Environmental cleaning to prevent hospital-acquired infections on non-intensive care units: a pragmatic, single-centre, cluster randomized controlled, crossover trial comparing soap-based, disinfection and probiotic cleaning

Probiotic-Based Approaches for Sustainable Control of Infectious Risk in Mass Transport: Current Data and Future Perspectives

The built environments of high-traffic areas can play a significant role in the transmission of microorganisms and associated infections, sometimes favouring the selection of multidrug-resistant (MDR) organisms due to the excessive use of conventional disinfectants. Probiotic-based sanitation (PBS) was suggested as a novel alternative approach to control the infectious risk in crowded community environments due to its effectiveness in reducing fungal, bacterial, and viral pathogens in sanitary settings. PBS may thus trigger a paradigm shift from chemical to biological strategies in cleaning environments with high human occupancy, offering an ecological and economically sustainable alternative to conventional chemical disinfection. Providing robust data supporting the results reported so far, it has the potential to optimise bioburden control and infection prevention in mass transportation spaces. This review brings together existing research on PBS in mass transportation areas, pinpoints areas of lack of information, and explores its potential future uses, including the creation of probiotic-based materials for sustainable biocontrol in high-traffic areas.

Prevalence of Hospital-Acquired Infections in Low- and Middle-Income Countries: Systematic Review and Meta-Analysis

The burden of hospital-acquired infections (HAIs) is particularly substantial in low- and middle-income countries (LMICs). However, a comprehensive understanding of their prevalence in these regions is lacking. This systematic review aimed to evaluate the prevalence of HAIs in LMICs. Major databases, including Scopus, PubMed, and Web of Science, were thoroughly searched for published studies between January 1, 2000, and July 15, 2024. The PRISMA guidelines were followed. The pooled prevalence of HAIs was estimated using a random-effects model and a 95% confidence interval. The literature search identified 87 studies reporting HAI prevalence in LMICs. The overall prevalence of HAIs across LMICs was 22% (95% CI = [17, 28]). The South-East Asian Region presented the highest prevalence at 37% (95% CI = [13, 62]). In terms of income level, low-income countries had the highest prevalence at 37% (95% CI = [23, 52]). Surgical site infections had the highest prevalence among infection types at 27% (95% CI = [23, 31]). This systematic review underscores the high prevalence of HAIs in most LMICs, emphasizing the need to facilitate the development of targeted prevention and control strategies to mitigate the impact of this critical public health issue, especially in resource-limited settings.

Profiling the resistome and virulome of Bacillus strains used for probiotic-based sanitation: a multicenter WGS analysis

BACKGROUND

Healthcare-associated infections (HAIs) caused by microbes that acquire antimicrobial resistance (AMR) represent an increasing threat to human health worldwide. The high use of chemical disinfectants aimed at reducing the presence of pathogens in the hospital environment can simultaneously favor the selection of resistant strains, potentially worsening AMR concerns. In the search for sustainable ways to control bioburden without affecting this aspect, probiotic-based sanitation (PBS) using Bacillus spp. was proposed to achieve stable reduction of pathogens, AMR, and associated HAIs. Although Bacillus probiotics are classified as nonpathogenic, comprehensive data about the potential genetic alterations of these probiotics following prolonged contact with surrounding pathogens are not yet available. This study aimed to assess in depth the genetic content of PBS-Bacillus isolates to evaluate any eventual variations that occurred during their usage.

RESULTS

WGS analysis was used for the precise identification of PBS-Bacillus species and detailed profiling of their SNPs, resistome, virulome, and mobilome. Analyses were conducted on both the original PBS detergent and 172 environmental isolates from eight hospitals sanitized with PBS over a 30-month period. The two species B. subtilis and B. velezensis were identified in both the original product and the hospital environment, and SNP analysis revealed the presence of two clusters in each species. No virulence/resistance genes or mobile conjugative plasmids were detected in either the original PBS-Bacillus strain or any of the analyzed environmental isolates, confirming their high genetic stability and their low/no tendency to be involved in horizontal gene transfer events.

CONCLUSIONS

The data obtained by metagenomic analysis revealed the absence of genetic sequences associated with PBS-Bacillus and the lack of alterations in all the environmental isolates analyzed, despite their continuous contact with surrounding pathogens. These results support the safety of the Bacillus species analyzed. Further metagenomic studies aimed at profiling the whole genomes of these and other species of Bacillus, possibly during longer periods and under stress conditions, would be of interest since they may provide further confirmation of their stability and safety.

Respiratory quaternary ammonium and volatile organic compound exposures experienced by home care aides during residential bathroom cleaning using conventional and green products

INTRODUCTION

US home care (HC) aide visits to clients' homes typically involve cleaning and disinfecting (C&D) environmental surfaces, particularly in bathrooms. Some ingredients in C&D products are associated with respiratory illness: sodium hypochlorite (bleach), quaternary ammonium compounds (QACs), and volatile organic compounds (VOCs). This study assessed and compared aides' respiratory exposures to specific VOCs and QACs while using 2 conventional and 1 "green" household C&D spray products during bathroom cleaning. Measured exposures were compared to ingredients listed on publicly available sources.

METHODS

Three C&D products were selected with principal active disinfecting ingredients: 1% to 5% sodium hypochlorite by weight ("bleach-based"); 0.1% to 1% QACs ("QACs-based"); and 0.05% thymol ("green"). Twenty-two aides were recruited to perform C&D tasks in a simulated residential bathroom constructed in an environmental monitoring laboratory. A balanced experimental study design involved each aide visiting the lab 4 times to perform typical cleaning tasks with the 3 products and distilled water (as a control), randomly assigned across the 4 visits. Aides wore air sampling equipment for breathing zone samples: canisters to collect whole air for VOC analyses and filter cassettes for QACs analyses.

RESULTS

Aides performed 84 cleaning visits contributing approximately 20 air samples each for VOCs and QACs, for each of the 3 products and distilled water. In total, 38 unique VOCs were identified in the canister whole air samples: 20 in the QACs-based product samples, 15 in the bleach-based, and 10 in the green. Most VOCs were not listed in publicly available sources of cleaning product ingredients. Toxicity information was limited. Few VOCs had occupational exposure limits. The QACs-based product generated QACs aerosol: benzalkonium chloride (BAC)12 (geometric mean (GM) = 6.98 µg/m3), BAC14 (GM=2.97 µg/m3), BAC16 (GM=0.78 µg/m3); and the 3 QACs summed (GM=10.86 µg/m3).

DISCUSSION

The use of C&D spray products for residential cleaning can generate respiratory exposures to complex mixtures of volatile and nonvolatile compounds. Notably, we measured aerosols containing QACs during the use of the QACs-based product. Dermal is usually considered the main route of exposure because QACs are nonvolatile salts. This study provides evidence that QACs inhalation exposure should be recognized and minimized in addition to the well-accepted dermal exposure routes. The green product generated the fewest VOCs. However, more toxicity information is needed on the health impacts of green C&D products. Spraying of C&D products, conventional and green, should be avoided.

CONCLUSIONS

Aides' respiratory health should be protected from chemical exposures while performing C&D in home care.

Risk analysis approaches for microbial ingredients in microbial-based cleaning products

Microbial-based cleaning products (MBCPs) are an emerging class of cleaning products that contain viable microorganisms, often bacteria or bacterial endospores, as intentionally added formulation ingredients for cleaning and/or odor control. Although several well-established methodologies exist to support risk analysis for conventional chemical-based cleaning products, at present there are no widely recognized methods or commonly utilized frameworks to support risk analysis for use of microbial ingredients present in MBCPs, specifically. The purpose of this work is to provide information to MBCP manufacturers and regulators that can be used to assist in developing their own approaches to MBCP risk assessment. As part of this assessment, potential hazards associated with use of bacterial or bacterial endospore ingredients of MBCPs can be adequately characterized, assessed, and managed as part of both product development and ongoing product stewardship. Accordingly, this document summarizes potential approaches to support strain-level identification of microbial ingredient(s), evaluate their hazards and potential for human exposure, and assess their potential effects following such exposures to different human populations. Recommendations for both hazard and risk characterization are discussed. Additionally, guidance is provided to support decision-making by risk managers, including guidance for the development of risk communication strategies, where appropriate, to mitigate the identified risks. Properly applied, the conceptual approaches described herein may facilitate the standardization and more consistent application of appropriate risk analysis procedures tailored to suit microbial ingredients present in MBCPs. Beyond their utility in assessing microbial ingredients commonly used in MBCPs today, these same approaches may help companies and regulators consider and manage risks for new microbial ingredients that may be utilized in future MBCP formulations.

Factors influencing women's satisfaction with well-woman services at the Manhyia Government Hospital, Ghana

INTRODUCTION

The provision of well-woman services to women is a very good intervention for promoting good health and well-being among women. Despite data needed to inform increasing accessibility to well-woman services, there is limited information about client's satisfaction with well-woman services.

OBJECTIVE

This study was conducted to determine factors influencing women's satisfaction with well-woman services at Manhyia Government Hospital.

DESIGN

An analytical cross-sectional study was conducted among women attending the well-woman clinic at the Manhyia Government Hospital, Kumasi from 10 May 2023 to 15 November 2023.

METHODS

A systematic sampling method was employed. A pretested structured questionnaire was used to collect data on participants' socio-demographic and clinical characteristics, health-facility-related factors, barriers to utilization and client satisfaction. A face-to-face interview was conducted for every woman included in the study. Data were analyzed using multivariable logistic regression analysis. p-Value for statistical significance was set at p < 0.05.

RESULTS

Of the 344 women who were recruited for the study, majority (65.7%) of them were satisfied with care at the well-woman clinic. About 59.3% of the women were willing to continue care at the clinic. The age range was 18-60 with mean of 34.6 ± 12.0 years. Some of the challenges the women reported in accessing well-woman services at the clinic included long waiting times (17.7%) and inadequately skilled staff (8.1%). After adjusting for significant variables in the multivariable logistic regression analysis (adjusted odds ratio (AOR)), comfortability of the waiting area (AOR: 7.71, 95% CI: 1.54-38.60), <6 months duration of accessing care (AOR: 8.82, 95% CI: 3.25-23.98) and friendly attitude of health workers (AOR: 27.03, 95% CI: 4.28-170.83) were significantly associated with the client's satisfaction with well-woman services.

CONCLUSION

There was high satisfaction with well-woman services at the clinic, and this was associated with factors such as duration of service, comfortability of the waiting area and the attitude of health workers. Training more skilled staff and expanding the clinic will help improve well-woman services.

How long do bacteria, fungi, protozoa, and viruses retain their replication capacity on inanimate surfaces? A systematic review examining environmental resilience versus healthcare-associated infection risk by "fomite-borne risk assessment"

SUMMARYIn healthcare settings, contaminated surfaces play an important role in the transmission of nosocomial pathogens potentially resulting in healthcare-associated infections (HAI). Pathogens can be transmitted directly from frequent hand-touch surfaces close to patients or indirectly by staff and visitors. HAI risk depends on exposure, extent of contamination, infectious dose (ID), virulence, hygiene practices, and patient vulnerability. This review attempts to close a gap in previous reviews on persistence/tenacity by only including articles (n = 171) providing quantitative data on re-cultivable pathogens from fomites for a better translation into clinical settings. We have therefore introduced the new term "replication capacity" (RC). The RC is affected by the degree of contamination, surface material, temperature, relative humidity, protein load, organic soil, UV-light (sunlight) exposure, and pH value. In general, investigations into surface RC are mainly performed in vitro using reference strains with high inocula. In vitro data from studies on 14 Gram-positive, 26 Gram-negative bacteria, 18 fungi, 4 protozoa, and 37 viruses. It should be regarded as a worst-case scenario indicating the upper bounds of risks when using such data for clinical decision-making. Information on RC after surface contamination could be seen as an opportunity to choose the most appropriate infection prevention and control (IPC) strategies. To help with decision-making, pathogens characterized by an increased nosocomial risk for transmission from inanimate surfaces ("fomite-borne") are presented and discussed in this systematic review. Thus, the review offers a theoretical basis to support local risk assessments and IPC recommendations.

Can probiotics trigger a paradigm shift for cleaning healthcare environments? A narrative review

BACKGROUND

The environment of healthcare institutions plays a major role in the transmission of multidrug resistant organisms (MDRO) and likely in subsequent healthcare-associated infections (HAIs). Probiotic cleaning products are a novel option for environmental cleaning. They represent a sustainable and biodegradable alternative to conventional chemical disinfectants for controlling microbial bioburden, and preventing pathogen transmission in hospital environments. High-quality studies including randomized clinical trials (RCT) triggered a summary with expert recommendations until further studies allow a critical review and meta-analysis of the data.

METHODS

Infection control experts from five European countries summarized available data as of June 2023. Authors presented their published RCTs, reviewed the existing literature on probiotic cleaning, summarized the results and identified knowledge gaps and subsequent research needs.

RESULTS

Probiotic cleaning was similarly effective for reducing HAI-related pathogens, enveloped viruses such as SARS-CoV-2 and MDRO in environmental samples compared to conventional chemical disinfectants. More importantly, probiotic cleaning was non-inferior to disinfectants in terms of preventing HAI in a large RCT. In addition, probiotic cleaning has also been shown to reduce antimicrobial resistance genes (ARG), costs and antimicrobial consumption in other hospital trials. They are biodegradable, do not require any protection for chemical hazards, and are compliant with occupational health. A paradigm shift, however, requires a very strong evidence to justify for such a change. In the past, this evidence was limited by the heterogeneity of study design, products, protocols, and few studies on clinical outcomes used in the trials. Furthermore, the regulatory, safety, and quality aspects of probiotic cleaning products are not, yet, completely defined and require clearing by authorities.

CONCLUSION

To date, probiotic cleaning is a breakthrough technology and a biological alternative for chemical disinfectant when treating hospital environment. It may also have a positive effect on MDRO transmission. However, the different compositions of probiotic products will require standardization, and more robust data should be generated to support these promising results on different compositions. This may trigger a paradigm shift in cleaning of healthcare institutions from chemical to biological control of the hospital environment.

Disinfectants efficacy in reducing pathogens related to health-care infection associated in universities hospitals of Gorgan, North of Iran

BACKGROUND

Disinfection has a fundamental role in the control of pathogens in the hospital environment. This study was designed to assess the efficacy and functional impact of disinfectants in reducing pathogens related to healthcare associated infections (HAIs) in hospitals.

METHODS

This observation study was conducted at three university hospitals in Gorgan, Iran, from May to Oct 2023. The data including used disinfectants and microbiological examination were obtained from the infection control unit of each hospital.

RESULTS

The results showed that a variety of disinfectants from intermediate to high levels were employed in accordance with the World Health Organization (WHO) protocols. The microbial result revealed that 31.6% (286 out of 906) of the sample had at least one microorganism. Among identified organisms, Bacillus spp. were the predominant species followed by Staphylococcus epidermis, fungus genera, Enterobacter spp., Enterococcus spp., Pseudomonas spp., Escherichia coli, Alcaligenes spp., Staphylococcus aureus, Citrobacter spp., Corynebacterium spp., Klebsiella spp., Acinetobacter spp., Micrococcus spp., Staphylococcus saprophyticus, and Serratias spp. The highest prevalence rates of microorganisms were observed in the wards of ICU, emergency, internal medicine, and women's ward. The chi-square test revealed a significant relationship between the presence of organisms and hospital wards (P < 0.05).

CONCLUSION

The presence of pathogens indicates a defect in the disinfection process, probably due to both little attention to disinfection protocols and multidrug resistance. It is not yet possible to eliminate pathogens from the hospital environment, but it can be minimized by education intervention, standardizing disinfecting processes, and monitoring by the infection control committee.

Tackling transmission of infectious diseases: A probiotic-based system as a remedy for the spread of pathogenic and resistant microbes

Built environments (BEs) currently represent the areas in which human beings spend most of their life. Consistently, microbes populating BEs mostly derive from human occupants and can be easily transferred from BE to occupants. The hospital microbiome is a paradigmatic example, representing a reservoir for harmful pathogens that can be transmitted to susceptible patients, causing the healthcare-associated infections (HAIs). Environmental cleaning is a crucial pillar in controlling BE pathogens and preventing related infections, and chemical disinfectants have been largely used so far towards this aim. However, despite their immediate effect, chemical-based disinfection is unable to prevent recontamination, has a high environmental impact, and can select/increase antimicrobial resistance (AMR) in treated microbes. To overcome these limitations, probiotic-based sanitation (PBS) strategies were recently proposed, built on the use of detergents added with selected probiotics able to displace surrounding pathogens by competitive exclusion. PBS was reported as an effective and low-impact alternative to chemical disinfection, providing stable rebalance of the BE microbiome and significantly reducing pathogens and HAIs compared to disinfectants, without exacerbating AMR and pollution concerns. This minireview summarizes the most significant results obtained by applying PBS in sanitary and non-sanitary settings, which overall suggest that PBS may effectively tackle the infectious risk meanwhile preventing the further spread of pathogenic and resistant microbes.

A critical assessment of microbial-based antimicrobial sanitizing of inanimate surfaces in healthcare settings

The global rise in antimicrobial resistance (AMR) poses a significant public health threat, especially in healthcare settings, where controlling the spread of antimicrobial genes is crucial. While person-to-person transmission remains the primary route for healthcare-associated infections (HAIs), hospital surfaces serve as key reservoirs for antimicrobial-resistant microorganisms. Regular cleaning and disinfection of these surfaces are essential. Microbial-based products for sanitizing hospital surfaces have emerged as promising tools to combat HAIs and AMR. However, a review of 32 publications found inconsistencies and potential risks. A total of 15 publications included hospital-based trials, while the rest were either in vitro or in situ assays, reviews, book chapters, or commentaries. In most of the hospital-based studies, specific strains of applied microorganisms were not identified, and the term "probiotic" was inaccurately used. These products mainly featured spores from Bacillus and Priestia genera, which was mainly hypothesized to work through competitive exclusion. Most hospital-based studies have shown that the application of microbial-based products resulted in a significant reduction in pathogens on surfaces, thereby contributing to a decrease in the incidence of healthcare-associated infections (HAIs). Further research is however needed to understand the effectiveness, mechanisms of action, and safety of microbial-based sanitizing agents. Strain-level identification is crucial for safety assessments, yet many reviewed products lacked this information. Consequently, there is a need for rigorous safety evaluations within existing regulatory frameworks to ensure the efficacy and safety of microbial-based cleaning products in healthcare settings.

Promiscuous, persistent and problematic: insights into current enterococcal genomics to guide therapeutic strategy

Vancomycin-resistant enterococci (VRE) are major opportunistic pathogens and the causative agents of serious diseases, such as urinary tract infections and endocarditis. VRE strains mainly include species of Enterococcus faecium and E. faecalis which can colonise the gastrointestinal tract (GIT) of patients and, following growth and persistence in the gut, can transfer to blood resulting in systemic dissemination in the body. Advancements in genomics have revealed that hospital-associated VRE strains are characterised by increased numbers of mobile genetic elements, higher numbers of antibiotic resistance genes and often lack active CRISPR-Cas systems. Additionally, comparative genomics have increased our understanding of dissemination routes among patients and healthcare workers. Since the efficiency of currently available antibiotics is rapidly declining, new measures to control infection and dissemination of these persistent pathogens are urgently needed. These approaches include combinatory administration of antibiotics, strengthening colonisation resistance of the gut microbiota to reduce VRE proliferation through commensals or probiotic bacteria, or switching to non-antibiotic bacterial killers, such as bacteriophages or bacteriocins. In this review, we discuss the current knowledge of the genomics of VRE isolates and state-of-the-art therapeutic advances against VRE infections.