Graham Ayliffe

Surgical Scrub and Skin Disinfection

The role of pre-operative disinfection of the surgeons hands and the skin of the operative site in the prevention of wound infection remains uncertain. The normal resident skin flora, consisting mainly of coagulase-negative staphylococci and aerobic and anaerobic diphtheroids, is an uncommon cause of infection except in prosthetic operations. Staphylococcus aureus is rarely a resident on normal skin other than the perineum, and is mostly present on the hands as a transient acquired from the nose. Nevertheless, it seems rational to kill or remove all transients on the hands of the surgeon and reduce residents to low levels. Surgical skin disinfection is usually assessed by measuring the reduction in organisms on the hands immediately after disinfection, after repeated applications of the disinfectant and after wearing gloves for two to three hours. The hands are commonly sampled in a bowl or plastic bag containing Ringers or a similar solution and relevant neutralizers, or by the use of glove washings. A standardized technique is necessary to provide a statistical comparison between agents. Antiseptic detergents, chlorhexidine or povidone iodine show immediate reductions in bacterial counts of 70% to 80%, increasing to 99% after repeated application. Hexachloraphene and triclosan detergents show a lower immediate reduction but a good residual effect. Seventy percent ethyl or 60% propyl alcohol, with or without an antiseptic, show an immediate reduction of over 95%, and in excess of 99% on repeated application. Residual levels of organisms tend to be lower after repeated alcohol treatment than following the use of antiseptic detergents.(ABSTRACT TRUNCATED AT 250 WORDS)

Disinfection in Healthcare

Preface.1. Principles of disinfection.2. Properties of chemical disinfectants.3. Disinfection Policy.4. Thermal Disinfection.5. Organisms of special significance.6. Cleaning of disinfection of the environment.7. Disinfection of the skin and mucous membranes.8. Disinfection of Medical Equipment.9. Disinfectants in pathology departments.10. Safety in chemical disinfection.Appendix 1 - Summary of Policy for Decontamination of Equipment or Environment.Appendix 2 - Bibliography

Evidence-based Practices in Infection Control

Abstract Evidence can be obtained from clinical trials and bacteriological studies. The latter consist mainly of measuring reductions in colonization, or reductions in bacterial counts on naturally or artificially contaminated surfaces, following the introduction of the measure to be tested. Controlled clinical trials usually provide the best evidence, but are infrequently carried out due to the large number of subjects required, low initial infection rates and a multiplicity of associated factors. Bacteriological studies can be carried out more easily and can often provide statistically significant results not readily available in clinical studies, but they require care in interpretation. Studies involving bacterial counts in the inanimate environment are particularly likely to give misleading results, but have often provided useful confirmatory evidence in eliminating rituals.

The emergence of the ICNA and progression to the IPS

utbreaks of penicillin resistant Staphylococcus aureus infections were reported in the 1940s and it soon became apparent that this organism was spreading in hospitals around the world. The introduction of phage typing enabled the different epidemic strains to be characterised and a particularly virulent strain, type 80/81, was identifi ed that often infected neonates and caused furunculosis in the nursing staff. Other strains of different phage types were common causes of postoperative sepsis. In 1955, Leonard Colebrook, who had previously worked on burns infections in Birmingham, proposed that hospitals should appoint a full-time control of infection offi cer to review information on sepsis and to coordinate preventive measures. Although the idea was widely accepted, no full-time offi cers were appointed in the UK. Meanwhile, about the same time, a severe outbreak of postoperative wound sepsis occurred in the Royal Devon and Exeter Hospital where Brendan Moore was Director of the Public Health Laboratory. He was a good research worker which was infl uenced by his early mathematical training, and his organising ability was aided by his considerable Irish charm. His main interests were in the bacteriology of the environment and water and he was well known for developing a special swab for detecting enteric pathogens in sewage. However, he immediately turned his attention to the problem of staphylococcal infections and helped to implement the recommendations later published in Staphylococcal Infections in Hospitals (Ministry of Health, 1959). These included the setting up of an Infection Control Committee and a ward record of infections fi lled in by the medical staff. These records were often inaccurate and although improved if completed by ward sisters, the information obtained was often too late to introduce useful preventive measures. He also observed in a study of sutures in infected wounds that the staphylococci isolated from them were mercury resistant and were often epidemic strains. This enabled him to develop a laboratory test for early recognition of epidemic strains in advance of phage typing results. Another major staphylococcal outbreak in Torbay hospital, which was some distance from Exeter, attracted Brendan Moores attention. An Infection Control Committee had also been set up and a surgeon, Mr AM Gardner, was appointed as the Infection Control Offi cer, but although interested, he had limited time available for epidemiological studies. The local laboratory facilities were also unable to deal with all the swabs required. The Matron, Mrs Stamm, on Brendan Moores suggestion and with the agreement of the hospital secretary and the consultants, offered the full-time services of a hospital sister to help in the ascertainment and prevention of infection in patients and to collect clearance swabs from staff. Miss E Cottrell was the fi rst Infection Control Sister (ICS) to be appointed in the country in 1959. She had been a theatre superintendent, which provided suitable background experience, and she was senior enough to be able to discuss problems with all staff, ranging from surgeons to ward cleaners. She played a major part in developing the role of Infection Control Nurse (ICN) today ( Moore, 1961 ; Gardner et al, 1962 ). The success of the ICS in Torbay led to the appointment of Sister Forman in Exeter in 1960. At that time, ward sisters were asked to keep a diary containing details of infection. The diary was inspected by the ICS on her daily rounds and further information added as necessary. A daily visit to the laboratory was also made listing the isolations of epidemic staphylococci, providing evidence of potential outbreaks. Sister Forman recognised the importance of microbiology in this new post and since no formal training was available she joined the laboratory technicians in their lectures. As well as surveillance, she also helped in assessing the adequacy of ward techniques in relation to teaching practices. The daily identifi cation of clinical infections enabled the incidence of infection to be calculated in the hospital or ward, but it was early recognised by Brendan Moore that the number of infections was usually too small for statistical comparisons to be made between hospitals as originally shown by Owen Lidwell, and infections arising after discharge of a patient from hospital were often missed. He described these diffi culties at the fi rst International Conference on Nosocomial Infections at the Centers for Disease Control (CDC), Atlanta in 1970 and explained how in Exeter the presence of an ICS visiting the wards every day enabled infected patients to be identifi ed more rapidly and where appropriate sent to the local isolation hospital ( Moore, 1971 ). A number of other hospitals with problems of infection were interested in the appointment of an ICS but were often uncertain of their duties. The newly appointed nurses often spent most of the day at their desks recording data on infection or collecting nasal swabs from staff, but useful action was often not followed. Others visited wards reprimanding staff for hygienic errors without the necessary knowledge to assess risks. A few ICSs were able to visit Exeter to discuss their role with Brendan Moore and Sister Forman. It was therefore decided by Brendan Moore, assisted by Rodney Cartwright, to organise an educational residential conference in Lyngford House, Taunton, in 1966. A small group of us, mainly interested bacteriologists and ICSs attended and heard talks by the Torbay and Exeter teams and discussed the problems found by the newly appointed ICSs. Further annual meetings were held in Taunton in 1967 and 1968 and with the increasing numbers of ICSs, a larger meeting was held in Birmingham in 1969 organised locally by Kathy Brightwell, the Infection Research Nurse, and her colleagues in the Hospital Infection Research Laboratory (HIRL). The only society at the time with a primary interest in hospital infection was the Central Sterilizing Club, which did not fulfi l the nurses’ requirements, and in 1970 at the Annual Conference in Bristol the Infection Control Nurses Association (ICNA) was formed. Dr Brendan Moore was the fi rst President, Henry Street from Torbay was the fi rst Chairman, Annette Seekers (previously Viant) from Bristol was appointed Secretary and Kathy Brightwell the Treasurer. One of the problems discussed was the membership and it was decided that only Infection Control Nurses should be full voting members.Whether this was the best decision remained uncertain because many Infection Control Offi cers (ICO) – later changed to Infection Control Doctors (ICD) – did not join as they were unwilling to be associate members (non-voting). This also applied to some Infection Control Technicians, particularly those from Holland, O

Should the government’s deep cleaning hospitals programme have been evaluated?

References Ayliffe GAJ. ( 2004 ) Evidence-based practices in infection control . British Journal of Infection Control 1 : 7 – 9 . Ayliffe GAJ , Collins BJ , Lowbury EJ , Babb JR , Lilly HA. ( 1967 ) Ward fl oors and other surfaces as reservoirs of hospital infection . Journal of Hygiene(Camb) 65: 515 – 36 . Brown CA , Lilford RJ. ( 2009 ) Should the UK government’s deep cleaning of hospitals programme have been evaluated? Journal of Infection Prevention 10: 143 – 7 . Hoffman P , Bradley C , Ayliffe GAJ. ( 2004 ). Disinfection in healthcare . 3rd edn. Blackwell : London . Should the government’s deep cleaning hospitals programme have been evaluated? Should the government’s deep cleaning hospitals programme have been evaluated?