The two main guides dealing with environmental microbiological monitoring in healthcare facilities, published respectively by the South-West Coordination Centre for the Control of Healthcare-Associated Infections (CClin Sud-Ouest) and the Technical Committee for Nosocomial Infections and Infections Related to Care (Ctinils) in 1998 and 2002, both required an update. This has now been achieved with the new best practice guide published by CClin Sud-Ouest.
In healthcare facilities, environmental control is one of the essential factors in preventing healthcare-associated infections. As part of a continuous quality and patient safety improvement process, environmental microbiological monitoring contributes to controlling environmental reservoirs and preventing cross-transmission. Several older guides addressed this subject, including those published by CClin Sud-Ouest and Ctinils of the Ministry of Health. Taking into account changes in regulations, standards and techniques, and after ensuring that no other guide on this subject was being drafted or revised, CClin Sud-Ouest commissioned a working group to update the 1998 document. The group, made up of ten people (hygiene specialists and biologists), began its work at the end of 2012 and produced this new guide, whose objectives are:
- to provide practical, field-based assistance to the “prescriber” (the infection prevention and control team and/or the CLIN acting on behalf of the healthcare facility director), as well as to the “operator” (sampling, analysis, validation of results, etc.);
- to update knowledge. In recent years, analytical techniques have improved, quality management has developed, and regulations, standards and/or recommendations (Legionella, air cleanliness, endoscopes, haemodialysis, etc.) have evolved;
- to encourage harmonisation of microbiological monitoring practices, regardless of the sector concerned (healthcare facilities, sterilisation, pharmacy, cell therapy, etc.), in order to improve document consistency, facilitate understanding between the various partners and stakeholders and, ultimately, obtain comparable data across healthcare facilities.
The document was reviewed in early 2015 by more than thirty reviewers, both hospital-based and external, who were involved in the subject. Their numerous corrections, comments and suggestions helped improve and strengthen the document.
The scope of this guide covers the microbiological monitoring of air, water, surfaces, endoscopes and associated equipment (washers, storage cabinets, etc.). Particle counting is not strictly part of microbiological monitoring, but it is a useful complement to microbiological air monitoring, allowing inert particles to be quantified.
Environmental inert particles (viable and non-viable) are therefore included in this document. Although endoscopes are not part of the environment, they are also included in the guide because microbiological monitoring is most often carried out by infection prevention and control teams in cooperation with endoscopy departments.
The actions to be taken in the event of non-compliant results are outside the scope of the document, as they must be adapted to each situation and graduated according to a benefit-risk analysis. The document is structured around the microbiological monitoring process rather than the traditional themes (air, water, surfaces, endoscopes). This approach inevitably leads to some repetition, but it allows each chapter to be read independently by the relevant stakeholders, while navigation by topic is also possible through links provided in a table repeated at the end of the main sections.
Chapters of the Best Practice Guide:
Chapter 1: presents the monitoring strategy, which should be designed from the need for monitoring through to the management of results. This chapter provides guidance for answering questions common to all monitoring activities: “why carry out monitoring?” and “who are the stakeholders?”, followed by recurring questions for each topic: “what?” (what are we looking for?), “where?” (monitoring points?), “when?” (timing and frequency of monitoring), and “how?” (method?).
Chapter 2: aims to provide guidance for properly drafting the technical requirements (sampling and analysis) when preparing the technical specifications document (CCTP), which defines the commitments of the partners involved in the requested services.
Chapter 3: the most extensive chapter, concerns sampling, which is a fundamental step because it determines the validity and representativeness of all analyses performed on the sample. A handling error can influence the analytical results. This chapter recommends general principles applicable to all topics (for example, having a sampling plan established and approved by the infection prevention and control team and/or the institution’s CLIN, having the necessary equipment in accordance with the protocol(s) for the analysis(es) to be performed, identifying samples, recording information, etc.). After these general recommendations, the chapter addresses each topic according to a common framework: principle, frequency, sampling time, equipment, procedure, identification, transport conditions and delivery time, and recording.
Chapter 4: (analysis, methods and results) is the chapter in which the working group, having observed significant variations in incubation temperatures and times, particularly for surface monitoring, agreed — except where different regulatory or normative requirements apply — to limit the choice of incubation temperatures and durations to:
- 30 ± 2 °C for viable aerobic flora (general-purpose media: bacteria and fungi) for 5 to 7 days,
- 22 ± 2 °C for targeted fungal testing (specific media) for 5 to 7 days.
In both cases, the first reading is performed between 48 and 72 hours, and the second between 5 and 7 days. The group also advises against “sequential” incubation (36 °C followed by 22 °C using the same culture)…
This guide is intended as a practical resource, but it cannot replace the essential prerequisites for any monitoring programme, which must take into account the characteristics and specific features of each healthcare facility. This requires thorough knowledge of the facility, a risk assessment, the definition of precise objectives for each monitoring activity or monitoring campaign, and anticipation of how the results will be managed.