Solid medical hospital waste in times of corona : increased volume but no increased biohazard risk

The effect of the COVID-19 pandemic on medical waste EWC/EURAL code 180103* (infectious medical waste) and 180104 (non-infectious medical waste) was investigated in 6 university hospitals and 6 general hospitals. Data on the number of in-hospital patients and on quantity and volume of waste were obtained during 2019 (control period) and in 2020 up to March 2021 (COVID-19 period) for the hospitals, from the waste managing company, and from the regional destruction facility. The presence of SARS-CoV-2 on the surface of waste recipients was analyzed using RTPCR. We found that the effect of the pandemic on the total weight of waste is limited during the first wave (March 2020), while during the second wave, the quantity of waste type 180103* increased. The main effect is a nearly doubling of the volume of waste during both waves caused by the use of cardboard hospital boxes with a yellow inner plastic bag. We demonstrated that the average weight of these cardboard boxes generated for the treatment of COVID-19 patients is significantly lower compared to the weight of the waste from non-COVID-19 patients. COVID-19-related health care activities caused a weight increase of the 180103* waste from historical data (0.2-1.4 kg/day/bed) up to 5-8 kg/day/bed. RT-PCR analysis of swabs demonstrated the absence of viral RNA on personal protection materials and on the surface of recipients containing the waste. We conclude that COVID-19-related hospital waste is predominantly of the EWC 180104 type

A recurrent and transesophageal echocardiography-associated outbreak of extended-spectrum β-lactamase-producing Enterobacter cloacae complex in cardiac surgery patients

BACKGROUND: We report a recurrent outbreak of postoperative infections with extended-spectrum β-lactamase (ESBL)-producing E. cloacae complex in cardiac surgery patients, describe the outbreak investigation and highlight the infection control measures. METHODS: Cases were defined as cardiac surgery patients in Ghent University Hospital who were not known preoperatively to carry ESBL-producing E. cloacae complex and who postoperatively had a positive culture for this multiresistant organism between May 2017 and January 2018. An epidemiological investigation, including a case-control study, and environmental investigation were conducted to identify the source of the outbreak. Clonal relatedness of ESBL-producing E. cloacae complex isolates collected from case patients was assessed using whole-genome sequencing-based studies. RESULTS: Three separate outbreak episodes occurred over the course of 9 months. A total of 8, 4 and 6 patients met the case definition, respectively. All but one patients developed a clinical infection with ESBL-producing E. cloacae complex, most typically postoperative pneumonia. Overall mortality was 22% (4/18). Environmental cultures were negative, but epidemiological investigation pointed to transesophageal echocardiography (TEE) as the outbreak source. Of note, four TEE probes showed a similar pattern of damage, which very likely impeded adequate disinfection. The first and second outbreak episode were caused by the same clone, whereas a different strain was responsible for the third episode. CONCLUSIONS: Health professionals caring for cardiac surgery patients and infection control specialists should be aware of TEE as possible infection source. Caution must be exercised to prevent and detect damage of TEE probes

Toilet drain water as a potential source of hospital room-to-room transmission of carbapenemase-producing Klebsiella pneumoniae

Background: Carbapenemase-producing Enterobacterales (CPE) have rapidly emerged in Europe, being responsible for nosocomial outbreaks. Aim: Following an outbreak in the burn unit of Ghent University Hospital, we investigated whether CPE can spread between toilets through drain water and therefrom be transmitted to patients. Methods: In 2017, the burn centre of our hospital experienced an outbreak of OXA-48-producing Klebsiella pneumoniae that affected five patients staying in three different rooms. Environmental samples were collected from the sink, shower, shower stretcher, hand rail of the bed, nursing carts, toilets, and drain water to explore a common source. Whole-genome sequencing and phylogenetic analysis was performed on K. pneumoniae outbreak isolates and two random K. pneumoniae isolates. Findings: OXA-48-producing K. pneumoniae was detected in toilet water in four out of six rooms and drain water between two rooms. The strain persisted in two out of six rooms after two months of daily disinfection with bleach. All outbreak isolates belonged to sequence type (ST) 15 and showed isogenicity (<15 allele differences). This suggests that the strain may have spread between rooms by drain water. Unexpectedly, one random isolate obtained from a patient who became colonized while residing at the geriatric ward clustered with the outbreak isolates, suggesting the outbreak to be larger than expected. Daily application of bleach tended to be superior to acetic acid to disinfect toilet water; however, disinfection did not completely prevent the presence of carbapenemase-producing K. pneumoniae in toilet water. Conclusion: Toilet drain water may be a potential source of hospital room-to-room transmission of carbapenemase-producing K. pneumoniae

ESBL-producing, carbapenem- and ciprofloxacin-resistant Escherichia coli in Belgian and Dutch broiler and pig farms : a cross-sectional and cross-border study

Background. The use of antibiotics in food production selects for resistant bacteria and may cause a threat to human and animal health. Belgium and the Netherlands have one of the highest densities of broilers and pigs in Europe, making active monitoring of antibiotic use and resistance in this region vital. Objectives. This study aimed to quantify ESBL-producing (ESBL-E. coli), carbapenem- and ciprofloxacin-resistant (CiproR) Escherichia coli in animal feces on broiler and pig farms with a history of high antibiotic use in Belgium and the Netherlands. Methods. A total of 779 broiler and 817 pig fecal samples, collected from 29 conventional broiler and 31 multiplier pig farms in the cross-border region of Belgium and the Netherlands, were screened for the presence of antibiotic-resistant E. coli using selective culturing. Results. Carbapenem-resistant E. coli were not detected. ESBL-E. coli were remarkably more prevalent in samples from Belgian than Dutch farms. However, CiproR-E. coli were highly prevalent in broilers of both countries. The percentage of samples with ESBL- and CiproR-E. coli was lower in pig compared to poultry farms and varied between farms. No clear association with the on-farm antibiotic use in the year preceding sampling was observed. Multidrug resistance was frequently observed in samples from both countries, but ESBL-production in combination with ciprofloxacin resistance was higher in samples from Belgium. Conclusions. This study demonstrated marked differences in antibiotic resistance between countries, farms and within farms. The observed variation cannot be explained straightforward by prior quantity of antibiotic use suggesting that it results from more complex interactions that warrant further investigation

Implementation of the Infection Risk Scan (IRIS) in nine hospitals in the Belgian-Dutch border region (i-4-1-Health project)

BACKGROUND: A tool, the Infection Risk Scan has been developed to measure the quality of infection control and antimicrobial use. This tool measures various patient-, ward- and care-related variables in a standardized way. We describe the implementation of this tool in nine hospitals in the Dutch/Belgian border area and the obtained results. METHODS: The IRIS consists of a set of objective and reproducible measurements: patient comorbidities, (appropriate) use of indwelling medical devices, (appropriate) use of antimicrobial therapy, rectal carriage of Extended-spectrum beta-lactamase producing Enterobacterales and their clonal relatedness, environmental contamination, hand hygiene performance, personal hygiene of health care workers and presence of infection prevention preconditions. The Infection Risk Scan was implemented by an expert team. In each setting, local infection control practitioners were trained to achieve a standardized implementation of the tool and an unambiguous assessment of data. RESULTS: The IRIS was implemented in 34 wards in six Dutch and three Belgian hospitals. The tool provided ward specific results and revealed differences between wards and countries. There were significant differences in the prevalence of ESBL-E carriage between countries (Belgium: 15% versus The Netherlands: 9.6%), environmental contamination (median adenosine triphosphate (ATP) level Belgium: 431 versus median ATP level The Netherlands: 793) and calculated hand hygiene actions based on alcohol based handrub consumption (Belgium: 12.5/day versus The Netherlands: 6.3/day) were found. CONCLUSION: The Infection risk Scan was successfully implemented in multiple hospitals in a large cross-border project and provided data that made the quality of infection control and antimicrobial use more transparent. The observed differences provide potential targets for improvement of the quality of care

ATP measurement as an objective method to measure environmental contamination in 9 hospitals in the Dutch/Belgian border area

Background The objective of this study was to determine the level of environmental contamination in hospitals in the Dutch/Belgian border area, using ATP measurements. Design A cross-sectional observational survey. Methods Standardized ATP measurements were conducted in 9 hospitals on 32 hospital wards. Thirty pre-defined surfaces per hospital ward were measured with the 3 M Clean Trace NG luminometer. Results are displayed in relative light units (RLU). RLU > 1000 was considered as "not clean." Differences in RLU values were compared between countries, hospitals, fomite groups and medical specialties. Results A total of 960 ATP measurements were performed, ranging from 60 up to 120 per hospital. The median RLU-value was 568 (range: 3-277,586) and 37.7% of the measurements were rated as not clean (RLU > 1000). There were significant differences between countries, hospitals and fomite groups. Conclusion ATP measurements can be used as a more objective approach to determine the level of environmental contamination in hospitals. Significant differences in ATP levels were found between hospitals and between countries. Also, substantial differences were found between different fomite groups. These findings offer potential targets for improvement of cleanliness in healthcare facilities

ATP measurement as an objective method to measure environmental contamination in 9 hospitals in the Dutch/Belgian border area

Background The objective of this study was to determine the level of environmental contamination in hospitals in the Dutch/Belgian border area, using ATP measurements. Design A cross-sectional observational survey. Methods Standardized ATP measurements were conducted in 9 hospitals on 32 hospital wards. Thirty pre-defined surfaces per hospital ward were measured with the 3 M Clean Trace NG luminometer. Results are displayed in relative light units (RLU). RLU > 1000 was considered as "not clean." Differences in RLU values were compared between countries, hospitals, fomite groups and medical specialties. Results A total of 960 ATP measurements were performed, ranging from 60 up to 120 per hospital. The median RLU-value was 568 (range: 3-277,586) and 37.7% of the measurements were rated as not clean (RLU > 1000). There were significant differences between countries, hospitals and fomite groups. Conclusion ATP measurements can be used as a more objective approach to determine the level of environmental contamination in hospitals. Significant differences in ATP levels were found between hospitals and between countries. Also, substantial differences were found between different fomite groups. These findings offer potential targets for improvement of cleanliness in healthcare facilities