NHMRC Public Consultations

No comments

2.1 Suggest that point 2 in the summary is extended to four elements, to include a portal of entry. The care of portals of entry created by healthcare are often critical control points as the infecting organism may be a commensal (in which case there is no transmission). Coag-neg Staphs and CLABSI is a case in point. Portal of entry is included in the diagram but perhaps inclusion in the summary gives more prominence.

Section 3.1.4

Recommendation 12

• Cleaning with detergent solution is a multiple stage process and this should be made plain. It involves the use of a detergent, a rinse and dry phase, as with hand hygiene. The drying of a surface serves as the rinse and dry for a surface and this should be made clear. To simply use a detergent and then not remove the soil and organisms loosened by the detergent is equivalent to wetting the hands, applying soap, rubbing and then ending the hand hygiene technique at this step.
• The phrase 'every known contamination' could mean anything, including touch. What does this mean in reality?
• In the practical information tab on the diagram, what do you mean by exact choice of detergent? Could you clarify this and if you are thinking of stating ‘neutral’ would you mean by anionic/cationic or by pH? What is the evidence base for stating that detergent-based wipes should not be used as a replacement for clean cloths and detergent solution?
• In the practical information tab, you state “When MROs are suspected or known to be present, routine cleaning is intensified and the use of a detergent solution is followed by the use of a disinfectant so that surfaces are cleaned and disinfected”. This is a multiple stage process involving wetting, rubbing, drying and disinfection and a human factors approach would be to combine these into a cleaning/disinfection step. Products are available from a number of manufacturers that would enable this approach and are in common use in many countries (including Australia)
• In the ‘use of disinfectants’ section
  • There is frequently uncertainty of whether a surface is contaminated or not. Could you consider whether a combined detetergent/disinfectant product be used for the avoidance or doubt?
  • you state “combined with a disinfectant registered in the Australian Register of Therapeutic Goods (ARTG) or sodium hypochlorite (TGA-listed) if indicated for use”. Why are you singling out one chemical when there are a variety of effective agents that are registered and accepted by the TGA? Could you consider recommending a TGA-registered disinfectant with evidence of efficacy against the target organisms rather than making a recommendation for chlorine specifically.
  • You state specifically that instrument disinfectants should not be used for surface cleaning. If you mean specific disinfectants you should state this. If you mean instrument grade disinfectants, there are now products that are used on surfaces that have achieved levels of efficacy that mean that they can be registered for instruments also and the TGA will state in a manufacturer’s certificate that it is also suitable for surfaces. This may mean that you are forcing everyone to have two products. One for the door handle and one for the medical device, which could be an IV pump. This could be financially disadvantageous and confusing for staff

  • Recommendation 13

    We fully support this statement, however shared clinical equipment will be used on many patients who are carrying pathogens, including MDROs that are unknown to staff. Shared equipment is implicated in many outbreak reports and we suggest that where available and subject to materials compatibility the equipment is cleaned with a combined detergent disinfectant. The use of detergent alone also means if using cloths and a detergent solution, collecting the equipment, washing, and a drying phase. This is not compatible with a human factors approach and therefore is unlikely to be carried out. A combined wipe available at the point of care does fit with a human factors approach. You should also recommend that the manufacturer of any equipment should provide information on validated cleaning methods and a list of compatible agents that should be used to decontaminate to the level required.

    • In the Practical info tab, your examples could also include items such as stethoscopes, axiallary temperature monitoring probes, blood pressure cuffs, and commodes. We submit that these items are frequently implicated in outbreaks
  • Recommendation 15
  • You state "chemical disinfectants such as hypochlorite". A number of suitable agents that are TGA-approved are available. Could you conside revising to state that a TGA-approved disinfectant with efficacy against the target organisms should be used. For example, spill kits with peracetic acid, a highly effective disinfectant that is not inactivated by organic matter could be an advantage over chlorine. To specify one agent could reduce investment in researching novel disinfectants and become an issue should the mounting evidence linking Chlorine with respiratory issued in users cause change in regulatory guidance.

  Recommendation 16

  • A number of suitable agents that are TGA-approved are available. Could you consider revising to state that a TGA-approved disinfectant with efficacy against Norovirus should be used. There are a number of agents that are affective against Norovirus and have achieved satisfactory results in standard and accepted tests in accredited laboratories that may be used when chlorine cannot be used on a surface.

  Section 3.15 Novel disinfection methods

  • Sodium hypochlorite is hardly novel
  • The evidence for UV light is supported by high-quality studies in high impact journals (Anderson, D.J., et al., Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study. Lancet, 2017. 389(10071): p. 805-814.), a higher class of evidence than used in many other recommendations.

  Recommendation 17

  • A number of suitable agents that are TGA-approved are available. Could you consider revising to state that a TGA-approved disinfectant with efficacy against the target organism should be used. There are a number of agents that are affective against MDROs and have achieved satisfactory results in standard and accepted tests in accredited laboratories that may be used when chlorine cannot be used on a surface. To continue to state that chlorine should be used is in some ways anti-competitive and stifles innovation and research into more user-friendly agents that have better surface compatibility.

  Recommendation 18

  • We are extremely surprised to see that Hydrogen peroxide is recommended against given the number of studies in high quality journals that suggest this has an impact in terms of outbreak cessation. We accept that the RCTs are not there however we suggest that the recommendation should be weak or ‘no recommendation’ to give practitioners some leeway is faced with an outbreak.

  Recommendation 19

  • The evidence for UV light is supported by high-quality studies in high impact journals (Anderson, D.J., et al., Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study. Lancet, 2017. 389(10071): p. 805-814.), a higher class of evidence than used in many other recommendations.

  3.2.1 Application of Transmission-based precautions

  • We support the statement that a TGA-listed agent be used but again respectfully ask you to consider why a specific agent is identified when there are many effective listed agents.

No comments, the section is very well composed

Section 5.13 Control of VRE

There is some evidence that the used of Chlorhexidine bathing in reducing transmssion of VRE and environmental contamination

1.    Septimus, E.J. and M.L. Schweizer, Decolonization in Prevention of Health Care-Associated Infections. Clin Microbiol Rev, 2016. 29(2): p. 201-22.
2.    Denny, J., Chlorhexidine Bathing Effects on Health-Care-Associated Infections. Biol Res Nurs, 2016.
3.    Bass, P., et al., Impact of chlorhexidine-impregnated washcloths on reducing incidence of vancomycin-resistant enterococci colonization in hematology-oncology patients. Am J Infect Control, 2013. 41(4): p. 345-8.
4.    Karki, S. and A.C. Cheng, Impact of non-rinse skin cleansing with chlorhexidine gluconate on prevention of healthcare-associated infections and colonization with multi-resistant organisms: a systematic review. J Hosp Infect, 2012. 82(2): p. 71-84.
5.    Vernon, M.O., et al., Chlorhexidine gluconate to cleanse patients in a medical intensive care unit: the effectiveness of source control to reduce the bioburden of vancomycin-resistant enterococci. Arch Intern Med, 2006. 166(3): p. 306-12.