Hand Sanitizer Won't Kill Norovirus?

Hand sanitizer is a daily staple for parents on diaper duty, commuters who hold those rarely-cleaned handle bars on buses and subways, and many other people in between. In fact, according to global information company NPD Group, hand sanitizer sales in the United States shot up 37 percent from 2017 to 2018 alone. And while it’s perfectly fine to turn to this bottled product as a last resort, you shouldn’t opt for hand sanitizer over washing your hands in the sink if there’s clean water and soap available to you.

As it turns out, there’s a reason why most hand sanitizer companies don’t claim to kill 100 percent of germs and bacteria: Because they don’t. Some of the viruses and germs you’re leaving on your hands every time you opt for hand sanitizer instead of soap and water.

According to the Centers for Disease Control and Prevention (CDC), norovirus is a “very contagious virus” that can be spread via direct contact, contaminated food or drinks, and contaminated surfaces. And while thoroughly washing your hands (and your produce) is a good way to ensure your safety, using alcohol-based hand sanitizer isn’t quite as effective.

In one 2011 study published in the American Journal of Infection Control, researchers analyzed data from health departments in three states and found that the facilities that relied on hand sanitizer were more likely to experience a norovirus outbreak than those that favored hand-washing.

Epidemiology and impact of norovirus outbreaks in Norwegian healthcare institutions, 2005–2018

Outbreaks in healthcare settings affect vulnerable populations, disrupt normal routines and may spread to other healthcare institutions (HCIs). Outbreaks can be limited in extent by good routines for detection, management of cases and other infection-control measures [1]. Norovirus infection is most often seen in the winter months and is a common cause of outbreaks in HCIs [2] as it has a low infectious dose, short incubation period, and symptoms such as diarrhoea and vomiting which facilitate spread. Symptoms normally lasts around one to three days, but can be longer in hospital patients [3]; and in this type of setting, infection can lead to slower recovery from other illness and even death [4]. Norovirus can be divided into several genogroups and genotypes [5]. Genogroup II genotype 4 is the most prevalent genotype globally [6] as well as in the Nordic countries [6]. There is no vaccine and immunity is not well understood; at best it is strain-specific but probably only partial and shortlived as the virus readily undergoes mutation [7, 8]. Humans are the only reservoir of the virus and spread of the infection in outbreaks is particularly difficult to control because of the low infectious dose, its stability in the environment and efficient transmission by person-to-person contact and exposure through contaminated surfaces [9]. Norway has national recommendations on norovirus infection in long-term-care facilities (LTCFs) in which the most important measure is isolation or cohort nursing of sick residents. Exclusion of sick staff until 48 h after they are symptom free is also recommended [10]. In a hospital setting, the infection-prevention-control unit will have local procedures. There are around 60 hospitals and 950 LTCFs in Norway [11]. The responsibility for management of local outbreaks lies within the hospital or with the community medical officer (one in each of the 422 municipalities) for outbreaks in LTCFs. All suspected outbreaks in Norwegian HCIs, regardless of the causative pathogen, should be alerted by law to relevant actors, including the Norwegian Insititute of Public Health (NIPH), to facilitate communication and response [12, 13]. The aim of this study was to describe, for the first time, the epidemiology and impact of these outbreaks in order to identify areas which may improve outbreak response.

This study shows that norovirus outbreaks pose an important burden for HCIs all over Norway, especially in the winter months. In addition to affecting an already vulnerable population, this study shows that these outbreaks indeed also impact on the internal workflow and resources, with a conservative estimate of around 1800 days of absenteeism per year due to these outbreaks, during which staff would have to be covered for by other internal or external healthcare staff.

Surveillance of norovirus outbreaks exists in Germany and Scotland. In Germany, reporting of norovirus outbreaks in HCIs has been mandatory since 2001. In contrast to what is seen in Norway, outbreaks were smaller (median nine cases vs 15 in this study) and around 80% of norovirus outbreaks were reported from hospitals (vs 23% in this study) during the first 12 months after introduction of the system [15]. Varying ways of counting interdepartmental outbreaks, better collaboration with the local level or under-reporting from hospitals may explain this. In Scotland, surveillance of ward closures due to norovirus infection has been in place since October 2017. From then until week 26, 2018, 219 wards or bays have been closed due to confirmed or suspected norovirus [16]. This is markedly more than the 16 reported outbreaks in hospitals in Norway 2017/18, in a population of similar size. The occurrence of norovirus outbreaks has also been studied prospectively; Curran et al. [17] aimed to identify the index cases of norovirus outbreaks in the UK and Ireland in 54 acute and non-acute healthcare centres; only five out of the 54 included centres did not experience any outbreak during one winter. Also, Lopman et al. found that 171 inpatients units, had on average 1.3 gastroenteritis outbreaks in the 1-year follow-up period. Of these, 63%were caused by norovirus [2].

It was seen that a small proportion of residents at LTCFs were admitted to hospital during norovirus outbreaks. This may be necessary in severe cases despite the risk of spread from one institution to the next. Our results suggest that hospitals are affected by norovirus outbreaks earlier in the epidemiological year than LTCFs. Potentially because there is a greater influx of patients from the community, where norovirus circulates, to and from hospital than between the community and LTCFs as also suggested by Sadique et al. [18]. This finding, however, could only be evaluated on the national level, as the number of reported outbreaks is low. That the start of the outbreak season seemed to start earlier in hospitals than in LTCFs, at least at the national level, suggests an opportunity that with improved communication, hospitals could alert LTCFs within the same area in order to prepare for the outbreak season and limit the extent of further outbreaks.

Slightly more cases were seen amongst healthcare staff in hospitals compared to LTCFs, though no information about the number of healthcare staff at risk during the outbreaks is available. The patient or resident:healthcare-staff ratio varies with the level of care needed and type of department and will most often be higher in hospitals. Whether this explains the slightly higher proportion of staff affected in hospital outbreaks is unknown. Nevertheless, healthcare staff do represent a big proportion of cases in the reported outbreaks, indicating a need for improved compliance with infection prevention and control measures. Outbreaks are an economic burden for HCIs, both as infected staff need to be covered for during illness and ‘quarantine’ and cohort nursing may require extra staff.

The relatively high number of people infected during an outbreak underscores the infectiousness of norovirus and norovirus can serve as a worst-case scenario for introduction of other, more virulent, person-to-person transmitted pathogens into HCIs. With the current information captured in the alert system, it was not possible to assess the extent to which national recommendations were followed and/or which infection prevention control procedures are in place locally. But the high number of people infected do suggest a potential for limiting spread, for example by having systems and routines in place before outbreaks happen, as advised in the national recommendations.

Even though NIPH routinely promotes the web-based outbreak alert system and teaches outbreak management, both at the regional and national level, in order to strengthen local capacity and encourage the use of the alert system, under-reporting is still apparent. If the under-reporting of outbreaks reflects a lack of awareness concerning outbreak management, or a lack of communication between the LTCF and the municipal doctors about ongoing outbreaks, it is worrying. The alert system serves to alert relevant stakeholders so that outbreak support and advice can be given in an early phase. The alert system can also be used for statistical purposes to get a national overview of outbreaks which will facilitate targeted capacity building, guideline development and communication messages in order to increase awareness and investigate whether there are any changes in trends.

This study has three main limitations: the sensitivity of the norovirus outbreak definition and under-reporting of number of outbreaks and number of cases in each outbreak. Classification as a norovirus outbreak is dependent on local definitions. The infection prevention measures for diarrhoea and vomiting are the same for all the common pathogens in this setting. Samples were submitted for testing in two thirds of the outbreaks and most were confirmed as norovirus at the time of reporting or updating. Information about the genotypes of the isolated strains from each outbreak or of dominant strain of the season was not available. For this reason, it was not possible to evaluate the effect of the genotype.

Concerning under-reporting, the number of outbreaks notified through the outbreak alert system and reported here, most likely represent only a proportion of all norovirus outbreaks occurring in Norwegian HCIs. Although outbreaks were reported from all parts of Norway, some areas had not reported any outbreaks of any kind during the 13-year study-period.

The alert system is used for the mandatory alerting of suspected outbreaks. Reporting should happen as soon as the outbreak is suspected and before the full extent of the outbreak is known. Even though the system sends a reminder to update the details about the outbreak, including the case numbers, three weeks after the initial alert, some under-reporting of the extent of each outbreak is expected.

This is the first comprehensive description of norovirus outbreaks in HCIs in Norway. Even though the analyses revealed under-reporting that is unlikely to reflect the real epidemiology, this study clearly shows that these outbreaks affect both hospital and LTCFs all over Norway. Norovirus infection may delay medically important procedures and recovery, but also presents a major challenge to the functional ability of an HCI and its resources as up to one-half of cases were healthcare personnel.

It is recommended that NIPH promotes the outbreak alert system to increase reporting and improve the quality of the data and strengthen local capacity for outbreak management and general infection control. It is also recommended to investigate possibilities for improving communication between hospitals and LTCFs regarding when the norovirus season starts and progresses, for hospitals and LTCFs to be prepared and to take early action to prevent and limit further spread.

Read full article: https://www.journalofhospitalinfection.com/article/S0195-6701(19)30268-3/fulltext?dgcid=raven_jbs_etoc_email

© 2019 The Authors. Published by Elsevier Ltd on behalf of The Healthcare Infection Society.

A Breeding Ground for a Fatal Scourge: Nursing Homes

From The New York Times:

Drug-resistant germs, including Candida auris, prey on severely ill patients in skilled nursing facilities, a problem sometimes amplified by poor care and low staffing.


“They are caldrons that are constantly seeding and reseeding hospitals with increasingly dangerous bacteria,” said Betsy McCaughey, a former lieutenant governor of New York who leads the nonprofit Committee to Reduce Infection Deaths. “You’ll never protect hospital patients until the nursing homes are forced to clean up.”

Resistant germs can then move from bed to bed, or from patient to family or staff, and then to hospitals and the public because of lax hygiene and poor staffing.

A recent inquiry by the New York State Department of Health found that some long-term hospitals grappling with C. auris were failing to take basic measures, such as using disposable gowns and latex gloves, or to post warning signs outside the rooms of infected patients. At one unnamed facility, it said, “hand sanitizers were completely absent.”


Antibiotic Resistance and the Importance of Hand Hygiene | Infection Control Today

The increasing risk of antibiotic-resistant infections is a threat in todayʼs world but can be reduced through key interventions such as hand hygiene. Better hand hygiene cannot eliminate all infections, but because of the central role contaminated hands play in a large number of infections, better hand hygiene practices used broadly in society would help to reduce the risk of infections in general and for those that are antibiotic resistant as well.

Read more about it here: https://www.infectioncontroltoday.com/hand-hygiene/antibiotic-resistance-and-importance-hand-hygiene

Historical perspective on hand hygiene in health care

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care. Geneva: World Health Organization; 2009.

Handwashing with soap and water has been considered a measure of personal hygiene for centuries48,49 and has been generally embedded in religious and cultural habits (see Part I, Section 17). Nevertheless, the link between handwashing and the spread of disease was established only two centuries ago, although this can be considered as relatively early with respect to the discoveries of Pasteur and Lister that occurred decades later.

In the mid-1800s, studies by Ignaz Semmelweis in Vienna, Austria, and Oliver Wendell Holmes in Boston, USA, established that hospital-acquired diseases were transmitted via the hands of HCWs. In 1847, Semmelweiss was appointed as a house officer in one of the two obstetric clinics at the University of Vienna Allgemeine Krankenhaus (General Hospital). He observed that maternal mortality rates, mostly attributable to puerperal fever, were substantially higher in one clinic compared with the other (16% versus 7%).50 He also noted that doctors and medical students often went directly to the delivery suite after performing autopsies and had a disagreeable odour on their hands despite handwashing with soap and water before entering the clinic. He hypothesized therefore that “cadaverous particles” were transmitted via the hands of doctors and students from the autopsy room to the delivery theatre and caused the puerperal fever. As a consequence, Semmelweis recommended that hands be scrubbed in a chlorinated lime solution before every patient contact and particularly after leaving the autopsy room. Following the implementation of this measure, the mortality rate fell dramatically to 3% in the clinic most affected and remained low thereafter.

Apart from providing the first evidence that cleansing heavily contaminated hands with an antiseptic agent can reduce nosocomial transmission of germs more effectively than handwashing with plain soap and water, this approach includes all the essential elements for a successful infection control intervention: “recognize-explain-act”.51 Unfortunately, both Holmes and Semmelweis failed to observe a sustained change in their colleagues’ behaviour. In particular, Semmelweis experienced great difficulties in convincing his colleagues and administrators of the benefits of this procedure. In the light of the principles of social marketing today, his major error was that he imposed a system change (the use of the chlorinated lime solution) without consulting the opinion of his collaborators. Despite these drawbacks, many lessons have been learnt from the Semmelweis intervention; the “recognize-explain-act” approach has driven many investigators and practitioners since then and has also been replicated in different fields and settings. Semmelweis is considered not only the father of hand hygiene, but his intervention is also a model of epidemiologically driven strategies to prevent A prospective controlled trial conducted in a hospital nursery and many other investigations conducted over the past 40 years have confirmed the important role that contaminated HCWs’ hands play in the transmission of health care-associated pathogens (see Part I, Sections 7–9).

The 1980s represented a landmark in the evolution of concepts of hand hygiene in health care.infection. The first national hand hygiene guidelines were published in the 1980s,53–55 followed by several others in more recent years in different countries. In 1995 and 1996, the CDC/Healthcare Infection Control Practices Advisory Committee (HICPAC) in the USA recommended that either antimicrobial soap or a waterless antiseptic agent be used56,57 the rooms of patients with multidrug-resistant pathogens. More recently, the HICPAC guidelines issued in 200258 defined alcohol-based handrubbing, where available, as the standard of care for situations only. The present guidelines are based on this previous document and represent the most extensive review of the evidence related to hand hygiene in the literature. They aim to expand the scope of recommendations to a global perspective, foster discussion and expert consultation on controversial issues related to hand hygiene in health care, and to propose a practical approach for successful implementation (see also Part VI).

As far as the implementation of recommendations on hand hygiene improvement is concerned, very significant progress has been achieved since the introduction and validation of the concept that promotional strategies must be multimodal to achieve any degree of success. In 2000, Pittet et al. reported the experience of the Geneva’s University Hospitals with the implementation of a strategy based on several essential components and not only the introduction of an alcohol-based handrub. The study showed remarkable results in terms of an improvement in hand hygiene compliance improvement and HCAI reduction.60 Taking inspiration from this innovative approach, the results of which were also demonstrated to be long-lasting,61 many other studies including further original aspects have enriched the scientific literature (see Table I.22.1). Given its very solid evidence base, this model has been adopted by the First Global Patient Safety Challenge to develop the WHO Hand Hygiene Improvement Strategy aimed at translating into practice the recommendations included in the present guidelines. In this final version of the guidelines, evidence generated from the pilot testing of the strategy during 2007–2008 is included (see also Part I, Section 21.5).62

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Bookshelf ID: NBK144018
hand hygiene practices in health-care settings, whereas handwashing is reserved for particular

Enterococcus hirae, Enterococcus faecium and Enterococcus faecalis show different sensitivities to typical biocidal agents used for disinfection

– Ethanol and other alcohols such as iso-propanol or n-propanol are typically used for hand disinfection or surface disinfection. An ethanol concentration of 40% will not be found in alcohol-based hand rubs because the bactericidal efficacy will be too low to fulfill European efficacy standards such as EN 1500. Even hand rubs based on 60% or 70% often fail to meet the EN 1500 efficacy requirements although the alcohols are effective against E. faecium and E. faecalis [11, 14, 15, 16]. In that respect it is of concern that the use of E. hirae may yield a sufficient efficacy against enterococci although E. faecium and E. faecalis are less susceptible.

Nosocomial infections or hospital-acquired infections (HAIs) are a major patient safety issue in hospitals.

The most frequent nosocomial infections are pneumonia (usually ventilator-associated), urinary tract infection (usually catheter-associated) and primary bloodstream infection (usually associated with the use of an intravascular device) [1]. Virtually every pathogen has the potential to cause infection in patients but only a limited number of bacterial species is responsible for the majority of HAIs. Among them Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa and enterococci are the most common [2]. Enterococci account for about 10% of hospital-acquired bacteremia cases and are a major cause of sepsis worldwide [3]. HAIs caused by enterococci are difficult to treat due to acquired resistance to many classes of antibiotics [4]. Considering the severity of the consequences of nosocomial infections, such as morbidity, mortality, prolonged stay, costs, and treatment problems, it is all the more important that preventive measures in hospitals and other health facilities are fully effective [5]. Targeted disinfection, with species that are considered to be the most resistant representatives of a whole range of human pathogenic microorganisms and, due to their role in nosocomial infections, also include enterococci. As part of the standardization efforts to determine the efficacy of disinfectants at European level, the enterococcal strain Enterococcus (E.) faecium, formerly used for chemical and chemo-thermal disinfection processes, was replaced by E. hirae. E. faecium is currently only used for testing thermal disinfection processes, such as for instance for testing laundry disinfection processes at temperatures above 60 °C [6]. The differences in heat tolerance between the enterococcal species is already well described resulting in the use of E.hirae for testing chemical disinfectants and E. faecium for chemo-thermal and thermal processes [7, 8]. Pidot et al. have shown in 2018 that some multidrug-resistant E. faecium isolates isolated recently are more tolerant to 23% iso-propanol than older isolates suggesting an adaptive cellular response [9]. Overall, the chemical susceptibility of two common clinical species (E. faecalis and E. faecium) and the commonly used test species (E. hirae) has not yet been sufficiently investigated [10, 11, 12]. The aim of this study was therefore to find out whether E. hirae is a suitable species to evaluate the efficacy of biocidal agents against the clinically relevant species E. faecalis and E. faecium. Therefore, we determined the in vitro bactericidal efficacy of five substances from commonly used groups of biocidal agents (aldehydes, alcohols, surfactants, oxidizing agents and halogens) on E. hirae, E. faecium and E. faecalis according to the European Norm EN 13727 [13].effective procedures and correctly performed, is one of the most important measures to interrupt the transmission of pathogens in hospitals. In Europe, the microbicidal effectivity of any disinfection procedure must be evaluated and confirmed in accordance with national or international standards and norms in vitro and under practical conditions before it can be used in hospitals [6]. These efficacy tests are performed with defined test

Our data show that the testing of disinfectants based upon a culture collection E. hirae strain alone may not represent the sensitivity of other collection Enterococcus spp. with more clinical relevance. At a 5 min exposure time the current EN 13727 test species E. hirae was found to be more tolerant to 0.2% glutaraldehyde and 0.0125% peracetic acid compared to E. faecium and E. faecalis whereas it was more susceptible to 40% ethanol and 3% sodium hypochlorite. Only with 0.00125% benzalkoniumchloride (15 min) the susceptibility of E. hirae was between E. faecium and E. faecalis. Based on these data E. hirae is a suitable species when bactericidal activity needs to be determined against enterococci with the biocidal agents glutaraldehyde and peracetic acid. It may, however, not be a suitable species for ethanol at 40% or sodium hypochlorite at 3% if the bactericidal activity shall include the clinical pathogens E. faecium and E. faecalis.

Ethanol and other alcohols such as iso-propanol or n-propanol are typically used for hand disinfection or surface disinfection. An ethanol concentration of 40% will not be found in alcohol-based hand rubs because the bactericidal efficacy will be too low to fulfill European efficacy standards such as EN 1500. Even hand rubs based on 60% or 70% often fail to meet the EN 1500 efficacy requirements although the alcohols are effective against E. faecium and E. faecalis [11, 14, 15, 16]. In that respect it is of concern that the use of E. hirae may yield a sufficient efficacy against enterococci although E. faecium and E. faecalis are less susceptible.

The situation is different in surface disinfection. Many low alcohol products are available for immediate use in the patient environment, often as presoaked tissues [17]. Low alcohol concentration has the advantage of a better compatibility with plastic surfaces which are now commonly found in healthcare such as mobile phones or tablet computers [18]. Based on our data obtained with suspension tests it seems to be possible that low alcohol surface disinfectants which are effective against E. hirae do not provide the same level of bacterial killing against E. faecium or E. faecalis. In 2014 a dramatic increase of infections caused by vancomycin-resistant enterococci has been described [19]. The reasons for the increase are still unknown. But it is known that Enterococcus spp. can survive on inanimate surfaces between 4 days and 4 months [20]. It is therefore important to ensure a sufficient bactericidal efficacy of alcohol-based surface disinfectant against Enterococcus spp. However even with higher concentrations of alcohol it is essential to apply a sufficient volume. Approximately 10% of the solution is released during wiping when a soaked tissue is used [16, 21]. It has been shown previously that the application of a low volume of an effective alcohol results in failure to meet the efficacy requirements [16].

Sodium hypochlorite at 3% was also more effective in 5 min against E. hirae and less effective against E. faecalis and E. faecium. It is a biocidal agent commonly used in many countries for surface disinfection [22]. Our findings with E. faecalis appear plausible because sodium hypochlorite at 2.5% has been described to achieve at least 5 log10 against ATCC 35550 (10 min) and ATCC 29212 (20 min) [23, 24]. The very low effect of 3% sodium hypochlorite even in 15 min against E. faecium is of concern and should be followed up with more research on the possible implications for its use in healthcare.

In this study we have only used culture collection strains from each of the three Enterococcus spp. in order to compare the susceptibility of potential test strains for disinfectant efficacy testing. We have not used any Enterococcus spp. clinical isolates. That is why we cannot evaluate whether the different biocidal agents would reveal a similar bactericidal activity against clinical isolates of each of the three Enterococcus species.

Another limitation of our study is that all experiments were carried out using a low organic load described as clean conditions. That is why we are unable to describe if similar or other results would be obtained under dirty conditions. Clean conditions were chosen because they reflect the majority of applications of these agents. Alcohol-based hand rubs are applied to clean hands, ethanol is a typical biocidal agent used for hand disinfection. Instrument disinfectant should be used on cleaned instruments, glutaraldehyde, benzalkonium chloride and peracetic acid are typical agents used for instrument disinfection. Surface disinfection is often performed without prior cleaning, benzalkonium chloride and sodium hypochlorite are typical agents used for surface disinfection. With sodium hypochlorite it has been described before that the bactericidal efficacy will be impaired in the presence of organic load [25].

E. hirae is a suitable species when a bactericidal activity should be determined against enterococci with glutaraldehyde and peracetic acid. E. hirae may not be a suitable species for ethanol at 40% or sodium hypochlorite at 3% if the bactericidal activity shall include the clinical pathogens E. faecium and E. faecalis.

By Miranda Suchomel, Anita Lenhardt, Günter Kampf, Andrea Grisold


For references: https://www.journalofhospitalinfection.com/article/S0195-6701(19)30345-7/references

Resistente bakterier blir med hjem fra ferien

Når vi reiser på ferie, bidrar vi til at resistente mikrober reiser verden rundt. Sykehusbesøk og antibiotikakur gir størst risiko.

Du kan bære dem med deg på huden eller i tarmen, og du kan ha dem med deg helt uten at du vet det. Og de kan bli lenger enn du aner.

En studie av 2000 nederlendere som reiste på utenlandstur, viste at hele 35 prosent av dem brakte med seg resistente tarmbakterier hjem.

Av dem som hadde vært i India eller landene rundt, bar hele 75 prosent av dem med seg resistente bakterier hjem. Dette var bakterier som er helt normalt å ha i tarmen, og ga ingen symptomer. Hadde disse nederlenderne ikke vært med i denne studien, ville de ikke visst at de hadde med seg slike bakterier fra turen.

Aller størst risiko
Men disse bakteriene som normalt finnes i tarmen, kan gi resistens-gener videre til sykdomsfremkallende bakterier i neste omgang. Og da er du ille ute. Da virker ikke de vanlige antibiotikaene lenger. Og 12 prosent av de reisende ga også de resistente bakteriene videre til andre personer i husholdningen.

Det som klart ga aller størst risiko for å bli bærer av resistente tarmbakterier (ESBL), var å ta en antibiotikakur under reisen. Men det var ikke likegyldig hva slags antibiotika de tok. Antibiotika som Ciprofloxacin ga klart høyest risiko, mens penicilliner ga mindre risiko. Diaré og kronisk tarmsykdom ga også økt risiko for å bli bærer av resistente bakterier.

Fakta: Dette gir økt risiko
Dette gir økt risiko for at man bærer med seg resistente bakterier hjem fra ferie i utlandet:

• Å bli innlagt på sykehus i utlandet.
• Å ta antibiotika på turen.
• Å få diaré under reisen. Risikoen øker hivs du tar antibiotika mot diareen, og risikoen blir enda større hvis du tar stoppende midler som for eksempel loperamid eller imodium.
• Reise utenfor Nord-Europa, Nord-Amerika og Australia. Særlig til det indiske subkontinent, men også i Sør- og Øst-Europa er forekomsten av resistens høy.

Men det som er det positive i denne studien, er at de fleste kvittet seg med de resistente bakteriene ganske raskt. Etter en måned hadde over halvparten kvittet seg med de resistente bakteriene. Men 11 prosent var fortsatt bærere et år etter. Antibiotikakurer gjennom året, kronisk stamsykdom og nye reiser var igjen risikofaktorer som gjorde at bærerskapet kunne vare ved.

Sykehus er verst
Det som helt klart gir høyest risiko for å bli bærer av multiresistente bakterier, er å bli innlagt på sykehus i utlandet.

Men du trenger ikke å reise til eksotiske land for at denne risikoen skal bli høy. Folkehelseinstituttet meldte nylig om et utbrudd av hyperresistente (KPB – karbapenemaseproduserende) bakterier med over 350 smittede pasienter ved syv sykehus i Italia.

Det Europeiske smitteverninstituttet melder om raskt økende forekomst av disse svært resistente bakteriene i Sør- og Øst-Europa, og de melder stadig nye utbrudd på sykehus.

I USA har én person nylig dødd og syv andre blitt syke av bakterier med denne typen hyperresistens etter å ha reist til Mexico for slankeoperasjon. Nå advarer delstaten Utah på sine nettsider folk mot disse helsereisene og mot den konkrete kirurgen som utførte disse inngrepene.

Fakta: Dette er resistente bakterier
Resistens gjør ikke bakteriene nødvendigvis mer sykdomsfremkallende, men mostanddyktige mot antibiotika. Ved multiresistents er bakteriene motstandsdyktige mot flere antibiotika.

Typer resistens:
MRSA – Methicillinresistente Staphylococus aureus: En type resistens som finnes hos gule stafylokokker. Stafylokokker er normalt en del av floraen på huden vår, men kan også gi sårinfeksjoner, og kommer de inn i blodet gir de alvorlige og livstruende infeksjoner. Når de bærer resistensgenet MRSA, vil slike infeksjoner bli vanskelig å behandle, fordi de antibiotika man da må behandle med, virker dårligere og har mer bivirkninger.

ESBL – Extended spectrum betalactamase: En type resistens som finnes hos en rekke tarmbakterier og noen bakterier som lett etablerer seg på utstyr og overflater i sykehus. Blant disse bakteriene finnes både sykdomsfremkallende bakterier og normalfloraen i tarmen. Denne type resistens kan også påvises i urin ved urinveisinfeksjon.

Når bakterier innen denne gruppen blir ekstra resistente kalles det ESBL-CARBA/KPB – Karbapenemase produserende bakterier. Disse er resistente mot nesten alle typer antibiotika, også de mest bredspektrede midlene vi har. Her må legene ofte ty til gamle og mindre effektive antibiotika med en rekke til dels alvorlige bivirkninger. Og når disse heller ikke virker: Da kan vi risiker å stå igjen uten behandlingsmuligheter.

VRE/LRE – vancomycin- eller linezolid resistente enterokokker: Enterokokker er også en bakterie som finnes normalt i tarmen, men kan gi sykdom i bl.a. i urinveier og i blodbanen. Det er i utgangspunktet få antibiotika som virker på denne bakterien, så når den i tillegg blir resistent mot disse få, blir den svært vanskelig å behandle. Denne bakterien har tidligere forårsaket utbrudd på norske sykehus.

Advarer mot helsereiser
Folkehelseinstituttet advarte mot å reise til utlandet for helsetjenester i en oppdatering tidligere i sommer. De ber deg unngå helsebehandling, inkludert tannbehandling, i utlandet dersom du kan få utført den samme behandlingen her til lands.

De anbefaler god håndhygiene og god kjøkkenhygiene for å unngå å plukke opp resistente bakterier, men fraråder ikke å reise. De understreker også at hvis du blir syk under reisen, må du ikke nøle med å oppsøke helsetjenester når du trenger det.

Hvem testes?
Pasientene som har størst risiko for å være bærer av resistente bakterier, isoleres og testes med både nese, hals, hud og avføringsprøve ved innleggelse på norske sykehus. Dette gjelder blant annet alle som har vært i kontakt med helsetjenesten i land utenfor Norden siste 12 månedene, for å unngå at resistens spres på sykehuset til andre og mer sårbare pasienter.

Bakteriene florerer
Men verst er selvfølgelig denne utviklingen for dem som bor i landene med høy forekomst av resistens, og som ikke har tilgang på andre helsetester enn sykehus hvor sykehusinfeksjoner med resistente bakterier florerer.

En organisasjon som har merket dette i sitt arbeid, er Leger Uten Grenser. De beskriver på sine nettsider en situasjon hvor nyere «siste utvei»-antibiotika er dyrere, og i mange mellom- og lavinntektsland kan disse være vanskelig å få tak i. Offentlige sykehus får ikke tak i riktig type antibiotika til pasienter som ikke kan betale selv, og de får ikke gitt pasientene sine fullgod behandling.
Leger Uten Grenser oppgir at årsakene til denne utviklingen er uregulert salg av antibiotika over disk uten krav om resept fra lege, dårlig smittevernkontroll i helsetjenesten, antibiotika av dårlig kvalitet på apotekene, dårlig forskrivningspraksis hos leger og mangel på diagnostisk utstyr, i tillegg til dårlig opplæring av pasientene.

Varsko om antibiotika
Tenkt deg om før du tar antibiotika mot en lett diaré på turen. Å ta toppende midler gir også økt risiko, ifølge en finsk studie. Å ta begge deler på én gang er enda verre.

Det beste er kanskje å la den gå over av seg selv for ikke å risikere å bære med deg resistente bakterier hjem. Skulle du da få en alvorlig infeksjon på toppen, kan den bli vanskelig å behandle.

Personer med alvorlig kronisk sykdom som har høy risiko for å måtte søke helsehjelp under turen, bør også være klar over risikoen for å bli smittet med multiresistente bakterier ved et sykehusopphold i utlandet. Har de også nedsatt immunforsvar, risikerer å få en infeksjon det kan bli vanskelig å bli kvitt.

Øyunn Holen Overlege, spesialist i infeksjonsmedisin Folkehelseinstituttet

Fakta: Dette er et Viten-innlegg fra Aftenposten
Viten er Aftenpostens satsing på forskning og vitenskap, der forskere fra hele landet bidrar med artikler.
Viten-artikler publiseres i Aftenpostens papirutgave tirsdager og torsdager, i tillegg til nettartikler på ap.no/viten.

Import and spread of extended- spectrum β-lactamase-producing Enterobacteriaceae by international travellers (COMBAT study): a prospective, multicentre cohort study


International travel contributes to the dissemination of antimicrobial resistance. We investigated the acquisition of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) during international travel, with a focus on predictive factors for acquisition, duration of colonisation, and probability of onward transmission.


Within the prospective, multicentre COMBAT study, 2001 Dutch travellers and 215 non-travelling household members were enrolled. Faecal samples and questionnaires on demographics, illnesses, and behaviour were collected before travel and immediately and 1, 3, 6, and 12 months after return. Samples were screened for the presence of ESBL-E. In post-travel samples, ESBL genes were sequenced and PCR with specific primers for plasmid-encoded β-lactamase enzymes TEM, SHV, and CTX-M group 1, 2, 8, 9, and 25 was used to confirm the presence of ESBL genes in follow-up samples. Multivariable regression analyses and mathematical modelling were used to identify predictors for acquisition and sustained carriage, and to determine household transmission rates. This study is registered with ClinicalTrials.gov, number NCT01676974.


633 (34·3%) of 1847 travellers who were ESBL negative before travel and had available samples after return had acquired ESBL-E during international travel (95% CI 32·1-36·5), with the highest number of acquisitions being among those who travelled to southern Asia in 136 of 181 (75·1%, 95% CI 68·4-80·9). Important predictors for acquisition of ESBL-E were antibiotic use during travel (adjusted odds ratio 2·69, 95%CI 1·79-4·05), traveller’s diarrhoea that persisted after return (2·31, 1·42-3·76), and pre-existing chronic bowel disease (2·10, 1·13-3·90). The median duration of colonisation after travel was 30 days (95% CI 29-33). 65 (11·3%) of 577 remained colonised at 12 months. CTX-M enzyme group 9 ESBLs were associated with a significantly increased risk of sustained carriage (median duration 75 days, 95% CI 48-102, p=0·0001). Onward transmission was found in 13 (7·7%) of 168 household members. The probability of transmitting ESBL-E to another household member was 12% (95% CI 5-18).


Acquisition and spread of ESBL-E during and after international travel was substantial and worrisome. Travellers to areas with a high risk of ESBL-E acquisition should be viewed as potential carriers of ESBL-E for up to 12 months after return.


Netherlands Organisation for Health Research and Development

Copyright © 2017 Elsevier Ltd. All rights reserved.

Mind the Staph: London Is Crawling with Antibiotic-Resistant Microbes

The bacteria are not a major threat, but they could transfer their resistance to more dangerous pathogens

London is teeming with bacteria—some of which have developed resistance to antibiotics. These microbes are mostly harmless, but if they do cause an infection, it can be hard to treat. And there is a chance that they could transfer their resistance to more dangerous strains, experts warn.

In a new study, researchers in England and their colleagues found that frequently touched surfaces—such as elevator buttons, ATMs and bathroom-door handles—can be reservoirs of drug-resistant staphylococcus, or staph, bacteria.

The researchers collected 600 samples from locations throughout East and West London such as hospitals, public washrooms and ticket machines, finding 11 species of staphylococci. Nearly half of the samples—including 57 percent in East London and about 41 percent in less crowded West London—contained bacteria resistant to two or more frontline antibiotics. Just under half of the staph found in hospital public areas was drug resistant, compared with 41 percent in community settings, the team reported Thursday in Scientific Reports.

“Resistance genes and elements present in these bacteria can spread to human pathogens and result in the emergence of new [antimicrobial-resistant] clones,” says Hermine Mkrtchyan, a senior lecturer at the University of East London, who headed the team that conducted the research. “Although these bacteria are nonpathogenic, the increased levels of antibiotic resistance that we found in general public settings in the community and in hospitals pose a potential risk to public health.”

Should people be worried?

“So long as you wash your hands after going out into public areas, it should be fine,” says Richard Stabler, co-director of the Antimicrobial Resistance Center at the London School of Hygiene & Tropical Medicine, who was not involved in the work. “I certainly recommend washing your hands after being out in London.”

Despite the high ick factor of the idea of touching potentially dangerous bacteria in familiar settings, Stabler concedes that these species are commonly found on skin, so it is no surprise that they would be found in public places where people are constantly shedding skin and microbes.

These bacteria do not pose a real danger right now, Stabler says, because although some of them were resistant to two common antibiotics, they cannot evade the entire medical arsenal. “This is potentially a problem out there, but at the moment, it’s still quite containable,” he says.

Antimicrobial resistance is a major public health threat across the globe, Mkrtchyan notes. Every year, more than 700,000 people die because of it, and the toll is predicted to rise to 10 million by 2050. Resistance means patients will stay sick for longer, which increases the cost of health care, Mkrtchyan says. “Our research highlights that general public areas (part of our everyday life) can be reservoirs for multidrug-resistant bacteria and alerts us that concrete global efforts are required to tackle the problem.”

Mkrtchyan and her colleagues previously found similar drug-resistant bacteria in a study of London hotel rooms. They are now comparing the genes of the 11 species found in both studies to better understand how they evade drugs and the physical environments that support their development and transmission.

Knowing about the presence of antibiotic-resistant bugs is useful, Stabler adds, because public officials can utilize the information to prepare and guide treatment. “It’s okay that they’re out there,” he says. “We have to live with them rather than trying to exterminate them—because that doesn’t work.”

Antimicrobial resistance is a major public health threat across the globe, Mkrtchyan notes. Every year, more than 700,000 people die because of it, and the toll is predicted to rise to 10 million by 2050. Resistance means patients will stay sick for longer, which increases the cost of health care, Mkrtchyan says. “Our research highlights that general public areas (part of our everyday life) can be reservoirs for multidrug-resistant bacteria and alerts us that concrete global efforts are required to tackle the problem.”

Mkrtchyan and her colleagues previously found similar drug-resistant bacteria in a study of London hotel rooms. They are now comparing the genes of the 11 species found in both studies to better understand how they evade drugs and the physical environments that support their development and transmission.

Knowing about the presence of antibiotic-resistant bugs is useful, Stabler adds, because public officials can utilize the information to prepare and guide treatment. “It’s okay that they’re out there,” he says. “We have to live with them rather than trying to exterminate them—because that doesn’t work.”

Lipkin notes that some antibiotic resistance exists naturally. Researchers have found resistant microbes in isolated caves, he says, suggesting that some bacteria have evolved to tolerate natural antibiotics. But humans have dramatically increased the prevalence of these microbes by using antibiotics inappropriately.

The findings are concerning but not a reason to panic, Lipkin says. Similar drug resistance has been found in other places for years. “It’s just another call to be more sensible about how we use antibiotics,” he explains. Still, “the fact that they’re there at all means that they’re capable of moving into people.”


Article shared from: https://www.scientificamerican.com
By Karen Weintraub

Karen Weintraub is a freelance health and science journalist who writes regularly for the New York Times, STAT and USA Today, among others.

Hand hygiene helps reduce HCAIs (healthcare-associated infection)

Chris Wakefield, Vice President at GOJO Industries-Europe Ltd, highlights how hand hygiene systems reduce the spread of healthcare-associated infection (HCAI)

It is estimated that 300,000 patients a year in England acquire a healthcare associated infection (HCAI) as a result of care within the NHS. Such infections draw large attention from patients, regulatory bodies and the media. Not only because of the magnitude of the problem – after all, they are associated with morbidity, mortality and the financial cost of treatment – but, also, because most are preventable.

Despite being avoidable, HCAIs continue to present a major threat to our public health. They are particularly difficult to eliminate due to the speed and ease that they can be transmitted – and because of their long-life span. Did you know, for example, that MRSA can live up to nine weeks, whilst C.Diff spores can live up to five months? Or that they can be spread through both direct and indirect contact?

Studies have shown that contaminated hands can sequentially transfer some viruses to up to seven surfaces, and that fourteen people can be contaminated by touching the same object one after the other. Perhaps itʼs not surprising then, that research indicates that you have a 50/50 chance of picking up a dangerous pathogen anytime you touch anything or anyone in a hospital.

Such outbreaks can have serious repercussions; including the increased risk to the lives of vulnerable patients, disruption of services and reduced clinical activity, such as the enforced closure of hospital wards, cancelled admissions and delayed discharges. There is also the cost of treatment to factor.
Indeed, a report by the National Audit Office estimated that a reduction in the rates of MRSA bloodstream infections saved the NHS in England between £45 million-£59 million in treatment costs between 2003/4 and 2008/9. It also identified that by reducing the rate of C. difficile infections, between £97 million-£204 million was saved in treatment costs between 2006/7 and 2007/8.

Going back to basics

A great deal of scientific research has shown that, if properly implemented, hand hygiene is the single most important, easiest and cost-effective means of reducing the prevalence of HCAIs and the spread of antimicrobial resistance. In fact, research shows it can cut the number of HCAI cases by up to 50%. Several other studies have also demonstrated that handwashing virtually eradicates the carriage of MRSA which invariably occurs on the hands of healthcare professionals working in intensive care units. An increase in handwashing adherence has also been found to be accompanied by a fall in MRSA rates.
In order to reduce the spread of illness, everyone has to engage with hand hygiene practices – not only healthcare workers, who already make this a part of their daily lives, but visitors and patients too. As a founder member of the World Health Organization (WHO) Private Organizations for Patient Safety group, GOJO is a strong advocate of the ‘total solutionʼ approach to making hand hygiene second nature to everyone in a healthcare setting. We believe that, to successfully change behaviour, a triple-pronged approach is required.

Firstly, handwashing facilities must be accessible and dispensers easy to use. The WHO recommends that an adequate number of appropriately positioned hand hygiene facilities should be readily available at the point of care.

Secondly, the high frequency with which healthcare workers clean their hands means that the formulations must be gentle yet effective against germs, complying with key hospital norms EN 1500, EN 14476 and EN 12791. Studies have also shown that using an alcohol-based handsanitising rub can improve hand hygiene practice, since it is quicker, is microbiologically more effective and is less irritating to skin than traditional hand washing with soap and water.
Finally, eye-catching signage is very effective as a prompt, especially at key germ hot-spots such as washrooms and waiting areas. Hand hygiene facilities must remain well-stocked and maintained at all times too.

Getting smart

Although evidence supports a ‘back to basicsʼ approach, digital innovation also has a role to play. GOJO has spent many years developing advanced formulations and high-tech dispensers, and has recently harnessed revolutionary smart technology to create its SMARTLINK™ Electronic Monitoring Solutions. These two mobile apps are a smarter way to help reduce the maintenance time spent on dispensers, and measure hand hygiene performance – ultimately helping to prevent the spread of germs.
Combining the latest technology with the simple act of hand hygiene, and working together to put effective systems in place, we can reduce the spread of HCAIs. GOJO, the leading global producer of skin health and hygiene solutions for away-from-home settings, is your specialist partner in healthcare hygiene.

For a tailored, effective, total solution for your setting, or for more information, please call +44 (0)1908 588444,
email infouk@GOJO.com or visit www.GOJO.com


By Kerrie Doughty
Trade Marketing & Communications Manager GOJO Industries-Europe
Tel: +44 (0)1908588457



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