUSION:

During use of a chlorine-based, 3-staged protocol, significantly higher
residual levels of VRE contamination were identified, compared with levels
detected during use of a benzalkonium chloride-based product for
disinfection. This reduction in VRE may be due to a new disinfection
product, more attention to the thoroughness of cleaning, or other
supplementary efforts in our institution.

Regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Thomson, Rachel EA (DHHS)
cleaning

Hi Glenys,

Yes I found that one in my research to date. I am interested in the
experience of Australian Healthcare facilities, and I particularly
interested in the impact (if any) on HAIs. It will be interesting to see if
anyone can share some outcome data aligned to this practice change.

Thanks & speak soon

Rachel

………………………….

Rachel Thomson

Nurse Unit Manager

Infection Prevention & Control Unit

Royal Hobart Hospital

Tasmanian Health Organisation-South

(: 03 62227882/8658

rachel.thomson@dhhs.tas.gov.au

Level 4, H Block

48 Liverpool Street

Hobart, 7000

Of Glenys Harrington

Hi Rachel,

This research publication may be of interest/use.

J Hosp Infect. 2012
Oct;82(2):114-21. doi: 10.1016/j.jhin.2012.06.014. Epub 2012 Aug 15.

Clinical and cost effectiveness of eight disinfection methods for terminal
disinfection of hospital isolation rooms contaminated with Clostridium
difficile 027.

Doan L1,
Forrest H,
Fakis A,
Craig J,
Claxton L,
Khare M.

Abstract

BACKGROUND:

Clostridium difficile spores can survive in the environment for months or
years, and contaminated environmental surfaces are important sources of
nosocomial C. difficile transmission.

AIM:

To compare the clinical and cost effectiveness of eight C. difficile
environmental disinfection methods for the terminal cleaning of hospital
rooms contaminated with C. difficile spores.

METHODS:

This was a novel randomized prospective study undertaken in three phases.
Each empty hospital room was disinfected, then contaminated with C.
difficile spores and disinfected with one of eight disinfection products:
hydrogen peroxide vapour (HPV; Bioquell Q10) 350-700 parts per million
(ppm); dry ozone at 25 ppm (Meditrox); 1000 ppm chlorine-releasing agent
(Actichlor Plus); microfibre cloths (Vermop) used in combination with and
without a chlorine-releasing agent; high temperature over heated dry
atomized steam cleaning (Polti steam) in combination with a sanitizing
solution (HPMed); steam cleaning (Osprey steam); and peracetic acid wipes
(Clinell). Swabs were inoculated on to C. difficile-selective agar and
colony counts were performed pre and post disinfection for each method. A
cost-effectiveness analysis was also undertaken comparing all methods to the
current method of 1000 ppm chlorine-releasing agent (Actichlor Plus).

FINDINGS:

Products were ranked according to the log(10) reduction in colony count from
contamination phase to disinfection. The three statistically significant
most effective products were hydrogen peroxide (2.303); 1000 ppm
chlorine-releasing agent (2.223) and peracetic acid wipes (2.134).

CONCLUSION:

The cheaper traditional method of using a chlorine-releasing agent for
disinfection was as effective as modern methods.

Regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Thomson, Rachel EA (DHHS)
cleaning

Hi all,

We are currently undertaking a major review in relation to environmental
hygiene within our own organisation. As part of this we are considering the
potential infection control outcomes relating to the introduction of novel
cleaning processes, with a particular interest in steam and microfibre
cleaning. I am aware of the body of work being led by a number of health
services, including Southern Health, but I am particularly interested in any
recorded impact on patient outcomes as a result of introducing steam and
microfibre cleaning by other healthcare services.

In our organisation we publicly report on a number of surveillance data
including

. MRSA acquisitions (colonisation and infection) [these are reported
to our State surveillance unit although not publicly reported at this time]

. VRE acquisitions (colonisation and infection)

. MRGN acquisitions (colonisation and infection)

. SAB, including HCA as separate from Community Onset

. Clostridium difficile infection, in particular HCA

I attach for the interest of subscribers the link to the publicly reported
HCAI data in Tasmania, which our hospital data.

http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0013/161023/Surveillance_R
eport_No_21_Quarter_1_2014.pdf

My question is; are any list members able or willing to share with me their
HCAI data both before and after introducing steam and microfibre cleaning?

I would be happy to receive replies off-line if this enquiry.

Thanks

Rachel

………………………….

Rachel Thomson

Nurse Unit Manager

Infection Prevention & Control Unit

Royal Hobart Hospital

Tasmanian Health Organisation-South

(: 03 62227882/8658

rachel.thomson@dhhs.tas.gov.au

Level 4, H Block

48 Liverpool Street

Hobart, 7000

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[Glenys Harrington]

Hi Rachel,

This research publication may be of interest/use.

J Hosp Infect. 2012
Oct;82(2):114-21. doi: 10.1016/j.jhin.2012.06.014. Epub 2012 Aug 15.

Clinical and cost effectiveness of eight disinfection methods for terminal
disinfection of hospital isolation rooms contaminated with Clostridium
difficile 027.

Doan L1,
Forrest H,
Fakis A,
Craig J,
Claxton L,
Khare M.

Abstract

BACKGROUND:

Clostridium difficile spores can survive in the environment for months or
years, and contaminated environmental surfaces are important sources of
nosocomial C. difficile transmission.

AIM:

To compare the clinical and cost effectiveness of eight C. difficile
environmental disinfection methods for the terminal cleaning of hospital
rooms contaminated with C. difficile spores.

METHODS:

This was a novel randomized prospective study undertaken in three phases.
Each empty hospital room was disinfected, then contaminated with C.
difficile spores and disinfected with one of eight disinfection products:
hydrogen peroxide vapour (HPV; Bioquell Q10) 350-700 parts per million
(ppm); dry ozone at 25 ppm (Meditrox); 1000 ppm chlorine-releasing agent
(Actichlor Plus); microfibre cloths (Vermop) used in combination with and
without a chlorine-releasing agent; high temperature over heated dry
atomized steam cleaning (Polti steam) in combination with a sanitizing
solution (HPMed); steam cleaning (Osprey steam); and peracetic acid wipes
(Clinell). Swabs were inoculated on to C. difficile-selective agar and
colony counts were performed pre and post disinfection for each method. A
cost-effectiveness analysis was also undertaken comparing all methods to the
current method of 1000 ppm chlorine-releasing agent (Actichlor Plus).

FINDINGS:

Products were ranked according to the log(10) reduction in colony count from
contamination phase to disinfection. The three statistically significant
most effective products were hydrogen peroxide (2.303); 1000 ppm
chlorine-releasing agent (2.223) and peracetic acid wipes (2.134).

CONCLUSION:

The cheaper traditional method of using a chlorine-releasing agent for
disinfection was as effective as modern methods.

Regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Thomson, Rachel EA (DHHS)
cleaning

Hi all,

We are currently undertaking a major review in relation to environmental
hygiene within our own organisation. As part of this we are considering the
potential infection control outcomes relating to the introduction of novel
cleaning processes, with a particular interest in steam and microfibre
cleaning. I am aware of the body of work being led by a number of health
services, including Southern Health, but I am particularly interested in any
recorded impact on patient outcomes as a result of introducing steam and
microfibre cleaning by other healthcare services.

In our organisation we publicly report on a number of surveillance data
including

. MRSA acquisitions (colonisation and infection) [these are reported
to our State surveillance unit although not publicly reported at this time]

. VRE acquisitions (colonisation and infection)

. MRGN acquisitions (colonisation and infection)

. SAB, including HCA as separate from Community Onset

. Clostridium difficile infection, in particular HCA

I attach for the interest of subscribers the link to the publicly reported
HCAI data in Tasmania, which our hospital data.

http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0013/161023/Surveillance_R
eport_No_21_Quarter_1_2014.pdf

My question is; are any list members able or willing to share with me their
HCAI data both before and after introducing steam and microfibre cleaning?

I would be happy to receive replies off-line if this enquiry.

Thanks

Rachel

………………………….

Rachel Thomson

Nurse Unit Manager

Infection Prevention & Control Unit

Royal Hobart Hospital

Tasmanian Health Organisation-South

(: 03 62227882/8658

rachel.thomson@dhhs.tas.gov.au

Level 4, H Block

48 Liverpool Street

Hobart, 7000

_____

CONFIDENTIALITY NOTICE AND DISCLAIMER
The information in this transmission may be confidential and/or protected by
legal professional privilege, and is intended only for the person or persons
to whom it is addressed. If you are not such a person, you are warned that
any disclosure, copying or dissemination of the information is unauthorised.
If you have received the transmission in error, please immediately contact
this office by telephone, fax or email, to inform us of the error and to
enable arrangements to be made for the destruction of the transmission, or
its return at our cost. No liability is accepted for any unauthorised use of
the information contained in this transmission.

MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO
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[Glenys Harrington]

Hi Ruth,

I imagine the risk of contamination in toilet/anteroom facilities with
bidets would be similar to the risks associated with the use of sprayers
(also called aerated spray wands) in patient toilet facilities?

In terms of the sprayers/wands these are hoses with a nozzle which are
installed at the back of the toilet and used to rinse out bed pans in the
toilet bowl in anteroom toilet/shower facilities (single/multi-bed rooms)
and in hoppers (wall-mounted sinks, with deep basins, large drains, and a
spray arm that flush like a toilet) in dirty utility rooms (see attached an
embedded images).

While they are not very common in Australian healthcare facilities for
patient toilets sprayers/wands seem to be more common in parts of Canada
and the US (mentioned in some of Carlings publications) and have contributed
in outbreaks of C.difficile in Canada Preliminary Findings with
C.difficile Outbreak in Cape Breton District Health Authority (CBDHA), 21
April 2011, Department of Health and Wellness, Nova Scotia – attached.

A June 2009 Quebec report (Comparative Analysis of Bedpan Processing
Equipment) by the Agence dvaluation des technologies et des modes
dintervention en sant (AETMIS now INESSS) recommended that staff must not
empty bedpans into sinks or toilets and must no longer use spray wands. The
report includes options in terms of appropriate reprocessing methods for bed
pans and a cost analysis of each option see link.

http://www.hygiecanada.com/img/media/Comparative%20Analysis%20of%20bedpan%20
Processing%20Equipment.pdf

cid:image005.png@01CD77E8.FA191C00cid:image006.png@01CD77E8.FA191C00
cid:image008.jpg@01CD77E8.FA191C00

With this at risk population (oncology) you would need an assurance that the
toilet seat and surrounding area did not become contaminated during use with
the bidet water (which will be contaminated with faecal and other
contaminants).

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Ruth Barratt

Has anyone had to consider the installation of bidets from an IPC
perspective. We are planning a brand new surgical wing and our Oncology
department want to install for patients with anal fissures and other medical
conditions. There are documented health benefits but I wondered about any
water or other contamination issues? I notice that the Australian IPC
Guidelines include a cleaning regime for bidets so I am assuming that in
principle they are acceptable.

Regards

Ruth

IPC logo for email signature

Ruth Barratt RN, BSc, MAdvPrac (Hons)

Clinical NurseSpecialist Infection Prevention and Control

:: ruth.barratt@cdhb.health.nz

(: + 64 3 3640 083 or ext.80083

1098272744j4O36h: 0275 263175

Level 5, Riverside Building

Christchurch Hospital | Private Bag 4710, Christchurch

Clean Hands Save Lives!

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[Glenys Harrington]

Hi Michael,

This may be the case in terms of what is available in Australia. Hence
hospital using either of these products for surgical skin preparation would
be wise to undertake an “offline risk assessment” until the
manufacturer/supplier has the correct TGA registration as this may take some
time as a significant amount of data is required for such registration.

In addition hospital would also be wise to stick with a preparation that is
recommended in the current literature (all be there is some debate about the
methodology of these studies) and a product that is has been recommended by
others rather than a preparation that at this point in time is recommended
for skin antisepsis prior to insertion of intravascular devices.

I see the NHS recommended 2% Chlorhexidine and Alcohol for surgical skin
preparation in there “High Impact Intervention Care Bundle to Prevent
Surgical Site Infection” link below

Ensure that 2% chlorhexidine gluconate in 70% isopropyl alcohol solution is
used for skin preparation (if patient sensitive, use povidone-iodine)

http://www.documents.hps.scot.nhs.uk/hai/infection-control/evidence-for-care
-bundles/key-recommendations/ssi/ssi-rec-6.pdf

Regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Michael Wishart

Hi Glenys

Agreed. The main problem is that the only formulations of chlorhexidine and
alcohol that are tinted red (both 0.5% and 2% chlorhexidine content)
available in Australia are all from the same manufacturer and all only
licensed by TGA for hard surface disinfection. The red tint is a specific
requirements for some surgeons to enable them to easily visualise where the
skin has been prepped.

Cheers

Michael

Michael Wishart

Infection Control Coordinator

Holy Spirit Northside Private Hospital

627 Rode Road, Chermside, Qld 4032

t: (07) 3326 3068 | f: (07) 3607 2226

e: Michael.Wishart@svha.org.au

w:
http://www.holyspiritnorthside.org.au

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5th May 2014

5may2014_top

Of Glenys Harrington

Hi Michael,

Until companies have their products correctly registered with the TGA
(inclusive of the purpose of use and labelling) users (i.e.
hospitals/surgeons) assume liability for any injuries resulting from any
“off-label use”.

As it is difficult to find any recommendations or publications supporting
the use of >0.5% chlorhexidine and Alcohol for surgical skin preparation at
this point in time hospitals would be wise to undertake an “offline risk
assessment” and have it endorsed by their Infection Control committee before
proceeding.

Regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Michael Wishart

Hi Matthias

I believe the labelling of the solution in question is more about TGA
licensing than the actual formulation of the solution. That has been
discussed here previously on this list. The manufacturer of that product has
never explicitly stated you cannot use this solution for skin antisepsis,
only that it is not current licensed for this use. A vexing issue indeed.

Cheers

Michael

Michael Wishart

Infection Control Coordinator

Holy Spirit Northside Private Hospital

627 Rode Road, Chermside, Qld 4032

t: (07) 3326 3068 | f: (07) 3607 2226

e: Michael.Wishart@svha.org.au

w:
http://www.holyspiritnorthside.org.au

Please consider the environment before printing this email

5th May 2014

5may2014_top

Of Matthias Maiwald (KKH)

Hi Glenys,

Thank you very much for these additional points.

I would like to add a few points for clarification.

It is indeed the case that the CDC Guidelines for the Prevention of
Intravascular Catheter-Related Infections 2011 state to “Prepare clean skin
with a >0.5% chlorhexidine preparation with alcohol” and that this cannot be
automatically inferred to surgical skin preparation. Apart from the IHI
document that you cited (apparently specifying 2%; I have not yet seen the
document), there does not seem to be a widely specified CHG percentage
(supported by data) to be added to the alcohol that is available in
guidelines.

The Carroll et al. 2014 study (from Melbourne) shows (in a non-RCT) for
surgical skin preparation that the combination of 1% iodine and 70% alcohol
(i.e. two antiseptics) performs better than a combination of 0.5% CHG and
70% alcohol (i.e. two antiseptics). Note that the type of iodine and the
alcohol types have not been specified in that study. These results seem
congruent with those of Swenson et al. ICHE 2009; 30: 964-71 (iodine+ALC
versus CHG+ALC).

The Darouiche et al. NEJM 2010 study clearly shows (in an RCT) for surgical
skin preparation that a combination of 2% CHG with 70% isopropanol (i.e. two
antiseptics) performs better than 10% povidone-iodine alone (i.e. only one
antiseptic). For anyone who has followed the microbiological literature on
antiseptics (which spans many decades), the outcome of this trial was hardly
surprising, because this is a massively unequal comparison: two antiseptics
against one, and the isopropanol in the 2%CHG/70%IPA trial arm outperforms
either CHG alone or PVI alone by a factor of 10 (!). Apart from that, it
indeed looks like the scientific part of the Darouiche trial is solid (as
you state).

The Carroll et al. 2014 study and the Darouiche et al. 2010 study — even in
synospsis — genuinely CANNOT be taken to infer that 0.5% CHG with alcohol
is any inferior to 2% CHG with alcohol (or vice versa).

I have not suggested to use alcohol alone for surgical skin preparation; the
combinations of either CHG+ALC or PVI+ALC have clear benefits of being
combination antiseptics with enhanced activity. What I was suggesting is
that people should get less hung up about the role of CHG in the CHG+ALC
combination. The microbiological properties of skin antiseptics have been
studied for over 100 years (e.g. Harrington and Walker. Boston Medical and
Surgical Journal. 1903; 148: 548-52), and a wealth of information
particularly came from studies done in the 1970s and 1980s. From this branch
of the literature, the microbiological properties of the various skin
antiseptics are well defined. Alcohols are known to be far superior in their
immediate antimicrobial activity than either CHG or PVI. While evidence from
clinical trials is clearly the best evidence, this evidence CANNOT be
assessed in isolation, and it is necessary — while assessing evidence — to
have a holistic picture with taking the necessary scientific background (in
this case: microbiological background) and the principles of biological
plausibility into account. That this was not commonly done in evidence
assessments for skin antisepsis — and people focussed blindly on clinical
trial outcomes — is presumably the reason for the massive, large-scale
medical literature error that we described in our PLoS One (2012) article
and subsequently commented upon further in our recent J Antimicrob Chemother
(2014) article.

The advice “Do not use to disinfect surfaces likely to come in contact with
broken skin” for the CHLORHEXIDINE 0.5% IN ALCOHOL 70% TINTED RED that you
mention presumably simply means that alcohol-containing antiseptics are
unsuitable to be used on wounds (also mucous membranes).

The range of CHG concentrations that I have seen in CHG+ALC combinations for
surgical skin preparation is 0.5% to 3.15% (the latter an odd number by one
particular manufacturer. The 4% CHG concentration would be typical of
aqueous CHG antiseptics (as John Ferguson states).

Best regards, Matthias.

—

Matthias Maiwald, MD, FRCPA

Consultant in Microbiology

Adj. Assoc. Prof., Natl. Univ. Singapore

Department of Pathology and Laboratory Medicine

KK Women’s and Children’s Hospital

100 Bukit Timah Road

Singapore 229899

Tel. +65 6394 8725 (Office)

Tel. +65 6394 1389 (Laboratory)

Fax +65 6394 1387

Of Glenys Harrington

Hi Matthias,

To access IHI information – you just need to register and then you can get
access to information such as the How to Guides – it’s free.

We should clarify for those following this thread that the CDC reference
to “Prepare clean skin with a >0.5% chlorhexidine preparation with
alcohol……” is referring to skin preparation for intravascular devices
not surgical (preoperative) skin preparation – extract from guidelines
below.

Guidelines for the Prevention of Intravascular Catheter-Related Infections,
2011

. “Prepare clean skin with a >0.5% chlorhexidine preparation with
alcohol before central venous catheter and peripheral arterial catheter
insertion and during dressing changes. If there is a contraindication to
chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used
as alternatives [82, 83]. Category IA”

While there may be supportive evidence for >0.5% chlorhexidine and alcohol
preparations for the prevention of catheter-related bloodstream infections
we shouldn’t assume that this will necessarily be the case for reducing
surgical site infections(SSIs). Hence until we see the studies that clearly
demonstrate that alcohol alone is better that CHG and alcohol, Iodine and
alcohol, CHG alone or Iodine alone for surgical (preoperative) skin
preparation to prevent surgical site infections we should be cautious about
what we suggest people focus on.

This recent publication from St Vincent’s Hospital, Melbourne may be of
interest to those considering a 0.5% CHG and alcohol preparation for
surgical (preoperative) skin preparation

The study showed that patients who received skin prep with 0.5%
chlorhexidine and alcohol prior to orthopaedic surgical procedures were at
higher risk of superficial infection than those who received 1% iodine
and alcohol, p=0.012.

Carroll K. et al. Risk factors for superficial wound complications in hip
and knee arthroplasty. Clinical Microbiology and Infection,

Volume 20, Issue 2, pages 130-135, February 2014

. “The study was performed over an 18-month period (January 2011 to
June 2012) and included 964 patients undergoing prosthetic hip or knee
replacement surgery

. In the multivariable logistic regression analysis patients who
received skin prep with 0.5% chlorhexidine and alcohol were at higher
risk of superficial infection than those who received 1% iodine and
alcohol, p=0.012.

. The authors acknowledge findings may reflect surgeon preference
and experience and that skin prep requires more evaluation/RCT”.

.

Thanks for forwarding the ProPublica scandal publication, very interesting
reading.

I see the US company concerned settled with the US Dept of Justice avoiding
criminal charges for allegations of fraud against the government and the
product is now approved by the FDA as outlined in a US Department of Justice
Press Release titled “CareFusion to Pay the Government $40.1 Million to
Resolve Allegations That Include More Than $11 Million in Kickbacks to One
Doctor” on Thursday, January 9, 2014:

. ” The settlement resolves allegations that, under agreements
entered into in 2008 by CareFusion’s predecessor, CareFusion paid $11.6
million in kickbacks to Dr. Charles Denham while Denham served as the
co-chair of the Safe Practices Committee at the National Quality Forum, a
non-profit organization that reviews, endorses and recommends standardized
health care performance measures and practices. The government contends
that the purpose of those payments was to induce Denham to recommend,
promote and arrange for the purchase of ChloraPrep by health care providers.
ChloraPrep has been approved by the Food and Drug Administration for the
preparation of a patient’s skin prior to surgery or injection”.

. “This settlement also resolves allegations that, during the period
between September 2009 and August 2011, CareFusion knowingly promoted the
sale of ChloraPrep for uses that were not approved by the Food and Drug
Administration, some of which were not medically accepted indications, and
made unsubstantiated representations about the appropriate uses of
ChloraPrep. ChloraPrep has been approved by the Food and Drug Administration
for the preparation of a patient’s skin prior to surgery or injection”.

http://www.justice.gov/opa/pr/2014/January/14-civ-021.html

http://www.ag.ny.gov/pdfs/Settlement_Agreement.pdf

In addition the product concerned has also been registered with the TGA in
Australia and is on the ARTG list for use as “Sterile tinted antiseptic
applied to patient’s skin prior to invasive medical procedures”.

https://www.ebs.tga.gov.au/servlet/xmlmillr6?dbid=ebs/PublicHTML/pdfStore.ns
f

&docidC1698728A822FDCA257CA5003CC3EC&agid=(PrintDetailsPublic)&actionid=1

While the FDA discredited the NEJM publication in court proceedings as
outlined at the ProPublica link I don’t see where the publication it has
been discredited by the NEJM nor the U.S. National Institutes of Health,
Clinical Trials Unit who approved the trail?

Given that the allegations of impropriety and kickbacks where towards Dr.
Charles Denham, who was not an author of the NEJM publication and the trail
was a randomized, double-blind, placebo-controlled trial and conflicts of
interest were disclosed the results and conclusion below may still be
valid.

Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis N
Engl J Med 2010;362:18-26.

Results

“A total of 849 subjects (409 in the chlorhexidine-alcohol group and 440 in
the povidone-iodine group) qualified for the intention-to-treat analysis.
The overall rate of surgical-site infection was significantly lower in the
chlorhexidine-alcohol group than in the povidone-iodine group (9.5% vs.
16.1%; P = 0.004; relative risk, 0.59; 95% confidence interval, 0.41 to
0.85). Chlorhexidine-alcohol was significantly more protective than
povidone-iodine against both superficial incisional infections (4.2% vs.
8.6%, P = 0.008) and deep incisional infections (1% vs. 3%, P = 0.05) but
not against organ-space infections (4.4% vs. 4.5%). Similar results were
observed in the per-protocol analysis of the 813 patients who remained in
the study during the 30-day follow-up period. Adverse events were similar in
the two study groups”.

Conclusion

“Preoperative cleansing of the patient’s skin with chlorhexidine-alcohol is
superior to cleansing with povidone-iodine for preventing surgical-site
infection after clean contaminated surgery. (ClinicalTrials.gov number,
NCT00290290.)

In addition I think you will find in the US that there are only 2
concentrations of CHG and alcohol available for surgical (preoperative) skin
preparation – 2% or 4 % – happy to be corrected.

In Australia the supplier/manufacturer of the CHLORHEXIDINE 0.5% IN
ALCOHOL 70% TINTED RED that I think jenny is referring to states the
following on their users product guide:

. Do not use to disinfect therapeutic devices.

. Do not use to disinfect surfaces likely to come in contact with
broken skin.

Regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Matthias Maiwald (KKH)

Hi Glenys,

Interesting. I had not yet seen the IHI Project JOINTS website. Some of the
contents seem to be behind a login-wall, though.

The “2%” CHX specified percentage brings up an interesting issue; there was
a recent US healthcare scandal in which it is alleged that an ex committee
member of the US National Quality Forum (NQF) inappropriately influenced the
NQF towards a 2% CHG-containing solution, at a time when only one
manufacturer provided that particular percentage (meaning a 2% endorsement
would direct consumers towards that manufacturer’s product) and at a time
when there was no clear evidence to prefer a particular CHX percentage over
another (as John Ferguson states).

http://www.propublica.org/article/hidden-financial-ties-rattle-top-health-qu
ality-group

People should not get so focused on the CHX component; as I have often
emphasised, it is known from many decades of microbiological testing both in
vitro and on human skin that alcohols, when well formulated, are about 10
times more microbiologically effective than CHX.

Interesting, the second reference (2014 Update) lists routine preoperative
CHX showering/bathing/wiping as an unresolved issue. While this practice is
supported by a good microbiological rationale (and those who know me know
that I like microbiological rationales), it is not yet quite established
whether this translates into better clinical outcomes. Note, this is
different from specific preoperative decolonisation of MSSA/MRSA cariers,
which seems indeed to translate into better outcomes. Also, for classical
skin antisepsis (‘skin prep’) as discussed above, it is also well
established that this translates into outcomes.

Best regards, Matthias.

—

Matthias Maiwald, MD, FRCPA

Consultant in Microbiology

Adj. Assoc. Prof., Natl. Univ. Singapore

Department of Pathology and Laboratory Medicine

KK Women’s and Children’s Hospital

100 Bukit Timah Road

Singapore 229899

Tel. +65 6394 8725 (Office)

Tel. +65 6394 1389 (Laboratory)

Fax +65 6394 1387

Of Glenys Harrington

Hi Jenny,

Sorry to join the discussion in relation to surgical preoperative skin
preparation late.

Your surgeons request may relate to the Institute of Healthcare Improvement
(IHI) Project JOINTS.

http://www.ihi.org/engage/initiatives/completed/projectjoints/Pages/default.
aspx

In addition to the interventions recommended by the Surgical Care
Improvement Project (SCIP) (i.e. appropriate use of prophylactic
antibiotics, appropriate hair removal…and so on) Project JOINTS recommends
the following interventions for elective hip and knee arthroplasty
procedures:

1. Use of an alcohol-containing antiseptic agent for preoperative skin
preparation.

Hospitals participating in the IHI Project JOINTS are using one of the
following surgical preoperative skin preparations (personal communication):

o 2% CHG plus alcohol

*10% Iodophor plus alcohol

You can find additional information in the IHI Project JOINTS, “How to
Guide” including the following.

. IHI Project JOINTS How-to Guide: Prevent Surgical Site Infection
for Hip and Knee Arthroplasty: “The combination of a long-acting agent
(either an iodophor or CHG) is better than povidone iodine alone for
preventing SSI. There is insufficient evidence to support recommending the
use of one combination agent over another”.

2. Preoperative bathing or showering with chlorhexidine gluconate (CHG)
soap for at least three days before surgery – most are using CHG wipes
(personal communication).

3. Staphylococcus aureus screening and use of intranasal mupirocin and CHG
bathing or showering to decolonize Staphylococcus aureus carriers.

In addition the recent publication from the Society for Healthcare
Epidemiology of America (SHEA) and the Infectious Diseases Society of
America (IDSA) Practice Recommendations “Strategies to Prevent Surgical Site
Infections in Acute Care Hospitals: 2014 Update – Intervention number one
is a Grade 1 (high) level of evidence recommendation and may be worth a
read.

“Use alcohol-containing preoperative skin preparatory agents if no
contraindication exists (quality of evidence: I).

a. Alcohol is highly bactericidal and effective for preoperative skin
antisepsis but does not have persistent activity when used alone. Rapid,
persistent, and cumulative antisepsis can be achieved by combining alcohol
with chlorhexidine gluconate or an iodophor.115

i. Alcohol is contraindicated for certain procedures, including procedures
in which the preparatory agent may pool or not dry (e.g., involving hair)
due to fire risk. Alcohol may also be contraindicated for procedures
involving mucosa, cornea, or ear.

b. The most effective disinfectant to combine with alcohol is unclear…”.

The publication is freely available online at the following link:
http://www.jstor.org/stable/10.1086/676022

Your surgeon may want a tinted product so he/she can see where it has been
applied, although any staining (tinted CHG or Idophor) may obscure signs of
inflammation post-operatively.

regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Jenny McCarthy

thankyou to everyone who responded to my question – its given me a great
basis for discusssion with the ortho surgeon !!

_____

Of Matthias Maiwald (KKH)

Hi John,

I was actually considering remaining in the background for this particular
discussion. You make very good points. The (potentially) increased incidence
of skin reactions is interesting information that may be worth publishing if
you can.

One may want to bear in mind that different applications of skin antisepsis
(e.g. blood culture collection, surgical skin prep, vascular catheter
insertion) have different functional and physiological characteristics and
requirements, and for surgical skin preparation (Jenny’s question), the
question of chlorhexidine/alcohol versus povidone-iodine/alcohol is
unresolved. Chlorhexidine/alcohol is an excellent choice, but iodine/alcohol
should not be discounted for this purpose.

Best regards, Matthias.

—

Matthias Maiwald, MD, FRCPA

Consultant in Microbiology

Adj. Assoc. Prof., Natl. Univ. Singapore

Department of Pathology and Laboratory Medicine

KK Women’s and Children’s Hospital

100 Bukit Timah Road

Singapore 229899

Tel. +65 6394 8725 (Office)

Tel. +65 6394 1389 (Laboratory)

Fax +65 6394 1387

Of John Ferguson

Dear Jenny

The critical point is that when chlorhex is mixed with alcohol , there is no
apparent benefit from exceeding 0.5%.

The old literature on 2% C and lines related to an aqueous preparation.

Furthermore, we found an increase in skin reactions to the more concentrated
products (went to a poster).

Matthias M will comment no doubt – he has recently published this piece that
is of relevance – Maiwald M, Chan ESY. Pitfalls in evidence assessment: the
case of chlorhexidine and alcohol in skin antisepsis (Leading Article). J.
Antimicrob. Chemother. (2014) Advance Access.

http://jac.oxfordjournals.org/content/early/2014/04/28/jac.dku121.abstract

Kind regards

John

Dr John Ferguson

Infectious Diseases & Microbiology

+61 428 885573

Of Tim Spencer

Hi Jenny,
There is lots of supportive evidence for 2%CHG in 70%IPA, particularly for
invasive device skin preparation (CVC/PICC/PIVC,ICC/Epidural, etc,etc..)
Here is a link to Dr William Jarvis discussing the differences of various
skin preps.
http://www.medscape.com/viewarticle/761489
There is both a video of the discussion..
To cut to the conclusion;
The findings were very interesting. Of greatest importance, the
investigators found that all products (0.5% chlorhexidine with ethanol, 1%
chlorhexidine with ethanol, and 2% chlorhexidine with isopropyl alcohol)
were equally effective. This will be very helpful information when you are
trying to select a product for preparation of the insertion site for
intravascular catheters or for a preoperative surgical antiseptic.
Chlorhexidine is effective, and different concentrations of chlorhexidine
are equally effective, with no statistically significant difference in
colony counts. All of these products should be equally beneficial to
patients in preventing central line-associated bloodstream infections or
surgical site infections.

Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert.
Clinical Nurse Consultant, Central Venous Access & Parenteral Nutrition
Service
Conjoint Lecturer, South West Sydney Clinical School | Faculty of Medicine |
University of NSW
President, Australian Vascular Access Society
Dept of Intensive Care, Level 2, Clinical Building, Liverpool Hospital,
Elizabeth Street, Liverpool, 2170, NSW, Australia
Tel (+61) 2 8738 3603 | Fax (+61) 2 8738 3551 | Mob +61 (0)409 463 428 |
Tim.Spencer@sswahs.nsw.gov.au | Timothy.Spencer@unsw.edu.au

“Be a yardstick of quality. Some people aren’t used to an environment where
excellence is expected.” – Steve Jobs

_____

McCarthy [jenny@MARYVALEPH.COM.AU]

Hi all – not sure if this has already been discussed and apologies if it has
– one of the orthopaedic surgeons here is requesting Chlorhexidine 2% with
70% alcohol (tinted red) as opposed to the 0.5% with 70% alcohol for skin
prep. Firstly, is there an advantage to using the 2% as opposed to the 0.5%
and if so would anyone have any literature to support this

Thanks
Jenny McCarthy
Maryvale Private Hospital

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[Glenys Harrington]

Hi Michael,

Until companies have their products correctly registered with the TGA
(inclusive of the purpose of use and labelling) users (i.e.
hospitals/surgeons) assume liability for any injuries resulting from any
“off-label use”.

As it is difficult to find any recommendations or publications supporting
the use of >0.5% chlorhexidine and Alcohol for surgical skin preparation at
this point in time hospitals would be wise to undertake an “offline risk
assessment” and have it endorsed by their Infection Control committee before
proceeding.

Regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Michael Wishart

Hi Matthias

I believe the labelling of the solution in question is more about TGA
licensing than the actual formulation of the solution. That has been
discussed here previously on this list. The manufacturer of that product has
never explicitly stated you cannot use this solution for skin antisepsis,
only that it is not current licensed for this use. A vexing issue indeed.

Cheers

Michael

Michael Wishart

Infection Control Coordinator

Holy Spirit Northside Private Hospital

627 Rode Road, Chermside, Qld 4032

t: (07) 3326 3068 | f: (07) 3607 2226

e: Michael.Wishart@svha.org.au

w:
http://www.holyspiritnorthside.org.au

Please consider the environment before printing this email

5th May 2014

5may2014_top

Of Matthias Maiwald (KKH)

Hi Glenys,

Thank you very much for these additional points.

I would like to add a few points for clarification.

It is indeed the case that the CDC Guidelines for the Prevention of
Intravascular Catheter-Related Infections 2011 state to “Prepare clean skin
with a >0.5% chlorhexidine preparation with alcohol” and that this cannot be
automatically inferred to surgical skin preparation. Apart from the IHI
document that you cited (apparently specifying 2%; I have not yet seen the
document), there does not seem to be a widely specified CHG percentage
(supported by data) to be added to the alcohol that is available in
guidelines.

The Carroll et al. 2014 study (from Melbourne) shows (in a non-RCT) for
surgical skin preparation that the combination of 1% iodine and 70% alcohol
(i.e. two antiseptics) performs better than a combination of 0.5% CHG and
70% alcohol (i.e. two antiseptics). Note that the type of iodine and the
alcohol types have not been specified in that study. These results seem
congruent with those of Swenson et al. ICHE 2009; 30: 964-71 (iodine+ALC
versus CHG+ALC).

The Darouiche et al. NEJM 2010 study clearly shows (in an RCT) for surgical
skin preparation that a combination of 2% CHG with 70% isopropanol (i.e. two
antiseptics) performs better than 10% povidone-iodine alone (i.e. only one
antiseptic). For anyone who has followed the microbiological literature on
antiseptics (which spans many decades), the outcome of this trial was hardly
surprising, because this is a massively unequal comparison: two antiseptics
against one, and the isopropanol in the 2%CHG/70%IPA trial arm outperforms
either CHG alone or PVI alone by a factor of 10 (!). Apart from that, it
indeed looks like the scientific part of the Darouiche trial is solid (as
you state).

The Carroll et al. 2014 study and the Darouiche et al. 2010 study — even in
synospsis — genuinely CANNOT be taken to infer that 0.5% CHG with alcohol
is any inferior to 2% CHG with alcohol (or vice versa).

I have not suggested to use alcohol alone for surgical skin preparation; the
combinations of either CHG+ALC or PVI+ALC have clear benefits of being
combination antiseptics with enhanced activity. What I was suggesting is
that people should get less hung up about the role of CHG in the CHG+ALC
combination. The microbiological properties of skin antiseptics have been
studied for over 100 years (e.g. Harrington and Walker. Boston Medical and
Surgical Journal. 1903; 148: 548-52), and a wealth of information
particularly came from studies done in the 1970s and 1980s. From this branch
of the literature, the microbiological properties of the various skin
antiseptics are well defined. Alcohols are known to be far superior in their
immediate antimicrobial activity than either CHG or PVI. While evidence from
clinical trials is clearly the best evidence, this evidence CANNOT be
assessed in isolation, and it is necessary — while assessing evidence — to
have a holistic picture with taking the necessary scientific background (in
this case: microbiological background) and the principles of biological
plausibility into account. That this was not commonly done in evidence
assessments for skin antisepsis — and people focussed blindly on clinical
trial outcomes — is presumably the reason for the massive, large-scale
medical literature error that we described in our PLoS One (2012) article
and subsequently commented upon further in our recent J Antimicrob Chemother
(2014) article.

The advice “Do not use to disinfect surfaces likely to come in contact with
broken skin” for the CHLORHEXIDINE 0.5% IN ALCOHOL 70% TINTED RED that you
mention presumably simply means that alcohol-containing antiseptics are
unsuitable to be used on wounds (also mucous membranes).

The range of CHG concentrations that I have seen in CHG+ALC combinations for
surgical skin preparation is 0.5% to 3.15% (the latter an odd number by one
particular manufacturer. The 4% CHG concentration would be typical of
aqueous CHG antiseptics (as John Ferguson states).

Best regards, Matthias.

—

Matthias Maiwald, MD, FRCPA

Consultant in Microbiology

Adj. Assoc. Prof., Natl. Univ. Singapore

Department of Pathology and Laboratory Medicine

KK Women’s and Children’s Hospital

100 Bukit Timah Road

Singapore 229899

Tel. +65 6394 8725 (Office)

Tel. +65 6394 1389 (Laboratory)

Fax +65 6394 1387

Of Glenys Harrington

Hi Matthias,

To access IHI information – you just need to register and then you can get
access to information such as the How to Guides – it’s free.

We should clarify for those following this thread that the CDC reference
to “Prepare clean skin with a >0.5% chlorhexidine preparation with
alcohol……” is referring to skin preparation for intravascular devices
not surgical (preoperative) skin preparation – extract from guidelines
below.

Guidelines for the Prevention of Intravascular Catheter-Related Infections,
2011

. “Prepare clean skin with a >0.5% chlorhexidine preparation with
alcohol before central venous catheter and peripheral arterial catheter
insertion and during dressing changes. If there is a contraindication to
chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used
as alternatives [82, 83]. Category IA”

While there may be supportive evidence for >0.5% chlorhexidine and alcohol
preparations for the prevention of catheter-related bloodstream infections
we shouldn’t assume that this will necessarily be the case for reducing
surgical site infections(SSIs). Hence until we see the studies that clearly
demonstrate that alcohol alone is better that CHG and alcohol, Iodine and
alcohol, CHG alone or Iodine alone for surgical (preoperative) skin
preparation to prevent surgical site infections we should be cautious about
what we suggest people focus on.

This recent publication from St Vincent’s Hospital, Melbourne may be of
interest to those considering a 0.5% CHG and alcohol preparation for
surgical (preoperative) skin preparation

The study showed that patients who received skin prep with 0.5%
chlorhexidine and alcohol prior to orthopaedic surgical procedures were at
higher risk of superficial infection than those who received 1% iodine
and alcohol, p=0.012.

Carroll K. et al. Risk factors for superficial wound complications in hip
and knee arthroplasty. Clinical Microbiology and Infection,

Volume 20, Issue 2, pages 130-135, February 2014

. “The study was performed over an 18-month period (January 2011 to
June 2012) and included 964 patients undergoing prosthetic hip or knee
replacement surgery

. In the multivariable logistic regression analysis patients who
received skin prep with 0.5% chlorhexidine and alcohol were at higher
risk of superficial infection than those who received 1% iodine and
alcohol, p=0.012.

. The authors acknowledge findings may reflect surgeon preference
and experience and that skin prep requires more evaluation/RCT”.

.

Thanks for forwarding the ProPublica scandal publication, very interesting
reading.

I see the US company concerned settled with the US Dept of Justice avoiding
criminal charges for allegations of fraud against the government and the
product is now approved by the FDA as outlined in a US Department of Justice
Press Release titled “CareFusion to Pay the Government $40.1 Million to
Resolve Allegations That Include More Than $11 Million in Kickbacks to One
Doctor” on Thursday, January 9, 2014:

. ” The settlement resolves allegations that, under agreements
entered into in 2008 by CareFusion’s predecessor, CareFusion paid $11.6
million in kickbacks to Dr. Charles Denham while Denham served as the
co-chair of the Safe Practices Committee at the National Quality Forum, a
non-profit organization that reviews, endorses and recommends standardized
health care performance measures and practices. The government contends
that the purpose of those payments was to induce Denham to recommend,
promote and arrange for the purchase of ChloraPrep by health care providers.
ChloraPrep has been approved by the Food and Drug Administration for the
preparation of a patient’s skin prior to surgery or injection”.

. “This settlement also resolves allegations that, during the period
between September 2009 and August 2011, CareFusion knowingly promoted the
sale of ChloraPrep for uses that were not approved by the Food and Drug
Administration, some of which were not medically accepted indications, and
made unsubstantiated representations about the appropriate uses of
ChloraPrep. ChloraPrep has been approved by the Food and Drug Administration
for the preparation of a patient’s skin prior to surgery or injection”.

http://www.justice.gov/opa/pr/2014/January/14-civ-021.html

http://www.ag.ny.gov/pdfs/Settlement_Agreement.pdf

In addition the product concerned has also been registered with the TGA in
Australia and is on the ARTG list for use as “Sterile tinted antiseptic
applied to patient’s skin prior to invasive medical procedures”.

https://www.ebs.tga.gov.au/servlet/xmlmillr6?dbid=ebs/PublicHTML/pdfStore.ns
f

&docidC1698728A822FDCA257CA5003CC3EC&agid=(PrintDetailsPublic)&actionid=1

While the FDA discredited the NEJM publication in court proceedings as
outlined at the ProPublica link I don’t see where the publication it has
been discredited by the NEJM nor the U.S. National Institutes of Health,
Clinical Trials Unit who approved the trail?

Given that the allegations of impropriety and kickbacks where towards Dr.
Charles Denham, who was not an author of the NEJM publication and the trail
was a randomized, double-blind, placebo-controlled trial and conflicts of
interest were disclosed the results and conclusion below may still be
valid.

Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis N
Engl J Med 2010;362:18-26.

Results

“A total of 849 subjects (409 in the chlorhexidine-alcohol group and 440 in
the povidone-iodine group) qualified for the intention-to-treat analysis.
The overall rate of surgical-site infection was significantly lower in the
chlorhexidine-alcohol group than in the povidone-iodine group (9.5% vs.
16.1%; P = 0.004; relative risk, 0.59; 95% confidence interval, 0.41 to
0.85). Chlorhexidine-alcohol was significantly more protective than
povidone-iodine against both superficial incisional infections (4.2% vs.
8.6%, P = 0.008) and deep incisional infections (1% vs. 3%, P = 0.05) but
not against organ-space infections (4.4% vs. 4.5%). Similar results were
observed in the per-protocol analysis of the 813 patients who remained in
the study during the 30-day follow-up period. Adverse events were similar in
the two study groups”.

Conclusion

“Preoperative cleansing of the patient’s skin with chlorhexidine-alcohol is
superior to cleansing with povidone-iodine for preventing surgical-site
infection after clean contaminated surgery. (ClinicalTrials.gov number,
NCT00290290.)

In addition I think you will find in the US that there are only 2
concentrations of CHG and alcohol available for surgical (preoperative) skin
preparation – 2% or 4 % – happy to be corrected.

In Australia the supplier/manufacturer of the CHLORHEXIDINE 0.5% IN
ALCOHOL 70% TINTED RED that I think jenny is referring to states the
following on their users product guide:

. Do not use to disinfect therapeutic devices.

. Do not use to disinfect surfaces likely to come in contact with
broken skin.

Regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Matthias Maiwald (KKH)

Hi Glenys,

Interesting. I had not yet seen the IHI Project JOINTS website. Some of the
contents seem to be behind a login-wall, though.

The “2%” CHX specified percentage brings up an interesting issue; there was
a recent US healthcare scandal in which it is alleged that an ex committee
member of the US National Quality Forum (NQF) inappropriately influenced the
NQF towards a 2% CHG-containing solution, at a time when only one
manufacturer provided that particular percentage (meaning a 2% endorsement
would direct consumers towards that manufacturer’s product) and at a time
when there was no clear evidence to prefer a particular CHX percentage over
another (as John Ferguson states).

http://www.propublica.org/article/hidden-financial-ties-rattle-top-health-qu
ality-group

People should not get so focused on the CHX component; as I have often
emphasised, it is known from many decades of microbiological testing both in
vitro and on human skin that alcohols, when well formulated, are about 10
times more microbiologically effective than CHX.

Interesting, the second reference (2014 Update) lists routine preoperative
CHX showering/bathing/wiping as an unresolved issue. While this practice is
supported by a good microbiological rationale (and those who know me know
that I like microbiological rationales), it is not yet quite established
whether this translates into better clinical outcomes. Note, this is
different from specific preoperative decolonisation of MSSA/MRSA cariers,
which seems indeed to translate into better outcomes. Also, for classical
skin antisepsis (‘skin prep’) as discussed above, it is also well
established that this translates into outcomes.

Best regards, Matthias.

—

Matthias Maiwald, MD, FRCPA

Consultant in Microbiology

Adj. Assoc. Prof., Natl. Univ. Singapore

Department of Pathology and Laboratory Medicine

KK Women’s and Children’s Hospital

100 Bukit Timah Road

Singapore 229899

Tel. +65 6394 8725 (Office)

Tel. +65 6394 1389 (Laboratory)

Fax +65 6394 1387

Of Glenys Harrington

Hi Jenny,

Sorry to join the discussion in relation to surgical preoperative skin
preparation late.

Your surgeons request may relate to the Institute of Healthcare Improvement
(IHI) Project JOINTS.

http://www.ihi.org/engage/initiatives/completed/projectjoints/Pages/default.
aspx

In addition to the interventions recommended by the Surgical Care
Improvement Project (SCIP) (i.e. appropriate use of prophylactic
antibiotics, appropriate hair removal…and so on) Project JOINTS recommends
the following interventions for elective hip and knee arthroplasty
procedures:

1. Use of an alcohol-containing antiseptic agent for preoperative skin
preparation.

Hospitals participating in the IHI Project JOINTS are using one of the
following surgical preoperative skin preparations (personal communication):

o 2% CHG plus alcohol

*10% Iodophor plus alcohol

You can find additional information in the IHI Project JOINTS, “How to
Guide” including the following.

. IHI Project JOINTS How-to Guide: Prevent Surgical Site Infection
for Hip and Knee Arthroplasty: “The combination of a long-acting agent
(either an iodophor or CHG) is better than povidone iodine alone for
preventing SSI. There is insufficient evidence to support recommending the
use of one combination agent over another”.

2. Preoperative bathing or showering with chlorhexidine gluconate (CHG)
soap for at least three days before surgery – most are using CHG wipes
(personal communication).

3. Staphylococcus aureus screening and use of intranasal mupirocin and CHG
bathing or showering to decolonize Staphylococcus aureus carriers.

In addition the recent publication from the Society for Healthcare
Epidemiology of America (SHEA) and the Infectious Diseases Society of
America (IDSA) Practice Recommendations “Strategies to Prevent Surgical Site
Infections in Acute Care Hospitals: 2014 Update – Intervention number one
is a Grade 1 (high) level of evidence recommendation and may be worth a
read.

“Use alcohol-containing preoperative skin preparatory agents if no
contraindication exists (quality of evidence: I).

a. Alcohol is highly bactericidal and effective for preoperative skin
antisepsis but does not have persistent activity when used alone. Rapid,
persistent, and cumulative antisepsis can be achieved by combining alcohol
with chlorhexidine gluconate or an iodophor.115

i. Alcohol is contraindicated for certain procedures, including procedures
in which the preparatory agent may pool or not dry (e.g., involving hair)
due to fire risk. Alcohol may also be contraindicated for procedures
involving mucosa, cornea, or ear.

b. The most effective disinfectant to combine with alcohol is unclear…”.

The publication is freely available online at the following link:
http://www.jstor.org/stable/10.1086/676022

Your surgeon may want a tinted product so he/she can see where it has been
applied, although any staining (tinted CHG or Idophor) may obscure signs of
inflammation post-operatively.

regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Jenny McCarthy

thankyou to everyone who responded to my question – its given me a great
basis for discusssion with the ortho surgeon !!

_____

Of Matthias Maiwald (KKH)

Hi John,

I was actually considering remaining in the background for this particular
discussion. You make very good points. The (potentially) increased incidence
of skin reactions is interesting information that may be worth publishing if
you can.

One may want to bear in mind that different applications of skin antisepsis
(e.g. blood culture collection, surgical skin prep, vascular catheter
insertion) have different functional and physiological characteristics and
requirements, and for surgical skin preparation (Jenny’s question), the
question of chlorhexidine/alcohol versus povidone-iodine/alcohol is
unresolved. Chlorhexidine/alcohol is an excellent choice, but iodine/alcohol
should not be discounted for this purpose.

Best regards, Matthias.

—

Matthias Maiwald, MD, FRCPA

Consultant in Microbiology

Adj. Assoc. Prof., Natl. Univ. Singapore

Department of Pathology and Laboratory Medicine

KK Women’s and Children’s Hospital

100 Bukit Timah Road

Singapore 229899

Tel. +65 6394 8725 (Office)

Tel. +65 6394 1389 (Laboratory)

Fax +65 6394 1387

Of John Ferguson

Dear Jenny

The critical point is that when chlorhex is mixed with alcohol , there is no
apparent benefit from exceeding 0.5%.

The old literature on 2% C and lines related to an aqueous preparation.

Furthermore, we found an increase in skin reactions to the more concentrated
products (went to a poster).

Matthias M will comment no doubt – he has recently published this piece that
is of relevance – Maiwald M, Chan ESY. Pitfalls in evidence assessment: the
case of chlorhexidine and alcohol in skin antisepsis (Leading Article). J.
Antimicrob. Chemother. (2014) Advance Access.

http://jac.oxfordjournals.org/content/early/2014/04/28/jac.dku121.abstract

Kind regards

John

Dr John Ferguson

Infectious Diseases & Microbiology

+61 428 885573

Of Tim Spencer

Hi Jenny,
There is lots of supportive evidence for 2%CHG in 70%IPA, particularly for
invasive device skin preparation (CVC/PICC/PIVC,ICC/Epidural, etc,etc..)
Here is a link to Dr William Jarvis discussing the differences of various
skin preps.
http://www.medscape.com/viewarticle/761489
There is both a video of the discussion..
To cut to the conclusion;
The findings were very interesting. Of greatest importance, the
investigators found that all products (0.5% chlorhexidine with ethanol, 1%
chlorhexidine with ethanol, and 2% chlorhexidine with isopropyl alcohol)
were equally effective. This will be very helpful information when you are
trying to select a product for preparation of the insertion site for
intravascular catheters or for a preoperative surgical antiseptic.
Chlorhexidine is effective, and different concentrations of chlorhexidine
are equally effective, with no statistically significant difference in
colony counts. All of these products should be equally beneficial to
patients in preventing central line-associated bloodstream infections or
surgical site infections.

Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert.
Clinical Nurse Consultant, Central Venous Access & Parenteral Nutrition
Service
Conjoint Lecturer, South West Sydney Clinical School | Faculty of Medicine |
University of NSW
President, Australian Vascular Access Society
Dept of Intensive Care, Level 2, Clinical Building, Liverpool Hospital,
Elizabeth Street, Liverpool, 2170, NSW, Australia
Tel (+61) 2 8738 3603 | Fax (+61) 2 8738 3551 | Mob +61 (0)409 463 428 |
Tim.Spencer@sswahs.nsw.gov.au | Timothy.Spencer@unsw.edu.au

“Be a yardstick of quality. Some people aren’t used to an environment where
excellence is expected.” – Steve Jobs

_____

McCarthy [jenny@MARYVALEPH.COM.AU]

Hi all – not sure if this has already been discussed and apologies if it has
– one of the orthopaedic surgeons here is requesting Chlorhexidine 2% with
70% alcohol (tinted red) as opposed to the 0.5% with 70% alcohol for skin
prep. Firstly, is there an advantage to using the 2% as opposed to the 0.5%
and if so would anyone have any literature to support this

Thanks
Jenny McCarthy
Maryvale Private Hospital

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[Glenys Harrington]

Hi Matthias,

To access IHI information – you just need to register and then you can get
access to information such as the How to Guides – it’s free.

We should clarify for those following this thread that the CDC reference
to “Prepare clean skin with a >0.5% chlorhexidine preparation with
alcohol……” is referring to skin preparation for intravascular devices
not surgical (preoperative) skin preparation – extract from guidelines
below.

Guidelines for the Prevention of Intravascular Catheter-Related Infections,
2011

. “Prepare clean skin with a >0.5% chlorhexidine preparation with
alcohol before central venous catheter and peripheral arterial catheter
insertion and during dressing changes. If there is a contraindication to
chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used
as alternatives [82, 83]. Category IA”

While there may be supportive evidence for >0.5% chlorhexidine and alcohol
preparations for the prevention of catheter-related bloodstream infections
we shouldn’t assume that this will necessarily be the case for reducing
surgical site infections(SSIs). Hence until we see the studies that clearly
demonstrate that alcohol alone is better that CHG and alcohol, Iodine and
alcohol, CHG alone or Iodine alone for surgical (preoperative) skin
preparation to prevent surgical site infections we should be cautious about
what we suggest people focus on.

This recent publication from St Vincent’s Hospital, Melbourne may be of
interest to those considering a 0.5% CHG and alcohol preparation for
surgical (preoperative) skin preparation

The study showed that patients who received skin prep with 0.5%
chlorhexidine and alcohol prior to orthopaedic surgical procedures were at
higher risk of superficial infection than those who received 1% iodine
and alcohol, p=0.012.

Carroll K. et al. Risk factors for superficial wound complications in hip
and knee arthroplasty. Clinical Microbiology and Infection,

Volume 20, Issue 2, pages 130-135, February 2014

. “The study was performed over an 18-month period (January 2011 to
June 2012) and included 964 patients undergoing prosthetic hip or knee
replacement surgery

. In the multivariable logistic regression analysis patients who
received skin prep with 0.5% chlorhexidine and alcohol were at higher
risk of superficial infection than those who received 1% iodine and
alcohol, p=0.012.

. The authors acknowledge findings may reflect surgeon preference
and experience and that skin prep requires more evaluation/RCT”.

.

Thanks for forwarding the ProPublica scandal publication, very interesting
reading.

I see the US company concerned settled with the US Dept of Justice avoiding
criminal charges for allegations of fraud against the government and the
product is now approved by the FDA as outlined in a US Department of Justice
Press Release titled “CareFusion to Pay the Government $40.1 Million to
Resolve Allegations That Include More Than $11 Million in Kickbacks to One
Doctor” on Thursday, January 9, 2014:

. ” The settlement resolves allegations that, under agreements
entered into in 2008 by CareFusion’s predecessor, CareFusion paid $11.6
million in kickbacks to Dr. Charles Denham while Denham served as the
co-chair of the Safe Practices Committee at the National Quality Forum, a
non-profit organization that reviews, endorses and recommends standardized
health care performance measures and practices. The government contends
that the purpose of those payments was to induce Denham to recommend,
promote and arrange for the purchase of ChloraPrep by health care providers.
ChloraPrep has been approved by the Food and Drug Administration for the
preparation of a patient’s skin prior to surgery or injection”.

. “This settlement also resolves allegations that, during the period
between September 2009 and August 2011, CareFusion knowingly promoted the
sale of ChloraPrep for uses that were not approved by the Food and Drug
Administration, some of which were not medically accepted indications, and
made unsubstantiated representations about the appropriate uses of
ChloraPrep. ChloraPrep has been approved by the Food and Drug Administration
for the preparation of a patient’s skin prior to surgery or injection”.

http://www.justice.gov/opa/pr/2014/January/14-civ-021.html

http://www.ag.ny.gov/pdfs/Settlement_Agreement.pdf

In addition the product concerned has also been registered with the TGA in
Australia and is on the ARTG list for use as “Sterile tinted antiseptic
applied to patient’s skin prior to invasive medical procedures”.

https://www.ebs.tga.gov.au/servlet/xmlmillr6?dbid=ebs/PublicHTML/pdfStore.ns
f

&docidC1698728A822FDCA257CA5003CC3EC&agid=(PrintDetailsPublic)&actionid=1

While the FDA discredited the NEJM publication in court proceedings as
outlined at the ProPublica link I don’t see where the publication it has
been discredited by the NEJM nor the U.S. National Institutes of Health,
Clinical Trials Unit who approved the trail?

Given that the allegations of impropriety and kickbacks where towards Dr.
Charles Denham, who was not an author of the NEJM publication and the trail
was a randomized, double-blind, placebo-controlled trial and conflicts of
interest were disclosed the results and conclusion below may still be
valid.

Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis N
Engl J Med 2010;362:18-26.

Results

“A total of 849 subjects (409 in the chlorhexidine-alcohol group and 440 in
the povidone-iodine group) qualified for the intention-to-treat analysis.
The overall rate of surgical-site infection was significantly lower in the
chlorhexidine-alcohol group than in the povidone-iodine group (9.5% vs.
16.1%; P = 0.004; relative risk, 0.59; 95% confidence interval, 0.41 to
0.85). Chlorhexidine-alcohol was significantly more protective than
povidone-iodine against both superficial incisional infections (4.2% vs.
8.6%, P = 0.008) and deep incisional infections (1% vs. 3%, P = 0.05) but
not against organ-space infections (4.4% vs. 4.5%). Similar results were
observed in the per-protocol analysis of the 813 patients who remained in
the study during the 30-day follow-up period. Adverse events were similar in
the two study groups”.

Conclusion

“Preoperative cleansing of the patient’s skin with chlorhexidine-alcohol is
superior to cleansing with povidone-iodine for preventing surgical-site
infection after clean contaminated surgery. (ClinicalTrials.gov number,
NCT00290290.)

In addition I think you will find in the US that there are only 2
concentrations of CHG and alcohol available for surgical (preoperative) skin
preparation – 2% or 4 % – happy to be corrected.

In Australia the supplier/manufacturer of the CHLORHEXIDINE 0.5% IN
ALCOHOL 70% TINTED RED that I think jenny is referring to states the
following on their users product guide:

. Do not use to disinfect therapeutic devices.

. Do not use to disinfect surfaces likely to come in contact with
broken skin.

Regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Matthias Maiwald (KKH)

Hi Glenys,

Interesting. I had not yet seen the IHI Project JOINTS website. Some of the
contents seem to be behind a login-wall, though.

The “2%” CHX specified percentage brings up an interesting issue; there was
a recent US healthcare scandal in which it is alleged that an ex committee
member of the US National Quality Forum (NQF) inappropriately influenced the
NQF towards a 2% CHG-containing solution, at a time when only one
manufacturer provided that particular percentage (meaning a 2% endorsement
would direct consumers towards that manufacturer’s product) and at a time
when there was no clear evidence to prefer a particular CHX percentage over
another (as John Ferguson states).

http://www.propublica.org/article/hidden-financial-ties-rattle-top-health-qu
ality-group

People should not get so focused on the CHX component; as I have often
emphasised, it is known from many decades of microbiological testing both in
vitro and on human skin that alcohols, when well formulated, are about 10
times more microbiologically effective than CHX.

Interesting, the second reference (2014 Update) lists routine preoperative
CHX showering/bathing/wiping as an unresolved issue. While this practice is
supported by a good microbiological rationale (and those who know me know
that I like microbiological rationales), it is not yet quite established
whether this translates into better clinical outcomes. Note, this is
different from specific preoperative decolonisation of MSSA/MRSA cariers,
which seems indeed to translate into better outcomes. Also, for classical
skin antisepsis (‘skin prep’) as discussed above, it is also well
established that this translates into outcomes.

Best regards, Matthias.

—

Matthias Maiwald, MD, FRCPA

Consultant in Microbiology

Adj. Assoc. Prof., Natl. Univ. Singapore

Department of Pathology and Laboratory Medicine

KK Women’s and Children’s Hospital

100 Bukit Timah Road

Singapore 229899

Tel. +65 6394 8725 (Office)

Tel. +65 6394 1389 (Laboratory)

Fax +65 6394 1387

Of Glenys Harrington

Hi Jenny,

Sorry to join the discussion in relation to surgical preoperative skin
preparation late.

Your surgeons request may relate to the Institute of Healthcare Improvement
(IHI) Project JOINTS.

http://www.ihi.org/engage/initiatives/completed/projectjoints/Pages/default.
aspx

In addition to the interventions recommended by the Surgical Care
Improvement Project (SCIP) (i.e. appropriate use of prophylactic
antibiotics, appropriate hair removal…and so on) Project JOINTS recommends
the following interventions for elective hip and knee arthroplasty
procedures:

1. Use of an alcohol-containing antiseptic agent for preoperative skin
preparation.

Hospitals participating in the IHI Project JOINTS are using one of the
following surgical preoperative skin preparations (personal communication):

o 2% CHG plus alcohol

*10% Iodophor plus alcohol

You can find additional information in the IHI Project JOINTS, “How to
Guide” including the following.

. IHI Project JOINTS How-to Guide: Prevent Surgical Site Infection
for Hip and Knee Arthroplasty: “The combination of a long-acting agent
(either an iodophor or CHG) is better than povidone iodine alone for
preventing SSI. There is insufficient evidence to support recommending the
use of one combination agent over another”.

2. Preoperative bathing or showering with chlorhexidine gluconate (CHG)
soap for at least three days before surgery – most are using CHG wipes
(personal communication).

3. Staphylococcus aureus screening and use of intranasal mupirocin and CHG
bathing or showering to decolonize Staphylococcus aureus carriers.

In addition the recent publication from the Society for Healthcare
Epidemiology of America (SHEA) and the Infectious Diseases Society of
America (IDSA) Practice Recommendations “Strategies to Prevent Surgical Site
Infections in Acute Care Hospitals: 2014 Update – Intervention number one
is a Grade 1 (high) level of evidence recommendation and may be worth a
read.

“Use alcohol-containing preoperative skin preparatory agents if no
contraindication exists (quality of evidence: I).

a. Alcohol is highly bactericidal and effective for preoperative skin
antisepsis but does not have persistent activity when used alone. Rapid,
persistent, and cumulative antisepsis can be achieved by combining alcohol
with chlorhexidine gluconate or an iodophor.115

i. Alcohol is contraindicated for certain procedures, including procedures
in which the preparatory agent may pool or not dry (e.g., involving hair)
due to fire risk. Alcohol may also be contraindicated for procedures
involving mucosa, cornea, or ear.

b. The most effective disinfectant to combine with alcohol is unclear…”.

The publication is freely available online at the following link:
http://www.jstor.org/stable/10.1086/676022

Your surgeon may want a tinted product so he/she can see where it has been
applied, although any staining (tinted CHG or Idophor) may obscure signs of
inflammation post-operatively.

regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Jenny McCarthy

thankyou to everyone who responded to my question – its given me a great
basis for discusssion with the ortho surgeon !!

_____

Of Matthias Maiwald (KKH)

Hi John,

I was actually considering remaining in the background for this particular
discussion. You make very good points. The (potentially) increased incidence
of skin reactions is interesting information that may be worth publishing if
you can.

One may want to bear in mind that different applications of skin antisepsis
(e.g. blood culture collection, surgical skin prep, vascular catheter
insertion) have different functional and physiological characteristics and
requirements, and for surgical skin preparation (Jenny’s question), the
question of chlorhexidine/alcohol versus povidone-iodine/alcohol is
unresolved. Chlorhexidine/alcohol is an excellent choice, but iodine/alcohol
should not be discounted for this purpose.

Best regards, Matthias.

—

Matthias Maiwald, MD, FRCPA

Consultant in Microbiology

Adj. Assoc. Prof., Natl. Univ. Singapore

Department of Pathology and Laboratory Medicine

KK Women’s and Children’s Hospital

100 Bukit Timah Road

Singapore 229899

Tel. +65 6394 8725 (Office)

Tel. +65 6394 1389 (Laboratory)

Fax +65 6394 1387

Of John Ferguson

Dear Jenny

The critical point is that when chlorhex is mixed with alcohol , there is no
apparent benefit from exceeding 0.5%.

The old literature on 2% C and lines related to an aqueous preparation.

Furthermore, we found an increase in skin reactions to the more concentrated
products (went to a poster).

Matthias M will comment no doubt – he has recently published this piece that
is of relevance – Maiwald M, Chan ESY. Pitfalls in evidence assessment: the
case of chlorhexidine and alcohol in skin antisepsis (Leading Article). J.
Antimicrob. Chemother. (2014) Advance Access.

http://jac.oxfordjournals.org/content/early/2014/04/28/jac.dku121.abstract

Kind regards

John

Dr John Ferguson

Infectious Diseases & Microbiology

+61 428 885573

Of Tim Spencer

Hi Jenny,
There is lots of supportive evidence for 2%CHG in 70%IPA, particularly for
invasive device skin preparation (CVC/PICC/PIVC,ICC/Epidural, etc,etc..)
Here is a link to Dr William Jarvis discussing the differences of various
skin preps.
http://www.medscape.com/viewarticle/761489
There is both a video of the discussion..
To cut to the conclusion;
The findings were very interesting. Of greatest importance, the
investigators found that all products (0.5% chlorhexidine with ethanol, 1%
chlorhexidine with ethanol, and 2% chlorhexidine with isopropyl alcohol)
were equally effective. This will be very helpful information when you are
trying to select a product for preparation of the insertion site for
intravascular catheters or for a preoperative surgical antiseptic.
Chlorhexidine is effective, and different concentrations of chlorhexidine
are equally effective, with no statistically significant difference in
colony counts. All of these products should be equally beneficial to
patients in preventing central line-associated bloodstream infections or
surgical site infections.

Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert.
Clinical Nurse Consultant, Central Venous Access & Parenteral Nutrition
Service
Conjoint Lecturer, South West Sydney Clinical School | Faculty of Medicine |
University of NSW
President, Australian Vascular Access Society
Dept of Intensive Care, Level 2, Clinical Building, Liverpool Hospital,
Elizabeth Street, Liverpool, 2170, NSW, Australia
Tel (+61) 2 8738 3603 | Fax (+61) 2 8738 3551 | Mob +61 (0)409 463 428 |
Tim.Spencer@sswahs.nsw.gov.au | Timothy.Spencer@unsw.edu.au

“Be a yardstick of quality. Some people aren’t used to an environment where
excellence is expected.” – Steve Jobs

_____

McCarthy [jenny@MARYVALEPH.COM.AU]

Hi all – not sure if this has already been discussed and apologies if it has
– one of the orthopaedic surgeons here is requesting Chlorhexidine 2% with
70% alcohol (tinted red) as opposed to the 0.5% with 70% alcohol for skin
prep. Firstly, is there an advantage to using the 2% as opposed to the 0.5%
and if so would anyone have any literature to support this

Thanks
Jenny McCarthy
Maryvale Private Hospital

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[Glenys Harrington]

Hi Jenny,

Sorry to join the discussion in relation to surgical preoperative skin
preparation late.

Your surgeons request may relate to the Institute of Healthcare Improvement
(IHI) Project JOINTS.

http://www.ihi.org/engage/initiatives/completed/projectjoints/Pages/default.
aspx

In addition to the interventions recommended by the Surgical Care
Improvement Project (SCIP) (i.e. appropriate use of prophylactic
antibiotics, appropriate hair removal…and so on) Project JOINTS recommends
the following interventions for elective hip and knee arthroplasty
procedures:

1. Use of an alcohol-containing antiseptic agent for preoperative skin
preparation.

Hospitals participating in the IHI Project JOINTS are using one of the
following surgical preoperative skin preparations (personal communication):

o 2% CHG plus alcohol

*10% Iodophor plus alcohol

You can find additional information in the IHI Project JOINTS, “How to
Guide” including the following.

. IHI Project JOINTS How-to Guide: Prevent Surgical Site Infection
for Hip and Knee Arthroplasty: “The combination of a long-acting agent
(either an iodophor or CHG) is better than povidone iodine alone for
preventing SSI. There is insufficient evidence to support recommending the
use of one combination agent over another”.

2. Preoperative bathing or showering with chlorhexidine gluconate (CHG)
soap for at least three days before surgery – most are using CHG wipes
(personal communication).

3. Staphylococcus aureus screening and use of intranasal mupirocin and CHG
bathing or showering to decolonize Staphylococcus aureus carriers.

In addition the recent publication from the Society for Healthcare
Epidemiology of America (SHEA) and the Infectious Diseases Society of
America (IDSA) Practice Recommendations “Strategies to Prevent Surgical Site
Infections in Acute Care Hospitals: 2014 Update – Intervention number one
is a Grade 1 (high) level of evidence recommendation and may be worth a
read.

“Use alcohol-containing preoperative skin preparatory agents if no
contraindication exists (quality of evidence: I).

a. Alcohol is highly bactericidal and effective for preoperative skin
antisepsis but does not have persistent activity when used alone. Rapid,
persistent, and cumulative antisepsis can be achieved by combining alcohol
with chlorhexidine gluconate or an iodophor.115

i. Alcohol is contraindicated for certain procedures, including procedures
in which the preparatory agent may pool or not dry (e.g., involving hair)
due to fire risk. Alcohol may also be contraindicated for procedures
involving mucosa, cornea, or ear.

b. The most effective disinfectant to combine with alcohol is unclear…”.

The publication is freely available online at the following link:
http://www.jstor.org/stable/10.1086/676022

Your surgeon may want a tinted product so he/she can see where it has been
applied, although any staining (tinted CHG or Idophor) may obscure signs of
inflammation post-operatively.

regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Jenny McCarthy

thankyou to everyone who responded to my question – its given me a great
basis for discusssion with the ortho surgeon !!

_____

Of Matthias Maiwald (KKH)

Hi John,

I was actually considering remaining in the background for this particular
discussion. You make very good points. The (potentially) increased incidence
of skin reactions is interesting information that may be worth publishing if
you can.

One may want to bear in mind that different applications of skin antisepsis
(e.g. blood culture collection, surgical skin prep, vascular catheter
insertion) have different functional and physiological characteristics and
requirements, and for surgical skin preparation (Jenny’s question), the
question of chlorhexidine/alcohol versus povidone-iodine/alcohol is
unresolved. Chlorhexidine/alcohol is an excellent choice, but iodine/alcohol
should not be discounted for this purpose.

Best regards, Matthias.

—

Matthias Maiwald, MD, FRCPA

Consultant in Microbiology

Adj. Assoc. Prof., Natl. Univ. Singapore

Department of Pathology and Laboratory Medicine

KK Women’s and Children’s Hospital

100 Bukit Timah Road

Singapore 229899

Tel. +65 6394 8725 (Office)

Tel. +65 6394 1389 (Laboratory)

Fax +65 6394 1387

Of John Ferguson

Dear Jenny

The critical point is that when chlorhex is mixed with alcohol , there is no
apparent benefit from exceeding 0.5%.

The old literature on 2% C and lines related to an aqueous preparation.

Furthermore, we found an increase in skin reactions to the more concentrated
products (went to a poster).

Matthias M will comment no doubt – he has recently published this piece that
is of relevance – Maiwald M, Chan ESY. Pitfalls in evidence assessment: the
case of chlorhexidine and alcohol in skin antisepsis (Leading Article). J.
Antimicrob. Chemother. (2014) Advance Access.

http://jac.oxfordjournals.org/content/early/2014/04/28/jac.dku121.abstract

Kind regards

John

Dr John Ferguson

Infectious Diseases & Microbiology

+61 428 885573

Of Tim Spencer

Hi Jenny,
There is lots of supportive evidence for 2%CHG in 70%IPA, particularly for
invasive device skin preparation (CVC/PICC/PIVC,ICC/Epidural, etc,etc..)
Here is a link to Dr William Jarvis discussing the differences of various
skin preps.
http://www.medscape.com/viewarticle/761489
There is both a video of the discussion..
To cut to the conclusion;
The findings were very interesting. Of greatest importance, the
investigators found that all products (0.5% chlorhexidine with ethanol, 1%
chlorhexidine with ethanol, and 2% chlorhexidine with isopropyl alcohol)
were equally effective. This will be very helpful information when you are
trying to select a product for preparation of the insertion site for
intravascular catheters or for a preoperative surgical antiseptic.
Chlorhexidine is effective, and different concentrations of chlorhexidine
are equally effective, with no statistically significant difference in
colony counts. All of these products should be equally beneficial to
patients in preventing central line-associated bloodstream infections or
surgical site infections.

Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert.
Clinical Nurse Consultant, Central Venous Access & Parenteral Nutrition
Service
Conjoint Lecturer, South West Sydney Clinical School | Faculty of Medicine |
University of NSW
President, Australian Vascular Access Society
Dept of Intensive Care, Level 2, Clinical Building, Liverpool Hospital,
Elizabeth Street, Liverpool, 2170, NSW, Australia
Tel (+61) 2 8738 3603 | Fax (+61) 2 8738 3551 | Mob +61 (0)409 463 428 |
Tim.Spencer@sswahs.nsw.gov.au | Timothy.Spencer@unsw.edu.au

“Be a yardstick of quality. Some people aren’t used to an environment where
excellence is expected.” – Steve Jobs

_____

McCarthy [jenny@MARYVALEPH.COM.AU]

Hi all – not sure if this has already been discussed and apologies if it has
– one of the orthopaedic surgeons here is requesting Chlorhexidine 2% with
70% alcohol (tinted red) as opposed to the 0.5% with 70% alcohol for skin
prep. Firstly, is there an advantage to using the 2% as opposed to the 0.5%
and if so would anyone have any literature to support this

Thanks
Jenny McCarthy
Maryvale Private Hospital

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[Glenys Harrington]

Hi Franciska,

By definition I would consider vaginal examinations and deliveries to fit
under the category of General asepsis – ie applies to procedures outside an
operating suite procedure area and aims to reduce the number of
microorganisms and prevent their spread.

Hence I would expect that sterile glove be worn for such procedures.

Regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Franciska Ferreira

Good morning all,

I was asked the question, whether sterile gloves or non-sterile gloves
should be used when conducting VE’s and Deliveries? I have little
knowledge/background in the obstetric field but have witnessed obstetricians
wearing sterile gloves for VE’s in the past.

From recent experience I’ve been told that most obstetricians using
non-sterile gloves and only uses sterile gloves for suturing.

Any comments or views on this matter would be appreciated.

Thank you

Franciska Ferreira

INFECTION PREVENTION & CONTROL /WOUND MANAGEMENT CONSULTANT

Burnside War Memorial Hospital

120 Kensington Road, Toorak Gardens, SA 5056

t: 08 8202 7222 f: 08 8407 8573 e: fferreira@burnsidehospital.asn.au

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[Glenys Harrington]

Hi Louisa,

The following may be useful:

The Australasian Health Facility Guidelines, Part D Infection Prevention
and Control, 900 Construction and Renovation, Verification 900.3.00)
refers to the need for a multidisciplinary team to oversee the commissioning
of areas that will be air sampled and cultured.

A multidisciplinary team should be established comprising, but not limited
to; infection control experts (medical and nursing); hospital engineers; OHS
staff; environmental health staff; client representatives; and project staff
(architect, facility planner, consulting engineers, project manager etc).
These resources should be involved and consulted throughout the stages of
planning, design, construction and commissioning.

Regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Joe-Anne Bendall
Control Guideline

Hi Louisa

This is good information for infection control

Thanks

Joe

Joe-Anne Bendall

(Monday – Wednesday)

HAI Project Officer | Clinical Nurse Consultant Infection Prevention and
Control

Clinical Governance Unit

(Thursday/Friday)

Joe-anne Bendall | Clinical Nurse Consultant Infection Prevention and
Control
Sydney Hospital and Sydney Eye Hospital

8 Macquarie St

SYDNEY NSW 2000

|( ph +61 2 9382 7199 |page 22070 via switch 9382 7111| 7 Fax 93827510 |

Mobile 0418984255 | * Joe-anne.Bendall@SESIAHS.HEALTH.NSW.GOV.AU

Of Louisa Sasko

Dear all,

I was wondering if anyone has a guideline they use in their health service
around construction and renovation and the necessity of having infection
control consultation during the planning process etc that they would be
willing to share

thanks in advance

Kind Regards

Louisa Sasko

Clinical Nurse Consultant (Manager) | IPACS – Infection Prevention & Control
Service

Blacktown Mt Druitt Hospital
Tel (02) 9881 8994 | Fax (02) 9881 7408 | Mob 0408 923 789 |
Louisa.Sasko@health.nsw.gov.au
http://www.health.nsw.gov.au/

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[Glenys Harrington]

Interesting discussion and good points Maree re: the issue of waste disposal.

What is the evidence that disposable curtains reduce the risk infections? Im not aware of any but happy to be corrected.

If there is no evidence then this is not an infection control issue.

From those responding to this thread it seems like most sites introduced disposable curtains/screens for either aesthetics, poor terminal cleaning resulting in increased turnaround times (a management issue) or HCW occupational health and safety issue.

Hence while there may be other reasons for introducing disposable curtains/screens HCF executive management need to be made aware of the following:

the lack of evidence to support the introduction disposable curtains/screens as an infection control strategy to reduce infections

the need to offset the introduction costs against the increased cost that will be associated with disposal of disposable curtains/screens.

Regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

I have been following the conversation in this thread and would like to raise an issue/question

My organisation is constantly looking at ways to reduce its environmental footprint.

We are a member of the Victorian Green Health Round Table Group, which provides a forum of information sharing for member organisations related to environmental concerns.

One key activity undertaken by this group is comparing waste volumes generated with the goal to reduce.

One of the major changes in providing health services since I began nursing (which was a good few years ago) is the increasing use of disposable items; from kimguard wraps, surgical drapes, suction tubing, endotracheal tubes, and surgical glovesthe list goes on.

Some of these are absolutely no-brainers when it comes to rationale.

Disposable curtains are large and take up a lot of space in a bin, hence in landfill, prior to breaking down.

How do organisations who use disposable curtains weigh up this issue in contrast to the infection control risk related to privacy screens?

Maree Sommerville

Infection Control Coordinator

Mercy Hospital for Women

Heidelberg

(03) 8458 4759

_____

Hi All,

Have a small issue Disposable curtains/screens!

Would appreciate feedback from areas that are using the disposable curtain/screens in their facilities

The issue is around cost of linen vs disposable curtains/screens.

We have trialed & like what we have but those who watch the pennies are questioning their use.

Originally we brought them into our ED because the poor terminal cleaning staff were frantic with attending the cleaning ( which involves the replacement of curtains).

The NUM of ED was indicating at this particular incident -that there were three ambulances waiting to off load patients onto ED beds which were being held up by the terminal cleaning required.

Amongst other actions taken regarding this issue in ED-was the implementation of the disposable curtains.

Now the question being asked is who else in other health areas has disposable curtains/screens & where are they ( ie high risk areas).

Much appreciate any assistance with this.

Thank you

Vicki Denyer

Clinical Nurse Consultant | Infection Prevention & Control Unit
Lismore Base Hospital
Tel 02 6620 2385 | vicki.denyer@ncahs.health.nsw.gov.au

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[Glenys Harrington]

Hi Terry,

I’d be looking for a design flaw in the Automated Endoscope Reprocessors
that is hindering contact of the cleaning and disinfecting agents with every
potentially contaminated surface particularly given that it sound like it is
in more that on processor. Is that correct?

Cross sectional drawing of the Automated Endoscope Reprocessor components
might be useful in identifying sections of the reprocessor that are
hindering contact of the cleaning and disinfecting agents.

See John Hopkins experience with design flaws in a bronchoscopes:

N Engl J Med. 2003 Jan
16;348(3):221-7.

An outbreak of Pseudomonas aeruginosa infections associated with flexible
bronchoscopes

http://www.ncbi.nlm.nih.gov/pubmed/12529462

and

“Bronchoscope pseudomonas outbreak rattles John Hopkins”

http://www.endonurse.com/articles/2002/05/bronchoscope-pseudomonas-outbreak-
rattles-johns-h.aspx

regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Terry McAuley

Hi Everyone,

I have had a recent spate where a number of my endoscopy procedure centre
clients have reported culturing of “Pseudomonas species” or Gram negative
bacilli after the monthly water testing of the Automated Endoscope
Reprocessors.

Upon further investigation, the organism has been identified as Cupriavidis
pauculus. This organism is often associated with ultra filtration systems
and although it has low pathogenicity it is a risk to immunocompromised
patients.

Despite repeated water line disinfections, filter changes, disinfectant
dumps etc this bug keeps cropping up over and over again. We find that we
have cleared it in the next test after filter changes etc etc but then a
month later – we get a positive result again.

Whilst in low numbers, it is causing some concern regarding potential risks
to patients. In all cases we are not growing the organism form the
endoscopes.

I am wondering if anyone else has been experiencing the same issues?

If so – what did you do about it both in terms of managing the machines and
the risks to patients?

If you have cultured this organism, did you manage to identify the cause of
the problem?

Happy to chat offline.

Regards

Terry McAuley

Sterilisation & Infection Prevention and Control Consultant

STEAM Consulting

E: terry@steamconsulting.com.au

W: http://www.steamconsulting.com.au

A: PO BOX 779

Endeavour Hills

VIC Australia 3802

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[Glenys Harrington]

Hi Jackie,

Is it possible for you to y include the full references details with your comments?

Regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Dear All
An interesting and useful dialogue. From my recent experience in the UK, financial penalties certainly focus the executive mind on outcomes.
The Gurses et al paper has some interesting and informative perspectives to offer our “industry”!
Shifting approaches without financial penalties appears to be problematic, though targets can lead to ‘train wrecks’ (Morton et al 2010) and there are lots of these.
Reuse of single use items must surely be one of our more difficult battles
Cheers

Jackie Miley

Project Coordinator Infection Prevention
Infection Prevention and Epidemiology

The Alfred
55 Commercial Road
Melbourne VIC 3004
PO Box 315 Prahran
VIC 3181 Australia

Melbourne 3000 Australia

Jackie

Jackie Miley MSc, PG Cert Public Health, Cert Infection Control, Dip Rn. Practice Educator

Senior Lecturer Infection Prevention and Control
Subject Coordinator MSc Infection Prevention and Control

Oxford Brookes University
Faculty of Health and Life Sciences
Room S1/12
Department of Biological and Medical Sciences
Gipsy Lane Campus
Headington
Oxford OX3 0BP
jmiley@brookes.ac.uk

Coordinator – Audit and Surveillance Forum. Infection Prevention Society UK

Have you seen?

Publication of the IPS audit and surveillance competences

Jane McNeish, Catharine Pym, Sandra Beaumont, Jackie Miley

Journal of Infection Prevention July 2013 14: 122-124, first published on May 14, 2013 doi:10.1177/1757177413486736

On 9 January 2014 11:26, Joe-Anne Bendall wrote:

Hi Cath
Great debate to start the New Year
I think each hospital has different risks. For example, here we can allocate MRO pts their own BP machine, tourniquet etc. The equipment is cleaned when the patient is discharged as part of the terminal cleaning process. With the focus on the health $, I am not sure we could sustain the costs associated with the costs for purchase, storage and disposal of single use items.

We are currently developing a local health district policy for the cleaning of shared patient care equipment. This should help with reducing the risks of sharing equipment.

Thanks

Joe-Anne Bendall

(Monday/Thursday/Friday)
Joe-anne Bendall | Clinical Nurse Consultant Infection Prevention and Control
Sydney Hospital and Sydney Eye Hospital
8 Macquarie St
SYDNEY NSW 2000
|| ph +61 2 9382 7199 |page 22070 via switch 9382 7111| ( Fax 93827510 |(
Mobile 0418984255 | | Joe-anne.Bendall@SESIAHS.HEALTH.NSW.GOV.AU

—–Original Message—–

Thanks Irene and Terrie
Whilst I appreciate Terrie’s position coming from his role with a provider of reusable waste equipment my question was more specifically about equipment used on patients for clinical care so things like BP cuffs, ECG leads and tourniquets. The various responses are interesting and please keep them coming as debate and expression are good for us as is an appreciation for the past (and yes I qualify and feel “oldie” as well 🙂 Cheers Cath

Regards
Cath

Dr Cathryn Murphy RN MPH PhD CIC
Executive Director
Infection Control Plus Pty Ltd

Adjunct Professor
Griffith University, School of Nursing and Midwifery
http://www.infectioncontrolplus.com.au

—–Original Message—–

Hi all,
as a fellow “oldie” I agree with Terry’s assessment of the trends over the years. I also support the final point about the issues involved in the decision making process. What has always puzzled me is how to accurately measure the environmental impact of either disposable or re-usable items?

Irene Wilkinson
Manager, Infection Control Service,
Communicable Disease Control Branch
SA Health
11 Hindmarsh Square,
Adelaide SA 5000
________________________________________

Hi Cath,
I had not heard of a movement back to single use items so I will be interested to hear members’ responses on this topic. For oldies like me it has been interesting to see the disposable/reusable “cycle” over the decades.

* in the 60’s we reused needles, glass syringes, gowns, etc, to reduce procurement costs;

* in the 70’s the cost of labour to process reusables (and modern technology enabling economic production of disposables) moved us to disposables;

* In the 80’s and 90’s waste disposal costs together with environmental impact of disposables, caused many to move to reusables again;

* Now with staff shortages, in-house processing of reusables is being re-examined (NB. processing by external contractors can still be economical, e.g. reprocessing single-use medical devices saves USA hospitals $300m annually.
As you point out, there have been relatively few evidence-based articles implicating disease transmission with either protocol.
The decision to use disposables or reusables must be evidence-based encompassing patient and staff safety, labour costs, procurement costs, and environmental impact. I look forward to members’ comments

Best regards, Terry

Terry Grimmond FASM, BAgrSc, GrDpAdEd
Consultant Microbiologist
Grimmond and Associates
Ph/Fx (NZ): +64 7 856 4042
Mob (NZ): +64 274 365 140
E: tg@gandassoc.com
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Happy new year all

As you may know there’s a subtle movement in Australia towards more widespread adoption of single-use items such as venepuncture tourniquets, lower limb surgical tourniquets, BP cuffs and ECG leads. Tom Gottlieb recently did some elegant research on venepuncture tourniquets and AT ACIPC 2013 Karen Vickery presented new perspectives on biofilm on reusable equipment. Single-use items have been adopted widely in the US for some years and recommendations to that effect are included in many Standards published by relevant professional associations eg AORN.

Whilst appreciating that demonstrating causality between reusable equipment and transmission of colonising organisms or infection is difficult either is biologically plausible. There are also issues of non-cleaning, lack of clarity about who’s role it actually is to clean reusable equipment, how frequently they need to be cleaned or reprocessed etc. These issues have plagued us for at least 3 decades that I know of and likely longer. I’m wondering what others in Australia and beyond think about single-use pt care items

So my questions are:

1. Has any ACIPC colleague successfully built a business case to convert their facility to single-use pt equipment? If so who was involved in that process?;

2. Which pieces of pt equipment do folks think are most in need of single-use alternative options?;

3. Other than price, storage, supply and environmental/waste issues and lack of detailed science what other factors would need to be addressed to help convince you or your organisation’s decision makers to invest in specific single-use equipment?.

I’d be grateful for any discussion here or as PMs on the email address below. If anyone is interested in my further work around this issue please email me.

Regards
Cath

Dr Cathryn Murphy RN MPH PhD CIC
Executive Director
Infection Control Plus Pty Ltd
Cath@infectioncontrolplus.com.au

Adjunct Professor
Griffith University, School of Nursing and Midwifery

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[Glenys Harrington]

Hi Rachel,

How do you keep the surface/s wet to achieve a 10minute contact time?

Regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Of Thomson, Rachel EA (DHHS)

Hi Vicki,

At the RHH we use a combined detergent and sodium hypochlorite disinfectant
solution at 1000ppm (commercially prepared solution). We use this as a 1 or
2 two-step agent. We clean and disinfect the room and associated items with
the product and then rinse susceptible surfaces after a minimum 10 minute
contact time. I would be happy to provide more detail re specifics if you
would like to contact me directly.

Kind regards

Rachel

Rachel Thomson

Nurse Unit Manager

Infection Prevention & Control Unit

Royal Hobart Hospital

E: rachel.thomson@dhhs.tas.gov.au

Of Denyer, Vicki

Hi all, was wondering what other facilities are using for disinfecting the
extreme risk areas

3.3.1 Extreme risk areas

The functional areas in this category represent areas that pose the greatest
risk of

transmission of infection. Patients in these areas are very susceptible to
infection or are

undergoing highly invasive procedures. In addition surgical instruments and
stock are

stored in these areas. Cleaning outcomes must be achieved through the
highest level of

cleaning intensity and frequency.

The use of disinfectants as part of routine cleaning is only required in10;

. Extreme Risk areas;

. As part of outbreak management; and

. Terminal cleaning following an MRO/infectious disease in any functional
area.

For the use of an environmental cleaning disinfectant for any other reason
staff must

contact the ICP for advice and approval that is based on the risk of
contamination to

patients and others.

Vicki Denyer

Clinical Nurse Consultant | Infection Prevention & Control Unit
Lismore Base Hospital
Tel 02 6620 2385 | vicki.denyer@ncahs.health.nsw.gov.au

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[Glenys Harrington]

Hi Wendy,

The abstract below from ID week (Oct 2013) may be of interest have you cultured any antiseptics or ointments being applied to the Vascath insertion sites?

848. An outbreak of Burckolderia cepacea bacteremia in a hemodialisis pediatric unit

https://idsa.confex.com/idsa/2013/webprogram/images/bullet_right_arrowlt.gifSession: Poster Abstract Session: Healthcare-associated Outbreaks and Pseudo Outbreaks

Friday, October 4, 2013

Posters

poster idweek.pdf (846.0 kB)

Maria Andrea Gatica, MD, Pediatric Infecious Diseases, HOSPITAL ROOSEVELT, Guatemala, Guatemala and Mario Melgar, MD, Infectious Diseases, HOSPITAL ROOSEVELT, Guatemala, Guatemala

https://idsa.confex.com/idsa/2013/webprogram/images/bullet_right_arrowlt.gifDisclosures:

M. A. Gatica, None

M. Melgar, None

Regards

Glenys

Glenys Harrington

Consultant

Infection Control Consultancy (ICC)

PO Box 5202

Middle Park

Victoria, 3206

Australia

H: +61 3 96902216

M: +61 404 816 434

infexion@ozemail.com.au

ABN 47533508426

Good morning

Currently at The Canberra Hospital we have identified a small cluster of Burkholderia cepacia in blood cultures and vas cath tips in renal dialysis patients. To date we have conducted environmental surveillance but not identified a cause.

Our question is: is anyone else seeing this at this time and if so have you identified a cause?

Wendy Beckingham
CNC Infection Prevention and Control
ph. (02) 6244 3695 or mobile 0478408787 orpager 50390
e. wendy.beckingham@act.gov.au

Care Excellence Collaboration Integrity

GERMS CAN KILL…

CH_Logo_ACT_Health_Lockup_CMYK_HR

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[Author]

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