Reduction in acquisition of vancomycin-resistant enterococcus after enforcement of routine environmental cleaning measures

Hygiene requirements for cleaning and disinfection of surfaces: recommendation of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute

This recommendation of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) addresses not only hospitals, but also outpatient health care facilities and compiles current evidence. The following criteria are the basis for the indications for cleaning and disinfection: Infectious bioburden and tenacity of potential pathogens on surfaces and their transmission routes, influence of disinfecting surface cleaning on the rate of nosocomial infections, interruption of cross infections due to multidrug-resistant organisms, and outbreak control by disinfecting cleaning within bundles. The criteria for the selection of disinfectants are determined by the requirements for effectiveness, the efficacy spectrum, the compatibility for humans and the environment, as well as the risk potential for the development of tolerance and resistance. Detailed instructions on the organization and implementation of cleaning and disinfection measures, including structural and equipment requirements, serve as the basis for their implementation. Since the agents for surface disinfection and disinfecting surface cleaning have been classified as biocides in Europe since 2013, the regulatory consequences are explained. As possible addition to surface disinfection, probiotic cleaning, is pointed out. In an informative appendix (only in German), the pathogen characteristics for their acquisition of surfaces, such as tenacity, infectious dose and biofilm formation, and the toxicological and ecotoxicological characteristics of microbicidal agents as the basis for their selection are explained, and methods for the evaluation of the resulting quality of cleaning or disinfecting surface cleaning are presented.

Beyond duodenoscope-transmitted infections: Analysis of surface bioburden and UV-C mitigation within a tertiary care endoscopy unit

BACKGROUND

An inpatient endoscopy unit is a care hub for patients from throughout the hospital and can be the site of health care-associated infections (HAIs). Shared surfaces and other nonmedical devices (keyboards) have been increasingly recognized as sites of pathogen transmission. Beyond standard cleaning of high-touch target areas, we queried whether the addition of automated devices delivering low-intensity doses of ultraviolet (UV)-C radiation could further reduce bioburden in an academic endoscopy unit.

METHODS

Bioburden on previously identified high-touch/communal surfaces was measured before and after the installation of automated, low-intensity UV-light emitting devices (UV Angel) that passively monitor and disinfect targeted surfaces with Ultraviolet-C light (UV-C) light.

RESULTS

High-touch sites (keyboards) had a baseline bacterial contamination of >80%, whereas individual procedure rooms and common areas had a >57% contamination rate. Following the implementation of automated UV-C light decontamination, bioburden was reduced on average by >91% at high-touch surfaces and within procedure rooms.

DISCUSSION/CONCLUSIONS

Nonsterile hubs of patient care could serve as sites of "silent" HAI transmission. We have identified high-touch surfaces within an endoscopy unit that have a high bioburden of bacterial contamination and demonstrated that the installation of passive, automated UV-C light disinfection devices can reduce bioburden significantly, possibly mitigating HAI transmission between patients.

Can the adenosine triphosphate (ATP) bioluminescence assay be used as an indicator for hospital cleaning? - A pilot study

Background

In hospital cleaning, there is currently no standard for uniform monitoring of surface cleaning, either in Germany or internationally. One possibility for monitoring is the use of so-called objective methods for checking cleaning performance (e.g. fluorescence or adenosine triphosphate (ATP) method).

Aim

The aim of the study was to monitor and evaluate the implementation of the adenosine triphosphate (ATP) bioluminescence assay as a cleaning indicator in everyday hospital cleaning, in order to verify its utility and effectiveness.

Methods

In three phases, five frequently touched surfaces were examined with the ATP bioluminescence assay at different time points. 846 measurements were performed on the dermatology ward of a university hospital (phase 1), 1,350 measurements were performed on five different wards of the university hospital (phase 2), and 1,044 measurements were performed on five wards of another large hospital (phase 3). For this purpose, one structurally old and one structurally new ward as well as an intensive care unit (ICU), an outpatient clinic and a radiology department were selected for phases 2 and 3.

Results

With the ATP bioluminescence method, we were able to demonstrate a reduction in values after cleaning: before cleaning mean of ATP, 907 relative light units (RLU) (95% confidence interval [CI] 777; 1,038); after cleaning mean=286 RLU (CI=233; 495) (phase 1) and by intervention (five hours after daily cleaning mean=360 RLU (CI=303; 428); five hours after daily cleaning and two additional cleanings mean=128 RLU (CI=107; 152) (phase 3). The ATP values increased five hours after cleaning in phases 1 and 2, and eight hours after cleaning in phase 3. The structurally old wards had the highest ATP content, the ICU and the radiology department, among others, the lowest. In all phases, door handles showed both a reduction after cleaning or intervention and a subsequent increase in ATP values. Chair armrests, examination tables and door handles had high ATP values overall.

Conclusion

The study shows ward differences both for cleaning effects and for the soiling characteristics of surfaces during the course of the day. In addition, it demonstrates the benefit of intermediate cleaning twice a day. It is noteworthy that structurally old stations and older inventory were more heavily soiled and, in some cases, more difficult to clean. The results show that the ATP bioluminescence method is suitable for detecting cleaning effects and can be used in everyday clinical practice for simple cleaning monitoring. Furthermore, it enables the detection of risk surfaces and easy-to-clean surfaces with significant re-soiling.

UVC Box: An Effective Way to Quickly Decontaminate Healthcare Facilities' Wheelchairs

Disinfection in the hospital environment remains challenging, especially for wide and structurally complex objects such as beds or wheelchairs. Indeed, the regular disinfection of these objects with chemicals is manually carried out by healthcare workers and is fastidious and time-consuming. Alternative antibacterial techniques were thus proposed in the past decades, including the use of naturally antimicrobial UVC. Here, the antibacterial efficiency of a large UVC box built to accommodate wheelchairs was investigated through testing bacterial burden reductions on various parts of a wheelchair, with various support types and with several treatment durations. The results demonstrate a time-dependent antibacterial effect, with a strong burden reduction at only five minutes of treatment (>3-log median reduction in Escherichia coli and Staphylococcus epidermidis). The UVC flux and residual bacterial burden both significantly varied depending on the spatial location on the wheelchair. However, the nature of the support impacted the antibacterial efficiency even more, with residual bacterial burdens being the lowest on rigid materials (steel, plastics) and being the highest on tissue. On metallic samples, the nature of the alloy and surface treatment had various impacts on the antibacterial efficiency of the UVC. This study highlights the efficiency of the tested UVC box to efficiently and quickly decontaminate complex objects such as wheelchairs, but also gives rise to the warning to focus on rigid materials and avoid porous materials in the conception of objects, so as to ensure the efficiency of UVC decontamination.

Lacticaseibacillus rhamnosus GG Versus Placebo for Eradication of Vancomycin-Resistant Enterococcus faecium in Intestinal Carriers: A Systematic Review and Meta-Analysis

The aim of this review was to assess the efficacy and safety of Lacticaseibacillus rhamnosus GG (LGG) (previously known as Lactobacillus rhamnosus GG) for the eradication of vancomycin-resistant Enterococcus faecium (VREfm) in colonized carriers. We searched Cochrane Central, EMBASE, and the PubMed Library from inception to 21 August 2023, for randomized controlled trials (RCTs) investigating the effectiveness of LGG for the eradication of gastrointestinal carriage of VREfm. An initial screening was performed followed by a full-text evaluation of the papers. Out of 4076 articles in the original screening, six RCTs (167 participants) were included in the review. All were placebo-controlled RCTs. The meta-analysis was inconclusive with regard to the effect of LGG for clearing VREfm colonization. The overall quality of the evidence was low due to inconsistency and the small number of patients in the trials. We found insufficient evidence to support the use of LGG for the eradication of VREfm in colonized carriers. There is a need for larger RCTs with a standardized formulation and dosage of LGG in future trials.

Non-touch treatment to solve the persistent contamination of culture plates with Aspergillus niger in a clinical microbiology laboratory of Spain

A pseudo-outbreak of Aspergillus caused by false positive cultures can have a high sanitary impact. We determined the effectiveness (fungal load elimination) of a non-touch disinfection system, vs conventional disinfection methods, to solve steady contamination of culture plates with Aspergillus niger at a clinical microbiology laboratory. Routine cleaning-disinfection (RCD), intensive cleaning-disinfection (ICD), and terminal airborne disinfection (TAD) were employed in stages. Air sampling was carried out before and after each procedure. The effectiveness of TAD on contact surfaces was tested by surface sampling. After RCD, ICD, and TAD, there was a mean decrease of 5.4 (95% CI = 1.8-9.0), 19.2 (95% CI = 12.4-26.0), and 4.4 (95% CI = 2.5-6.3) CFU per tested area, and 46.2%, 21.7%, and 95.5% of contaminated areas became sterile, respectively. There was a mean decrease of 30.6 CFU per tested surface (p < 0.0007) and 50% of tested surfaces became sterile. Global effectiveness of RCD, ICD, and TAD was 68.8% (95% CI = 68.5-69.1), 82.2% (95% CI = 82.1-82.3), and 99.0% (95% CI = 98.8-99.2), respectively. The effectiveness was higher with TAD (4.1 CFU/cm2 less than with ICD; p = 0.0290). No further contamination has occurred since then. When construction and renovation activities are discarded and RCD and ICD practices are insufficient, non-touch disinfection remove residual dust contamination and avoid recurrence.

Environmental approaches to controlling Clostridioides difficile infection in healthcare settings

As today's most prevalent and costly healthcare-associated infection, hospital-onset Clostridioides difficile infection (HO-CDI) represents a major threat to patient safety world-wide. This review will discuss how new insights into the epidemiology of CDI have quantified the prevalence of C. difficile (CD) spore contamination of the patient-zone as well as the role of asymptomatically colonized patients who unavoidable contaminate their near and distant environments with resilient spores. Clarification of the epidemiology of CD in parallel with the development of a new generation of sporicidal agents which can be used on a daily basis without damaging surfaces, equipment, or the environment, led to the research discussed in this review. These advances underscore the potential for significantly mitigating HO-CDI when combined with ongoing programs for optimizing the thoroughness of cleaning as well as disinfection. The consequence of this paradigm-shift in environmental hygiene practice, particularly when combined with advances in hand hygiene practice, has the potential for significantly improving patient safety in hospitals globally by mitigating the acquisition of CD spores and, quite plausibly, other environmentally transmitted healthcare-associated pathogens.

Multimodal environmental cleaning strategies to prevent healthcare-associated infections

Infection transmission in healthcare is multifaceted and by in large involves the complex interplay between a pathogen, a host and their environment. To prevent transmission, infection prevention strategies must also consider these complexities and incorporate targeted interventions aimed at all possible transmission pathways. One strategy to prevent and control infection is environmental cleaning. There are many aspects to an environmental cleaning strategy. We believe the key to successfully reducing the risk of healthcare-associated infections through the environment, is to design and implement a multimodal intervention. This paper aims to provide an overview of important considerations for designing a meaningful and sustainable environmental program for healthcare facilities.

Environmental chamber studies of eye and respiratory irritation from use of a peracetic acid-based hospital surface disinfectant

Objective

To characterize personal exposures and measures of eye and respiratory tract irritation in controlled environmental chamber studies of 44 healthy adult volunteers simulating upper-bound use of peracetic acid (PAA)-based surface disinfectant for terminal cleaning of hospital patient rooms.

Design

Experimental, within-subject, double-blinded cross-over design.

Methods

Objective and subjective exposure effects were assessed for PAA and its components: acetic acid (AA) and hydrogen peroxide (HP). Deionized water was included as a control. Breathing-zone concentrations of PAA, AA, and HP were assessed for 8 female multiday volunteers (5 consecutive days) and 36 single-day volunteers (32 females and 4 males). Wetted cloths were used to wipe high-touch surfaces for 20 minutes per trial. Also, 15 objective measures of tissue injury or inflammation and 4 subjective odor or irritation scores were assessed.

Results

Disinfectant trials showed 95th percentile breathing zone concentrations of 101 ppb PAA, 500 ppb AA, and 667 ppb HP. None of the volunteers observed over 75 test days exhibited significant increases in IgE or objective measures of eye and respiratory tract inflammation. Subjective ratings for disinfectant and AA-only trials showed similar increases for odor intensity and nose irritation, with lower ratings for eye and throat irritation. Females were 2.5-fold more likely than males to assign moderate + irritation ratings.

Conclusions

Simulated upper-bound hospital use of PAA-based disinfectant led to no significant increases in objective markers of tissue injury, inflammation, or allergic sensitization, and no frank signs of eye or respiratory tract irritation.

Mitigating hospital-onset Clostridioides difficile: The impact of an optimized environmental hygiene program in eight hospitals

OBJECTIVE

To evaluate the impact of a standardized, process-validated intervention utilizing daily hospital-wide patient-zone sporicidal disinfectant cleaning on incidence density of healthcare-onset Clostridioides difficile infection (HO-CDI) standardized infection ratios (SIRs).

DESIGN

Multi-site, quasi-experimental study, with control hospitals and a nonequivalent dependent variable.

SETTING

The study was conducted across 8 acute-care hospitals in 6 states with stable endemic HO-CDI SIRs.

METHODS

Following an 18-month preintervention control period, each site implemented a program of daily hospital-wide sporicidal disinfectant patient zone cleaning. After a wash-in period, thoroughness of disinfection cleaning (TDC) was monitored prospectively and optimized with performance feedback utilizing a previously validated process improvement program. Mean HO-CDI SIRs were calculated by quarter for the pre- and postintervention periods for both the intervention and control hospitals. We used a difference-in-differences analysis to estimate the change in the average HO-CDI SIR and HO-CAUTI SIR for the pre- and postintervention periods.

RESULTS

Following the wash-in period, the TDC improved steadily for all sites and by 18 months was 93.6% for the group. The mean HO-CDI SIRs decreased from 1.03 to 0.6 (95% CI, 0.13-0.75; P = .009). In the adjusted difference-in-differences analysis in comparison to controls, there was a 0.55 reduction (95% CI, -0.77 to -0.32) in HO-CDI (P < .001) or a 50% relative decrease from baseline.

CONCLUSIONS

This study represents the first multiple-site, quasi-experimental study with control hospitals and a nonequivalent dependent variable to evaluate a 4-component intervention on HO-CDI. Following ongoing improvement in cleaning thoroughness, there was a sustained 50% decrease in HO-CDI SIRs compared to controls.

Longitudinal Study on the Antimicrobial Performance of a Polyhexamethylene Biguanide (PHMB)-Treated Textile Fabric in a Hospital Environment

Healthcare workers in the hospital environment are at risk of infection and body fluids such as saliva, bacterial contamination, oral bacteria, etc. directly or indirectly exacerbate this issue. These bio-contaminants, when adhered to hospital linens and clothing, grow substantially, as conventional textile products provide a favorable medium for bacterial and viral growth, adding to the risk of transmitting infectious diseases in the hospital environment. Textiles with durable antimicrobial properties prevent microbial colonization on their surfaces and help contain the spread of pathogens. This longitudinal study aimed to investigate the antimicrobial performance of PHMB-treated healthcare uniforms during prolonged usage and repetitive laundry cycles in a hospital environment. The PHMB-treated healthcare uniforms displayed non-specific antimicrobial properties and remained efficient (>99% against S. aureus and K. pneumoniae) after use for 5 months. With the fact that no antimicrobial resistance was reported towards PHMB, the presented PHMB-treated uniform may reduce infection in hospital settings by minimizing the acquisition, retention, and transmission of infectious diseases on textile products.

Validating agent-based simulation model of hospital-associated Clostridioides difficile infection using primary hospital data

As agent-based models (ABMs) are increasingly used for modeling infectious diseases, model validation is becoming more crucial. In this study, we present an alternate approach to validating hospital ABMs that focuses on replicating hospital-specific conditions and proposes a new metric for validating the social-environmental network structure of ABMs. We adapted an established ABM representing Clostridioides difficile infection (CDI) spread in a generic hospital to a 426-bed Midwestern academic hospital. We incorporated hospital-specific layout, agent behaviors, and input parameters estimated from primary hospital data into the model, referred to as H-ABM. We compared the predicted CDI rate against the observed rate from 2013-2018. We used colonization pressure, a measure of nearby infectious agents, to validate the socio-environmental agent networks in the ABM. Finally, we conducted additional experiments to compare the performance of individual infection control interventions in the H-ABM and the generic model. We find that the H-ABM is able to replicate CDI trends during 2013-2018, including a roughly 46% drop during a period of greater infection control investment. High CDI burden in socio-environmental networks was associated with a significantly increased risk of C. difficile colonization or infection (Risk ratio: 1.37; 95% CI: [1.17, 1.59]). Finally, we found that several high-impact infection control interventions have diminished impact in the H-ABM. This study presents an alternate approach to validation of ABMs when large-scale calibration is not appropriate for specific settings and proposes a new metric for validating socio-environmental network structure of ABMs. Our findings also demonstrate the utility of hospital-specific modeling.

Clinically relevant pathogens on surfaces display differences in survival and transcriptomic response in relation to probiotic and traditional cleaning strategies

Indoor surfaces are paradoxically presumed to be both colonized by pathogens, necessitating disinfection, and "microbial wastelands." In these resource-poor, dry environments, competition and decay are thought to be important drivers of microbial community composition. However, the relative contributions of these two processes have not been specifically evaluated. To bridge this knowledge gap, we used microcosms to evaluate whether interspecies interactions occur on surfaces. We combined transcriptomics and traditional microbiology techniques to investigate whether competition occurred between two clinically important pathogens, Acinetobacter baumannii and Klebsiella pneumoniae, and a probiotic cleaner containing a consortium of Bacillus species. Probiotic cleaning seeks to take advantage of ecological principles such as competitive exclusion, thus using benign microorganisms to inhibit viable pathogens, but there is limited evidence that competitive exclusion in fact occurs in environments of interest (i.e., indoor surfaces). Our results indicate that competition in this setting has a negligible impact on community composition but may influence the functions expressed by active organisms. Although Bacillus spp. remained viable on surfaces for an extended period of time after application, viable colony forming units (CFUs) of A. baumannii recovered following exposure to a chemical-based detergent with and without Bacillus spp. showed no statistical difference. Similarly, for K. pneumoniae, there were small statistical differences in CFUs between cleaning scenarios with or without Bacillus spp. in the chemical-based detergent. The transcriptome of A. baumannii with and without Bacillus spp. exposure shared a high degree of similarity in overall gene expression, but the transcriptome of K. pneumoniae differed in overall gene expression, including reduced response in genes related to antimicrobial resistance. Together, these results highlight the need to fully understand the underlying biological and ecological mechanisms for community assembly and function on indoor surfaces, as well as having practical implications for cleaning and disinfection strategies for infection prevention.

Environmental cleaning and disinfection: Sustaining changed practice and improving quality in the community hospital

OBJECTIVE

Short-term improvements in hospital room cleaning can readily be achieved but are difficult to maintain. This is particularly true for high-risk, "high-touch" surfaces. Therefore, we embarked on a process to sustain improvements in surface cleaning and disinfection to reduce hospital-acquired infection (HAI) rates.

INTERVENTIONS

Our environmental services (EVS) and infection prevention departments incorporated a formal education, monitoring, and feedback process for focused cleaning and disinfection of high-touch surfaces into their routine policies and procedures in 2011. Cleaning validation was performed by infection prevention liaison nurses using a fluorescent targeting method to evaluate the thoroughness of cleaning.

RESULTS

Surface cleaning performance on medical-surgical units in 2011 was 74.7%, but this rate incrementally increased in response to the interventions and has been sustained at >90% for the past 6 years. Similar patterns of improvement were observed in the operating room, labor and delivery, endoscopy suite and cardiac catheterization laboratory. Conversely, HAI rates, particularly C. difficile rates, decreased by 75% and surgical site infection rates decreased by 55%.

CONCLUSIONS

EVS training, monitoring, and feedback interventions, instituted 10 years ago have enhanced our environmental cleaning and disinfection efforts in multiple areas of the hospital and have been sustained to the present. Although other concurrent initiatives to reduce infection rates also existed, the improvements in environmental cleaning were associated with dramatic reductions in HAI rates over the 10-year period.

Are There Bad ICU Rooms? Temporal Relationship between Patient and ICU Room Microbiome, and Influence on Vancomycin-Resistant Enterococcus Colonization

The gut microbiome of an individual can shape the local environmental surface microbiome. We sought to determine how the intensive care unit (ICU) patient gut microbiome shapes the ICU room surface microbiome, focusing on vancomycin-resistant Enterococcus (VRE), a common ICU pathogen. This was an ICU-based prospective cohort study. Rectal swabs were performed in adult ICU patients immediately at the time of ICU admission and environmental surface swabs were performed at five predetermined time points. All swabs underwent 16S rRNA gene sequencing and culture for VRE. 304 ICU patients and 24 ICU rooms were sampled (5 longitudinal samples per ICU room). Spatially adjacent ICU rooms were no more microbially similar than nonadjacent rooms. Microbial signatures within rooms diverged rapidly over time: in 14 days, ICU rooms were as similar to other ICU rooms as they were to their prior selves. This divergence over time was more pronounced in rooms with higher patient turnover. Examining VRE status by culture, patient VRE gut colonization had modest agreement with room surface VRE (kappa statistic 0.36). There were no ICU rooms that consistently cultured positive for VRE, including those that housed VRE positive patients. Individual ICU patients had a limited impact on ICU room surface microbiome, and rooms diverged similarly over time regardless of patients. Patient VRE gut colonization may have a modest influence on room surface VRE but there were no “bad rooms” that consistently cultured positive for VRE. These results may be useful in planning infection control measures.

IMPORTANCE This study found that intensive care unit (ICU) room microbial signatures diverged from their baseline quickly: within 2 weeks, individual ICU rooms had lost distinguishing characteristics and were as similar to other ICU rooms as they were to their former selves. Patient turnover within rooms accelerated this drift. Patient gut colonization with vancomycin-resistant Enterococcus (VRE) was associated with ICU room surface contamination with VRE; again, within 2 weeks, this association was substantially diminished. These results provide dynamic information regarding how patients control the microbiota on local hospital room surfaces and may facilitate decision making for infection prevention and control measures targeting VRE or other organisms.

Feedback of ATP measurement as a tool for reducing environmental contamination in hospitals in the Dutch/Belgian border area

DESIGN

A two-phase prospective intervention study.

OBJECTIVE

The objective of this study was to determine if feedback of adenosine triphosphate (ATP) measurements decreases environmental contamination within hospitals in the Dutch/Belgian border area.

METHODS

Standardized ATP measurements were conducted in nine hospitals on pre-defined fomites. Four different fomite groups were defined: medical devices, patient-bound materials, ward-bound materials and sanitary items. ATP results were reported in relative light unit (RLU), RLU >1000 was considered as 'not clean.' Two rounds of ATP measurements were conducted. After the first round of ATP measurements, results were provided to the wards and cleaning staff. The second round of ATP measurements was performed one year later. The amount of surface contamination before and after the feedback was compared.

RESULTS

In total 1923 ATP measurements were performed. Before feedback 960 ATP measurements were conducted and after feedback 963 were conducted. The overall median reduction in RLU was 381 (P < 0.001), from 568 before feedback to 187 afterward. In each hospital there was a reduction of the median RLU after feedback.

CONCLUSIONS

Substantial reductions in RLU values were found after feedback of ATP measurements. Feedback of ATP measurement in itself was associated with a major reduction of surface contamination in hospitals.

Brought to Light: How Ultraviolet Disinfection Can Prevent the Nosocomial Transmission of COVID-19 and Other Infectious Diseases

The novel coronavirus disease 2019 (COVID-19) pandemic has brought to light the role of environmental hygiene in controlling disease transmission. Healthcare facilities are hot spots for infectious pathogens where physical distancing and personal protective equipment (PPE) are not always sufficient to prevent disease transmission. Healthcare facilities need to consider adjunct strategies to prevent transmission of infectious pathogens. In combination with current infection control procedures, many healthcare facilities are incorporating ultraviolet (UV) disinfection into their routines. This review considers how pathogens are transmitted in healthcare facilities, the mechanism of UV microbial inactivation and the documented activity of UV against clinical pathogens. Emphasis is placed on the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) as well as multidrug resistant organisms (MDROs) that are commonly transmitted in healthcare facilities. The potential benefits and limitations of UV technologies are discussed to help inform healthcare workers, including clinical studies where UV technology is used in healthcare facilities.

Infection prevention and surgery in the pandemic era

The COVID-19 pandemic has had a significant impact on surgical specialties. COVID-19 carries a significant risk to the surgical patient and the healthcare workers looking after them, with an increased incidence of pulmonary complications and mortality in patients who test positive perioperatively. Appropriate infection prevention and control measures are critical to ensure appropriate care is given and to reduce the risk of onward transmission. This article will discuss the measures that have been instigated and contributed to infection control in surgery, such as testing, patient isolation, personal protective equipment and ventilation. The COVID-19 pandemic has led to healthcare workers across many specialities working together to provide essential clinical care. This collaborative approach is critical to maintain excellent infection prevention and control practices required during this pandemic, which protect patients and preserve surgical services.

Improving hospital-based point-of-care ultrasound cleaning practices using targeted interventions: a pre-post study

BACKGROUND

Point-of-care ultrasound (POCUS) devices are becoming more widely used in healthcare and have the potential to act as fomites. The objective of this project was to study the thoroughness of cleaning of POCUS machines before and after a quality improvement initiative. We designed a mixed-methods, pre/post study which took place over the course of one year at a university-affiliated health center. Cleaning rates of four ultrasound machines used by hospital medicine and critical care medicine services were evaluated using fluorescent marking. Interventions targeted physicians' knowledge of best practices and improved access to cleaning supplies. Pre- and post-intervention cleaning rates were compared using a generalized linear model. The impact of the corona virus disease of 2019 (COVID-19) pandemic on baseline cleaning rates was also evaluated. Physicians' attitudes and knowledge of cleaning practices were evaluated via unpaired pre/post surveys.

RESULTS

There was significant improvement in thoroughness of cleaning following intervention (pre 0.62, SE 0.05; post 0.89, SE 0.07), p < 0.0001). There was no difference in baseline cleaning rates before (0.63, SE 0.09) and after (0.61, SE 0.1) the onset of the COVID-19 pandemic (p = 0.78). Post-intervention surveying found improved understanding of guideline-based cleaning practice, better performance on knowledge-based questions, and fewer reported barriers to machine cleaning.

CONCLUSION

Thoroughness of cleaning of POCUS machines can be improved with practical interventions that target knowledge and access to cleaning supplies.

HAND HYGIENE COMPLIANCE IN THE PREVENTION OF HOSPITAL ACQUIRED INFECTIONS: A SYSTEMATIC REVIEW

BACKGROUND

Healthcare worker's (HCW) hands are known to be a primary source of transmission of hospital-acquired infections (HAIs). Thus, practicing hand hygiene (HH) and adhering to HH guidelines are both expected to decrease the risk of transmission but there is no consensus on the optimal hand hygiene compliance (HHC) rate that HCWs should aim for.

AIM

The objective of this study was to systematically review the published literature to determine an optimal threshold of HCW HHC rate associated with the lowest incidence rate of HAIs.

METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. We searched online databases using a comprehensive search criterion for randomized controlled trials and non-randomized controlled studies, investigating the impact of HCW's HHC rate on HAI rates in patients of all ages, within healthcare facilities in high income countries.

FINDINGS

Of the 8,093 articles citations and abstracts screened, 35 articles were included in the review. Most studies reported overall HAIs per 1000 patient-days and device-associated HAIs per 1000 device-days. Most studies reported HHC rates between 60%-70%. Lower incidence HAI rates seemed to be achieved with HHC rates of approximately 60%. Studies included were not originally designed to assess the impact of HHC on HAI rates but risk of bias was assessed as per our predetermined exposure and outcome criterion. 11 (31%) of studies were deemed at low risk of bias.

CONCLUSIONS

Although HHC is part of HCW's code of conduct, very high HHC rates were difficult to reach. In observational studies, HHC and HAI followed a negative relationship up to about 60%. Due to flaws in study design, causality could not be inferred; only general trends could be discussed. Given the limitations, there is a need for high-quality evidence to support the implementation of specified targets of HHC rates.

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

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

Health Care Environmental Hygiene: New Insights and Centers for Disease Control and Prevention Guidance

Recent research has significantly clarified the impact of optimizing patient-zone environmental hygiene. New insights into the environmental microbial epidemiology of many hospital-associated pathogens, especially Clostridioides difficile, have clarified and quantified the role of ongoing occult pathogen transmission from the near-patient environment. The recent development of safe, broadly effective surface chemical disinfectants has led to new opportunities to broadly enhance environmental hygiene in all health care settings. The Centers for Disease Control and Prevention has recently developed a detailed guidance to assist all health care settings in implementing optimized programs to mitigate health care-associated pathogen transmission from the near-patient surfaces.

Spinning and Fully Integrated Microdevice for Rapid Screening of Vancomycin-Resistant Enterococcus

This study introduces a spinning and fully integrated paper-based microdevice that can perform multiple functions, including DNA extraction, amplification, and colorimetric detection, for monitoring two major vancomycin-resistant Enterococci (VREs), which carry the vanA and vanB genes. The spinning microdevice is composed of a stationary part and a spinning part. The square-shaped stationary part has two zones: the lysis and reaction zones. The spinning part, which has a spin wheel-like shape, was inserted perpendicularly into the stationary part so that its two semicircles remained on the upper and lower parts. Sodium hydroxide-treated glass microfiber filter discs, inserted in the upper semicircle, were soaked in the lysis chambers by folding them toward the lysis zone to capture DNA in the lysis chambers. The captured DNA was transferred to the reaction chambers by folding the discs toward the reaction chambers. Water was added to the sodium hydroxide-treated glass microfiber filter discs to elute purified DNA into the reaction chambers. The upper semicircle was then unfolded, and the reaction chambers were sealed for subsequent loop-mediated isothermal amplification (LAMP) for 45 min. After the reaction, the spinning part was spun in the lysis zone direction to bring the lower semicircle, inserted with phenolphthalein-treated glass microfiber filter discs, toward the upper part of the stationary part. By folding it toward the reaction chambers, the lower semicircle came into contact with them and the phenolphthalein-treated glass microfiber filter discs were soaked in the reaction chambers and expressed color after 30 s. Based on the pH change during the LAMP reaction, the phenolphthalein-treated discs remained pink in the absence of target DNA, while those in contact with the positive samples turned colorless. A sensitive detection with a VRE limit of detection of 10² CFU/mL for tap water spiked with VRE carrying the vanA gene was achieved using this microdevice. Both VREs, carrying vanA and vanB genes, were successfully identified from tap water and contaminated equipment surfaces within 75 min. The introduced microdevice demonstrated a rapid, accurate, and sensitive performance for the environmental assessment of VRE contamination in resource-limited regions.

Microbial burden on environmental surfaces in patient rooms before daily cleaning-Analysis of multiple confounding variables

OBJECTIVES

Estimated levels of microbial burden on hospital environmental surfaces vary substantially among published studies. Cultures obtained during a cluster-controlled crossover trial of a quaternary ammonium (Quat) disinfectant versus an improved hydrogen peroxide (IHP) disinfectant provided additional data on the amount of microbial burden on selected surfaces.

METHODS

RODAC plates containing D/E neutralizing agar were used to sample a convenience sample of 5-8 high-touch surfaces in patient rooms on 2 medical wards, an intensive care unit, and a step-down unit at a large hospital. Before routine daily cleaning, samples were obtained in varying rooms over an 11-month period. RODAC plates (1 per surface sampled) were incubated for 72 hours, and aerobic colony counts per plate (ACCs) were determined. Statistical analysis was used to determine the potential impact on ACCs of study period, cleaning compliance rate, disinfectant used, ward, surface sampled, and isolation room status.

RESULTS

Overall, 590 cultures were obtained on Quat wards and 589 on IHP wards. Multivariable regression analysis revealed that mean ACCs differed significantly by site (P < .001), type of ward (P < .001), isolation room status (P = .039), and study period (P = .036). The highest mean ACCs per RODAC plate were on toilet seats (112.8), bedside rails (92.0), and bathroom grab bars (79.5).

CONCLUSIONS

The combination of factors analyzed revealed that estimating microbial burden is complex and is affected by multiple factors. Additional studies should evaluate individual sites, ward types, cleaning and disinfection practices, and isolation room status.

Evaluation of dry hydrogen peroxide in reducing microbial bioburden in a healthcare facility

BACKGROUND

Standard manual cleaning and disinfection practices are often inadequate. Persistent contamination in the environment poses an infection risk that may be mitigated by no-touch disinfection systems. This study evaluates the efficacy of dry hydrogen peroxide (DHP) on microbial air and surface contamination as an adjunct to routine cleaning and disinfection in a large urban hospital.

METHODS

Surface samples were collected in five different hospital units, two pediatric and three adult, after manual cleaning on multiple days before and after DHP implementation. Air samples were also collected in each unit pre- and post-DHP use. Data outcomes were reported as colony forming units (CFU) with species identification.

RESULTS

The overall mean surface microbial burden was reduced by 96.5 percent for all units post-DHP compared to baseline (P < 0.001), with the greatest reductions achieved on privacy curtains (99.5 %). Mean microbial air sample counts were also reduced post-DHP compared to pre-DHP.

CONCLUSIONS

This study demonstrates that DHP was effective in reducing both air and surface microbial contamination in a variety of settings within a large, tertiary care hospital.

Does enhanced environmental cleaning reduce carbapenem-resistant Acinetobacter baumannii colonization in the intensive care unit?

OBJECTIVE

To evaluate the impact of enhanced environmental cleaning (two times per day) compared with conventional cleaning on the acquisition of carbapenem-resistant Acinetobacter baumannii (CRAB) in a highly endemic intensive care unit (ICU).

METHODS

The intervention consisted of alternating environmental cleaning and conventional cleaning every 3 months during the study period from July 2018 to June 2019. CRAB acquisition was assessed using incidence and prevalence rates, and colonization pressure.

RESULTS

The incidence rates of CRAB with and without enhanced cleaning were 16.3 and 13.9 cases per 1000 population, respectively; and the prevalence rates were 66.9 and 61.7 cases per 1000 population, respectively. Colonization pressure was 53.3% with enhanced cleaning and 51.3% without enhanced cleaning. No association was found between enhanced environmental cleaning and the incidence (P=0.156), prevalence (P=0.888) and colonization pressure (P=0.825) of CRAB acquisition. The ventilator utilization ratio increased the colonization pressure of CRAB acquisition (P=0.010, β coefficient=0.37). The proportion of new nurses with <3 years of clinical practice experience was positively correlated with the incidence and prevalence of CRAB acquisition.

CONCLUSION

Enhanced environmental cleaning alone failed to reduce CRAB acquisition in a highly endemic ICU. The ventilator utilization ratio may be of more importance than environmental cleaning. Inexperienced nurses may need to be monitored regarding infection control activities in addition to hand hygiene adherence.

Factors associated with environmental service worker cleaning practices in health care settings: A systematic review of the literature

INTRODUCTION

Health care-associated infections can be reduced through better environmental disinfection practices. Central to effective disinfection is the environmental service worker (ESW). The aim of this systematic literature review was to identify factors associated with the disinfection practices of ESWs in health care settings.

METHODS

A systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses principles. Ten online databases and search engines were selected for the review of English-language studies published between 2000 and 2019.

RESULTS

Thirty-one (31) eligible studies were identified. Environmental disinfection was associated with many factors (eg, knowledge, perceptions) as well as ESW exposure to education/training sessions. When education/training was combined with performance evaluation/feedback, significant improvement in ESW disinfection practices was reported.

CONCLUSIONS

To sustain improvements in disinfection practices, education/training sessions need to be continuous. The long-term commitment of an organization is also essential for continuous improvement in disinfection outcomes. While knowledge transfer is critical for behavior change, education/training also needs to focus on the skills and perceptions of ESWs. Future studies need to use a randomized controlled design with larger sample sizes to determine a true effect.

Effect of ultraviolet-C light on the environmental bacterial bioburden in various veterinary facilities

OBJECTIVE

To determine the effect of a mobile UV-C disinfection device on the environmental bacterial bioburden in veterinary facilities.

SAMPLES

40 swab samples of surfaces from the operating theaters of 3 veterinary hospitals and 1 necropsy laboratory.

PROCEDURES

Various surfaces were swabbed, and collected material was eluted from the swabs in PBSS. Then, an aliquot of the sample fluid was processed with a bacteria-specific rapid metabolic assay to quantify bacterial bioburden. Each site was then treated with UV-C light with an automated disinfection device for approximately 45 minutes. The same surfaces were swabbed following UV-C treatment, and bioburden was quantified. The bioburden at additional time points, including after a second UV-C treatment, was determined for the small animal operating theater.

RESULTS

All surfaces at all sites had a persistent viable bacterial population following manual cleaning. Disinfection with UV-C achieved a mean bioburden reduction of 94% (SD, 5.2%; range, 91% to 95%) for all surfaces, compared with manual disinfection alone. Repeated UV-C treatment of the small animal operating theater reduced mean bioburden by 99% (SD, 0.8%), including no detectable bacteria on 4 of 10 surfaces.

CONCLUSIONS AND CLINICAL RELEVANCE

Disinfection with UV-C light may be a beneficial adjunct method for terminal disinfection of veterinary operating theaters to reduce environmental bioburden. (Am J Vet Res 2021;82:582-588).

Back to Basics: Choosing the Appropriate Surface Disinfectant

From viruses to bacteria, our lives are filled with exposure to germs. In built environments, exposure to infectious microorganisms and their byproducts is clearly linked to human health. In the last year, public health emergency surrounding the COVID-19 pandemic stressed the importance of having good biosafety measures and practices. To prevent infection from spreading and to maintain the barrier, disinfection and hygiene habits are crucial, especially when the microorganism can persist and survive on surfaces. Contaminated surfaces are called fomites and on them, microorganisms can survive even for months. As a consequence, fomites serve as a second reservoir and transfer pathogens between hosts. The knowledge of microorganisms, type of surface, and antimicrobial agent is fundamental to develop the best approach to sanitize fomites and to obtain good disinfection levels. Hence, this review has the purpose to briefly describe the organisms, the kind of risk associated with them, and the main classes of antimicrobials for surfaces, to help choose the right approach to prevent exposure to pathogens.

Systematic review on use, cost and clinical efficacy of automated decontamination devices

BACKGROUND

More evidence is emerging on the role of surface decontamination for reducing hospital-acquired infection (HAI). Timely and adequate removal of environmental pathogens leads to measurable clinical benefit in both routine and outbreak situations.

OBJECTIVES

This systematic review aimed to evaluate published studies describing the effect of automated technologies delivering hydrogen peroxide (H202) or ultra-violet (UV) light on HAI rates.

METHODS

A systematic review was performed using relevant search terms. Databases were scanned from January 2005 to March 2020 for studies reporting clinical outcome after use of automated devices on healthcare surfaces. Information collected included device type, overall findings; hospital and ward data; study location, length and size; antimicrobial consumption; domestic monitoring; and infection control interventions. Study sponsorship and duplicate publications were also noted.

RESULTS

While there are clear benefits from non-touch devices in vitro, we found insufficient objective assessment of patient outcome due to the before-and-after nature of 36 of 43 (84%) studies. Of 43 studies, 20 (47%) used hydrogen peroxide (14 for outbreaks) and 23 (53%) used UV technology (none for outbreaks). The most popular pathogen targeted, either alone or in combination with others, was Clostridium difficile (27 of 43 studies: 63%), followed by methicillin-resistant Staphylococcus aureus (MRSA) (16 of 43: 37%). Many owed funding and/or personnel to industry sponsorship (28 of 43: 65%) and most were confounded by concurrent infection control, antimicrobial stewardship and/or cleaning audit initiatives. Few contained data on device costs and rarely on comparable costs (1 of 43: 2%). There were expected relationships between the country hosting the study and location of device companies. None mentioned the potential for environmental damage, including effects on microbial survivors.

CONCLUSION

There were mixed results for patient benefit from this review of automated devices using H202 or UV for surface decontamination. Most non-outbreak studies lacked an appropriate control group and were potentially compromised by industry sponsorship. Concern over HAI encourages delivery of powerful disinfectants for eliminating pathogens without appreciating toxicity or cost benefit. Routine use of these devices requires justification from standardized and controlled studies to understand how best to manage contaminated healthcare environments.

Environmental cleaning and disinfection of hospital rooms: A nationwide survey

BACKGROUND

As an important reservoir for hospital-acquired infections, environmental surfaces have long been targeted by interventions to improve cleaning and disinfection. Differences in disinfection practices across US hospitals, however, are still unclear.

METHODS

We conducted a nationwide survey of environmental services (EVS) personnel in the United States regarding their environmental surface disinfection practices from January 2019 to June 2019. We developed and pilot tested the survey in conjunction with EVS specialists. Survey questions inquired about choices of disinfectants and cleaning equipment during daily and terminal disinfection of both contact isolation and non-contact isolation rooms. We contacted 273 EVS personnel by phone and email to participate in the survey.

RESULTS

Fourty-seven EVS personnel representing different hospitals from 26 US states were included in the analysis. Hypochlorite (bleach) and quaternary ammonium compounds were the most frequently used disinfectants. Most respondents reported using microfiber-based cloths and mops to carry out disinfection. High-touch surfaces in contact isolation rooms were frequently disinfected using bleach (81%, n = 38); floors, however, were not disinfected as frequently in patient rooms. The vast majority of respondents reported use of sporicidal disinfectants for contact isolation rooms but not regular rooms.

CONCLUSIONS

While frequently used to disinfectant contact isolation rooms, sporicidal agents are rarely used to disinfect regular rooms. Patient room floors are inconsistently disinfected compared to high-touch surfaces.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Reduction of bacterial load with the addition of ultraviolet-C disinfection inside the hyperbaric chamber

INTRODUCTION

Healthcare acquired infections (HAIs) are associated with increased mortality, morbidity and prolonged hospital stays. Microbiological contamination of the hospital environment directly contributes to HAIs. Optimising environmental cleaning reduces transmission of HAIs. The hyperbaric chamber poses a specific challenge for infection control as certain disinfectants and alcohol-based hand sanitisers are prohibited due to fire risk. Patients often possess multiple risk factors for HAIs. This study compared the bacteria remaining on a surface (bioburden) after a standard clean and after adjunctive disinfection with an ultraviolet-C (UV-C) robot.

METHODS

Internal hyperbaric chamber surfaces were first manually cleaned with Clinell® universal wipes and the floor was mopped with Whiteley neutral detergent. Allocated surfaces were swabbed using sterile cotton swabs and processed using a standard microbial culture and a bacteria-specific rapid metabolic assay. Bacterial contamination was also measured by direct contact plating on flat surfaces. The plexiglass ports were covered to protect from potential UV-C mediated damage and used as a negative control. A UV-C disinfection robot was then used to disinfect the chamber for 30 min, whereafter surfaces were swabbed again.

RESULTS

There was a significantly greater mean reduction in bioburden following adjunctive UV-C disinfection than with standard cleaning alone. The surfaces not routinely manually cleaned (e.g., bench, phone) showed greatest reduction in bacterial load following UV-C cleaning.

CONCLUSIONS

There was a significant reduction in the bacterial load in the chamber following an adjunctive UV-C clean compared with that of a standard clean. Adjunctive cleaning of the hyperbaric chamber environment with a non-touch UV-C device shows promise as a method to reduce HAIs.

Behavioral strategies for reducing disease transmission in the workplace

The coronavirus pandemic highlighted that workplaces may serve as a hub of disease transmission if proper precautions are not enacted. The Centers for Disease Control recommends several strategies for decreasing the spread of illnesses in the workplace, including a) promoting proper hand hygiene, b) cleaning and sanitizing the work area, c) encouraging sick employees to stay home, d) personal protective equipment, and, e) social distancing. Research suggests that instructions are often not sufficient to change work behaviors, and behavioral interventions may be needed. Thus, the present paper reviews existing research that informs the implementation of behavioral strategies to reduce the spread of disease in the workplace, and makes recommendations for organizations to protect employees, clients, and customers. Intervention components such as training, prompts, the reduction of response effort, clear workplace policies, feedback, and consequences are discussed, and practical recommendations and suggestions for future research are provided.

Environmental Surface Hygiene in the OR: Strategies for Reducing the Transmission of Health Care-Associated Infections

Health care-associated infections (HAIs) cost billions of dollars annually in the United States and cause patient morbidity and mortality. There is increasing evidence that environmental surfaces in the OR setting, including anesthesia work areas, can harbor pathogens that can lead to HAIs. Patient-care equipment used routinely in the OR, such as electrocardiograph wires, blood pressure cuffs, pulse oximetry probes, and monitor cables, can become contaminated with pathogens during surgical procedures; without proper cleaning and disinfection between procedures, these items pose a risk for pathogen transmission and subsequent patient infections. This article discusses the association between contaminated surfaces in the OR and the risk for HAIs. It is essential that perioperative nurses, environmental services personnel, anesthesia technicians, and anesthesia professionals properly disinfect environmental surfaces to prevent HAIs.

Zero or More: Methodological Challenges of Counting and Estimating Deaths Related to Antibiotic-resistant Infections

Estimates of the number of deaths from antimicrobial-resistant (AMR) infections are important data for clinicians and public health officials advocating for resources to prevent and treat these infections. The aims of this article are to describe the various approaches to calculating deaths from AMR infections, to compare the tally of deaths by each approach, and to explain how to interpret the results. Currently, none of the 3 methods employed by vital statistics systems to count deaths from specific causes (underlying cause of deaths, multiple causes of death, and avoidable deaths) count deaths from AMR infections. These deaths can be estimated by 4 approaches: case-fatality rate, infection-related mortality, and excess mortality using controls with antibiotic-susceptible infections or controls without antibiotic-resistant infections. When encountering discrepant estimates of AMR-related deaths, it is important to consider which method was used and whether it was the right method to answer the question being asked.

Enterococcus faecium: from microbiological insights to practical recommendations for infection control and diagnostics

Early in its evolution, Enterococcus faecium acquired traits that allowed it to become a successful nosocomial pathogen. E. faecium inherent tenacity to build resistance to antibiotics and environmental stressors that allows the species to thrive in hospital environments. The continual wide use of antibiotics in medicine has been an important driver in the evolution of E. faecium becoming a highly proficient hospital pathogen.For successful prevention and reduction of nosocomial infections with vancomycin resistant E. faecium (VREfm), it is essential to focus on reducing VREfm carriage and spread. The aim of this review is to incorporate microbiological insights of E. faecium into practical infection control recommendations, to reduce the spread of hospital-acquired VREfm (carriage and infections). The spread of VREfm can be controlled by intensified cleaning procedures, antibiotic stewardship, rapid screening of VREfm carriage focused on high-risk populations, and identification of transmission routes through accurate detection and typing methods in outbreak situations. Further, for successful management of E. faecium, continual innovation in the fields of diagnostics, treatment, and eradication is necessary.

Evaluation of the Cost-effectiveness of Infection Control Strategies to Reduce Hospital-Onset Clostridioides difficile Infection

Importance

Clostridioides difficile infection is the most common hospital-acquired infection in the United States, yet few studies have evaluated the cost-effectiveness of infection control initiatives targeting C difficile.

Objective

To compare the cost-effectiveness of 9 C difficile single intervention strategies and 8 multi-intervention bundles.

Design, Setting, and Participants

This economic evaluation was conducted in a simulated 200-bed tertiary, acute care, adult hospital. The study relied on clinical outcomes from a published agent-based simulation model of C difficile transmission. The model included 4 agent types (ie, patients, nurses, physicians, and visitors). Cost and utility estimates were derived from the literature.

Interventions

Daily sporicidal cleaning, terminal sporicidal cleaning, health care worker hand hygiene, patient hand hygiene, visitor hand hygiene, health care worker contact precautions, visitor contact precautions, C difficile screening at admission, and reduced intrahospital patient transfers.

Main Outcomes and Measures

Cost-effectiveness was evaluated from the hospital perspective and defined by 2 measures: cost per hospital-onset C difficile infection averted and cost per quality-adjusted life-year (QALY).

Results

In this agent-based model of a simulated 200-bed tertiary, acute care, adult hospital, 5 of 9 single intervention strategies were dominant, reducing cost, increasing QALYs, and averting hospital-onset C difficile infection compared with baseline standard hospital practices. They were daily cleaning (most cost-effective, saving $358 268 and 36.8 QALYs annually), health care worker hand hygiene, patient hand hygiene, terminal cleaning, and reducing intrahospital patient transfers. Screening at admission cost $1283/QALY, while health care worker contact precautions and visitor hand hygiene interventions cost $123 264/QALY and $5 730 987/QALY, respectively. Visitor contact precautions was dominated, with increased cost and decreased QALYs. Adding screening, health care worker hand hygiene, and patient hand hygiene sequentially to the daily cleaning intervention formed 2-pronged, 3-pronged, and 4-pronged multi-intervention bundles that cost an additional $29 616/QALY, $50 196/QALY, and $146 792/QALY, respectively.

Conclusions and Relevance

The findings of this study suggest that institutions should seek to streamline their infection control initiatives and prioritize a smaller number of highly cost-effective interventions. Daily sporicidal cleaning was among several cost-saving strategies that could be prioritized over minimally effective, costly strategies, such as visitor contact precautions.

One Health in hospitals: how understanding the dynamics of people, animals, and the hospital built-environment can be used to better inform interventions for antimicrobial-resistant gram-positive infections

Despite improvements in hospital infection prevention and control, healthcare associated infections (HAIs) remain a challenge with significant patient morbidity, mortality, and cost for the healthcare system. In this review, we use a One Health framework (human, animal, and environmental health) to explain the epidemiology, demonstrate key knowledge gaps in infection prevention policy, and explore improvements to control Gram-positive pathogens in the healthcare environment. We discuss patient and healthcare worker interactions with the hospital environment that can lead to transmission of the most common Gram-positive hospital pathogens – methicillin-resistant Staphylococcus aureus, Clostridioides (Clostridium) difficile, and vancomycin-resistant Enterococcus – and detail interventions that target these two One Health domains. We discuss the role of animals in the healthcare settings, knowledge gaps regarding their role in pathogen transmission, and the absence of infection risk mitigation strategies targeting animals. We advocate for novel infection prevention and control programs, founded on the pillars of One Health, to reduce Gram-positive hospital-associated pathogen transmission.

ATP measurement as an objective method to measure environmental contamination in 9 hospitals in the Dutch/Belgian border area

Background

The objective of this study was to determine the level of environmental contamination in hospitals in the Dutch/Belgian border area, using ATP measurements.

Design

A cross-sectional observational survey.

Methods

Standardized ATP measurements were conducted in 9 hospitals on 32 hospital wards. Thirty pre-defined surfaces per hospital ward were measured with the 3 M Clean Trace NG luminometer. Results are displayed in relative light units (RLU). RLU > 1000 was considered as “not clean.” Differences in RLU values were compared between countries, hospitals, fomite groups and medical specialties.

Results

A total of 960 ATP measurements were performed, ranging from 60 up to 120 per hospital. The median RLU-value was 568 (range: 3–277,586) and 37.7% of the measurements were rated as not clean (RLU > 1000). There were significant differences between countries, hospitals and fomite groups.

Conclusion

ATP measurements can be used as a more objective approach to determine the level of environmental contamination in hospitals. Significant differences in ATP levels were found between hospitals and between countries. Also, substantial differences were found between different fomite groups. These findings offer potential targets for improvement of cleanliness in healthcare facilities.

Implementation of human factors engineering approach to improve environmental cleaning and disinfection in a medical center

Background

Inadequate hospital cleaning may contribute to cross-transmission of pathogens. It is important to implement effective cleaning for the safe hospital environment. We conducted a three-phase study using human factors engineering (HFE) approach to enhance environmental cleanliness.

Methods

This study was conducted using a prospective interventional trial, and 28 (33.3%) of 84 wards in a medical center were sampled. The three-phases included pre-intervention analysis (Phase 1), implementing interventions by HFE principles (Phase 2), and programmatic analysis (Phase 3). The evaluations of terminal cleaning and disinfection were performed using the fluorescent marker, the adenosine triphosphate bioluminescence assay, and the aerobic colony count method simultaneously in all phases. Effective terminal cleaning and disinfection was qualified with the aggregate outcome of the same 10 high-touch surfaces per room. A score for each high-touch surface was recorded, with 0 denoting a fail and 10 denoting a pass by the benchmark of the evaluation method, and the total terminal cleaning and disinfection score (TCD score) was a score out of 100.

Results

In each phase, 840 high-touch surfaces were collected from 84 rooms after terminal cleaning and disinfection. After the interventions, the TCD score by the three evaluation methods all showed significant improved. The carriage incidence of multidrug-resistant organism (MDRO) decreased significantly from 4.1 per 1000 patient-days to 3.6 per 1000 patient-days (P = .03).

Conclusion

The HFE approach can improve the thoroughness and the effectiveness of terminal cleaning and disinfection, and resulted in a reduction of patient carriage of MDRO at hospitals. Larger studies are necessary to establish whether such efforts of cleanliness can reduce the incidence of healthcare-associated infection.

Quantitative and Fast Sterility Assurance Testing of Surfaces by Enumeration of Germinable Endospores

A fast Endospore Germinability Assay (EGA) was validated with traditional plate counts to enumerate single endospore germination events for monitoring surface sterilization. The assay is based on a time-gated luminescence microscopy technique enabling visualization and enumeration of individual germinating endospores. Germinating endospores release calcium dipicolinate to form highly luminescent terbium dipicolinate complexes surrounding each germinating endospore. EGA and heterotrophic plate counting (HPC) were used to evaluate the swab/rinse recovery efficiency of endospores from stainless steel surfaces. EGA and HPC results were highly correlated for endospore recovery from stainless steel coupons inoculated with range of 1,000 endospores per coupon down to sterility. Dosage-dependent decrease of surface endospore germinability were observed in dry heat, UV irradiation, oxygen plasma and vaporized hydrogen peroxide treatments, measured with EGA and HPC. EGA is a fast and complementary method to traditional HPC for quantitative sterility assurance testing of surfaces. This work introduces and validates a 15-minute or faster assay for germinable endospores to complement the conventional lengthy, culture-based surface sterility validation, which is critical in hospitals, food and pharmaceutical industries to help minimize nosocomial infection, food spoilage, and pharmaceutical contamination.

An overview of automated room disinfection systems: When to use them and how to choose them

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.

Predictors for vancomycin resistant Enterococcus faecium transforming from colonization to infection: a case control study

Background

Little is known about risk factors for subsequent infections among vancomycin resistant Enterococcus faecium (VREfm) colonizers, especially characterized by concordant pulsotypes (CP) of paired colonization and infection-related isolates.

Methods

This case-control study was conducted at a teaching hospital between 2011 and 2014. Targeted patients received active surveillance culture for VREfm by anal swabs at admission. Cases were those who developed VREfm infection within 180 days after colonization of VREfm. Controls were those colonized with VREfm without subsequent VREfm infection. CP were defined by similarities ≥86.7% using pulsed-field gel electrophoresis between paired colonization and infection-related isolates.

Results

Ninety-seven cases and 194 controls were enrolled. By conditional multivariable logistic regression analysis, the risk factors for subsequent infection among VREfm colonizers were intensive care unit (ICU) admission (adjusted odds ratio [aOR], 9.32; 95% CI, 3.61–24.02), receipt of central venous catheters (CVC) (aOR, 3.38; 95% CI, 1.30–8.82), and utilization of third- and fourth-generation cephalosporins (aOR, 4.06; 95% CI, 1.79–9.20, and aOR, 5.32; 95% CI, 1.85– 10.29, respectively) (all P ≤ 0.01). Fifty-six (57.7%) of case patients belonged to the CP group, which were associated with ICU admission (aOR, 3.74; 95% CI, 1.38–10.13), and infection developing within 30 days after colonization (aOR, 3.34; 95% CI, 1.25–8.91).

Conclusions

Among VREfm colonizers, being admitted to ICU and receiving CVC or broad spectrum cephalosporins, were the risk factors for subsequent infections. These findings highlight the importance of conducting more strict infection control measures on specific groups of VREfm colonizers.