Hygienic concepts as preventive veterinary medicine - Why?
Hygienic working is perceived as obvious by many practicing veterinary and that it is provided by the initial professional training. The functionality of sterilizers or disinfections measures is frequently not reconsidered. There is a false feeling of security applying appropriate devices or chemicals. Examinations of sterilizers accomplished by LABOKLIN by means of bio-indicators actually demonstrated that approximately 12% of the devices had no sterilization activity any more. Another 12% of the tested sterilizers exhibited substantial lack of function (n = 151, investigation period: 1 year).
Such devices do not supply sterile equipment and are thus to be deployed and/or to be submitted to a technical examination. In addition, the following figures should be considered: approx. 1% of the body mass of humans consists of bacteria and humans in rest offset approx. 1000 bacteria per minute to the environment. For mammals we might expect at least the same figures. Unfortunately the hygiene as preventive measure still is not considered an attractive topic in veterinary practice nonetheless the attendance of an advanced training seminar.
For good reasons, this is handled completely different in clinical practice in man.
Nosocomial infections (N.I.) are defined by the hospital hygienist and the legislator as infections, which were not present or in incubation prior to the admission to a hospital or visit in a practice. Therefore we are talking exclusively about a timely but not a causal dependency. N.I. are not necessarily caused on the side of the doctor, because in general it is a multifactorial condition, with contribution as well from the patients` side. In clinical practice in man an increase of N.I. can be observed. From a current follow up in Germany a number of 500,000 to 800,000 cases of N.I. can be estimated.
The following infections are monitored: infections of the urinary passage, airway and surgical wound infections and septicemia. The frequency of surgical wound infections ranks only at place 3 but causes more than 50% of the subsequent costs of all N.I. and is therefore of economical relevance. In 1992, e.g. in the USA the economical burden of N.I. is estimated to be in the range of 4.5 billion US$. Aside of the socioeconomic costs the burden for the individual can be unbearable: the risk of dying of a surgical patient with N.I. doubles. In Germany, e.g. N.I. accounts for more than 14,000 deaths per year.
Animals appear often to have a higher resistance to infections compared to man. However the immune system of our pets is often impaired due to the increased life span and the associated geriatric diseases, and the long lines of breeding. Therefore N.I. are to be expected to increase in our pets, in particular as we are opening new doors for N.I. when applying clinical standards for man in diagnostics and therapy (e.g. in endoscopy, catheterization and so on). Investigations in N.I in veterinary medicine is not often found in literature yet. In the 70's a study performed at an university hospital (USA) found 3% of N.I. in wound infections in dogs and cats. Already at that time it turned out that pathogens in N.I. were more resistant to antibiotics than their counterpart germs with an origin from outside the clinic. This problem of selection of resistance under hospital conditions still increases today.
In recent studies with a high number of animals, several risk factors for wound infections in animals were identified (among others duration of surgery, duration of anesthesia, duration between clipping and start of surgery). In a study in a German veterinary intensive care unit (university), in 15% of surgeries in companion animals wound infection were found.
The (figures of , the four internationally accepted contamination degrees of surgical wounds (categories: ´clean´, ´clean-contaminated´, ´contaminated´ and ´dirty´) showed higher numbers than observed in humans. This study demonstrated that when thorough examination before and after surgery is done one has to be aware of a high risk of N.I.
LABOKLIN investigated 578 wound swabs. In these swabs we found St. aureus in over 7% of wound infections from dogs. This result was unexpected, as this germ is hardly relevant in dogs. Even in pyodermia this germ was found to be involved only in 2% of the cases (own investigations). But it is noteworthy that St. aureus is shedded intermittently by approx. 60% of all humans e.g. from the nose. St. aureus (with multiple resistance) called MRSA and cause large problems in hospitals. Meanwhile MRSA could be identified also as pathogens of wound infections in dogs and in some cases even the transmission of humans to the domestic animal has been shown.
|Extended hygienic concept|
The objective of a veterinarian surgeon considering the hygienic status of his practice is the establishing of a an extended hygienic concept. Legal regulations only represent the basic requirements of a hygienic concept (e.g. rules for the prevention of accidents, regulations for the handling of chemical or biological agents). They are intended for the protection of persons. The major intention of a voluntary extended hygienic concept is the prevention of nosocomial infections in the veterinary patient. Beyond that, such a well documented concept provides reassurance to the veterinarian taking into account that pet owners today faster seek legal assistance assuming misconduct of the vet. Being able to document working according to the latest scientific hygienic standards will strengthen the position of the practice in a law suit. Finally such a concept contributes to a high quality standard which is of particular relevance taking into account that a visible quality management is recognized and well appreciated and in that an important point of differentiation against the competitors. With good reasons GVP dedicates an own paragraph on hygiene in veterinary practice.
|Establishing of a hygienic concept|
How to achieve such an extended hygienic concept? First it is important to assess, which hygienic rules are already in place. Then new standards can be developed, e.g. by the attendance of a suitable advanced training. This can be delegated to interested co-workers who are afterwards taking responsibility for the hygienic program. After the training, new standards are to be defined, documented in a plan and the feasibility of this plan is to be tested in the practice. After this first test run all of the affected stuff should give a feedback to finalize the concept.
In recent years the standards for personal and room hygiene, as well as sterilization of equipment has experienced several changes. Changes in sterilization procedures have become necessary because the used instruments became more and more fine and with smaller lumen. Therefore e.g. hot-air sterilization often is not sufficient any longer to sterilize the instruments properly. Another example is the area of skin disinfections: nowadays protection of the skin is considered more important and the recommendations have changed accordingly. These are only two examples from the large spectrum of hygiene, which show that there is constant progress and adjustment in terms of knowledge which should be considered.
|Surveillance of the hygienic standards|
An important aspect of an extended hygienic concept is the reassurance of the efficacy of the applied measures. A documentation of those regular tests is helpful to demonstrate high hygiene standards in case of a law suit. In Germany in clinical practice in man these controls and their documentation are regulated by law as is the occurrence of N.I. These regulations are based upon EU-harmonization guidelines, therefore we expect them to exist in principal in all countries of the EU. Today, for veterinary practice such investigations are only recommended, e.g. in the lists of recommended disinfectants of the German Veterinary Association. We expect that certain parts of those regulations are soon be changed from voluntary to obligatory.
|LABOKLIN offers full support for your hygiene concept:|
1. Control of sterilizers/autoclaves by means of bio-indicators: this is one of the most important
examinations, which should be accomplished half-yearly. Procedure: 5 paper stripes (available
at LABOKLIN) which are coated with certain germs are put into the sterilizer in a normal
sterilization process. Afterwards the stripes are send back to LABOKLIN and are cultured for
several days. There should not be any growth of bacteria, when the sterilization was successful.
The test will be returned as a ranked analysis (all o.k., function impaired, call the technical
service, no sterilization at all). If the sterilizer works two times perfectly, a hygiene certificate will
be issued by LABOKLIN. This certificate can be a useful tool in client binding.
2. Surveillance of endoscopes: at least as important as surveillance of autoclaves, since these
instruments enter the body. A fixed sequence of tests should be followed at least half-yearly.
3. Surveillance of the disinfections of surfaces e.g. tables or hands with special agar plates.
4. Surveillance of the room air by means of special agar plates: only applicable if substantial
hygienic problems have occurred and other tests could not identify the cause.
All necessary materials for the sampling are supplied by LABOKLIN, together with a detailed
description of application. In addition we are happy to provide information by phone concerning
details of this program (e.g. preferred places for sampling and how these are prepared,
frequency of testing).
|Hygiene as preventive medicine in the veterinary practice -How to get a good standard fast?|
1. Designate a representative for hygiene in your practice, let her/him visit an advanced training
and survey on the current hygienic standards of the practice.
2. The representative for hygiene: defines new hygienic standards and the hygiene concept,
instruction of all coworkers and keep the documentation of this
3. Regular controls of sterilizers/autoclaves, if applicable endoscopes, surfaces (half yearly),
include this in the hygiene concept
4. Display the so acquired hygiene certificate, to strengthen the confidence into the practice
5. Regularly survey the standards, regularly instructions of coworkers, keep the minutes
6. If problems occur e.g. wound infections: apply swaps for generation of antibiograms,
treatment in agreement with antibiotic guidelines, document the problem