ReportInfectious Disease

Increasing tolerance of hospital Enterococcus faecium to handwash alcohols

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Science Translational Medicine  01 Aug 2018:
Vol. 10, Issue 452, eaar6115
DOI: 10.1126/scitranslmed.aar6115

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  • Alcohol-Based Hand Rub or Environmental Hygiene: What is the Right Concern in Vancomycin-Resistant Enteroccoci Control?

    Romain Martischang, Alexandra Peters, Didier Pittet,
    Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland

    The research article by Pidot et al.(1) examined increasing tolerance of Enterococcus faecium to low concentrations of short chain alcohols (isopropanol 23% v/v and ethanol 35% v/v). Their study tested various Australian strains of E. faecium for alcohol tolerance using an alcohol kill test to evaluate bactericidal effects, an animal model to estimate effect of an increased alcohol tolerance on environmental acquisition. The authors concluded that “alcohol-tolerant strains of Enterococcus faecium have the potential to undermine the effectiveness” of alcohol-based handrubs (ABHRs). ABHRs with an alcohol concentration of 60-90% (v/v) are the gold standard for hand hygiene in healthcare, and the cornerstone for infection prevention and control.(2) According to the authors, if some strains of E. faecium are developing tolerance to alcohol, it may explain the increase in vancomycin-resistant Enterococcus (VRE) infections globally reported in hospitals. They argue that their findings would necessitate additional procedure to prevent E.faecium from spreading in hospital settings. We aim to highlight the importance of wording in research, the risk when linking experimental study and clinical inference, and a call for further research on the mechanisms of increased al...

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    Competing Interests: None declared.
  • RE: Response to Ingeborg Schwebke et al., “Is the effectiveness of alcohol-based handrubs against enterococci really compromised?"
    • Timothy P. Stinear, Research scientist, University of Melbourne
    • Other Contributors:
      • Paul D. R. Johnson, Infectious diseases physician, Austin Health
      • M. Lindsay Grayson, Infectious diseases physician, Austin Health

    We thank Schwebke et al., for their interest in our research. Members of our group were early adopters of the Geneva Hospitals’ model of alcohol-based hand hygiene and we have found it to be gratifyingly effective, particularly for controlling endemic methicillin resistant Staphylococcus aureus (1). Our positive experience has been influential in Australia and has been translated into state-wide (2) and national programs (3). We remain strong advocates for alcohol-based hand hygiene in healthcare and have no intention of winding back our successful programs.

    In their letter commenting on our recent research on Enterococcus faecium (4) Schwebke et al, comment that we “…deduced that more tolerant VRE strains could potentially endanger the safety of standard hand hygiene”. That is not one of our conclusions. In fact, we suggest that “In hospitals with endemic VRE, it would seem prudent to optimize adherence to alcohol-based disinfectant protocols to ensure adequate exposure times and use of sufficient volumes of product, particularly each time a health care worker cleans their hands.” (4).

    Schwebke et al, have also commented that we “… reveal gaps in European standards for handrub efficacy”, which again is not our intention or the content of our research. Instead, we found that hospital-adapted E. faecium is changing in a time-dependent way, and we note that some recent clones (e.g. ST796) that were the most tolerant in our in vitro research assay, have caused...

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    Competing Interests: None declared.
  • Is the effectiveness of alcohol-based handrubs against enterococci really compromised?
    • Ingeborg Schwebke, Robert Koch-Institute, Division 14 for Hospital Hygiene, Infection Prevention and Control, Nordufer 20, 13353 Berlin, Germany
    • Other Contributors:
      • Mardjan Arvand, Robert Koch-Institute, Division 14 for Hospital Hygiene, Infection Prevention and Control, Nordufer 20, 13353 Berlin, Germany
      • Guido Werner, Robert Koch-Institute, Division 13 for Nosocomial Pathogens and Antibiotic Resistances, Burgstraße 37, 38855 Wernigerode, German
      • Katharina Konrat, Robert Koch-Institute, Division 14 for Hospital Hygiene, Infection Prevention and Control, Nordufer 20, 13353 Berlin, Germany.
      • Melanie Brunke, Robert Koch-Institute, Division 14 for Hospital Hygiene, Infection Prevention and Control, Nordufer 20, 13353 Berlin, Germany.

    In August 2018 Pidot et al.(1) published a study in Science Translational Medicine which received significant media coverage. The authors investigated alcohol tolerance in enterococci, particularly in clinically important vancomycin-resistant E. faecium (VRE). Looking for causes of the high prevalence of VRE infections in Australia, they hypothesized that a development of alcohol-tolerant isolates was due to the introduction of alcohol-based handrubs (ABHR) in 2002, and the result of increased selective pressure. The authors deduced that more tolerant VRE strains could potentially endanger the safety of standard hand hygiene. The evaluation in the media and the resulting uncertainty among experts prompted us to analyze the work by Pidot et al. in order to discuss its relevance concerning the effectiveness of ABHR against enterococci. The question arises as to whether the presented results reveal gaps in European standards for handrub efficacy, and if they actually point out a real threat to the effectiveness of ABHRs. Therefore, we examined the study by Pidot et al. in regards to German and European standards for handrub activity.

    In German and European standards the efficacy of ABHR is validated by suspension tests as well as practical laboratory-based testing. European standards and test methods of the Association for Applied Hygiene (VAH) are the basis. In suspension tests defined reference strains of different species including Enterococcus hirae are used. Addi...

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    Competing Interests: None declared.

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