Areas for special consideration

Disinfection of Physical Rehabilitation Equipment
(Underwater Treadmill, Mats, Balls)

Physical rehabilitation equipment poses a unique challenge for infection control, as items for this use are frequently difficult to disinfect (e.g., foam construction, underwater treadmill with chemical-sensitive materials). Patients receiving physical rehabilitation are often at increased risk for shedding or acquiring HAI pathogens (e.g., older with concurrent disease or skin infections, patients with fecal or urinary incontinence, surgical complications including SSIs). Further, some pathogens may be frequently encountered in rehabilitation environments (e.g., MDR Pseudomonas spp.), yet such environments are often overlooked as a source of HAIs.35,36 Infection control, prevention, and biosecurity for a physical rehabilitation unit should focus on screening of patients, restricting or adjusting use based on risk (e.g., confirmed/suspected infectious disease, recent history of diarrhea), regular cleaning and disinfection of all equipment surfaces, monitoring and adjusting water chemistry for water devices (e.g., appropriate chlorine levels will provide adequate disinfection for healthy patients), and educating the entire practice team for proper technique and the use of PPE. SOPs unique to this environment (e.g., fecal accidents in water devices) should be developed.37

Animals Fed a Raw Meat Diet
Raw meat diets have grown in popularity.38 Pets fed raw foods are a unique source of HAI-associated pathogens in the hospital environment because they may shed organisms (often asymptomatically) that can cause illness in humans or other pets.39–41 Education of the client is of utmost importance with this population of patients because risk avoidance starts in the home environment with adequate cooking of raw ingredients before the patient reaches the hospital. Patients fed raw meat products within the past 30 days likely pose the greatest risk and may warrant enhanced precautions such as use of PPE with or without isolation. Proper handling of feces and surfaces contaminated by patients fed raw animal diets (e.g., PPE, prompt cleaning and disinfection) is critical.

Multidrug-Resistant Organisms
MDR organisms (e.g., MRSP, methicillin-resistant Saureus, extended spectrum b-lactamase-producing Enterobacteriaceae such as E coli, enterococci, Salmonella spp., Acinetobacter spp., Pseudomonas spp.) have become increasingly problematic in veterinary medicine. These organisms can be passed directly or indirectly between patients, the environment, and staff, resulting in infections that are challenging to treat.6 Close attention to hand hygiene, early identification of patients infected or colonized with these organisms, prompt removal of feces, environmental cleaning and disinfection, proper PPE, surveillance, antimicrobial stewardship, and education of clients and the practice team are the keys to minimizing HAIs by these bacteria.6,42

Surgical site infections are an inherent risk in veterinary medicine and are complicated by the emergence of MDR organisms and the evolution of more invasive procedures and increasing frequency of immunocompromised patients.43 Examples of risk factors for SSIs are the length and invasiveness of the procedure, perioperative hypotension, the presence of MDR organisms on the patient or environment, a “clean” versus “dirty” procedure, and the presence of an implant.43 In a recent study of veterinary SSIs, the majority of infections were caused by MRSP, an organism that is not controlled solely by most patient pre- or postsurgical protocols or perioperative prophylaxis with beta-lactam antimicrobials (e.g., cephalosporins).43 HAIs in surgery can be controlled or prevented through attention to environmental cleaning and disinfection, patient preparation, proper surgical technique, simplified surgical suite design, PPE of surgeons and staff, the use of proper hand preparation techniques, appropriate (drug, dose, frequency) perioperative antimicrobial prophylaxis, and meticulous postoperative wound managment.6,44 Because of enhanced antibacterial efficacy, rapid action, fewer side effects (e.g., do not cause skin abrasion), lower potential for resistance development, and time savings (generally 3 min rub time), presurgical hand rubbing using alcohol-based formulations is now encouraged over traditional scrubs.45

The primary HAI considerations for a veterinary dentistry unit are the heightened risk of aerosolization of infectious particles; contamination of equipment such as wet tables, endotracheal tubes, and drills; and staff education on environmental cleaning and disinfection and PPE.46 Aerosols (defined as particles ,50 m that have the potential to remain airborne and penetrate the airways and lower lung passages of humans) can transmit pathogens, saliva, blood, and bacteria-laden debris.46 As pathogens frequently reside in the oral cavity of companion animals and aerosolization of pathogens is possible, zoonotic transmission during veterinary dentistry is a concern.7,47 Pathogens of recent interest and relevance to veterinary dentistry, such as Pasteurella multocida and Staphylococcus spp., emphasize the importance of proper ICPB practices. Irrigating the oral cavity with a 0.12% chlorhexidine solution before dental scaling has been recommended by some to decrease bacterial aerosolization.48,49 Dental procedures should be performed in a designated location distant from other procedures, patient housing, and staff so as not to potentiate HAIs via aerosolization. Proper face protection (e.g., goggles/face shield and face mask), gowns, and gloves should be used, and surfaces cleaned and disinfected between patients.7

Considerations for ICPB for cardiopulmonary resuscitation procedures are similar to what are proposed for dentistry. Aerosolization and exposure to direct contact with pathogens are similar risk factors for HAIs and zoonotic transmission to the practice team. Environmental cleaning, separate areas for resuscitation (if possible) to avoid cross-contamination, and the use of PPE during resuscitation are critical, and can be easily overlooked during an emergency.7 The acute nature of resuscitation emphasizes the need for regular (e.g., quarterly) “practice runs” in order to prepare the veterinary practice team to properly incorporate hand hygiene, PPE, and cleaning and disinfection into resuscitation procedures.

Immunocompromised Patients
Immunocompromised patients include those receiving chemotherapy or other immunosuppressive agents and those with immune-altering comorbidities (e.g., cancer, asplenia), as well as very young and geriatric patients. Proper identification of these individuals is important so that individualized procedures can be developed for each patient. When possible, the use of higher-risk procedures should be avoided (e.g., in-dwelling urinary catheters); when used, additional attention should be placed on protocols that reduce HAI (See sample protocols for placing and maintaining intravenous and urethral catheters.). In addition, hand hygiene and proper PPE should be strictly enforced.7

Zoonotic risks of exposure to Brucella canis, C burnetii, and other infectious pathogens result from contact with birthing fluids of parturient animals, stillborn fetuses, and infected neonates.7 Proper PPE includes gloves, waterproof gowns, and facial protection. In some circumstances, respiratory tract protection is necessary (e.g., when handling aborted fetuses likely to be infected with C burnetii).7 It is helpful to know in advance what pathogens are common in a geographic area in order to take appropriate infection control precautions.

Burn Care
Although burn victims are relatively uncommon in veterinary medicine, they present special challenges because the patients in these cases are immunocompromised and have wounds that require invasive techniques. Burns trigger a cascade of necrotic changes in tissue that are directly related to the cause of the injury and temperature of exposure.50 Precautions for HAIs depend on the depth and severity of burnresulting thermal injury.50 Infection control, prevention, and biosecurity related to burns focus on wound control and exposure of patient and veterinary practice team members to potential MDR pathogens as well as other HAIs.As appropriate, isolation and wound management including cleaning of the burn site, use of only sterile equipment, and careful attention to hand hygiene with proper PPE are critical for protecting these patients.

Necropsy presents several infection risks for veterinary personnel including personal injury while performing the procedure, exposure to zoonotic pathogens originating from the animal, and environmental contamination with pathogens.7 Eye protection, respiratory protection, and cut-proof gloves are necessary PPE for necropsy procedures.7 Necropsies should be performed in a location distant from the general hospitalized population and staff. However, if this is not possible, adherence to PPE, removing organic debris, and postprocedural cleaning and disinfection will help minimize HAI risks.