Removal of sinks from ICU Patient rooms & the effect on gram negative colonisation rates Alma Tostmann, PhD EPIET (C2009) – EAN Vice President Dept of Primary and Community Care Radboud university medical centre Nijmegen/ Netherlands

HCAI at intensive care units HCAI at Intensive Care Unit  morbidity and mortality Environmental contamination: potential source transmission Hand washing sinks : best practice of ICU design (hygiene) But: source of trouble reported since 1970’s. Ayliffe, et al, The Lancet, 1974 Edmonds, et al, Applied Microbiology, 1972 Teres, et al, The Lancet, 1973 EAN Mini Module HCAI 2017

Outbreaks multidrug-resistant gram-negative bacilli (MDR-GNB) intensive care units, including paediatric and neonatal ICUs sinks EAN Mini Module HCAI 2017

Intensive Care Unit Radboudumc Radboudumc: 953 beds IC: 50 single rooms Selective digestive tract decontamination (SDD)1 Low MRSA and VRE prevalence (in Netherlands) All patients: contact isolation at ICU Increase antibiotic resistance (gram negative rods) 2 outbreaks related to sinks Klebsiella pneumoniae ESBL Enterobacter cloacae ESBL EAN Mini Module HCAI 2017 1N Engl J Med 2009; 360:2138-2141, may 2009

Outbreak at ICU Enterobacter cloacae ESBL spring 2014. Routine SDD cultures. Related? Outbreak? Same genotype Clustering in time and space (1 IC unit) Transmission between patients (genotype) Same pathogen found in the patient room sinks EAN Mini Module HCAI 2017

What happened next? Hand washing sinks removed from all patient rooms Summer 2014. Research: effect on colonization gram negative pathogens? EAN Mini Module HCAI 2017

Design Environmental (ecological) intervention study intervention = removal of sinks. Data source: routine SDD cultures Time period: 1 year before vs. 1 year after sink removal Outcome measure: gram negative colonisation rate / 1000 admission days. Sensitivity analysis: longer duration admission First GN+ culture ≥2, ≥5, ≥7, ≥10, ≥14 days. ‘negative control’: Candida colonisation (routine SDD cultures) Interrupted time series analysis (ITS) EAN Mini Module HCAI 2017

When comparing ‘mean rate’ pre – post: 1: mean rate seems higher after intervention 2: mean rate seems lower after intervention In reality: no effect, just existing trend. 2 1 EAN Mini Module HCAI 2017

https://academic.oup.com/ije/article/46/1/348/2622842/Interrupted-time-series-regression-for-the EAN Mini Module HCAI 2017

Results Before intervention: 1496 patients (9153 admission days) After intervention : 1444 patients (9044 admission days) Segmented regression analysis: after removal sinks stat. sign. Reduction in gram negative colonisation rate. Effect more pronounced in sensitivity analysis Largest effect among patients with longer duration admission (2-3x less) EAN Mini Module HCAI 2017

In conclusion Removal sinks from patients rooms ICU Reduced colonisation ICU-acquired gram negative pathogens, incl multidrug resistant pathogens No difference in Candida colonisation Larger effect in patients with longer duration of admission Increased likehood of ICU-acquired colonization No alternative explanations Patient population pre / post Hand hygiene compliance Cleaning and disinfection practice EAN Mini Module HCAI 2017

ICU-rooms pre  post EAN Mini Module HCAI 2017

Implementation Round table discussion with Doctors Nurses Care assistants EAN Mini Module HCAI 2017

Discussion Remove all hand washing sinks? Depends on the setting What is the effect in hospitals with high gram negative pathogen sepsis? Hospitals with no SDD on ICUs Low income countries Hospitals with frequent Clostridium difficile Effective method to ‘work around behavioural change’ Worth considering EAN Mini Module HCAI 2017

SOCO ;-) Sinks can be a source of transmission in hospitals Especially gram negative pathogens (water) When implementing such a drastic measure, input and engagement of personell is essential Alma Tostmann [Alma.Tostmann@Radboudumc.nl] Joost Hopman, head Hygiene Infection Control unit [Joost.Hopman@radboudumc.nl] Many thanks! Acknowlegdements: - Medical Microbiology, Radboudumc: Prof. Andreas Voss, Eva Kolwijck, Rita Bos - ICU, Radboudumc: Prof. Hans van der Hoeven, prof. Peter Pickkers Medical Microbiology, Laurentius hospital Roermond: Patrick Sturm Paper sinks: https://aricjournal.biomedcentral.com/articles/10.1186/s13756-017-0213-0 General info ITS: https://academic.oup.com/ije/article/46/1/348/2622842/Interrupted-time-series-regression-for-the EAN Mini Module HCAI 2017