Health Europa speaks to infection control expert, Dr Jennie Wilson, to discuss high standard infection prevention and control practices, and whether current practices could be contributing to the spread of antimicrobial resistant pathogens.
Infection control practices need to be performed at a high standard in critical care settings in order to protect both staff and patients, and to prevent the spread of healthcare-associated infections, such as antimicrobial resistant bacteria and Clostrioides difficile. Since the COVID-19 outbreak, critical care settings have been high risk areas, with many patients in these settings needing aerosol generating procedures (AGPs) such as tracheostomies, intubation, or extubation. These procedures increase the risk that staff will acquire the infection by inhaling aerosols.
Health Europa editor Stephanie Price speaks to Dr Jennie Wilson, Professor of Healthcare Epidemiology at the University of West London, and Vice-President of the Infection Prevention Society, to find out more about infection control in intensive care unit (ICU) settings. Wilson raises concerns that current PPE guidance could be contributing to the spread of antimicrobial resistant pathogens.
Using the correct PPE for respiratory viruses
Dr Wilson, along with Dr Hugh Montgomery, Professor of Intensive Care Medicine, University College, London, and Whittington Health NHS Trust, recently developed a Q&A for the Infection Prevention Society outlining rational use of PPE in ICU settings. Wilson raises that it is time to reconsider what kind of PPE is needed in ICU now that there are fewer cases of COVID-19, and fewer patients needing AGPs in these settings.
Wilson said: “now the peak of the epidemic has passed most patients who were seriously ill with COVID-19 cases have moved out of ICU and are in various stages of recovery, but no longer infectious.
“Initially, when the ICUs were full of patients with COVID-19 there was an overwhelming demand for PPE but now that the situation has changed, we need to think differently about PPE. The type of PPE used was based on the assumption that all of the patients had COVID-19 and were infectious, and that all of them were undergoing AGPs. In reality, in many ICUs, even if they had patients with COVID-19 most were not undergoing those procedures.
“The key procedures associated with the generation of aerosols in ICU are when the patient is being exubated or intubated, and in some cases undergoing high flow nasal oxygen or non-invasive ventilation. If the patient is not undergoing these procedures, then the higher level of PPE – such as the FFP3 respirator and gown – is not required.”
Dr Wilson points out that the guidance, developed by NHS England in collaboration with the other UK countries, was based on World Health Organization (WHO) guidance, and the idea that COVID-19 is a respiratory organism that predominately transmits through droplets, by coughing and sneezing.
Wilson said: “For care of patients who do not need AGP procedures, staff need to apply droplet precautions – a face mask and eye protection is all that’s required. Although the guidance also suggests using ‘contact precautions’, which is wearing gloves and plastic aprons for all contact with the patient, there is actually no intrinsic risk associated with touching these patients provided you wash your hands afterwards and always wash them between patients.”
Contact precautions: contributing to the spread of antimicrobial pathogens
Wilson cautions against the overuse of gloves and gowns in ICU settings – noting that it could be contributing to the spread of antimicrobial resistant pathogens if staff do not change their PPE between caring for different patients.
Wilson said: “It is often thought that it’s better to use gloves because then it doesn’t matter if people don’t wash their hands. However, it does matter, because if gloves are not removed then they will spread pathogens to surfaces and other patients in the unit. Although it’s easy to contaminate your hands as you take gloves off the virus does not pass through your skin and is destroyed very easily with soap and water.
“To make matters worse, staff have been encouraged to put on all of their PPE before coming into the unit. This gives the impression that gloves should not be taken off until going out of the unit and this frequently led staff to put on two or more pair of gloves in order to always keep their hands covered with the base pair of gloves. This practice was influenced by high-level PPE guidance based on infection control for Ebola.
“Since Ebola is a haemorrhagic fever and can be transmitted by exposure of cuts or abrasions to any blood or body fluid, it is important to protect every area of skin. The risk is totally different from COVID-19, as the only way to get the infection is through inhaling respiratory droplets or getting the virus directly onto your mucus membranes.
“The idea that gloves should not be removed whilst in the unit resulted in people washing the gloves rather than taking them off, increasing the risk of spreading pathogens from patient to patient and transferring it to shared equipment such as computer or phones. The use of gowns also adds to the problem because the long sleeves will become contaminated during contact with the patient and these may then transfer pathogens to other patients that staff have contact with.
“Many ICUs have experienced problems with the transmission of antimicrobial resistant pathogens between patients and it is likely that the way gloves are used, and the use of the same gowns between caring for patients, has contributed to this problem. It is hard to know the extent of the problem, however, antimicrobial resistant pathogens are genuinely a concern because they can spread easily between patients and cause infections that are very difficult to treat.
“One of the problems that added to this during the acute phase of COVID-19 was that many patients were seriously ill with damage to their lungs, and antibiotics were commonly used. This creates the dual problem of the use of a lot of antibiotics encouraging the development of antimicrobial resistant pathogens, and then using PPE in a way that helped transfer pathogens from patient to patient – this is something that needs to be guarded against.”
Improving PPE guidelines
Infection prevention guidance needs to be reconsidered now that we are past the peak of the pandemic, says Wilson.
“We need PPE guidance that works better to prevent transmission of infection as well as protecting staff. I would like to see a move away from the requirement to put on gloves before entering an area where AGPs are being performed and encourage them to be put on only for the direct care of the patients and then removed, and hands decontaminated, between different tasks on the same patient and after leaving the patient. We also need to look at providing short sleeve gowns which will protect the clothing but enable hands and forearms to be easily washed between caring for different patients.
“We need to prepare ourselves for the next cases of COVID-19 so that we have a more sensible way of using PPE in a way that doesn’t have a risk of transferring pathogens between them.”