Practical Approaches for Assessment of Daily and Post-discharge Room Disinfection in Healthcare Facilities

Does repeated exposure to hydrogen peroxide induce Candida auris resistance?

BACKGROUND

To minimize environmental colonization by microorganisms that may persist and thrive in healthcare settings, thus reducing healthcare-associated infections (HAIs), new insights over already known biocides are certainly of relevance. Although the efficacy of hydrogen peroxide (H2O2) against the emergent yeast Candida auris is moderately documented, concerns over the potential induction of resistance after repeated exposure do persist. The main objective of the present study was to evaluate the hypothetical induction of Candida auris resistance following 30 days of consecutive exposure to lethal and sublethal concentrations of H2O2. Furthermore, the authors aimed to elucidate about the rank of efficacy of H2O2 against C. auris comparing to other Candida species and whether different strains of C. auris may display different susceptibilities to H2O2.

METHODS

During the induction of resistance assays, both type strains and clinical isolates of Candida auris, Candida albicans and Candida parapsilosis were exposed repeatedly to defined concentrations of H2O2, for 30 days.

RESULTS

After that period, no significant differences were found when comparing the minimal inhibitory concentration values of H2O2 in case of the induced strains versus each respective positive control. Moreover, H2O2 displayed similar effectiveness against all the tested Candida species and no differences were demonstrated among the distinct strains of C. auris.

CONCLUSIONS

The adoption of H2O2 solutions in routine protocols in order to promote disinfection standards against Candida auris, improving patient safety and reducing healthcare costs, is certainly welcomed.

In-use contamination of a hospital-grade disinfectant

BACKGROUND

Microbiological monitoring of disinfection of high-touch surfaces identified heavy growth of Serratia marcescens and Achromobacter xylosoxidans not present on surfaces before disinfection, suggesting contamination of the disinfectant used.

METHODS

An investigation included interview of the housekeeper involved, level of bacterial contamination of the in-use quaternary ammonium (Quat) disinfectant, bactericidal activity of the contaminated disinfectant, pulsed field gel electrophoresis of S.marcescens and Achromobacter isolates, survival of S. marcescens on dry surfaces, and genome sequencing to identify possible Quat resistance genes.

RESULTS

The housekeeper, who seldom cleaned patient rooms, had used the disinfectant for months without emptying and drying the bucket between uses. The contaminated disinfectant contained 9.3 × 10⁴ CFU of S. marcescens plus A. xylosoxidans. The log₁₀ reduction of S. marcescens by fresh Quat was 10²-fold lower than that achieved against a control strain (S. marcescens ATCC 13380). Genome sequencing of S. marcescens isolates identified the following genes previously shown to encode for efflux pumps associated with Quat resistance: sdeXY, sdeAB, smfY, and a sugE-like gene.

CONCLUSIONS

Failure to follow existing guidelines and manufacturer's instructions for use resulted in contamination by A. xylosoxidans and by S. marcescens that possessed multiple genes associated with Quat resistance.

Efficacy assessment of different time-cycles of nebulized hydrogen peroxide against bacterial and yeast biofilm

BACKGROUND

The prevention of healthcare-associated infections requires a continuous effort. In order to achieve better practical results, the control of environmental microbial biofilms with effective disinfection strategies should be addressed.

AIM

This study aims to test the efficacy of different time-cycles of nebulized H₂O₂ against bacterial and yeast dry biofilm.

METHODS

The efficacy of a standard cycle (SC) and of a fast cycle (FC) of nebulized H₂O₂ was compared. Microbial biofilms were previously grown on different material coupons. The biofilm metabolic activity was determined by XTT assay and the biofilm total biomass by crystal violet assay.

FINDINGS

Regarding the efficacy of nebulized H₂O₂ against biofilms, the mean reduction of metabolic activity of the SC was 55.2% (±19.4%), comparing to a reduction of 50.4% (±17.7%) of the FC. The mean reduction of total biomass of the SC was 45.5% (±22.7%), versus 46.7% (±21.7%) of the FC. No statistical significant differences were found when comparing the tested cycles and distinct materials.

CONCLUSION

H₂O₂ nebulization was found to exhibit a good efficacy against healthcare-associated microbial dry biofilms. Moreover, similar efficacies were found between the tested cycles.

Preliminary Study on Light-Activated Antimicrobial Agents as Photocatalytic Method for Protection of Surfaces with Increased Risk of Infections

Preventing and controlling the spread of multidrug-resistant (MDR) bacteria implicated in healthcare-associated infections is the greatest challenge of the health systems. In recent decades, research has shown the need for passive antibacterial protection of surfaces in order to reduce the microbial load and microbial biofilm development, frequently associated with transmission of infections. The aim of the present study is to analyze the efficiency of photocatalytic antimicrobial protection methods of surfaces using the new photocatalytic paint activated by light in the visible spectrum. The new composition is characterized by a wide range of analytical methods, such as UV-VIS spectroscopy, electron microscopy (SEM), X-ray powder diffraction (PXRD) or X-ray photoelectron spectroscopy (XPS). The photocatalytic activity in the UV-A was compared with the one in the visible light spectrum using an internal method developed on the basis of DIN 52980: 2008-10 standard and ISO 10678—2010 standard. Migration of metal ions in the composition was tested based on SR EN1186-3: 2003 standard. The new photocatalytic antimicrobial method uses a type of photocatalytic paint that is active in the visible spectral range and generates reactive oxygen species with inhibitory effect against all tested microbial strains.

Microbial bioburden of inpatient and outpatient areas beyond patient hospital rooms

OBJECTIVE

To investigate the frequency of environmental contamination in hospital areas outside patient rooms and in outpatient healthcare facilities.

DESIGN

Culture survey.

SETTING

This study was conducted across 4 hospitals, 4 outpatient clinics, and 1 surgery center.

METHODS

We conducted 3 point-prevalence culture surveys for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, Clostridioides difficile, Candida spp, and gram-negative bacilli including Enterobacteriaceae, Pseudomonas aeruginosa, Acinetobacter baumanii, and Stenotrophomonas maltophilia in each facility. In hospitals, high-touch surfaces were sampled from radiology, physical therapy, and mobile equipment and in emergency departments, waiting rooms, clinics, and endoscopy facilities. In outpatient facilities, surfaces were sampled in exam rooms including patient and provider areas, patient bathrooms, and waiting rooms and from portable equipment. Fluorescent markers were placed on high-touch surfaces and removal was assessed 1 day later.

RESULTS

In the hospitals, 110 (9.4%) of 1,195 sites were positive for 1 or more bacterial pathogens (range, 5.3%-13.7% for the 4 hospitals) and 70 (5.9%) were positive for Candida spp (range, 3.7%-5.9%). In outpatient facilities, 31 of 485 (6.4%) sites were positive for 1 or more bacterial pathogens (range, 2% to 14.4% for the 5 outpatient facilities) and 50 (10.3%) were positive for Candida spp (range, 3.9%-23.3%). Fluorescent markers had been removed from 33% of sites in hospitals (range, 28.4%-39.7%) and 46.3% of sites in outpatient clinics (range, 7.4%-82.8%).

CONCLUSIONS

Surfaces in hospitals outside patient rooms and in outpatient facilities are frequently contaminated with healthcare-associated pathogens. Improvements in cleaning and disinfection practices are needed to reduce contamination.

Infection Prevention in the Neonatal Intensive Care Unit

Although many aspects of infection prevention and control (IPC) mirror institutional efforts, optimization of IPC practices in the neonatal intensive care unit requires careful consideration of its unique population and environment, addressed here for key IPC domains. In addition, innovative mitigation efforts to address challenges specific to limited resource settings are discussed.

Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review

Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolong hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach whereby different strategies may be implemented together, next to targeted, risk-based approaches, in order to reduce the risk of HAIs for patients. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. This review focuses on routine environmental cleaning and disinfection including areas with a moderate risk of contamination, such as general wards. As scientific evidence has not yet resulted in universally accepted guidelines nor led to universally accepted practical recommendations pertaining to surface cleaning and disinfection, this review provides expert guidance for healthcare workers in their daily practice. It also covers outbreak situations and suggests practical guidance for clinically relevant pathogens. Key elements of environmental cleaning and disinfection, including a fundamental clinical risk assessment, choice of appropriate disinfectants and cleaning equipment, definitions for standardized cleaning processes and the relevance of structured training, are reviewed in detail with a focus on practical topics and implementation.

A review of wipes used to disinfect hard surfaces in health care facilities

BACKGROUND

Despite a plethora of wipes available for use in health care facilities, there is a paucity of articles describing wipe composition, potential interactions between wipes and disinfectants, the manner in which wipes are used, and their relative efficacy. The purpose of this article is to provide an in-depth review of wipes used for disinfection of hard surfaces in health care settings.

METHODS

Comprehensive searches of the Pubmed database and Internet were conducted, and articles published from 1953 through September 2019 and pertinent on-line documents were reviewed. Bibliographies of relevant articles were reviewed.

RESULTS

Wipes vary considerably in their composition, and the disinfectants with which they are used. With reusable dry wipes, the ratio of wipe material to disinfectant and the amount of disinfectant absorbed by the wipe and delivered to surfaces is difficult to standardize, which may affect their efficacy. The manner in which wipes are used by health care personnel is highly variable, due in part to insufficient instructions for use and inadequate education of relevant personnel.

CONCLUSIONS

Additional research is needed regarding the best practices for using different types of wipes, improved methods for educating staff, and establishing the relative efficacy of wipes in reducing environmental contamination and health care-associated infections.

Impact of Educational Intervention on Cleaning and Disinfection of an Emergency Unit

We aimed to evaluate the impact of an educational intervention on the surface cleaning and disinfection of an emergency room. This is an interventional, prospective, longitudinal, analytical and comparative study. Data collection consisted of three stages (Stage 1-baseline, Stage 2-intervention and immediate assessment, Stage 3-long term assessment). For the statistical analysis, we used a significance level of α = 0.05. The Wilcoxon and the Mann-Whitney test tests were applied. We performed 192 assessments in each stage totaling 576 evaluations. Considering the ATP method, the percentage of approval increased after the educational intervention, as the approval rate for ATP was 25% (Stage 1), immediately after the intervention it went to 100% of the approval (Stage 2), and in the long run, 75% of the areas have been fully approved. Stage 1 showed the existence of significant differences between the relative light units (RLU) scores on only two surfaces assessed: dressing cart (p = 0.021) and women's toilet flush handle (p = 0.014); Stage 2 presented three results with significant differences for ATP: dressing cart (p = 0.014), women's restroom door handle (p = 0.014) and women's toilet flush handle (p = 0.014); in step III, there was no significant difference for the ATP method. Therefore, conclusively, the educational intervention had a positive result in the short term for ATP; however, the same rates are not observed with the colony-forming units (CFU), due to their high sensitivity and the visual inspection method since four surfaces had defects in their structure.

Evaluating bio-burden of frequently touched surfaces using Adenosine Triphosphate bioluminescence (ATP): Results from the Researching Effective Approaches to Cleaning in Hospitals (REACH) trial

BACKGROUND

Environmental cleaning is an important approach to reducing healthcare-associated infection. The aim of this short research paper is to describe changes in the efficacy of post-discharge cleaning by examining the amount of bio-burden on frequent touch points (FTPs) in patient areas, using a validated Adenosine Triphosphate (ATP) bioluminescence sampling method. In so doing, we present findings from a secondary outcome of a recent trial, the Researching Effective Approaches to Cleaning in Hospitals (REACH) study.

METHODS

The REACH study used a prospective, stepped-wedge randomised cluster design. Cross sectional ATP sampling was conducted at three of the 11 participating hospitals. At each hospital, during the control and intervention phase of the study, six Frequent Touch Points (FTPs) were sampled: toilet flush, bathroom tap, inside bathroom door handle, patient call button, over bed tray table, and bed rails.

RESULTS

Across the three hospitals, 519 surfaces in 49 rooms (control phase) and 2856 surfaces in 251 rooms (intervention phase) were sampled. Bedroom FTP cleaning improved across all three hospitals. The cleaning of bathroom FTPs was generally high from the outset and remained consistent throughout the whole study period. Average cleaning outcomes for bathroom FTPs were consistently high during the control period however outcomes varied between individual FTP. Changes in cleaning performance over time reflected variation in intervention effectiveness at the hospital level.

CONCLUSION

Findings confirm improvement in cleaning in the FTPs in bedrooms, demonstrating improvements in discharge cleaning aligned with the improvements seen when using fluorescent marking technology as a marker of performance.

Profile of environmental service managers and workers in Brazilian hospitals

INTRODUCTION

Contamination through the hands of professionals and surfaces is one of the main agents involved in health care-associated infections in health services. Flaws in the execution of hospital housekeeping can lead to the contamination of surfaces and health equipment though, representing a risk for patient safety and highlighting the need to maximize the quality of cleaning processes in these institutions.

OBJECTIVE

To describe the profile of managers and environmental service workers (ESWs) in Brazilian hospitals.

METHODS

A cross-sectional study was undertaken in January 2018, involving 155 participants, being 12 managers and 143 workers from the housekeeping team of two health institutions, being one private and the other public.

RESULTS

Most participants were female (86%), with a mean age of 45 years and primary education level, 52% being outsourced workers. The participants positively assessed their job satisfaction, satisfaction with training, basic knowledge and performance; nevertheless, situations were identified that were perceived as risks for patient safety and occupational health. The questions involving motivational incentives received the lowest scores.

CONCLUSION

Inconsistencies were found in the housekeeping professionals'. Preparation, indicating that the institutions studied do not value this type of service and that an investment policy in these workers' motivation is lacking.

Beyond high-touch surfaces: Portable equipment and floors as potential sources of transmission of health care-associated pathogens

Efforts to improve environmental cleaning and disinfection typically focus primarily on high-touch surfaces in patient rooms. This review highlights evidence that portable equipment and other shared devices and floors may be underappreciated as sources of dissemination of health care-associated pathogens. Practical approaches to address these sites of contamination are emphasized.

Novel colour additive for bleach disinfectant wipes reduces corrosive damage on stainless steel

Bleach disinfectant wipes are corrosive to hospital surfaces and equipment. This study measured the effect of two widely used bleach wipes, with and without Highlight^® colour additive, on stainless steel to quantify the rate of corrosion and to determine the effect of Highlight^® on reducing surface damage caused by bleach wipes. The two bleach wipes alone caused severe corrosion [>5 mils per year (mpy), where 1 mil = 0.001 inch], while the addition of Highlight^® reduced the rate of corrosion significantly (<2 mpy) and prevented discolouration of the metal. These results indicate that Highlight^® reduces the deleterious corrosive effects of bleach wipes, thus improving their viability for cleaning healthcare surfaces.