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Lundquist NA, Kifelew LG, Elmas S, Jia Z, Speck PG, Chalker JM. Inactivation of human coronaviruses using an automated room disinfection device. Sci Rep 2023; 13:20048. [PMID: 37973822 PMCID: PMC10654563 DOI: 10.1038/s41598-023-47082-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023] Open
Abstract
The emergence of more virulent and epidemic strains of viruses, especially in the context of COVID-19, makes it more important than ever to improve methods of decontamination. The objective of this study was to evaluate the potential of on-demand production of chlorine species to inactivate human coronaviruses. The commercial prototype disinfection unit was provided by Unipolar Water Technologies. The Unipolar device generates active chlorine species using an electrochemical reaction and dispenses the disinfectant vapour onto surfaces with an aspirator. The minimum effective concentration and exposure time of disinfectant were evaluated on human hepatoma (Huh7) cells using 50% tissue culture infectious dose (TCID50) assay and human coronavirus 229E (HCoV-229E), a surrogate for pathogenic human coronaviruses. We showed that chlorine species generated in the Unipolar device inactivate HCoV-229E on glass surfaces at ≥ 400 parts per million active chlorine concentration with a 5 min exposure time. Here, inactivation refers to the inability of the virus to infect the Huh7 cells. Importantly, no toxic effect was observed on Huh7 cells for any of the active chlorine concentrations and contact times tested.
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Affiliation(s)
- Nicholas A Lundquist
- Institute for Nanoscale Science and Technology, College of Science and Engineering, Flinders University, Bedford Park, SA, 5042, Australia
| | - Legesse G Kifelew
- Molecular Biosciences, College of Science and Engineering, Flinders University, Bedford Park, SA, 5042, Australia
| | - Sait Elmas
- Institute for Nanoscale Science and Technology, College of Science and Engineering, Flinders University, Bedford Park, SA, 5042, Australia
| | - Zhongfan Jia
- Institute for Nanoscale Science and Technology, College of Science and Engineering, Flinders University, Bedford Park, SA, 5042, Australia
| | - Peter G Speck
- Molecular Biosciences, College of Science and Engineering, Flinders University, Bedford Park, SA, 5042, Australia.
| | - Justin M Chalker
- Institute for Nanoscale Science and Technology, College of Science and Engineering, Flinders University, Bedford Park, SA, 5042, Australia.
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2
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Pérez-Díaz JL, Martín-Pérez T, Del Álamo C, Sánchez-García-Casarrubios J, Copa-Patiño JL, Soliveri J, Orellana-Muriana JM, Pérez-Serrano J, Llerena-Aguilar FJ. Optimal Fast Integral Decontamination of Bacillus thuringiensis Aerosols and Fast Disinfection of Contaminated Surfaces. Microorganisms 2023; 11:microorganisms11041021. [PMID: 37110444 PMCID: PMC10143539 DOI: 10.3390/microorganisms11041021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 03/30/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
Aerosolized anthrax (Bacillus anthracis) spores are of extreme health concern and can remain airborne for hours and contaminate all kinds of surfaces, constituting reservoirs from which resuspension is easily produced. The assessment of decontamination techniques must therefore consider both air and surfaces. In the present study, several kinds of disinfecting fogs were experimentally tested against Bacillus thuringiensis spores, which served as a surrogate for Bacillus anthracis, both as aerosols released into the air and spread on porous and non-porous surfaces with different positions and orientations. This technology removed Bacillus thuringiensis spores from the air in 20 min with just a 1 min application of fog. The dynamics and characteristics of the fog, related to aerosol and surface interactions, proved to be critical for optimal performance and decontamination. An optimal configuration could provide effective disinfection even on indirectly reached surfaces. In all cases, 8% hydrogen peroxide (H2O2) provided a higher disinfection rate than 2% glutaraldehyde.
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Affiliation(s)
- José Luis Pérez-Díaz
- Escuela Politécnica Superior, Universidad de Alcalá, 28801 Alcalá de Henares, Spain
| | - Tania Martín-Pérez
- Department of Biomedicine and Biotechnology, Universidad de Alcalá, 28801 Alcalá de Henares, Spain
| | - Cristina Del Álamo
- Escuela Politécnica Superior, Universidad de Alcalá, 28801 Alcalá de Henares, Spain
| | | | - José Luis Copa-Patiño
- Department of Biomedicine and Biotechnology, Universidad de Alcalá, 28801 Alcalá de Henares, Spain
| | - Juan Soliveri
- Department of Biomedicine and Biotechnology, Universidad de Alcalá, 28801 Alcalá de Henares, Spain
| | | | - Jorge Pérez-Serrano
- Department of Biomedicine and Biotechnology, Universidad de Alcalá, 28801 Alcalá de Henares, Spain
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Piletić K, Linšak DT, Kovač B, Mežnarić S, Repustić M, Radmanović-Skrbić M, Gobin I. Ozone disinfection efficiency against airborne microorganisms in hospital environment: a case study. Arh Hig Rada Toksikol 2022; 73:270-276. [PMID: 36607720 PMCID: PMC9985346 DOI: 10.2478/aiht-2022-73-3651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/01/2022] [Accepted: 12/01/2022] [Indexed: 01/07/2023] Open
Abstract
Even though ozone has shown its potential for air disinfection in hospital environment, its more frequent use has earned attention only with the COVID-19 pandemic due to its proven antimicrobial effect and low cost of production. The aim of this study was to determine its antimicrobial efficiency against the most common bacterial species in a real-life setting, that is, in the air of one postoperative room of the General Hospital Dr Ivo Pedišić (Sisak, Croatia). Air was sampled for aiborne bacteria before and after treatment with the ozone concentration of 15.71 mg/m3 for one hour. The most dominant Gram-positive bacteria of the genera Micrococcus, Staphylococcus, and Bacillus were reduced by 33 %, 58 %, and 61 %, respectively. The genus Micrococcus proved to be the most resistant. Considering our findings, we recommend longer air treatment with higher ozone concentrations in combination with mechanical cleaning and frequent ventilation.
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Affiliation(s)
- Kaća Piletić
- University of Rijeka Faculty of Medicine, Department of Microbiology and Parasitology, Rijeka, Croatia
| | - Dijana Tomić Linšak
- University of Rijeka Faculty of Medicine, Department of Health Ecology, Rijeka, Croatia
| | - Bruno Kovač
- University of Rijeka Faculty of Medicine, Department of Microbiology and Parasitology, Rijeka, Croatia
| | - Silvestar Mežnarić
- University of Rijeka Faculty of Medicine, Department of Microbiology and Parasitology, Rijeka, Croatia
| | | | | | - Ivana Gobin
- University of Rijeka Faculty of Medicine, Department of Microbiology and Parasitology, Rijeka, Croatia
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4
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Combined Biocidal Effect of Gaseous Ozone and Citric Acid on Acinetobacter baumannii Biofilm Formed on Ceramic Tiles and Polystyrene as a Novel Approach for Infection Prevention and Control. Processes (Basel) 2022. [DOI: 10.3390/pr10091788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Acinetobacter baumannii is a prominent emerging pathogen responsible for a variety of hospital-acquired infections. It can contaminate inanimate surfaces and survive in harsh environmental conditions for prolonged periods of time in the form of biofilm. Biofilm is difficult to remove with only one method of disinfection, so combined disinfection methods and biocidal active substances are needed for biofilm eradication. Additionally, having in mind ecological demands, legislators are more prone using fewer toxic substances for disinfection that produce less solid waste and hazardous disinfection byproducts. Gaseous ozone and citric acid are natural biocidal compounds, and the purpose of this study was to determine their combined biocidal effects on A. baumannii biofilm formed on ceramics and polystyrene. Twenty-four-hour A. baumannii biofilm formed on ceramic tiles and polystyrene was exposed to different combinations of disinfection protocols with 25 ppm of gaseous ozone for 1 h exposure time and 15% citric acid for 10 min exposure. The total number of bacteria was counted afterwards and expressed as CFU/cm2. The determined disinfection protocols of A. baumannii biofilm with combined citric acid and gaseous ozone caused reduction of 2.8 to 5.89 log10 CFU (99.99% inhibition rate) of total viable bacteria for each method, with the citric acid–ozone–citric acid disinfection protocol being most successful in eradication of viable bacteria on both ceramics and polystyrene. In conclusion, gaseous ozone and citric acid showed good combined biocidal effects on A. baumannii biofilm and successfully reduced early A. baumannii biofilm from ceramic and polystyrene surfaces. The given combination of active substances can be a good option for eco-friendly disinfection of hospital inanimate surfaces from A. baumannii biofilm contamination with prior mechanical cleaning.
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Rangel K, Cabral FO, Lechuga GC, Carvalho JPRS, Villas-Bôas MHS, Midlej V, De-Simone SG. Potent Activity of a High Concentration of Chemical Ozone against Antibiotic-Resistant Bacteria. Molecules 2022; 27:3998. [PMID: 35807244 PMCID: PMC9268618 DOI: 10.3390/molecules27133998] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/15/2022] [Accepted: 06/15/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Health care-associated infections (HAIs) are a significant public health problem worldwide, favoring multidrug-resistant (MDR) microorganisms. The SARS-CoV-2 infection was negatively associated with the increase in antimicrobial resistance, and the ESKAPE group had the most significant impact on HAIs. The study evaluated the bactericidal effect of a high concentration of O3 gas on some reference and ESKAPE bacteria. MATERIAL AND METHODS Four standard strains and four clinical or environmental MDR strains were exposed to elevated ozone doses at different concentrations and times. Bacterial inactivation (growth and cultivability) was investigated using colony counts and resazurin as metabolic indicators. Scanning electron microscopy (SEM) was performed. RESULTS The culture exposure to a high level of O3 inhibited the growth of all bacterial strains tested with a statistically significant reduction in colony count compared to the control group. The cell viability of S. aureus (MRSA) (99.6%) and P. aeruginosa (XDR) (29.2%) was reduced considerably, and SEM showed damage to bacteria after O3 treatment Conclusion: The impact of HAIs can be easily dampened by the widespread use of ozone in ICUs. This product usually degrades into molecular oxygen and has a low toxicity compared to other sanitization products. However, high doses of ozone were able to interfere with the growth of all strains studied, evidencing that ozone-based decontamination approaches may represent the future of hospital cleaning methods.
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Affiliation(s)
- Karyne Rangel
- Center for Technological Development in Health (CDTS), National Institute of Science and Technology for Innovation in Neglected Population Diseases (INCT-IDPN), FIOCRUZ, Rio de Janeiro 21040-900, Brazil; (G.C.L.); (J.P.R.S.C.)
- Laboratory of Epidemiology and Molecular Systematics (LESM), Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro 21040-900, Brazil
| | - Fellipe O. Cabral
- Microbiology Department, National Institute for Quality Control in Health (INCQS), FIOCRUZ, Rio de Janeiro 21040-900, Brazil; (F.O.C.); (M.H.S.V.-B.)
| | - Guilherme C. Lechuga
- Center for Technological Development in Health (CDTS), National Institute of Science and Technology for Innovation in Neglected Population Diseases (INCT-IDPN), FIOCRUZ, Rio de Janeiro 21040-900, Brazil; (G.C.L.); (J.P.R.S.C.)
- Laboratory of Epidemiology and Molecular Systematics (LESM), Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro 21040-900, Brazil
| | - João P. R. S. Carvalho
- Center for Technological Development in Health (CDTS), National Institute of Science and Technology for Innovation in Neglected Population Diseases (INCT-IDPN), FIOCRUZ, Rio de Janeiro 21040-900, Brazil; (G.C.L.); (J.P.R.S.C.)
- Laboratory of Epidemiology and Molecular Systematics (LESM), Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro 21040-900, Brazil
- Post-Graduation Program in Science and Biotechnology, Department of Molecular and Cellular Biology, Biology Institute, Federal Fluminense University, Niterói 22040-036, Brazil
| | - Maria H. S. Villas-Bôas
- Microbiology Department, National Institute for Quality Control in Health (INCQS), FIOCRUZ, Rio de Janeiro 21040-900, Brazil; (F.O.C.); (M.H.S.V.-B.)
| | - Victor Midlej
- Laboratory of Cellular and Ultrastructure, Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro 21040-900, Brazil;
| | - Salvatore G. De-Simone
- Center for Technological Development in Health (CDTS), National Institute of Science and Technology for Innovation in Neglected Population Diseases (INCT-IDPN), FIOCRUZ, Rio de Janeiro 21040-900, Brazil; (G.C.L.); (J.P.R.S.C.)
- Laboratory of Epidemiology and Molecular Systematics (LESM), Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro 21040-900, Brazil
- Post-Graduation Program in Science and Biotechnology, Department of Molecular and Cellular Biology, Biology Institute, Federal Fluminense University, Niterói 22040-036, Brazil
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Piletić K, Kovač B, Perčić M, Žigon J, Broznić D, Karleuša L, Lučić Blagojević S, Oder M, Gobin I. Disinfecting Action of Gaseous Ozone on OXA-48-Producing Klebsiella pneumoniae Biofilm In Vitro. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19106177. [PMID: 35627712 PMCID: PMC9140702 DOI: 10.3390/ijerph19106177] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/11/2022] [Accepted: 05/17/2022] [Indexed: 02/04/2023]
Abstract
Klebsiella pneumoniae is an emerging multidrug-resistant pathogen that can contaminate hospital surfaces in the form of a biofilm which is hard to remove with standard disinfectants. Because of biofilm resistance to conservative disinfectants, the application of new disinfection technologies is becoming more frequent. Ozone gas has antimicrobial activity but there is lack of data on its action against K. pneumoniae biofilm. The aim of this study was to investigate the effects and mechanisms of action of gaseous ozone on the OXA-48-procuding K. pneumoniae biofilm. A 24 h biofilm of K. pneumoniae formed on ceramic tiles was subsequently exposed to different concentrations of ozone during one and two hours to determine the optimal ozone concentration. Afterwards, the total bacteria count, total biomass and oxidative stress levels were monitored. A total of 25 ppm of gaseous ozone was determined to be optimal ozone concentration and caused reduction in total bacteria number in all strains of K. pneumoniae for 2.0 log10 CFU/cm2, followed by reduction in total biomass up to 88.15%. Reactive oxygen species levels significantly increased after the ozone treatment at 182% for the representative K. pneumoniae NCTC 13442 strain. Ozone gas in the concentration of 25 ppm caused significant biofilm reduction but did not completely eradicate the K. pneumoniae biofilm formed on ceramics. In conclusion, ozone gas has great potential to be used as an additional hygiene measure in joint combat against biofilm in hospital environments.
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Affiliation(s)
- Kaća Piletić
- Department of Microbiology and Parasitology, Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia; (K.P.); (B.K.)
| | - Bruno Kovač
- Department of Microbiology and Parasitology, Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia; (K.P.); (B.K.)
| | - Marko Perčić
- Faculty of Engineering & Centre for Micro- and Nanosciences and Technologies, University of Rijeka, 51000 Rijeka, Croatia;
| | - Jure Žigon
- Department of Wood Science and Technology, Biotechnical Faculty, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Dalibor Broznić
- Department of Medical Chemistry, Biochemistry and Clinical Chemistry, Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia;
| | - Ljerka Karleuša
- Department of Physiology and Immunology, Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia;
| | - Sanja Lučić Blagojević
- Faculty of Chemical Engineering and Technology, University of Zagreb, 10000 Zagreb, Croatia;
| | - Martina Oder
- Department of Sanitary Engineering, Faculty of Health Sciences, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Ivana Gobin
- Department of Microbiology and Parasitology, Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia; (K.P.); (B.K.)
- Correspondence:
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Kruszewska E, Grześ H, Czupryna P, Pancewicz S, Groth M, Wondim M, Moniuszko-Malinowska A. Corrigendum: Fogging With Peracetic Acid in Schools and Kindergartens. Front Public Health 2022; 10:867618. [PMID: 35372218 PMCID: PMC8964362 DOI: 10.3389/fpubh.2022.867618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 11/22/2022] Open
Affiliation(s)
- Ewelina Kruszewska
- Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Bialystok, Poland
| | - Henryk Grześ
- Microbiology Laboratory, University Clinical Hospital in Bialystok, Bialystok, Poland
| | - Piotr Czupryna
- Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Bialystok, Poland
| | - Sławomir Pancewicz
- Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Bialystok, Poland
| | - Monika Groth
- Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Bialystok, Poland
| | - Mulugeta Wondim
- Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Bialystok, Poland
| | - Anna Moniuszko-Malinowska
- Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Bialystok, Poland
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8
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Automated room decontamination: report of a Healthcare Infection Society Working Party. J Hosp Infect 2022; 124:97-120. [DOI: 10.1016/j.jhin.2022.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 01/07/2022] [Indexed: 01/24/2023]
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9
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Kruszewska E, Grześ H, Czupryna P, Pancewicz S, Groth M, Wondim M, Moniuszko-Malinowska A. Fogging With Peracetic Acid in Schools and Kindergartens. Front Public Health 2021; 9:697917. [PMID: 34604154 PMCID: PMC8486081 DOI: 10.3389/fpubh.2021.697917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/17/2021] [Indexed: 11/15/2022] Open
Abstract
Disinfection is a key element in controlling infections. Fogging, also known as fumigation, is one of the most effective chemical disinfection methods. Peracetic acid (PAA) is a powerful oxidant with bactericidal and fungicidal properties. The aim of this study is to determine the type of bacteria and fungi present in educational institutions and whether disinfection by PAA fumigation in these institutions is also effective and useful, as demonstrated previously in healthcare centers. This study was carried out in five kindergartens and five primary schools in Bialystok, Poland. Three rooms have been selected in each of these educational institutions, and the disinfection was carried out in 30 rooms in total. Fogging with PAA was performed in selected rooms. Before and after disinfection, samples were collected from four surfaces: walls, tables, doors, and chair backs. Most frequently detected microorganisms in schools and kindergartens were Micrococcus luteus (M. luteus), Staphylococcus warneri (S. warneri), Paracoccus yeei (P. yeei), Staphylococcus hominis ssp. hominis (S. hominis), Kocuria rhizophila (K. rhizophila), Kocuria rosea (K. rosea). In addition, Staphylococcus haemolyticus (S. haemolyticus), Acinetobacter lwoffii (A. lwoffii), Kocuria kristinae (K. kristinae), Lactococcus lactis ssp. lactis (L. lactis) were the most prevalent in kindergartens, whereas Kytococcus sedentarius (K. sedentarius) was the most prevalent in schools. Comparison of the bacterial flora of schools and kindergartens showed statistically significant differences in the prevalence of bacteria on different surfaces. A significant decrease in the number of colonies after disinfection was observed on all surfaces (p < 0.05). In addition, the calculated effectiveness of disinfection was 99.7% in kindergartens and 99.3% in schools. The results indicate that fogging of PAA is a highly effective method of surface disinfection in kindergartens and schools.
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Affiliation(s)
- Ewelina Kruszewska
- Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Bialystok, Poland
| | - Henryk Grześ
- Microbiology Laboratory, University Clinical Hospital in Bialystok, Bialystok, Poland
| | - Piotr Czupryna
- Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Bialystok, Poland
| | - Sławomir Pancewicz
- Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Bialystok, Poland
| | - Monika Groth
- Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Bialystok, Poland
| | - Mulugeta Wondim
- Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Bialystok, Poland
| | - Anna Moniuszko-Malinowska
- Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Bialystok, Poland
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Bryaskova R, Philipova N, Georgiev N, Lalov I, Bojinov V, Detrembleur C. Photoactive mussels inspired polymer coatings: Preparation and antibacterial activity. J Appl Polym Sci 2021. [DOI: 10.1002/app.50769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Rayna Bryaskova
- Department of Polymer Engineering University of Chemical Technology and Metallurgy Sofia Bulgaria
| | - Nikoleta Philipova
- Department of Polymer Engineering University of Chemical Technology and Metallurgy Sofia Bulgaria
| | - Nikolay Georgiev
- Department of Organic Synthesis University of Chemical Technology and Metallurgy Sofia Bulgaria
| | - Ivo Lalov
- Department of Biotechnology University of Chemical Technology and Metallurgy Sofia Bulgaria
| | - Vladimir Bojinov
- Department of Organic Synthesis University of Chemical Technology and Metallurgy Sofia Bulgaria
| | - Christophe Detrembleur
- Center for Education and Research on Macromolecules (CERM), CESAM Research Unit, Chemistry Department University of Liege Liège Belgium
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11
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Franke G, Knobling B, Brill FH, Becker B, Klupp EM, Belmar Campos C, Pfefferle S, Lütgehetmann M, Knobloch JK. An automated room disinfection system using ozone is highly active against surrogates for SARS-CoV-2. J Hosp Infect 2021; 112:108-113. [PMID: 33864891 PMCID: PMC8046700 DOI: 10.1016/j.jhin.2021.04.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/31/2021] [Accepted: 04/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The presence of coronaviruses on surfaces in the patient environment is a potential source of indirect transmission. Manual cleaning and disinfection measures do not always achieve sufficient removal of surface contamination. This increases the importance of automated solutions in the context of final disinfection of rooms in the hospital setting. Ozone is a highly effective disinfectant which, combined with high humidity, is an effective agent against respiratory viruses. Current devices allow continuous nebulization for high room humidity as well as ozone production without any consumables. AIM In the following study, the effectiveness of a fully automatic room decontamination system based on ozone was tested against bacteriophage Φ6 (phi 6) and bovine coronavirus L9, as surrogate viruses for the pandemic coronavirus SARS-CoV-2. METHODS For this purpose, various surfaces (ceramic tile, stainless steel surface and furniture board) were soiled with the surrogate viruses and placed at two different levels in a gas-tight test room. After using the automatic decontamination device according to the manufacturer's instructions, the surrogate viruses were recovered from the surfaces and examined by quantitative cultures. Then, reduction factors were calculated. FINDINGS The ozone-based room decontamination device achieved virucidal efficacy (reduction factor >4 log10) against both surrogate organisms regardless of the different surfaces and positions confirming a high activity under the used conditions. CONCLUSION Ozone is highly active against SARS-CoV-2 surrogate organisms. Further investigations are necessary for a safe application and efficacy in practice as well as integration into routine processes.
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Affiliation(s)
- G Franke
- Institute for Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - B Knobling
- Institute for Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - F H Brill
- Dr. Brill + Partner GmbH Institute for Hygiene and Microbiology, Bremen, Germany
| | - B Becker
- Dr. Brill + Partner GmbH Institute for Hygiene and Microbiology, Bremen, Germany
| | - E M Klupp
- Institute for Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - C Belmar Campos
- Institute for Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - S Pfefferle
- Institute for Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M Lütgehetmann
- Institute for Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J K Knobloch
- Institute for Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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12
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Knobling B, Franke G, Klupp EM, Belmar Campos C, Knobloch JK. Evaluation of the Effectiveness of Two Automated Room Decontamination Devices Under Real-Life Conditions. Front Public Health 2021; 9:618263. [PMID: 33708756 PMCID: PMC7940181 DOI: 10.3389/fpubh.2021.618263] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/02/2021] [Indexed: 01/26/2023] Open
Abstract
To evaluate the effectiveness of automated room decontamination devices, a common aerosolized hydrogen peroxide (aHP) as well as a recent gaseous ozone-based device, which produces the disinfectant reagent without the need of consumables, were tested under real-life conditions. Twenty-two contaminated surfaces were positioned in different areas in a patient room with adjacent bathroom and anteroom. Following the decontamination process bacteria were recovered and reduction factors were calculated after performing quantitative culture. Following the manufactures instructions, the ozone-based device displayed a bactericidal effect (log10 > 5), whereas the aHP system failed for a high bacterial burden and achieves only a complete elimination of a realistic bioburden (log10 2). After increasing the exposure time to 30 min, the aHP device also reached a bactericidal effect. Nevertheless, our results indicate, that further research and development is necessary, to get knowledge about toxicity, efficacy and safety by using in complex hospital conditions and achieve meaningful integration in cleaning procedures, to reach positive effects on disinfection performance.
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Affiliation(s)
| | | | | | | | - Johannes K. Knobloch
- Institute for Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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13
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Wang Z, Kowal SF, Carslaw N, Kahan TF. Photolysis-driven indoor air chemistry following cleaning of hospital wards. INDOOR AIR 2020; 30:1241-1255. [PMID: 32485006 DOI: 10.1111/ina.12702] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 04/17/2020] [Accepted: 05/19/2020] [Indexed: 05/25/2023]
Abstract
Effective cleaning techniques are essential for the sterilization of rooms in hospitals and industry. No-touch devices (NTDs) that use fumigants such as hydrogen peroxide (H2 O2 ), formaldehyde (HCHO), ozone (O3 ), and chlorine dioxide (OClO) are a recent innovation. This paper reports a previously unconsidered potential consequence of such cleaning technologies: the photochemical formation of high concentrations of hydroxyl radicals (OH), hydroperoxy radicals (HO2 ), organic peroxy radicals (RO2 ), and chlorine radicals (Cl) which can form harmful reaction products when exposed to chemicals commonly found in indoor air. This risk was evaluated by calculating radical production rates and concentrations based on measured indoor photon fluxes and typical fumigant concentrations during and after cleaning events. Sunlight and fluorescent tubes without covers initiated photolysis of all fumigants, and plastic-covered fluorescent tubes initiated photolysis of only some fumigants. Radical formation was often dominated by photolysis of fumigants during and after decontamination processes. Radical concentrations were predicted to be orders of magnitude greater than background levels during and immediately following cleaning events with each fumigant under one or more illumination condition. Maximum predicted radical concentrations (1.3 × 107 molecule cm-3 OH, 2.4 ppb HO2 , 6.8 ppb RO2 and 2.2 × 108 molecule cm-3 Cl) were much higher than baseline concentrations. Maximum OH concentrations occurred with O3 photolysis, HO2 with HCHO photolysis, and RO2 and Cl with OClO photolysis. Elevated concentrations may persist for hours after NTD use, depending on the air change rate and air composition. Products from reactions involving radicals could significantly decrease air quality when disinfectants are used, leading to adverse health effects for occupants.
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Affiliation(s)
- Zixu Wang
- Department of Environment and Geography, University of York, York, UK
| | - Shawn F Kowal
- Department of Chemistry, Syracuse University, Syracuse, NY, USA
| | - Nicola Carslaw
- Department of Environment and Geography, University of York, York, UK
| | - Tara F Kahan
- Department of Chemistry, Syracuse University, Syracuse, NY, USA
- Department of Chemistry, University of Saskatchewan, Saskatoon, SK, Canada
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14
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Scarano A, Inchingolo F, Lorusso F. Environmental Disinfection of a Dental Clinic during the Covid-19 Pandemic: A Narrative Insight. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8896812. [PMID: 33145359 PMCID: PMC7596431 DOI: 10.1155/2020/8896812] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 09/27/2020] [Accepted: 10/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The control of biological hazard risk in health care and dental clinic environments represents a critical point in relation to the Covid-19 infection outbreak and international public health emergency. The purpose of the present review was to evaluate the scientific literature on the no-touch disinfection procedures in dental clinics aiming to limit transmission via airborne particles or fomites using no-touch procedures for environmental decontamination of dental clinics. METHODS An electronic database literature search was performed to retrieve research papers about Covid-19 and no-touch disinfection topics including full-length articles, editorials, commentaries, and outbreak studies. A total of 86 papers were retrieved by the electronic research. RESULTS No clinical article about the decontamination of a dental clinic during the Covid-19 pandemic was detected. About the topic of hospital decontamination, we found different no-touch disinfection procedures used in hospital against highly resistant organisms, but no data were found in the search for such procedures with respect to SARS-CoV-2: (1) aerosolized hydrogen peroxide, (2) H2O2 vapor, (3) ultraviolet C light, (4) pulsed xenon, and (5) gaseous ozone. One paper was retrieved concerning SARS-CoV-2; 32 documents focused on SARS and MERS. The cleaning and disinfection protocol of health care and dental clinic environment surfaces are essential elements of infection prevention programs, especially during the SARS-CoV-2 pandemic. CONCLUSION The decontamination technique that best suits the needs of the dental clinic is peroxide and hypochlorous which can be sprayed via a device at high turbine speed with the ability of producing small aerosol particles, recommendable also for their low cost.
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Affiliation(s)
- Antonio Scarano
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, Via dei Vestini 31, 66100 Chieti, Italy
| | - Francesco Inchingolo
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70121 Bari, Italy
| | - Felice Lorusso
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, Via dei Vestini 31, 66100 Chieti, Italy
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15
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Hankenson FC, Mauntel M, Willard J, Pittsley L, Degg W, Burnell N, Vierling A, Griffis S. Vaporized Hydrogen Peroxide Decontamination of N95 Respirators in a Dedicated Animal Research Facility for Reuse During a Novel Coronavirus Pandemic. APPLIED BIOSAFETY 2020; 25:142-149. [PMID: 38602982 PMCID: PMC7315381 DOI: 10.1177/1535676020936381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Introduction During the COVID-19 pandemic, health care systems and safety providers have faced an unprecedented challenge of limited access to personal protective equipment (PPE) to conduct patient and public care. In federal emergencies, reuse of PPE after disinfection can occur by processes, like vaporized hydrogen peroxide (VHP), recommended by the Centers for Disease and Control and Prevention. We identified a vacant animal holding facility at our institution to repurpose into a regional VHP decontamination center. Methods The facility is a multiroom, 20 000 ft2 building with control of HVAC to adjust to VHP conditional requirements. H2O2 was delivered to rooms using robotic HaloFoggers, dispersing H2O2 vapor and increasingly concentrated microdroplets as a fog for a timed period based on cubic footage of rooms. Results Fogging cycles eliminated 6-log Geobacillus stearothermophilus up to 7 days postcycle. Functional efficacy of treated N95s was confirmed by fit tests of institutional personnel. Signage, process flow mapping, and training materials facilitated ease of workflow and adherence to safety expectations within the building. Discussion and Conclusion Our study determined that a variety of N95 respirator types and sizes were able to be cleared of potential bacterial and viral agents using VHP in a controlled fog/dwell/exhaust cycle. This repurposed animal facility has the capacity to decontaminate up to 6700 respirators daily, which will address the predicted surge of COVID-19 cases in the state, and ultimately allow each respirator to be reused multiple times. There is no other public site in the region with our capacity to offset the continued supply chain issues for PPE needs.
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Affiliation(s)
- F. Claire Hankenson
- Campus Animal Resources, Michigan State University, East Lansing, MI, USA
- Department of Pathobiology and Diagnostic Investigation, College of Veterinary Medicine, Michigan State University, East Lansing, MI, USA
| | - Mark Mauntel
- Campus Animal Resources, Michigan State University, East Lansing, MI, USA
| | - Jamie Willard
- Environmental Health and Safety, Office of Regulatory Affairs, Michigan State University, East Lansing, MI, USA
| | - Leslie Pittsley
- Campus Animal Resources, Michigan State University, East Lansing, MI, USA
| | | | | | | | - Stanley Griffis
- Department of Supply Chain Management, Eli Broad College of Business, Michigan State University, East Lansing, MI, USA
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16
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Kushwah V, Poms J, Vuylsteke B, Peter A, Paudel A. Towards an Understanding of the Adsorption of Vaporized Hydrogen Peroxide (VHP) Residues on Glass Vials After a VHP Decontamination Process Using a Miniaturized Tool. J Pharm Sci 2020; 109:2454-2463. [DOI: 10.1016/j.xphs.2020.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/10/2020] [Accepted: 04/13/2020] [Indexed: 01/21/2023]
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17
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Abstract
Background: Patients with large, acute burn injuries are a major challenge for clinicians. The loss of skin barrier protection against micro-organisms combined with the induced immunosuppression after burn injury makes this population especially vulnerable to infection. For burn-injured patients who survive immediate management considerations and burn resuscitation after acute injury, sepsis remains the primary cause of death. The purpose of this article is to describe current strategies and innovations in burn sepsis prevention and management. Methods: This work reviews the current understanding of the systemic inflammatory response to burn injury and burn sepsis as well as current strategies in insolation and infection prevention, newer burn unit design strategies in the context of infection prevention, and novel therapies being considered in topical antimicrobial wound care management. Results: A review of burn sepsis is key to understanding current paradigms and innovation in burn management and prevention. Key management principles begin from the time of injury and persist throughout the patient's hospital course. This includes use of personal protective equipment, burn unit design considerations, and knowledge of critical care principles such as central venous catheter management strategies. Innovations on wound dressing types, forms, and use have been key to better controlling burn wound sepsis and improving wound healing. Products incorporating nanotechnology, novel anions, oxygen, and even light have been key to introducing previously unconsidered methods to fight or prevent infection. Conclusion: Understanding the pathophysiology and source identification of sepsis from burn wounds has been a key contributor in developing innovative prevention and therapeutic strategies in burn management. The emergence of drug-resistant pathogens and the difficulty of systemic antibiotic agents to reach poorly vascularized wounds have further reinforced the need to anticipate management strategies moving forward. A proactive, multidisciplinary approach is necessary to minimize the morbidity and mortality associated with infection control.
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Affiliation(s)
- Shawn Tejiram
- The Burn Center, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jeffrey W Shupp
- The Burn Center, MedStar Washington Hospital Center, Washington, DC, USA.,Department of Surgery, Biochemistry, Molecular and Cellular Biology, Georgetown University School of Medicine, Washington, DC, USA
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18
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Role of Hydrogen Peroxide Vapor (HPV) for the Disinfection of Hospital Surfaces Contaminated by Multiresistant Bacteria. Pathogens 2020; 9:pathogens9050408. [PMID: 32456303 PMCID: PMC7281489 DOI: 10.3390/pathogens9050408] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 12/14/2022] Open
Abstract
The emergence of multiresistant bacterial strains as agents of healthcare-related infection in hospitals has prompted a review of the control techniques, with an added emphasis on preventive measures, namely good clinical practices, antimicrobial stewardship, and appropriate environmental cleaning. The latter item is about the choice of an appropriate disinfectant as a critical role due to the difficulties often encountered in obtaining a complete eradication of environmental contaminations and reservoirs of pathogens. The present review is focused on the effectiveness of hydrogen peroxide vapor, among the new environmental disinfectants that have been adopted. The method is based on a critical review of the available literature on this topic.
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19
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Wood JP, Wendling M, Richter W, Rogers J. The use of ozone gas for the inactivation of Bacillus anthracis and Bacillus subtilis spores on building materials. PLoS One 2020; 15:e0233291. [PMID: 32437373 PMCID: PMC7241793 DOI: 10.1371/journal.pone.0233291] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 05/02/2020] [Indexed: 11/19/2022] Open
Abstract
A study was conducted to assess the efficacy of ozone gas in inactivating spores of both Bacillus anthracis and Bacillus subtilis inoculated onto six building materials (glass, wood, carpet, laminate, galvanized metal, and wallboard paper). Testing conditions consisted of ozone gas concentrations ranging from 7,000-12,000 parts per million (ppm), contact times from 4 to 12 h, and two relative humidity (RH) levels of 75 and 85%. Results showed that increasing the ozone concentration, contact time, and RH generally increased decontamination efficacy. The materials in which the highest decontamination efficacy was achieved for B. anthracis spores were wallboard paper, carpet, and wood with ≥ 6 log10 reduction (LR) occurring with 9,800 ppm ozone, 85% RH, for 6 h. The laminate and galvanized metal materials were generally more difficult to decontaminate, requiring 12,000 ppm ozone, 85% RH, and 9-12 h contact time to achieve ≥6 LR of B. anthracis. Lastly, overall, there were no significant differences in decontamination efficacy between the two species.
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Affiliation(s)
- Joseph P. Wood
- Office of Research and Development, U.S. Environmental Protection Agency, National Homeland Security Research Program, Research Triangle Park, North Carolina, United States of America
| | - Morgan Wendling
- Battelle Memorial Institute, Columbus, Ohio, United States of America
| | - William Richter
- Battelle Memorial Institute, Columbus, Ohio, United States of America
| | - James Rogers
- Battelle Memorial Institute, Columbus, Ohio, United States of America
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20
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Rubiano ME, Maillard JY, Rubino JR, Ijaz MK. Use of a small-scale, portable test chamber for determining the bactericidal efficacy of aerosolized glycol formulations. Lett Appl Microbiol 2020; 70:356-364. [PMID: 32092165 DOI: 10.1111/lam.13289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 11/28/2022]
Abstract
This study aimed to understand the efficacy and mechanisms of action of an aerosolized glycol-ethanol formulations against bacteria. We validated a small-scale in-house test chamber to determine the microbicidal efficacy of four aerosolized formulations combining dipropylene glycol and ethanol against Staphylococcus aureus and Escherichia coli embedded in alginate. The aerosolized glycol/ethanol formulation decreased bacterial viability by 3 log10 and was more efficacious than an ethanol only control formulation. Electron microscopic examination indicated extensive structural damage in both bacteria, and membrane damage was confirmed with potassium release in S. aureus and DNA release in E. coli. The development of a small test chamber facilitated the measurement of the microbicidal efficacy and experiments to understand the mechanism of action of an aerosolized microbicidal formulation. SIGNIFICANCE AND IMPACT OF THE STUDY: There is an increased interest in developing effective microbicidal-aerosolized formulations. The development of a small in-house test chamber allowed the measurement of the microbicidal efficacy of an aerosolized glycol/ethanol formulation at a low cost. We showed that a glycol/ethanol aerosolized formulation caused extensive structural damage in Gram-negative and -positive bacteria resulting in a 3 log10 reduction in viability.
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Affiliation(s)
- M E Rubiano
- Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK
| | - J-Y Maillard
- Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK
| | - J R Rubino
- Research & Development, RB, Montvale, NJ, USA
| | - M K Ijaz
- Research & Development, RB, Montvale, NJ, USA.,Department of Biology, Medgar Evers College of the City University of New York (CUNY), Brooklyn, NY, USA
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21
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Otter J, Yezli S, Barbut F, Perl T. An overview of automated room disinfection systems: When to use them and how to choose them. DECONTAMINATION IN HOSPITALS AND HEALTHCARE 2020. [PMCID: PMC7153347 DOI: 10.1016/b978-0-08-102565-9.00015-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Conventional disinfection methods are limited by reliance on the operator to ensure appropriate selection, formulation, distribution, and contact time of the agent. Automated room disinfection (ARD) systems remove or reduce reliance on operators and so they have the potential to improve the efficacy of terminal disinfection. The most commonly used systems are hydrogen peroxide vapor (H2O2 vapor), aerosolized hydrogen peroxide (aHP), and ultraviolet (UV) light. These systems have important differences in their active agent, delivery mechanism, efficacy, process time, and ease of use. The choice of ARD system should be influenced by the intended application, the evidence base for effectiveness, practicalities of implementation, and cost considerations.
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Affiliation(s)
- J.A. Otter
- NIHR Health Protection Research Unit (HPRU) in HCAIs and AMR at Imperial College London, and Imperial College Healthcare NHS Trust, Infection Prevention and Control, London, United Kingdom
| | - S. Yezli
- Global Centre for Mass Gatherings Medicine, WHO Collaborating Centre for Mass Gatherings Medicine, Ministry of Health-Public Health Directorate, Riyadh, Kingdom of Saudi Arabia
| | - F. Barbut
- National Reference Laboratory for C. difficile, Infection Control Unit, Hôpital Saint Antoine, Paris, France,INSERM S-1139, Faculté de Pharmacie de Paris, Université de Paris, Paris, France
| | - T.M. Perl
- Infectious Diseases and Geographic Medicine, UT Southwestern Medical Center, Dallas, TX, United States
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22
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Cabral J, Ag R. Blue Light Disinfection in Hospital Infection Control: Advantages, Drawbacks, and Pitfalls. Antibiotics (Basel) 2019; 8:antibiotics8020058. [PMID: 31067733 PMCID: PMC6627448 DOI: 10.3390/antibiotics8020058] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/27/2019] [Accepted: 05/02/2019] [Indexed: 01/09/2023] Open
Abstract
Hospital acquired infections (HAIs) are a serious problem that potentially affects millions of patients whenever in contact with hospital settings. Worsening the panorama is the emergence of antimicrobial resistance by most microorganisms implicated in HAIs. Therefore, the improvement of the actual surveillance methods and the discovery of alternative approaches with novel modes of action is vital to overcome the threats created by the emergence of such resistances. Light therapy modalities represent a viable and effective alternative to the conventional antimicrobial treatment and can be preponderant in the control of HAIs, even against multidrug resistant organisms (MDROs). This review will initially focus on the actual state of HAIs and MDROs and which methods are currently available to fight them, which is followed by the exploration of antimicrobial photodynamic therapy (aPDT) and antimicrobial blue light therapy (aBLT) as alternative approaches to control microorganisms involved in HAIs. The advantages and drawbacks of BLT relatively to aPDT and conventional antimicrobial drugs as well as its potential applications to destroy microorganisms in the healthcare setting will also be discussed.
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Affiliation(s)
- João Cabral
- Division of Microbiology, Department of Pathology, Porto Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal.
| | - Rodrigues Ag
- Division of Microbiology, Department of Pathology, Porto Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal.
- CINTESIS-Center for Health Technology and Services Research, 4200-450 Porto, Portugal.
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23
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Wood JP, Adrion AC. Review of Decontamination Techniques for the Inactivation of Bacillus anthracis and Other Spore-Forming Bacteria Associated with Building or Outdoor Materials. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2019; 53:4045-4062. [PMID: 30901213 PMCID: PMC6547374 DOI: 10.1021/acs.est.8b05274] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Since the intentional release of Bacillus anthracis spores through the U.S. Postal Service in the fall of 2001, research and development related to decontamination for this biological agent have increased substantially. This review synthesizes the advances made relative to B. anthracis spore decontamination science and technology since approximately 2002, referencing the open scientific literature and publicly available, well-documented scientific reports. In the process of conducting this review, scientific knowledge gaps have also been identified. This review focuses primarily on techniques that are commercially available and that could potentially be used in the large-scale decontamination of buildings and other structures, as well as outdoor environments. Since 2002, the body of scientific data related to decontamination and microbial sterilization has grown substantially, especially in terms of quantifying decontamination efficacy as a function of several factors. Specifically, progress has been made in understanding how decontaminant chemistry, the materials the microorganisms are associated with, environmental factors, and microbiological methods quantitatively impact spore inactivation. While advancement has been made in the past 15 years to further the state of the science in the inactivation of bacterial spores in a decontamination scenario, further research is warranted to close the scientific gaps that remain.
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Affiliation(s)
- Joseph P. Wood
- United States Environmental Protection Agency, Offce of Research and Development, National Homeland Security Research Center, Research Triangle Park, North Carolina United States
- Corresponding Author: Phone: (919) 541-5029;
| | - Alden Charles Adrion
- United States Environmental Protection Agency, Offce of Research and Development, National Homeland Security Research Center, Research Triangle Park, North Carolina United States
- Oak Ridge Institute for Science and Education Postdoctoral Fellow, Oak Ridge, Tennessee 37830, United States
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24
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Zargar B, Sattar SA, Rubino JR, Ijaz MK. A quantitative method to assess the role of indoor air decontamination to simultaneously reduce contamination of environmental surfaces: testing with vegetative and spore-forming bacteria. Lett Appl Microbiol 2019; 68:206-211. [PMID: 30578733 DOI: 10.1111/lam.13109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 12/15/2018] [Accepted: 12/17/2018] [Indexed: 11/28/2022]
Abstract
Indoor air can spread pathogens, which can be removed/inactivated by a variety of means in healthcare and other settings. We quantitatively assessed if air decontamination could also simultaneously reduce environmental surface contamination in the same setting. Two types of vegetative bacteria (Staphylococcus aureus and Acinetobacter baumannii), and a bacterial spore-former (Geobacillus stearothermophilus) were tested as representative airborne bacteria. They were separately aerosolized with a Collison nebulizer into a 24-m3 aerobiology chamber and air samples collected with a programmable slit-to-agar sampler. Settling airborne particles were collected on culture plates placed at, and collected from, five different locations on the floor of the chamber with a custom-built remote plate-placement and -retriever system. Experimentally contaminated air in the chamber was decontaminated for 45 min with a device based on HEPA filtration and UV light. The plates were incubated and CFU counted. The device reduced the viability levels of all tested bacteria in the air by >3 log10 (>99·9%) in 45 min. Based on two separate tests, the average reductions in surface contamination for S. aureus, A. baumannii and G. stearothermophilus were respectively, 97, 87 and 97%. We thus showed that air decontamination could substantially and simultaneously reduce the levels of surface contamination in the same setting irrespective of the type of pathogen present. SIGNIFICANCE AND IMPACT OF THE STUDY: The innovative and generic test protocol described can quantitatively assess the reduction in environmental surface contamination from microbial decontamination of indoor air in the same setting. This added advantage from air decontamination has implications for infection prevention and control in healthcare and other settings without the need for additional expense or effort. Continuous operation of an air decontamination device, such as the one tested here, can lead to ongoing reductions in pathogens in air and on environmental surfaces.
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Affiliation(s)
- B Zargar
- CREM Co Labs, Units 1-2, 3403 American Drive, Mississauga, ON, Canada
| | - S A Sattar
- CREM Co Labs, Units 1-2, 3403 American Drive, Mississauga, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - M K Ijaz
- RB, Montvale, NJ, USA.,Department of Biology, Medgar Evers College of the City University of New York (CUNY), Brooklyn, NY, USA
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25
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McNeil JC, Campbell JR, Crews JD. The Role of the Environment and Colonization in Healthcare-Associated Infections. HEALTHCARE-ASSOCIATED INFECTIONS IN CHILDREN 2019. [PMCID: PMC7120697 DOI: 10.1007/978-3-319-98122-2_2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Healthcare-associated infections (HAIs) can be caused by endogenous host microbial flora or by exogenous microbes, including those found in the hospital environment. Efforts to decrease endogenous pathogens via decolonization and skin antisepsis may decrease the risk of infection in some settings. Controlling the spread of potential pathogens from the environment requires meticulous attention to cleaning and disinfection practices. In addition to selection of the appropriate cleaning agent, use of tools that assess the adequacy of cleaning and addition of no-touch cleaning technology may decrease environmental contamination. Hand hygiene is also a critical component of preventing transmission of pathogens from the environment to patients via healthcare worker hands.
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Affiliation(s)
- J. Chase McNeil
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX USA
| | - Judith R. Campbell
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX USA
| | - Jonathan D. Crews
- Department of Pediatrics, Baylor College of Medicine and The Children’s Hospital of San Antonio, San Antonio, TX USA
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26
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de Kraker MEA, Harbarth S, Dancer SJ. Shining a light on ultraviolet-C disinfection: No golden promises for infection prevention. Am J Infect Control 2018; 46:1422-1423. [PMID: 30293742 DOI: 10.1016/j.ajic.2018.07.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 07/13/2018] [Indexed: 10/28/2022]
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27
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Caselli E. Hygiene: microbial strategies to reduce pathogens and drug resistance in clinical settings. Microb Biotechnol 2017; 10:1079-1083. [PMID: 28677216 PMCID: PMC5609343 DOI: 10.1111/1751-7915.12755] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 06/02/2017] [Indexed: 12/14/2022] Open
Abstract
Healthcare‐associated infections (HAIs) are a global concern, affecting all western hospitals, and profoundly impairing the clinical outcome of up to 15% of all hospitalized patients. Persistent microbial contamination of hospital surfaces has been suggested to contribute to HAIs onset, representing a reservoir for hospital pathogens. On the other hand, conventional chemicals‐based sanitation do not prevent recontamination and can select drug‐resistant strains, resulting in over 50% of surfaces persistently contaminated. There is therefore an urgent need for alternative sustainable and effective ways to control pathogens contamination and transmission. Toward this goal, we recently reported that a probiotic‐based sanitation can stably decrease surface pathogens up to 90% more than conventional disinfectants, without selecting resistant species. This paper summarizes some of our most significant results.
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Affiliation(s)
- Elisabetta Caselli
- CIAS, Section of Microbiology, Department of Medical Sciences, University of Ferrara, via L. Borsari 46, 44121, Ferrara, Italy
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28
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Wu Y, Wu J, Zhang Z, Cheng C. DNA decontamination methods for internal quality management in clinical PCR laboratories. J Clin Lab Anal 2017; 32. [PMID: 28665527 DOI: 10.1002/jcla.22290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 06/03/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The polymerase chain reaction (PCR) technique, one of the most commonly applied methods in diagnostic and molecular biology, has a frustrating downside: the occurrence of false-positive signals due to contamination. In previous research, various DNA decontamination methods have been developed to overcome this limitation. Unfortunately, the use of random or poorly focused sampling methods for monitoring air and/or object surfaces leads to the incomplete elimination during decontamination procedures. We herein attempted to develop a novel DNA decontamination method (environmental surveillance, including surface and air sampling) and quality management program for clinical molecular diagnostic laboratories (or clinical PCR laboratories). METHODS Here, we performed a step-by-step evaluation of current DNA decontamination methods and developed an effective procedure for assessing the presence of decontaminating DNA via PCR analysis. Performing targeted environmental surveillance by sampling, which reached optimal performance over 2 weeks, and the decontamination process had been verified as reliable. Additionally, the process was validated to not affect PCR amplification efficiency based on a comparative study. RESULTS In this study, effective guidelines for DNA decontamination were developed. The method employed ensured that surface DNA contamination could be effectively identified and eliminated. Furthermore, our study highlighted the importance of overall quality assurance and good clinical laboratory practices for preventing contamination, which are key factors for compliance with regulatory or accreditation requirements. CONCLUSIONS Taken together, we provided the evidence that the presented scheme ranged from troubleshooting to the elimination of surface contamination, could serve as critical foundation for developing regular environmental surveillance guidelines for PCR laboratories.
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Affiliation(s)
- Yingping Wu
- Department of Clinical Laboratory, The Fourth Affiliated Hospital Zhejiang University School of Medicine, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jianyong Wu
- Department of Clinical Laboratory, The Fourth Affiliated Hospital Zhejiang University School of Medicine, College of Medicine, Zhejiang University, Hangzhou, China
| | - Zhihui Zhang
- Department of Clinical Laboratory, The Fourth Affiliated Hospital Zhejiang University School of Medicine, College of Medicine, Zhejiang University, Hangzhou, China
| | - Chen Cheng
- Department of Clinical Laboratory, The Fourth Affiliated Hospital Zhejiang University School of Medicine, College of Medicine, Zhejiang University, Hangzhou, China
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Cobrado L, Silva-Dias A, Azevedo MM, Rodrigues AG. High-touch surfaces: microbial neighbours at hand. Eur J Clin Microbiol Infect Dis 2017. [PMID: 28647859 PMCID: PMC7087772 DOI: 10.1007/s10096-017-3042-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Despite considerable efforts, healthcare-associated infections (HAIs) continue to be globally responsible for serious morbidity, increased costs and prolonged length of stay. Among potentially preventable sources of microbial pathogens causing HAIs, patient care items and environmental surfaces frequently touched play an important role in the chain of transmission. Microorganisms contaminating such high-touch surfaces include Gram-positive and Gram-negative bacteria, viruses, yeasts and parasites, with improved cleaning and disinfection effectively decreasing the rate of HAIs. Manual and automated surface cleaning strategies used in the control of infectious outbreaks are discussed and current trends concerning the prevention of contamination by the use of antimicrobial surfaces are taken into consideration in this manuscript.
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Affiliation(s)
- L Cobrado
- Division of Microbiology, Department of Pathology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200, Porto, Portugal. .,Burn Unit, Department of Plastic and Reconstructive Surgery, Centro Hospitalar São João, Porto, Portugal. .,CINTESIS, Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal.
| | - A Silva-Dias
- Division of Microbiology, Department of Pathology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200, Porto, Portugal.,CINTESIS, Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
| | - M M Azevedo
- Division of Microbiology, Department of Pathology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200, Porto, Portugal.,CINTESIS, Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
| | - A G Rodrigues
- Division of Microbiology, Department of Pathology, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200, Porto, Portugal.,Burn Unit, Department of Plastic and Reconstructive Surgery, Centro Hospitalar São João, Porto, Portugal.,CINTESIS, Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
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Effects of mild ozonisation on gene expression and nuclear domains organization in vitro. Toxicol In Vitro 2017; 44:100-110. [PMID: 28652203 DOI: 10.1016/j.tiv.2017.06.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 06/15/2017] [Accepted: 06/22/2017] [Indexed: 12/14/2022]
Abstract
In the last two decades, the use of ozone (O3) as a complementary medical approach has progressively been increasing; however, its application is still limited due to the numerous doubts about its possible toxicity, despite the low concentrations used in therapy. For an appropriate and safe clinical application of a potentially toxic agent such as O3, it is crucial to elucidate the cellular response to its administration. Molecular analyses and transmission electron microscopy were here combined to investigate in vitro the effects of O3 administration on transcriptional activity and nuclear domains organization of cultured SH-SY5Y neuronal cells; low O3 concentrations were used as those currently administered in clinical practice. Mild ozonisation did not affect cell proliferation or death, while molecular analyses showed an O3-induced modulation of some genes involved in the cell response to stress (HMOX1, ERCC4, CDKN1A) and in the transcription machinery (CTDSP1). Ultrastructural cytochemistry after experiments of bromouridine incorporation consistently demonstrated an increased transcriptional rate at both the nucleoplasmic (mRNA) and the nucleolar (rRNA) level. No ultrastructural alteration of nuclear domains was observed. Our molecular, ultrastructural and cytochemical data demonstrate that a mild toxic stimulus such as mild ozonisation stimulate cell protective pathways and nuclear transcription, without altering cell viability. This could possibly account for the positive effects observed in ozone-treated patients.
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Jelden KC, Gibbs SG, Smith PW, Hewlett AL, Iwen PC, Schmid KK, Lowe JJ. Ultraviolet (UV)-reflective paint with ultraviolet germicidal irradiation (UVGI) improves decontamination of nosocomial bacteria on hospital room surfaces. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2017; 14:456-460. [PMID: 28278065 DOI: 10.1080/15459624.2017.1296231] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
An ultraviolet germicidal irradiation (UVGI) generator (the TORCH, ClorDiSys Solutions, Inc.) was used to compare the disinfection of surface coupons (plastic from a bedrail, stainless steel, and chrome-plated light switch cover) in a hospital room with walls coated with ultraviolet (UV)-reflective paint (Lumacept) or standard paint. Each surface coupon was inoculated with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus faecalis (VRE), placed at 6 different sites within a hospital room coated with UV-reflective paint or standard paint, and treated by 10 min UVC exposure (UVC dose of 0-688 mJ/cm2 between sites with standard paint and 0-553 mJ/cm2 with UV-reflective paint) in 8 total trials. Aggregated MRSA concentrations on plastic bedrail surface coupons were reduced on average by 3.0 log10 (1.8 log10 Geometric Standard Deviation [GSD]) with standard paint and 4.3 log10 (1.3 log10 GSD) with UV-reflective paint (p = 0.0005) with no significant reduction differences between paints on stainless steel and chrome. Average VRE concentrations were reduced by ≥4.9 log10 (<1.2 log10 GSD) on all surface types with UV-reflective paint and ≤4.1 log10 (<1.7 log10 GSD) with standard paint (p < 0.05). At 5 aggregated sites directly exposed to UVC light, MRSA concentrations on average were reduced by 5.2 log10 (1.4 log10 GSD) with standard paint and 5.1 log10 (1.2 log10 GSD) with UV-reflective paint (p = 0.017) and VRE by 4.4 log10 (1.4 log10 GSD) with standard paint and 5.3 log10 (1.1 log10 GSD) with UV-reflective paint (p < 0.0001). At one indirectly exposed site on the opposite side of the hospital bed from the UVGI generator, MRSA concentrations on average were reduced by 1.3 log10 (1.7 log10 GSD) with standard paint and 4.7 log10 (1.3 log10 GSD) with UV-reflective paint (p < 0.0001) and VRE by 1.2 log10 (1.5 log10 GSD) with standard paint and 4.6 log10 (1.1 log10 GSD) with UV-reflective paint (p < 0.0001). Coating hospital room walls with UV-reflective paint enhanced UVGI disinfection of nosocomial bacteria on various surfaces compared to standard paint, particularly at a surface placement site indirectly exposed to UVC light.
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Affiliation(s)
- Katelyn C Jelden
- a Department of Environmental , Agricultural & Occupational Health, University of Nebraska Medical Center , Omaha , Nebraska
| | - Shawn G Gibbs
- b Department of Environmental Health , Indiana University School of Public Health , Bloomington , Indiana
| | - Philip W Smith
- c Department of Internal Medicine, Division of Infectious Diseases , University of Nebraska Medical Center , Omaha , Nebraska
| | - Angela L Hewlett
- c Department of Internal Medicine, Division of Infectious Diseases , University of Nebraska Medical Center , Omaha , Nebraska
| | - Peter C Iwen
- d Department of Pathology and Microbiology, College of Medicine , University of Nebraska Medical Center , Omaha , Nebraska
- e Nebraska Public Health Laboratory , Omaha , Nebraska
| | - Kendra K Schmid
- f Department of Biostatistics ; University of Nebraska Medical Center , Omaha , Nebraska
| | - John J Lowe
- a Department of Environmental , Agricultural & Occupational Health, University of Nebraska Medical Center , Omaha , Nebraska
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Scheepers PTJ, Van Wel L, Beckmann G, Anzion RBM. Chemical Characterization of the Indoor Air Quality of a University Hospital: Penetration of Outdoor Air Pollutants. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14050497. [PMID: 28481324 PMCID: PMC5451948 DOI: 10.3390/ijerph14050497] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 04/27/2017] [Accepted: 05/04/2017] [Indexed: 11/24/2022]
Abstract
For healthcare centers, local outdoor sources of air pollution represent a potential threat to indoor air quality (IAQ). The aim of this study was to study the impact of local outdoor sources of air pollution on the IAQ of a university hospital. IAQ was characterized at thirteen indoor and two outdoor locations and source samples were collected from a helicopter and an emergency power supply. Volatile organic compounds (VOC), acrolein, formaldehyde, nitrogen dioxide (NO2), respirable particulate matter (PM-4.0 and PM-2.5) and their respective benz(a)pyrene contents were determined over a period of two weeks. Time-weighted average concentrations of NO2 (4.9–17.4 μg/m3) and formaldehyde (2.5–6.4 μg/m3) were similar on all indoor and outdoor locations. The median concentration VOC in indoor air was 119 μg/m3 (range: 33.1–2450 μg/m3) and was fivefold higher in laboratories (316 μg/m3) compared to offices (57.0 μg/m3). PM-4.0 and benzo(a)pyrene concentration were lower in buildings serviced by a >99.95% efficiency particle filter, compared to buildings using a standard 80–90% efficiency filter (p < 0.01). No indications were found that support a significant contribution of known local sources such as fuels or combustion engines to any of the IAQ parameters measured in this study. Chemical IAQ was primarily driven by known indoor sources and activities.
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Affiliation(s)
- Paul T J Scheepers
- Research Lab Molecular Epidemiology, Radboud Institute for Health Sciences, Radboudumc, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
| | - Luuk Van Wel
- Research Lab Molecular Epidemiology, Radboud Institute for Health Sciences, Radboudumc, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
- Institute for Risk Assessment Sciences (IRAS), Utrecht University, Yalelaan 2, 3584 CM Utrecht, The Netherlands.
| | - Gwendolyn Beckmann
- Research Lab Molecular Epidemiology, Radboud Institute for Health Sciences, Radboudumc, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
| | - Rob B M Anzion
- Research Lab Molecular Epidemiology, Radboud Institute for Health Sciences, Radboudumc, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
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Pennathur PR, Herwaldt LA. Role of Human Factors Engineering in Infection Prevention: Gaps and Opportunities. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2017; 9:230-249. [PMID: 32226329 PMCID: PMC7100866 DOI: 10.1007/s40506-017-0123-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Human factors engineering (HFE), with its focus on studying how humans interact with systems, including their physical and organizational environment, the tools and technologies they use, and the tasks they perform, provides principles, tools, and techniques for systematically identifying important factors, for analyzing and evaluating how these factors interact to increase or decrease the risk of Healthcare-associated infections (HAI), and for identifying and implementing effective preventive measures. We reviewed the literature on HFE and infection prevention and control and identified major themes to document how researchers and infection prevention staff have used HFE methods to prevent HAIs and to identify gaps in our knowledge about the role of HFE in HAI prevention and control. Our literature review found that most studies in the healthcare domain explicitly applying (HFE) principles and methods addressed patient safety issues not infection prevention and control issues. In addition, most investigators who applied human factors principles and methods to infection prevention issues assessed only one human factors element such as training, technology evaluations, or physical environment design. The most significant gap pertains to the limited use and application of formal HFE tools and methods. Every infection prevention study need not assess all components in a system, but investigators must assess the interaction of critical system components if they want to address latent and deep-rooted human factors problems.
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Affiliation(s)
- Priyadarshini R. Pennathur
- Department of Mechanical and Industrial Engineering, 2132 Seamans Center for the Engineering Arts and Sciences, University of Iowa, Iowa City, IA USA
| | - Loreen A. Herwaldt
- Department of Medicine, University of Iowa School of Medicine, Iowa City, IA USA
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Affiliation(s)
- Didier Ngabo
- Public Health England, Porton, Salisbury, Wiltshire, UK
| | | | - Allan Bennett
- Public Health England, Porton, Salisbury, Wiltshire, UK
| | - Simon Parks
- Public Health England, Porton, Salisbury, Wiltshire, UK
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Abstract
Clostridium difficile infections (CDIs) have emerged as one of the principal threats to the health of hospitalized and immunocompromised patients. The importance of C difficile colonization is increasingly recognized not only as a source for false-positive clinical testing but also as a source of new infections within hospitals and other health care environments. In the last five years, several new treatment strategies that capitalize on the increasing understanding of the altered microbiome and host defenses in patients with CDI have completed clinical trials, including fecal microbiota transplantation. This article highlights the changing epidemiology, laboratory diagnostics, pathogenesis, and treatment of CDI.
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Evolutionary clade affects resistance of Clostridium difficile spores to Cold Atmospheric Plasma. Sci Rep 2017; 7:41814. [PMID: 28155914 PMCID: PMC5290531 DOI: 10.1038/srep41814] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 12/30/2016] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile is a spore forming bacterium and the leading cause of colitis and antibiotic associated diarrhoea in the developed world. Spores produced by C. difficile are robust and can remain viable for months, leading to prolonged healthcare-associated outbreaks with high mortality. Exposure of C. difficile spores to a novel, non-thermal atmospheric pressure gas plasma was assessed. Factors affecting sporicidal efficacy, including percentage of oxygen in the helium carrier gas admixture, and the effect on spores from different strains representing the five evolutionary C. difficile clades was investigated. Strains from different clades displayed varying resistance to cold plasma. Strain R20291, representing the globally epidemic ribotype 027 type, was the most resistant. However all tested strains displayed a ~3 log reduction in viable spore counts after plasma treatment for 5 minutes. Inactivation of a ribotype 078 strain, the most prevalent clinical type seen in Northern Ireland, was further assessed with respect to surface decontamination, pH, and hydrogen peroxide concentration. Environmental factors affected plasma activity, with dry spores without the presence of organic matter being most susceptible. This study demonstrates that cold atmospheric plasma can effectively inactivate C. difficile spores, and highlights factors that can affect sporicidal activity.
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Malik DJ, Shaw CM, Shama G, Clokie MRJ, Rielly CD. An Investigation into the Inactivation Kinetics of Hydrogen Peroxide Vapor Against Clostridium difficile Endospores. CHEM ENG COMMUN 2016. [DOI: 10.1080/00986445.2016.1223058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- D. J. Malik
- Department of Chemical Engineering, Loughborough University, Loughborough, Leicester, LE11 3TU, UK
| | - C. M. Shaw
- Department of Chemical Engineering, Loughborough University, Loughborough, Leicester, LE11 3TU, UK
| | - G. Shama
- Department of Chemical Engineering, Loughborough University, Loughborough, Leicester, LE11 3TU, UK
| | - M. R. J. Clokie
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, LE1 9HN, UK
| | - C. D. Rielly
- Department of Chemical Engineering, Loughborough University, Loughborough, Leicester, LE11 3TU, UK
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Michael K, No D, Dankoff J, Lee K, Lara-Crawford E, Roberts MC. Clostridium difficile environmental contamination within a clinical laundry facility in the USA. FEMS Microbiol Lett 2016; 363:fnw236. [PMID: 27744367 DOI: 10.1093/femsle/fnw236] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/24/2016] [Accepted: 10/11/2016] [Indexed: 12/15/2022] Open
Abstract
Clostridium difficile is both a hospital and community-acquired pathogen. The current study determined if C. difficile could be cultured from clinical laundry facility surfaces. A total of 240 surface samples were collected from dirty areas (n = 120), which handle soiled clinical linens, and from clean areas (n = 120), which process and fold the clean linens, within the University of Washington Consolidated Laundry facility in 2015. Sampling was done four times over the course of 1 year. The dirty area was significantly more contaminated than the clean area (21% vs 2%, P < 0.001). Clostridium difficile isolates were genetically characterized using multilocus sequence typing and PCR for the detection of genes encoding toxin A and toxin B. The MLST types 1, 2, 3, 15, 26, 34, 35, 39, 42, 43, 44, 53, 63 and 284 were identified and have previously been found in both clinical and community settings. Toxin positive isolates were identified in both the dirty (n = 16/25) and clean areas (n = 2/2). Seasonal variation was observed with 40% of the 27 isolates cultured in April 2015. The study suggests that soiled clinical linens may be a source of C. difficile surface contamination.
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Application of ozone gas for decontamination of nucleoside anticancer drugs. J Pharm Health Care Sci 2016; 2:26. [PMID: 27729988 PMCID: PMC5048470 DOI: 10.1186/s40780-016-0058-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/17/2016] [Indexed: 11/22/2022] Open
Abstract
Background Exposure to anticancer drugs is hazardous and may lead to chromosomal abnormalities and spontaneous abortion in healthcare workers. Guidelines recommend surface decontamination and cleaning in order to minimize the occupational exposure to anticancer drugs, although no single process has been found to deactivate all currently available hazardous drugs. Ozone gas is oxidative and a decontaminant for bacteria; its characteristic as a gas has advantages in that it does not need to be wiped off or neutralized after use. Methods The nucleoside anticancer drugs, cytarabine and fluorouracil, were exposed to ozone gas on plates under controlled humidity. The levels of exposed ozone were evaluated using the concentration-time (CT) value, which is the mathematical product of ozone concentration and exposure time. The effects of exposure to ozone on levels of the anticancer drugs were determined by high-performance liquid chromatography (HPLC). Results The levels of cytarabine decreased with increasing CT value and were not detected beyond 40,000 CT. The decomposition levels of the anticancer drug by ozone were CT-dependent irrespective of the maximum concentration of ozone. Higher humidity in the range from 70 to 90 % accelerated the decomposition of cytarabine and fluorouracil, and neither of the drugs were detected at 90 % humidity after exposure to ozone gas. Conclusions Ozone gas decomposed these nucleoside anticancer drugs. This is the first report of the applicability of ozone gas as a decontaminator for anticancer drugs.
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Weber DJ, Rutala WA, Anderson DJ, Chen LF, Sickbert-Bennett EE, Boyce JM. Effectiveness of ultraviolet devices and hydrogen peroxide systems for terminal room decontamination: Focus on clinical trials. Am J Infect Control 2016; 44:e77-84. [PMID: 27131140 PMCID: PMC7132689 DOI: 10.1016/j.ajic.2015.11.015] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 11/10/2015] [Indexed: 02/08/2023]
Abstract
Over the last decade, substantial scientific evidence has accumulated that indicates contamination of environmental surfaces in hospital rooms plays an important role in the transmission of key health care-associated pathogens (eg, methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, Clostridium difficile, Acinetobacter spp). For example, a patient admitted to a room previously occupied by a patient colonized or infected with one of these pathogens has a higher risk for acquiring one of these pathogens than a patient admitted to a room whose previous occupant was not colonized or infected. This risk is not surprising because multiple studies have demonstrated that surfaces in hospital rooms are poorly cleaned during terminal cleaning. To reduce surface contamination after terminal cleaning, no touch methods of room disinfection have been developed. This article will review the no touch methods, ultraviolet light devices, and hydrogen peroxide systems, with a focus on clinical trials which have used patient colonization or infection as an outcome. Multiple studies have demonstrated that ultraviolet light devices and hydrogen peroxide systems have been shown to inactivate microbes experimentally plated on carrier materials and placed in hospital rooms and to decontaminate surfaces in hospital rooms naturally contaminated with multidrug-resistant pathogens. A growing number of clinical studies have demonstrated that ultraviolet devices and hydrogen peroxide systems when used for terminal disinfection can reduce colonization or health care-associated infections in patients admitted to these hospital rooms.
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Affiliation(s)
- David J Weber
- Department of Hospital Epidemiology, University of North Carolina Health Care, Chapel Hill, NC; Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC.
| | - William A Rutala
- Department of Hospital Epidemiology, University of North Carolina Health Care, Chapel Hill, NC; Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Luke F Chen
- Division of Infectious Diseases, Duke University Medical School, Durham, NC
| | - Emily E Sickbert-Bennett
- Department of Hospital Epidemiology, University of North Carolina Health Care, Chapel Hill, NC; Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC
| | - John M Boyce
- Division of Infectious Diseases, Yale School of Medicine, New Haven, CT
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Boyce JM. Modern technologies for improving cleaning and disinfection of environmental surfaces in hospitals. Antimicrob Resist Infect Control 2016; 5:10. [PMID: 27069623 PMCID: PMC4827199 DOI: 10.1186/s13756-016-0111-x] [Citation(s) in RCA: 201] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 03/23/2016] [Indexed: 12/21/2022] Open
Abstract
Experts agree that careful cleaning and disinfection of environmental surfaces are essential elements of effective infection prevention programs. However, traditional manual cleaning and disinfection practices in hospitals are often suboptimal. This is often due in part to a variety of personnel issues that many Environmental Services departments encounter. Failure to follow manufacturer’s recommendations for disinfectant use and lack of antimicrobial activity of some disinfectants against healthcare-associated pathogens may also affect the efficacy of disinfection practices. Improved hydrogen peroxide-based liquid surface disinfectants and a combination product containing peracetic acid and hydrogen peroxide are effective alternatives to disinfectants currently in widespread use, and electrolyzed water (hypochlorous acid) and cold atmospheric pressure plasma show potential for use in hospitals. Creating “self-disinfecting” surfaces by coating medical equipment with metals such as copper or silver, or applying liquid compounds that have persistent antimicrobial activity surfaces are additional strategies that require further investigation. Newer “no-touch” (automated) decontamination technologies include aerosol and vaporized hydrogen peroxide, mobile devices that emit continuous ultraviolet (UV-C) light, a pulsed-xenon UV light system, and use of high-intensity narrow-spectrum (405 nm) light. These “no-touch” technologies have been shown to reduce bacterial contamination of surfaces. A micro-condensation hydrogen peroxide system has been associated in multiple studies with reductions in healthcare-associated colonization or infection, while there is more limited evidence of infection reduction by the pulsed-xenon system. A recently completed prospective, randomized controlled trial of continuous UV-C light should help determine the extent to which this technology can reduce healthcare-associated colonization and infections. In conclusion, continued efforts to improve traditional manual disinfection of surfaces are needed. In addition, Environmental Services departments should consider the use of newer disinfectants and no-touch decontamination technologies to improve disinfection of surfaces in healthcare.
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Affiliation(s)
- John M Boyce
- J.M. Boyce Consulting, LLC, 62 Sonoma Lane, Middletown, CT 06457 USA
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43
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Morphological and chemical changes of aerosolized E. coli treated with a dielectric barrier discharge. Biointerphases 2016; 11:011009. [PMID: 26872580 DOI: 10.1116/1.4941367] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This study presents the morphological and chemical modification of the cell structure of aerosolized Escherichia coli treated with a dielectric barrier discharge (DBD). Exposure to DBD results in severe oxidation of the bacteria, leading to the formation of hydroxyl groups and carbonyl groups and a significant reduction in amine functionalities and phosphate groups. Near edge x-ray absorption fine structure (NEXAFS) measurements confirm the presence of additional oxide bonds upon DBD treatment, suggesting oxidation of the outer layer of the cell wall. Electron microscopy images show that the bacteria undergo physical distortion to varying degrees, resulting in deformation of the bacterial structure. The electromagnetic field around the DBD coil causes severe damage to the cell structure, possibly resulting in leakage of vital cellular materials. The oxidation and chemical modification of the bacterial components are evident from the Fourier transform infrared spectroscopy and NEXAFS results. The bacterial reculture experiments confirm inactivation of airborne E. coli upon treating with DBD.
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Caselli E, D’Accolti M, Vandini A, Lanzoni L, Camerada MT, Coccagna M, Branchini A, Antonioli P, Balboni PG, Di Luca D, Mazzacane S. Impact of a Probiotic-Based Cleaning Intervention on the Microbiota Ecosystem of the Hospital Surfaces: Focus on the Resistome Remodulation. PLoS One 2016; 11:e0148857. [PMID: 26886448 PMCID: PMC4757022 DOI: 10.1371/journal.pone.0148857] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 01/25/2016] [Indexed: 12/15/2022] Open
Abstract
Background Contamination of hospital surfaces by clinically-relevant pathogens represents a major concern in healthcare facilities, due to its impact on transmission of healthcare-associated infections (HAIs) and to the growing drug resistance of HAI-associated pathogens. Routinely used chemical disinfectants show limitations in controlling pathogen contamination, due to their inefficacy in preventing recontamination and selection of resistant strains. Recently we observed that an innovative approach, based on a cleanser added with spores of non-pathogenic probiotic Bacilli, was effective in stably counteracting the growth of several pathogens contaminating hospital surfaces. Methods Here, we wanted to study the impact of the Bacillus-based cleanser on the drug-resistance features of the healthcare pathogens population. In parallel, the ability of cleanser-derived Bacilli to infect hospitalized patients was also investigated. Results Collected data showed that Bacilli spores can germinate on dry inanimate surfaces, generating the bacterial vegetative forms which counteract the growth of pathogens and effectively substitute for them on treated surfaces. Strikingly, this procedure did not select resistant species, but conversely induced an evident decrease of antibiotic resistance genes in the contaminating microbial population. Also importantly, all the six HAI-positive patients hosted in the treated areas resulted negative for probiotic Bacilli, thus adding evidences to their safety-to-use. Conclusions These results indicate that this probiotic-based procedure is active not only in controlling surface microbial contamination but also in lowering drug-resistant species, suggesting that it may have relevant clinical and therapeutical implications for the management of HAIs.
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Affiliation(s)
- Elisabetta Caselli
- Section of Microbiology and Medical Genetics, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
- CIAS Interdepartmental Research Center for pollution control in high sterility rooms, University of Ferrara, Ferrara, Italy
- * E-mail:
| | - Maria D’Accolti
- Section of Microbiology and Medical Genetics, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
- CIAS Interdepartmental Research Center for pollution control in high sterility rooms, University of Ferrara, Ferrara, Italy
| | - Alberta Vandini
- CIAS Interdepartmental Research Center for pollution control in high sterility rooms, University of Ferrara, Ferrara, Italy
- Architecture and Urban Planning (XXX cycle), Department of Architecture, University of Ferrara, Ferrara, Italy
| | - Luca Lanzoni
- CIAS Interdepartmental Research Center for pollution control in high sterility rooms, University of Ferrara, Ferrara, Italy
| | - Maria Teresa Camerada
- CIAS Interdepartmental Research Center for pollution control in high sterility rooms, University of Ferrara, Ferrara, Italy
- Architecture and Urban Planning (XXX cycle), Department of Architecture, University of Ferrara, Ferrara, Italy
| | - Maddalena Coccagna
- CIAS Interdepartmental Research Center for pollution control in high sterility rooms, University of Ferrara, Ferrara, Italy
| | - Alessio Branchini
- Section of Biochemistry and Molecular Biology, Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
| | - Paola Antonioli
- Department of Infection Prevention Control and Risk Management, S. Anna University Hospital, Ferrara, Italy
| | - Pier Giorgio Balboni
- CIAS Interdepartmental Research Center for pollution control in high sterility rooms, University of Ferrara, Ferrara, Italy
| | - Dario Di Luca
- Section of Microbiology and Medical Genetics, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
- CIAS Interdepartmental Research Center for pollution control in high sterility rooms, University of Ferrara, Ferrara, Italy
| | - Sante Mazzacane
- CIAS Interdepartmental Research Center for pollution control in high sterility rooms, University of Ferrara, Ferrara, Italy
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Wood JP, Wendling M, Richter W, Lastivka A, Mickelsen L. Evaluation of the Efficacy of Methyl Bromide in the Decontamination of Building and Interior Materials Contaminated with Bacillus anthracis Spores. Appl Environ Microbiol 2016; 82:2003-2011. [PMID: 26801580 PMCID: PMC4807506 DOI: 10.1128/aem.03445-15] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 01/08/2016] [Indexed: 12/03/2022] Open
Abstract
The primary goal of this study was to determine the conditions required for the effective inactivation of Bacillus anthracis spores on materials by using methyl bromide (MeBr) gas. Another objective was to obtain comparative decontamination efficacy data with three avirulent microorganisms to assess their potential for use as surrogates for B. anthracis Ames. Decontamination tests were conducted with spores of B. anthracis Ames and Geobacillus stearothermophilus, B. anthracis NNR1Δ1, and B. anthracis Sterne inoculated onto six different materials. Experimental variables included temperature, relative humidity (RH), MeBr concentration, and contact time. MeBr was found to be an effective decontaminant under a number of conditions. This study highlights the important role that RH has when fumigation is performed with MeBr. There were no tests in which a ≥6-log10 reduction (LR) of B. anthracis Ames was achieved on all materials when fumigation was done at 45% RH. At 75% RH, an increase in the temperature, the MeBr concentration, or contact time generally improved the efficacy of fumigation with MeBr. This study provides new information for the effective use of MeBr at temperatures and RH levels lower than those that have been recommended previously. The study also provides data to assist with the selection of an avirulent surrogate for B. anthracis Ames spores when additional tests with MeBr are conducted.
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Affiliation(s)
- Joseph P Wood
- U.S. Environmental Protection Agency, Office of Research and Development, National Homeland Security Research Center, Research Triangle Park, North Carolina, USA
| | | | | | | | - Leroy Mickelsen
- U.S. Environmental Protection Agency, Office of Emergency Management, Research Triangle Park, North Carolina, USA
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Touchless Technologies for Decontamination in the Hospital: a Review of Hydrogen Peroxide and UV Devices. Curr Infect Dis Rep 2015; 17:498. [DOI: 10.1007/s11908-015-0498-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Mbamalu O, Uebel R, Meki B. Control of airborne microbes in a poultry setting using Dioxy MP 14. BRAZILIAN JOURNAL OF POULTRY SCIENCE 2015. [DOI: 10.1590/1516-635x170177-86] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
| | - R Uebel
- University of the Western Cape
| | - B Meki
- University of the Western Cape, South Africa
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Decontamination of the Hospital Environment: New Technologies for Infection Control. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2015. [DOI: 10.1007/s40506-015-0037-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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49
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New and Emerging Bacterial Food Pathogens. Food Saf (Tokyo) 2015. [DOI: 10.1016/b978-0-12-800245-2.00014-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] Open
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50
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Dancer SJ. Controlling hospital-acquired infection: focus on the role of the environment and new technologies for decontamination. Clin Microbiol Rev 2014; 27:665-90. [PMID: 25278571 PMCID: PMC4187643 DOI: 10.1128/cmr.00020-14] [Citation(s) in RCA: 375] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
There is increasing interest in the role of cleaning for managing hospital-acquired infections (HAI). Pathogens such as vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA), multiresistant Gram-negative bacilli, norovirus, and Clostridium difficile persist in the health care environment for days. Both detergent- and disinfectant-based cleaning can help control these pathogens, although difficulties with measuring cleanliness have compromised the quality of published evidence. Traditional cleaning methods are notoriously inefficient for decontamination, and new approaches have been proposed, including disinfectants, steam, automated dispersal systems, and antimicrobial surfaces. These methods are difficult to evaluate for cost-effectiveness because environmental data are not usually modeled against patient outcome. Recent studies have reported the value of physically removing soil using detergent, compared with more expensive (and toxic) disinfectants. Simple cleaning methods should be evaluated against nonmanual disinfection using standardized sampling and surveillance. Given worldwide concern over escalating antimicrobial resistance, it is clear that more studies on health care decontamination are required. Cleaning schedules should be adapted to reflect clinical risk, location, type of site, and hand touch frequency and should be evaluated for cost versus benefit for both routine and outbreak situations. Forthcoming evidence on the role of antimicrobial surfaces could supplement infection prevention strategies for health care environments, including those targeting multidrug-resistant pathogens.
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Affiliation(s)
- Stephanie J Dancer
- Department of Microbiology, Hairmyres Hospital, East Kilbride, Lanarkshire, Scotland, United Kingdom
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