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Thampi N, Guzman-Cottrill J, Bartlett AH, Berg W, Cantey JB, Kitt E, Ravin K, Zangwill KM, Elward A. SHEA NICU white paper series: Practical approaches for the prevention of viral respiratory infections. Infect Control Hosp Epidemiol 2024; 45:267-276. [PMID: 37877172 DOI: 10.1017/ice.2023.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
This white paper provides clinicians and hospital leaders with practical guidance on the prevention and control of viral respiratory infections in the neonatal intensive care unit (NICU). This document serves as a companion to Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee (HICPAC)'s "Prophylaxis and Screening for Prevention of Viral Respiratory Infections in Neonatal Intensive Care Unit Patients: A Systematic Review." It provides practical, expert opinion and/or evidence-based answers to frequently asked questions about viral respiratory detection and prevention in the NICU. It was developed by a writing panel of pediatric and pathogen-specific experts who collaborated with members of the HICPAC systematic review writing panel and the SHEA Pediatric Leadership Council to identify questions that should be addressed. The document has been endorsed by SHEA, the American Hospital Association (AHA), The Joint Commission, the Pediatric Infectious Diseases Society (PIDS), the Association for Professionals in Infection Control and Epidemiology (APIC), the Infectious Diseases Society of America (IDSA), and the National Association of Neonatal Nurses (NANN).
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Affiliation(s)
- Nisha Thampi
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | - Allison H Bartlett
- University of Chicago and Comer Children's Hospital, Chicago, Illinois, USA
| | - Wendy Berg
- Children's Minnesota, St. Paul, Minnesota, USA
| | - Joseph B Cantey
- The University of Texas Health Science Center, San Antonio, Texas, USA
| | - Eimear Kitt
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Karen Ravin
- Nemours Children's Health, Wilmington, Delaware, USA
| | | | - Alexis Elward
- Washington University School of Medicine, St. Louis, Missouri, USA
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Carling PC, Parry MF, Olmstead R. Environmental approaches to controlling Clostridioides difficile infection in healthcare settings. Antimicrob Resist Infect Control 2023; 12:94. [PMID: 37679758 PMCID: PMC10483842 DOI: 10.1186/s13756-023-01295-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 08/25/2023] [Indexed: 09/09/2023] Open
Abstract
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.
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Prayag PS, Patwardhan SA, Panchakshari SP, Prayag AP. Clostridium difficile in Oncology Patients—Review of Diagnosis and Management in the Indian Setting. Indian J Med Paediatr Oncol 2023. [DOI: 10.1055/s-0042-1760316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
Abstract
Clostridoides (formerly Clostridium) difficile (C. difficile) is a toxin-producing, gram-positive anaerobic bacillus, commonly implicated in antibiotic-associated diarrhea and pseudomembranous colitis. The true burden of C. difficile infection is unclear in India, as it is likely underdiagnosed and underreported. Its incidence is much higher in oncology patients where it can contribute significantly to morbidity and mortality. There are several challenges in the Indian setting, including lack of uniform availability of testing infrastructure, as well as therapy. Oncology patients further present with a unique set of challenges. This article will review the approach to diagnosis and management of C. difficile-associated diarrhea in India, with a focus on oncology patients.
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Affiliation(s)
- Parikshit S Prayag
- Department of Infectious Diseases, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Sampada A Patwardhan
- Department of Microbiology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Shweta P Panchakshari
- Department of Infectious Diseases, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Amrita P Prayag
- Department of Research, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
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Jin T, Chen X, Nishio M, Zhuang L, Shiomi H, Tonosaki Y, Yokohata R, King MF, Kang M, Fujii K, Zhang N. Interventions to prevent surface transmission of an infectious virus based on real human touch behavior: a case study of the norovirus. Int J Infect Dis 2022; 122:83-92. [PMID: 35649497 PMCID: PMC9148625 DOI: 10.1016/j.ijid.2022.05.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES Infectious viruses (e.g., SARS-CoV-2, norovirus) can transmit through surfaces. Norovirus has infected millions of individuals annually. Interventions on norovirus transmission in high-risk indoor environment are important. METHODS This study focused on a restaurant in Guangzhou, China. More than 41,000 touches by both diners and staff members were collected using video cameras. A surface transmission model was developed and combined with these real human touch behaviors to analyze the effectiveness of different norovirus prevention strategies. RESULTS When the virus carrier was a diner, the virus intake fraction of diners in the same table was the highest. Increasing the touch frequency on personal private surfaces would reduce the virus exposure. The virus intake fraction was reduced by 18.4% on average if public surfaces were not touched. Optimization on surface materials could reduce the virus intake fraction by 86.6%. Additionally, disinfecting tablecloths, clothes of diners, and chairs were the three most effective surface disinfection strategies. CONCLUSION Controlling human touch behavior (e.g., reducing the self-touches on mucous membranes) is more effective than surface disinfection in controlling norovirus transmission, but surface disinfection cannot be ignored because human behavior is difficult to be controlled.
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Affiliation(s)
- Tianyi Jin
- Beijing Key Laboratory of Green Built Environment and Energy Efficient Technology, Beijing University of Technology, Beijing, China
| | - Xuguang Chen
- Guangdong Provincial Center for Disease Control and Prevention, Guangdong province, China
| | - Masaya Nishio
- R&D-Safety Science, Kao Corporation, Japan,R&D-Strategy, Kao Corporation, Japan
| | - Linan Zhuang
- Beijing Key Laboratory of Green Built Environment and Energy Efficient Technology, Beijing University of Technology, Beijing, China
| | - Hiroyuki Shiomi
- R&D-Processing Development Research Laboratories, Kao Corporation, Japan
| | - Yosuke Tonosaki
- R&D-Processing Development Research Laboratories, Kao Corporation, Japan
| | | | | | - Min Kang
- Guangdong Provincial Center for Disease Control and Prevention, Guangdong province, China
| | - Kenkichi Fujii
- R&D-Safety Science, Kao Corporation, Japan,R&D-Strategy, Kao Corporation, Japan
| | - Nan Zhang
- Beijing Key Laboratory of Green Built Environment and Energy Efficient Technology, Beijing University of Technology, Beijing, China,Corresponding author: Nan Zhang, Key Laboratory of Green Built Environment and Energy Efficient Technology, Beijing University of Technology, Room 204, Pingleyuan 100, Chaoyang District, Beijing, China, Telephone: +86 18210064566
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Parry MF, Sestovic M, Renz C, Pangan A, Grant B, Shah AK. Environmental cleaning and disinfection: Sustaining changed practice and improving quality in the community hospital. Antimicrob Steward Healthc Epidemiol 2022; 2:e113. [PMID: 36483421 PMCID: PMC9726550 DOI: 10.1017/ash.2022.257] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/06/2022] [Accepted: 06/06/2022] [Indexed: 06/17/2023]
Abstract
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.
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Affiliation(s)
- Michael F. Parry
- Division of Infectious Diseases, Department of Medicine, Stamford Health, Stamford, Connecticut
- Vagelos Columbia College of Physicians and Surgeons, New York, New York
| | - Merima Sestovic
- Infection Prevention Department, Stamford Health, Stamford, Connecticut
| | | | - Abegail Pangan
- Infection Prevention Department, Stamford Health, Stamford, Connecticut
| | - Brenda Grant
- Infection Prevention Department, Stamford Health, Stamford, Connecticut
| | - Asha K. Shah
- Division of Infectious Diseases, Department of Medicine, Stamford Health, Stamford, Connecticut
- Vagelos Columbia College of Physicians and Surgeons, New York, New York
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Purwar T, Dey S, Al-Kayyali OZA, Zalar AF, Doosttalab A, Castillo L, Castano VM. Electrostatic Spray Disinfection Using Nano-Engineered Solution on Frequently Touched Surfaces in Indoor and Outdoor Environments. Int J Environ Res Public Health 2022; 19:ijerph19127241. [PMID: 35742489 PMCID: PMC9223583 DOI: 10.3390/ijerph19127241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/24/2022] [Accepted: 06/09/2022] [Indexed: 02/01/2023]
Abstract
The COVID-19 pandemic has resulted in high demand for disinfection technologies. However, the corresponding spray technologies are still not completely optimized for disinfection purposes. There are important problems, like the irregular coverage and dripping of disinfectant solutions on hard and vertical surfaces. In this study, we highlight two major points. Firstly, we discuss the effectiveness of the electrostatic spray deposition (ESD) of nanoparticle-based disinfectant solutions for systematic and long-lasting disinfection. Secondly, we show that, based on the type of material of the substrate, the effectiveness of ESD varies. Accordingly, 12 frequently touched surface materials were sprayed using a range of electrostatic spray system parameters, including ion generator voltage, nozzle spray size and distance of spray. It was observed that for most cases, the surfaces become completely covered with the nanoparticles within 10 s. Acrylic, Teflon, PVC, and polypropylene surfaces show a distinct effect of ESD and non-ESD sprays. The nanoparticles form a uniform layer with better surface coverage in case of electrostatic deposition. Quantitative variations and correlations show that 1.5 feet of working distance, an 80 μm spray nozzle diameter and an ion generator voltage of 3–7 kV ensures a DEF (differential electric field) that corresponds to an optimized charge-to-mass ratio, ensuring efficient coverage of nanoparticles.
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Affiliation(s)
- Tanya Purwar
- School of Mechanical Engineering, Purdue University, West Lafayette, IN 47907, USA; (S.D.); (O.Z.A.A.-K.); (A.F.Z.); (A.D.); (L.C.)
- Correspondence:
| | - Shamya Dey
- School of Mechanical Engineering, Purdue University, West Lafayette, IN 47907, USA; (S.D.); (O.Z.A.A.-K.); (A.F.Z.); (A.D.); (L.C.)
| | - Osama Zaid Ali Al-Kayyali
- School of Mechanical Engineering, Purdue University, West Lafayette, IN 47907, USA; (S.D.); (O.Z.A.A.-K.); (A.F.Z.); (A.D.); (L.C.)
| | - Aaron Floyd Zalar
- School of Mechanical Engineering, Purdue University, West Lafayette, IN 47907, USA; (S.D.); (O.Z.A.A.-K.); (A.F.Z.); (A.D.); (L.C.)
| | - Ali Doosttalab
- School of Mechanical Engineering, Purdue University, West Lafayette, IN 47907, USA; (S.D.); (O.Z.A.A.-K.); (A.F.Z.); (A.D.); (L.C.)
| | - Luciano Castillo
- School of Mechanical Engineering, Purdue University, West Lafayette, IN 47907, USA; (S.D.); (O.Z.A.A.-K.); (A.F.Z.); (A.D.); (L.C.)
| | - Victor M. Castano
- Centro de Física Aplicada Tecnología Avanzada, Universidad Nacional Autónoma de México, Juriquilla, Querétaro 76230, Mexico;
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Huang J, Park GW, Jones RM, Fraser AM, Vinjé J, Jiang X. Efficacy of EPA-registered disinfectants against two human norovirus surrogates and Clostridioides difficile endospores. J Appl Microbiol 2022; 132:4289-4299. [PMID: 35279925 PMCID: PMC9119914 DOI: 10.1111/jam.15524] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/04/2022] [Accepted: 03/10/2022] [Indexed: 11/27/2022]
Abstract
AIMS To determine the efficacy of a panel of nine EPA-registered disinfectants against two human norovirus (HuNoV) surrogates (feline calicivirus [FCV] and Tulane virus [TuV]) and Clostridioides difficile endospores. METHODS AND RESULTS Nine EPA-registered products, five of which contained H2 O2 as active ingredient, were tested against infectious FCV, TuV and C. difficile endospores using two ASTM methods, a suspension and carrier test. Efficacy claims against FCV were confirmed for 8 of 9 products. The most efficacious product containing H2 O2 as ingredient achieved a >5.1 log reduction of FCV and >3.1 log reduction of TuV after 5 min, and >6.0 log reduction of C. difficile endospores after 10 min. Of the five products containing H2 O2 , no strong correlation (R2 = 0.25, p = 0.03) was observed between disinfection efficacy and H2 O2 concentration. Addition of 0.025% ferrous sulphate to 1% H2 O2 solution improved efficacy against FCV, TuV and C. difficile. CONCLUSION Disinfectants containing H2 O2 are the most efficacious disinfection products against FCV, TuV and C. difficile endospores. Product formulation, rather than the concentration of H2 O2 in a product, impacts the efficacy of a disinfection product. SIGNIFICANCE AND IMPACT OF STUDY H2 O2 -based disinfectants are efficacious against surrogate viruses for HuNoV and C. difficile endospores.
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Affiliation(s)
- Jinge Huang
- Department of Food, Nutrition, and Packaging Sciences, Clemson University, Clemson, South Carolina, USA
| | - Geun Woo Park
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Rachael M. Jones
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Angela M. Fraser
- Department of Food, Nutrition, and Packaging Sciences, Clemson University, Clemson, South Carolina, USA
| | - Jan Vinjé
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Xiuping Jiang
- Department of Food, Nutrition, and Packaging Sciences, Clemson University, Clemson, South Carolina, USA
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Zhao P, Wang Q, Wang P, Xiao S, Li Y. Influence of network structure on contaminant spreading efficiency. J Hazard Mater 2022; 424:127511. [PMID: 34688007 DOI: 10.1016/j.jhazmat.2021.127511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/03/2021] [Accepted: 10/12/2021] [Indexed: 06/13/2023]
Abstract
Contaminants, such as pathogens or non-living substances, can spread through the interaction of their carriers (e.g., air and surfaces), which constitute a network. The structure of such networks plays an important role in the contaminant spread. We measured the contaminant spreading efficiency in different networks using a newly defined parameter. We analyzed basic networks to identify the effect of the network structure on the contaminant spread. The spreading efficiency was highly related to some network parameters, such as the source node's average path length and degree, and considerably varied with the transfer rate per inter-node interaction. We compared the contaminant spreading efficiencies in some complex networks, namely scale-free, random, regular-lattice, and bipartite networks, with centralized, linear, and fractal networks. The contaminant spreading was particularly efficient in the fractal network when the transfer rate was ~0.5. Two categories of experiments were performed to validate the effect of the network structure on contaminant spreading in practical cases: (I) gas diffusion in multi-compartment cabins (II) bacteria transfer in multi-finger networks. The gas diffusion could be well estimated based on the diffusion between two compartments, and it was considerably affected by the network structure. Meanwhile, the bacteria spread was generally less efficient than expected.
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Affiliation(s)
- Pengcheng Zhao
- Department of Mechanical Engineering, The University of Hong Kong, Pokfulam, Hong Kong, China
| | - Qun Wang
- Department of Mechanical Engineering, The University of Hong Kong, Pokfulam, Hong Kong, China
| | - Peihua Wang
- Department of Mechanical Engineering, The University of Hong Kong, Pokfulam, Hong Kong, China
| | - Shenglan Xiao
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, China
| | - Yuguo Li
- Department of Mechanical Engineering, The University of Hong Kong, Pokfulam, Hong Kong, China; School of Public Health, The University of Hong Kong, Pokfulam, Hong Kong, China.
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9
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Xu J, Wang C, Fu SC, Chao CYH. The effect of head orientation and personalized ventilation on bioaerosol deposition from a cough. Indoor Air 2022; 32:e12973. [PMID: 34888956 DOI: 10.1111/ina.12973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 06/13/2023]
Abstract
Head orientations directly determine movement directions of exhaled pathogen-laden droplets, while there is a lack of research about the effect of the infected person's head orientations on respiratory disease transmission during close contact. This work experimentally investigated the effect of different head orientations of an infected person (IP) on the bioaerosol deposition on a healthy person (HP) during close contact. Also, the effectiveness of PV flow in reducing bioaerosol deposition on the HP under the IP's different head orientations was investigated. Bacteriophage T3 was employed to represent viruses inside the cough-generated aerosols. The bioaerosol depositions on different locations of the HP's upper body (chest, shoulder, and neck) and face (chin, mucous membranes, cheek, and forehead) were characterized by a cultivation method. Results showed that the IP's different head orientations resulted in significantly different deposition density on the HP. PV flow could reduce the bioaerosol deposition remarkably for most cases investigated. The effectiveness of PV flow in reducing deposition on the HP was significantly affected by the IP's head orientations. Findings suggest that changing head orientations can be a control measure to reduce the bioaerosol deposition. Personalized ventilation can be a potential method to reduce the bioaerosol deposition on the HP.
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Affiliation(s)
- Jingcui Xu
- Department of Mechanical and Aerospace Engineering, The Hong Kong University of Science and Technology, Hong Kong, China
- Department of Civil and Environmental Engineering, The Hong Kong Polytechnic University, Hong Kong, China
| | - Cunteng Wang
- Department of Mechanical and Aerospace Engineering, The Hong Kong University of Science and Technology, Hong Kong, China
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, China
| | - Sau Chung Fu
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, China
| | - Christopher Y H Chao
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, China
- Department of Building Environment and Energy Engineering, Department of Mechanical Engineering, The Hong Kong Polytechnic University, Hong Kong, China
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Rosenberg M, Visnapuu M, Saal K, Danilian D, Pärna R, Ivask A, Kisand V. Preparation and Characterization of Photocatalytically Active Antibacterial Surfaces Covered with Acrylic Matrix Embedded Nano-ZnO and Nano-ZnO/Ag. Nanomaterials (Basel) 2021; 11:3384. [PMID: 34947733 DOI: 10.3390/nano11123384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/04/2021] [Accepted: 12/10/2021] [Indexed: 12/22/2022]
Abstract
In the context of healthcare-acquired infections, microbial cross-contamination and the spread of antibiotic resistance, additional passive measures to prevent pathogen carryover are urgently needed. Antimicrobial high-touch surfaces that kill microbes on contact or prevent their adhesion could be considered to mitigate the spread. Here, we demonstrate that photocatalytic nano-ZnO- and nano-ZnO/Ag-based antibacterial surfaces with efficacy of at least a 2.7-log reduction in Escherichia coli and Staphylococcus aureus viability in 2 h can be produced by simple measures using a commercial acrylic topcoat for wood surfaces. We characterize the surfaces taking into account cyclic wear and variable environmental conditions. The light-induced antibacterial and photocatalytic activities of the surfaces are enhanced by short-term cyclic wear, indicating their potential for prolonged effectivity in long-term use. As the produced surfaces are generally more effective at higher relative air humidity and silver-containing surfaces lost their contact-killing properties in dry conditions, it is important to critically evaluate the end-use conditions of materials and surfaces to be tested and select application-appropriate methods for their efficacy assessment.
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Singh V, Narula H, Supehia S, Sharma M, Gupta PK, Sharma A, Rao S. Impact of Video Modules-Based Training on Knowledge, Attitude, and Practices of Cleaning and Disinfection Among Housekeeping Staff at a Tertiary Care Center During the COVID-19 Pandemic. Cureus 2021; 13:e19125. [PMID: 34868766 PMCID: PMC8627668 DOI: 10.7759/cureus.19125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2021] [Indexed: 11/24/2022] Open
Abstract
Aim To assess the knowledge, attitude, and practice toward cleaning and disinfection among housekeeping (HK) staff amid the coronavirus disease 2019 (COVID-19) pandemic. Methods A quasi-experimental was undertaken among HK staff at a tertiary care hospital. A 30-item structured questionnaire was used in the study, which consisted of questions pertaining to knowledge (11), attitude (8), and practice (11) toward cleaning and disinfection. Result One-hundred-two participants were included by convenient sampling, with mean age = 30-37 years. There was an improvement in pre-test and post-test knowledge (6.21 to 9.7) and practice score (9.97 to post-test 10.52). However, the attitude score did not show a significant change in the post-test score (p=0.964), showing that they were having a positive attitude toward the practices before training too. Conclusion Improvement in the post-test score shows that periodic targeted training sessions on cleaning and disinfection among housekeeping staff help improve their knowledge, attitude, and practices toward infection prevention and control (IPC) during the COVID-19 pandemic, thus minimizing the spread of the virus in a hospital environment, reducing their apprehension, and preparing them to work in such pandemic situations.
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Affiliation(s)
- Vanya Singh
- Microbiology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Himanshu Narula
- Microbiology, Rifleman Jaswant Singh Rawat (RJSH) COVID Hospital, All India Institute of Medical Sciences, Rishikesh, IND
| | - Sakshi Supehia
- Public Health, All India Institute of Medical Sciences, Rishikesh, IND
| | - Maneesh Sharma
- College of Nursing, All India Institute of Medical Sciences, Rishikesh, IND
| | - Puneet K Gupta
- Microbiology, All India Institute of Medical Sciences, Bilaspur, IND
| | - Anita Sharma
- Hospital Infection Control, All India Institute of Medical Sciences, Rishikesh, IND
| | - Shalinee Rao
- Pathology, All India Institute of Medical Sciences, Rishikesh, IND
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12
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Sood G, Perl TM. Outbreaks in Health Care Settings. Infect Dis Clin North Am 2021; 35:631-666. [PMID: 34362537 DOI: 10.1016/j.idc.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Outbreaks and pseudo-outbreaks in health care settings are complex and should be evaluated systematically using epidemiologic and molecular tools. Outbreaks result from failures of infection prevention practices, inadequate staffing, and undertrained or overcommitted health care personnel. Contaminated hands, equipment, supplies, water, ventilation systems, and environment may also contribute. Neonatal intensive care, endoscopy, oncology, and transplant units are areas at particular risk. Procedures, such as bronchoscopy and endoscopy, are sources of infection when cleaning and disinfection processes are inadequate. New types of equipment can be introduced and lead to contamination or equipment and medications can be contaminated at the manufacturing source.
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Affiliation(s)
- Geeta Sood
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Mason F. Lord Building, Center Tower, 3rd Floor, 5200 Eastern Avenue, Baltimore, MD 21224, USA.
| | - Trish M Perl
- Division of Infectious Diseases and Geographic Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Y7;302, Dallas, TX 75390, USA
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13
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Schoyer E, Hall K. Environmental Cleaning and Decontamination to Prevent Clostridioides difficile Infection in Health Care Settings: A Systematic Review. J Patient Saf 2020; 16:S12-5. [PMID: 32809996 DOI: 10.1097/PTS.0000000000000749] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Objective The aim of this systematic review was to examine the most effective and feasible methods for environmental cleaning and decontamination to prevent Clostridioides difficile infection (CDI) in health care settings. Methods A systematic search of the databases CINAHL and MEDLINE was conducted from 2008 to 2018 for English language articles with search terms including “Clostridium difficile,” and related medical subject headings, in combination with terms like “disinfection,” “decontamination,” and “no-touch decontamination.” Results Twelve studies and 2 systematic reviews were selected for inclusion in this review. The studies were primarily in hospitals (10/12) and used a before-after approach. The studied interventions included cleaning and decontamination with a chlorine-based agent (i.e., bleach; 2 studies), standard cleaning plus the use of hydrogen peroxide decontamination (3 studies), and standard bleach cleaning plus the use of ultraviolet light decontamination (6 studies), and there was 1 study about launderable bed covers. The interventions ranged in frequency, duration, and the area selected for cleaning and decontamination (e.g., all patient rooms versus only CDI patients’ rooms). Studies showed significant reductions in CDI associated with use of bleach (versus quaternary ammonium compound) and hydrogen peroxide decontamination after standard bleach cleaning (versus bleach cleaning alone). Four of 6 studies found significant reductions in CDI after the implementation of ultraviolet light decontamination after standard bleach cleaning. Conclusions The studied practices for environmental cleaning and decontamination were associated with significant decreases in facility-level CDI rates in most of the reviewed studies; however, study quality was low. Implementation challenges are worthy of further examination.
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Han Z, Pappas E, Simmons A, Fox J, Donskey CJ, Deshpande A. Environmental cleaning and disinfection of hospital rooms: A nationwide survey. Am J Infect Control 2021; 49:34-39. [PMID: 32798634 DOI: 10.1016/j.ajic.2020.08.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/06/2020] [Accepted: 08/07/2020] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Zheyi Han
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
| | - Ethan Pappas
- Medicine Institute Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH
| | - Adrienne Simmons
- Medicine Institute Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH
| | - Jacqueline Fox
- Medicine Institute Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH
| | - Curtis J Donskey
- Geriatric Research Education and Clinical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Abhishek Deshpande
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH; Medicine Institute Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH; Department of Infectious Diseases, Cleveland Clinic, Cleveland, OH.
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Boyce JM. A review of wipes used to disinfect hard surfaces in health care facilities. Am J Infect Control 2021; 49:104-114. [PMID: 32569612 DOI: 10.1016/j.ajic.2020.06.183] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 06/13/2020] [Accepted: 06/15/2020] [Indexed: 11/25/2022]
Abstract
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.
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Alhmidi H, Cadnum JL, Koganti S, Jencson AL, Bonomo RA, Wilson BM, Mayer J, Samore MH, Donskey CJ. Shedding of multidrug-resistant gram-negative bacilli by colonized patients during procedures and patient care activities. Am J Infect Control 2020; 48:1336-40. [PMID: 32522609 DOI: 10.1016/j.ajic.2020.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 06/01/2020] [Accepted: 06/01/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Medical procedures and patient care activities may facilitate environmental shedding of health care-associated pathogens. METHODS We conducted a cohort study of hospitalized patients in contact precautions for carriage of extended-spectrum beta-lactamase (ESBL)-producing gram-negative bacilli (N = 38) or carbapenem-resistant gram-negative bacilli (CR-GNB) (N = 22) to determine the frequency of environmental shedding during procedures and care activities. Perirectal, wound, and skin were cultured for ESBL-producing and CR-GNB. High-touch surfaces and portable equipment were disinfected before and cultured after procedures; control cultures were collected in the absence of procedures. RESULTS Of 60 patients enrolled, 34 (57%) had positive perirectal and/or skin or wound cultures. For these 34 patients, 15 (44%) shed their colonizing organism to surfaces during 1 or more procedures. Patients with shedding had significantly higher concentrations of the pathogens recovered from perirectal swabs than those with no shedding (mean, 3.5 vs 2.2 log10 colony-forming units per swab; P < .01). Environmental shedding occurred more frequently during procedures and care activities than in the absence of a procedure (21 of 117, 18% vs 1 of 61, 2%; P < .01), and 6 of 56 (10%) portable devices used for procedures became contaminated. CONCLUSIONS Environmental shedding of antibiotic-resistant gram-negative bacilli occurs frequently during medical procedures and patient care activities. Decontamination of surfaces and equipment and approaches that reduce the burden of carriage could reduce the risk for dissemination.
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Branch R, Amiri A. Environmental Surface Hygiene in the OR: Strategies for Reducing the Transmission of Health Care-Associated Infections. AORN J 2020; 112:327-342. [PMID: 32990964 DOI: 10.1002/aorn.13175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
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.
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Kukla M, Adrych K, Dobrowolska A, Mach T, Reguła J, Rydzewska G. Guidelines for Clostridium difficile infection in adults. Prz Gastroenterol 2020; 15:1-21. [PMID: 32215122 PMCID: PMC7089862 DOI: 10.5114/pg.2020.93629] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/17/2020] [Indexed: 12/16/2022]
Abstract
Clostridium difficile infection (CDI) has become a serious medical and epidemiological problem, especially in well developed countries. There has been evident increase in incidence and severity of CDI. Prevention, proper diagnosis and effective treatment are necessary to reduce the risk for the patients, deplete the spreading of infection and diminish the probability of recurrent infection. Antibiotics are the fundamental treatment of CDI. In patients who had recurrent CDI fecal microbiota transplantation seems to be promising and efficient strategy. These guidelines systematize existing data and include recent changes implemented in the management of CDI.
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Affiliation(s)
- Michał Kukla
- Department of Internal Medicine and Geriatrics, Jagiellonian University Medical College, Krakow, Poland
- Department of Endoscopy, University Hospital, Krakow, Poland
| | - Krystian Adrych
- Department of Gastroenterology and Hepatology, Medical University of Gdansk, Gdansk, Poland
| | - Agnieszka Dobrowolska
- Department of Gastroenterology, Dietetics and Internal Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Tomasz Mach
- Department of Gastroenterology, Hepatology and Infectious Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Jarosław Reguła
- Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Postgraduate Education Centre, Warsaw, Poland
- Department of Gastrointestinal Oncology, “Maria Sklodowska-Curie” Clinical Oncology Institute, Warsaw, Poland
| | - Grażyna Rydzewska
- Central Clinical Hospital of Ministry of Inferior and Administration, Warsaw, Poland
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland
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Abstract
The Gram-positive, spore-forming bacterium, Clostridioides difficile is the leading cause of healthcare-associated infections in the United States, although it also causes a significant number of community-acquired infections. C. difficile infections, which range in severity from mild diarrhea to toxic megacolon, cost more to treat than matched infections, with an annual treatment cost of approximately $6 billion for almost half-a-million infections. These high-treatment costs are due to the high rates of C. difficile disease recurrence (>20%) and necessity for special disinfection measures. These complications arise in part because C. difficile makes metabolically dormant spores, which are the major infectious particle of this obligate anaerobe. These seemingly inanimate life forms are inert to antibiotics, resistant to commonly used disinfectants, readily disseminated, and capable of surviving in the environment for a long period of time. However, upon sensing specific bile salts in the vertebrate gut, C. difficile spores transform back into the vegetative cells that are responsible for causing disease. This review discusses how spores are ideal vectors for disease transmission and how antibiotics modulate this process. We also describe the resistance properties of spores and how they create challenges eradicating spores, as well as promote their spread. Lastly, environmental reservoirs of C. difficile spores and strategies for destroying them particularly in health care environments will be discussed.
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Affiliation(s)
- Aimee Shen
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, Massachusetts
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Song X, Cvelbar U, Strazar P, Vossebein L, Zille A. Antimicrobial Efficiency and Surface Interactions of Quaternary Ammonium Compound Absorbed on Dielectric Barrier Discharge (DBD) Plasma Treated Fiber-Based Wiping Materials. ACS Appl Mater Interfaces 2020; 12:298-311. [PMID: 31816226 DOI: 10.1021/acsami.9b18746] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The physicochemical interactions between alkyldimethylbenzylammonium chloride (ADBAC) as disinfectant and three commercial wiping materials made from 100% polyester (PET), 55%cellulose/45%PET (blend), and 100% cellulose were investigated after treatment with dielectric barrier discharge (DBD) plasma at atmospheric pressure. Wipe material type in terms of cellulose content, liquor ratio, and immersion time demonstrated a significant influence on the adsorption of ADBAC. The higher the content of cellulose in the material, the higher is the adsorption of ADBAC active ingredient. The antimicrobial tests confirm that the ADBAC adsorbed on pure cellulosic material is inactivated losing its bactericidal activity, while 100% PET and blend wipes showed good antimicrobial efficacy. XPS analysis demonstrates the strong interactions of ADBAC with the plasma-generated oxygen species in the polyester-containing wipes surface. Unexpectedly, plasma-treated blend wipe displays a reverse antimicrobial effect compared to untreated samples, performing better in Gram-negative bacteria. The best result was obtained in the plasma treated 100% polyester wipe showing an improvement of about 20% in Gram-positive bacteria and an excellent performance in Gram-negative ones. This method allows the unprecedented use of pure polyester as effective wiping material for surface disinfection eliminating the major drawback of pure polyester, its high hydrophobicity.
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Affiliation(s)
- Xinyu Song
- 2C2T - Centro de Ciência e Tecnologia Têxtil , Universidade do Minho , Campus de Azurém , 4800-058 Guimarães , Portugal
| | - Uros Cvelbar
- Jozef Stefan Institute , Jamova cesta 39 , SI-1000 Ljubljana , Slovenia
| | - Petra Strazar
- Jozef Stefan Institute , Jamova cesta 39 , SI-1000 Ljubljana , Slovenia
| | - Lutz Vossebein
- Faculty of Textile and Clothing Technology , Niederrhein University of Applied Sciences , Webschulstrasse 31 , 41065 Mönchengladbach , Germany
| | - Andrea Zille
- 2C2T - Centro de Ciência e Tecnologia Têxtil , Universidade do Minho , Campus de Azurém , 4800-058 Guimarães , Portugal
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Nana T, Moore C, Boyles T, Brink AJ, Cleghorn J, Devenish LM, du Toit B, Fredericks ES, Lekalakala-Mokaba MR, Maluleka C, Rajabally MN, Reubenson G, Shuping L, Swart K, Swe Han KS, Wadula J, Wojno J, Lowman W. South African Society of Clinical Microbiology Clostridioides difficile infection diagnosis, management and infection prevention and control guideline. S Afr J Infect Dis 2020; 35:219. [PMID: 34485483 PMCID: PMC8378053 DOI: 10.4102/sajid.v35i1.219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/24/2020] [Indexed: 12/17/2022] Open
Abstract
Clostridioides difficile infection (CDI) is a problem in both developed and developing countries and is a common hospital-acquired infection. This guideline provides evidence-based practical recommendations for South Africa and other developing countries. The scope of the guideline includes CDI diagnostic approaches; adult, paediatric and special populations treatment options; and surveillance and infection prevention and control recommendations.
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Affiliation(s)
- Trusha Nana
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Charlotte Maxeke Johannesburg Academic Hospital Microbiology Laboratory, National Health Laboratory Services, Johannesburg, South Africa
| | | | - Tom Boyles
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Adrian J. Brink
- Department of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Joy Cleghorn
- Life Healthcare Group, Johannesburg, South Africa
| | - Lesley M. Devenish
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Infection Control Services Laboratory, National Health Laboratory Services, Johannesburg, South Africa
| | | | - Ernst S. Fredericks
- Department of Physiology, Faculty of Science, Nelson Mandela University, Port Elizabeth, South Africa
| | - Molebogeng R. Lekalakala-Mokaba
- Department of Microbiology, Faculty of Health Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
- Dr George Mukhari Academic Hospital Microbiology Laboratory, National Health Laboratory Services, Pretoria, South Africa
| | - Caroline Maluleka
- Department of Microbiology, Faculty of Health Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
- Dr George Mukhari Academic Hospital Microbiology Laboratory, National Health Laboratory Services, Pretoria, South Africa
| | | | - Gary Reubenson
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Liliwe Shuping
- Centre for Healthcare-Associated Infections, National Institute for Communicable Diseases, a division of National Health Laboratory Service, Johannesburg, South Africa
| | - Karin Swart
- Netcare Hospitals Limited, Johannesburg, South Africa
| | - Khine Swe Swe Han
- Medical Microbiology Department, Inkosi Albert Luthuli Central Hospital Academic Complex, National Health Laboratory Services, Durban, South Africa
- Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Jeannette Wadula
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Chris Hani Baragwanath Hospital Microbiology Laboratory, National Health Laboratory Services, Johannesburg, South Africa
| | | | - Warren Lowman
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Clinical Microbiology, PathCare/Vermaak Pathologists, Johannesburg, South Africa
- Department of Clinical Microbiology and Infection Prevention and Control, WITS Donald Gordon Medical Centre, Johannesburg, South Africa
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McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, Dubberke ER, Garey KW, Gould CV, Kelly C, Loo V, Shaklee Sammons J, Sandora TJ, Wilcox MH. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2019; 66:e1-e48. [PMID: 29462280 DOI: 10.1093/cid/cix1085] [Citation(s) in RCA: 1199] [Impact Index Per Article: 239.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.
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Affiliation(s)
| | | | - Stuart Johnson
- Edward Hines Jr Veterans Administration Hospital, Hines.,Loyola University Medical Center, Maywood, Illinois
| | | | - Karen C Carroll
- Johns Hopkins University School of Medicine, Baltimore, Maryl
| | | | - Erik R Dubberke
- Washington University School of Medicine, St Louis, Missouri
| | | | - Carolyn V Gould
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ciaran Kelly
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vivian Loo
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
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Song X, Vossebein L, Zille A. Efficacy of disinfectant-impregnated wipes used for surface disinfection in hospitals: a review. Antimicrob Resist Infect Control 2019; 8:139. [PMID: 31452873 PMCID: PMC6701098 DOI: 10.1186/s13756-019-0595-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 08/12/2019] [Indexed: 12/21/2022] Open
Abstract
Background "Ready-to-use" disinfecting wipes (also known as pre-impregnated disinfecting wipe) are broadly used in food industry and domestic situations. Their application in hospitals and healthcare centres for decontamination of medical devices and surfaces is steadily increasing because of their convenient implementation in practice and reliable performance. Beside their acceptable compliance and easy application, literature reported the disinfection failure due to the interaction between textile substrate and active ingredients, which can highly increase the risk of an infection outbreak. This review aims to call attention to the wide range of variables affecting the disinfectant-impregnated wipes' (DIWs) disinfection performances in hospitals. Methods A systematic literature search based on the five categories i. wipes, ii. disinfectants, iii. Application methods, iv. interaction between wipes and active ingredients and v. wiping strategy which can possibly influence the disinfection effectiveness of DIWs was conducted by Google scholar. Studies regarding the efficacy evaluation of DIWs in clinical applications were also reviewed from the National Centre for Biotechnology Information database. Results Variables that impact on the disinfection performance of disinfectant-impregnated wipes in surface disinfection in hospitals were summarised and critically discussed. In addition to the information, current disinfectant-impregnated wipes' decontamination efficacy test standards were reviewed, and different standards exposed some disadvantage in their testing design. Conclusion Various parameters contribute to the impact of DIWs disinfection performance in practice. The interaction between disinfectant active ingredients and the wiping materials barricades their broad application in hospitals. More studies of the DIWs' disinfection efficacy in clinical practice are in need. Current standards evaluating the DIWs' efficacy are required to improve for more realistic condition simulation and differentiating between mechanical removal of inoculum from a surface and chemical inactivation of the test microbe.
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Affiliation(s)
- Xinyu Song
- 2C2T – Centro de Ciência e Tecnologia Têxtil, Universidade do Minho, Campus de Azurém, 4800-058 Guimarães, Portugal
| | - Lutz Vossebein
- Faculty of Textile and Clothing Technology, Niederrhein University of Applied Sciences, Webschulstrasse 31, 41065 Mönchengladbach, Germany
| | - Andrea Zille
- 2C2T – Centro de Ciência e Tecnologia Têxtil, Universidade do Minho, Campus de Azurém, 4800-058 Guimarães, Portugal
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24
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Hygienemaßnahmen bei Clostridioides difficile-Infektion (CDI): Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 62:906-23. [DOI: 10.1007/s00103-019-02959-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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25
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Montoya A, Schildhouse R, Goyal A, Mann JD, Snyder A, Chopra V, Mody L. How often are health care personnel hands colonized with multidrug- resistant organisms? A systematic review and meta-analysis. Am J Infect Control 2019; 47:693-703. [PMID: 30527283 DOI: 10.1016/j.ajic.2018.10.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/16/2018] [Accepted: 10/17/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hands of health care personnel (HCP) can transmit multidrug-resistant organisms (MDROs), resulting in infections. Our aim was to determine MDRO prevalence on HCP hands in adult acute care and nursing facility settings. METHODS A systematic search of PubMed/MEDLINE, Web of Science, CINAHL, Embase, and Cochrane CENTRAL was performed. Studies were included if they reported microbiologic culture results following HCP hands sampling; included prevalent MDROs, such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus, Clostridium difficile, Acinetobacter baumannii, or Pseudomonas aeruginosa, and were conducted in acute care or nursing facility settings. RESULTS Fifty-nine articles comprising 6,840 hand cultures were included. Pooled prevalence for MRSA, P aeruginosa, A baumannii, and vancomycin-resistant Enterococcus were 4.26%, 4.59%, 6.18%, and 9.03%, respectively. Substantial heterogeneity in rates of pathogen isolation were observed across studies (I2 = 81%-95%). Only 4 of 59 studies sampled for C difficile, with 2 of 4 finding no growth. Subgroup analysis of MRSA revealed the highest HCP hand contamination rates in North America (8.28%). Sample collection methods used were comparable for MRSA isolation (4%-7%) except for agar direct contact (1.55%). CONCLUSIONS Prevalence of common MDROs on HCP hands vary by pathogen, care setting, culture acquisition method, study design, and geography. When obtained at an institutional level, these prevalence data can be utilized to enhance knowledge, practice, and research to prevent health care-associated infections.
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Affiliation(s)
- Ana Montoya
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI.
| | - Richard Schildhouse
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI; Division of General Medicine,Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Anupama Goyal
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI
| | - Jason D Mann
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI
| | - Ashley Snyder
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI
| | - Vineet Chopra
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI; Division of General Medicine,Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI; Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
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Abstract
The contaminated surface environment in the rooms of hospitalized patients is an important risk factor for the colonization and infection of patients with multidrug-resistant pathogens. Improved terminal cleaning and disinfection have been demonstrated to reduce the incidence of health care-associated infections. In the United States, hospitals generally perform daily cleaning and disinfection of patient rooms. However, cleaning and disinfection are limited by the presence of the patient in room (eg, current ultraviolet devices and hydrogen peroxide systems cannot be used) and the fact that after disinfection pathogenic bacteria rapidly recolonize surfaces and medical devices/equipment. For this reason, there has been great interest in developing methods of continuous room disinfection and/or "self-disinfecting" surfaces. This study will review the research on self-disinfecting surfaces (eg, copper-coated surfaces and persistent chemical disinfectants) and potential new room disinfection methods (eg, "blue light" and diluted hydrogen peroxide systems).
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27
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Abstract
"No-touch" decontamination devices are increasingly used as an adjunct to standard cleaning and disinfection in health care facilities. Although there is evidence that these devices are effective in reducing contamination, there are several areas of controversy regarding their use. This review addresses some of the questions frequently posed by infection prevention and environmental services personnel about decontamination devices.
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Affiliation(s)
- Curtis J Donskey
- Geriatric Research, Education and Clinical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH.
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Alhmidi H, Cadnum JL, Koganti S, Jencson AL, Rutter JD, Bonomo RA, Wilson BM, Mayer J, Samore MH, Donskey CJ. Shedding of methicillin-resistant Staphylococcus aureus by colonized patients during procedures and patient care activities. Infect Control Hosp Epidemiol 2019; 40:328-32. [PMID: 30777587 DOI: 10.1017/ice.2018.342] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Medical procedures and patient care activities may facilitate environmental dissemination of healthcare-associated pathogens such as methicillin-resistant Staphylococcus aureus (MRSA). DESIGN Observational cohort study of MRSA-colonized patients to determine the frequency of and risk factors for environmental shedding of MRSA during procedures and care activities in carriers with positive nares and/or wound cultures. Bivariate analyses were performed to identify factors associated with environmental shedding. SETTING A Veterans Affairs hospital. PARTICIPANTS This study included 75 patients in contact precautions for MRSA colonization or infection. RESULTS Of 75 patients in contact precautions for MRSA, 55 (73%) had MRSA in nares and/or wounds and 25 (33%) had positive skin cultures. For the 52 patients with MRSA in nares and/or wounds and at least 1 observed procedure, environmental shedding of MRSA occurred more frequently during procedures and care activities than in the absence of a procedure (59 of 138, 43% vs 8 of 83, 10%; P 0.9 m from the patient (52 of 138, 38% vs 25 of 138, 18%; P = .0004). Contamination occurred frequently on surfaces touched by personnel (12 of 38, 32%) and on portable equipment used for procedures (25 of 101, 25%). By bivariate analysis, the presence of a wound with MRSA was associated with shedding (17 of 29, 59% versus 6 of 23, 26%; P = .04). CONCLUSIONS Environmental shedding of MRSA occurs frequently during medical procedures and patient care activities. There is a need for effective strategies to disinfect surfaces and equipment after procedures.
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Garvey MI, Wilkinson MAC, Bradley CW, Holden KL, Holden E. Wiping out MRSA: effect of introducing a universal disinfection wipe in a large UK teaching hospital. Antimicrob Resist Infect Control 2018; 7:155. [PMID: 30574298 PMCID: PMC6299988 DOI: 10.1186/s13756-018-0445-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 12/03/2018] [Indexed: 11/23/2022] Open
Abstract
Background Contamination of the inanimate environment around patients constitutes an important reservoir of MRSA. Here we describe the effect of introducing a universal disinfection wipe in all wards on the rates of MRSA acquisitions and bacteraemias across a large UK teaching hospital. Methods A segmented Poisson regression model was used to detect any significant changes in the monthly numbers per 100,000 bed days of MRSA acquisitions and bacteraemias from April 2013 - December 2017 across QEHB. Results From April 2013 to April 2016, cleaning of ward areas and multi-use patient equipment by nursing staff consisted of a two-wipe system. Firstly, a detergent wipe was used, which was followed by a disinfection step using an alcohol wipe. In May 2016, QEHB discontinued the use of a two-wipe system for cleaning and changed to a one wipe system utilising a combined cleaning and disinfection wipe containing a quaternary ammonium compound. The segmented Poisson regression model demonstrated that the rate of MRSA acquisition/100,000 patient bed days was affected by the introduction of the new wiping regime (20.7 to 9.4 per 100,000 patient bed days; p <0.005). Discussion Using a Poisson model we demonstrated that the average hospital acquisition rate of MRSA/100,000 patient bed days reduced by 6.3% per month after the introduction of the new universal wipe. Conclusion We suggest that using a simple one wipe system for nurse cleaning is an effective strategy to reduce the spread and incidence of healthcare associated MRSA.
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Affiliation(s)
- Mark I. Garvey
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, B15 2WB England
- Institute of Microbiology and Infection, The University of Birmingham, Edgbaston, Birmingham, England
| | - Martyn A. C. Wilkinson
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, B15 2WB England
| | - Craig W. Bradley
- Gloucestershire Hospital’s NHS Foundation Trust, Gloucester Royal Hospital, Great Western Road, Gloucester, GL1 3NN England
| | - Kerry L. Holden
- Gloucestershire Hospital’s NHS Foundation Trust, Gloucester Royal Hospital, Great Western Road, Gloucester, GL1 3NN England
| | - Elisabeth Holden
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, B15 2WB England
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Zhang N, Li Y, Huang H. Surface touch and its network growth in a graduate student office. Indoor Air 2018; 28:963-972. [PMID: 30178613 DOI: 10.1111/ina.12505] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 08/16/2018] [Accepted: 08/28/2018] [Indexed: 06/08/2023]
Abstract
Fomites transmit infection. A key question is how surface contamination in a building is spread by human touch. Using video cameras, we collected more than 120 000 touch actions from 60 hours of high-resolution data on surface touch across five typical weekdays in a graduate student office. The students touched surfaces with one or both hands during 94.6% of the observed period. On average, each student made five touches per minute, with an average duration of 22 seconds per touch. High-touch and high-risk surfaces and people were identified. 98.8% of the surfaces touched, such as mobile phones and human faces, were private, but public surfaces, such as a water dispenser button, were touched by 68% of the students in the office on average. Compared with females, males spent 3% more time touching surfaces. Right hands always had higher touch frequency than left hands. The surface network in the office was scale-free, whereas the hand network was small-world. The results revealed power law and logistic growth in the number of contaminated surfaces which suggests that fomite transmission can be extremely effective. The time taken for most surfaces to be contaminated after one surface became contaminated was much shorter for public than for private surfaces.
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Affiliation(s)
- Nan Zhang
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, China
| | - Yuguo Li
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, China
| | - Hong Huang
- Institute of Public Safety Research, Department of Engineering Physics, Tsinghua University, Beijing, China
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Siani H, Wesgate R, Maillard JY. Impact of antimicrobial wipes compared with hypochlorite solution on environmental surface contamination in a health care setting: A double-crossover study. Am J Infect Control 2018; 46:1180-1187. [PMID: 29759641 DOI: 10.1016/j.ajic.2018.03.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 03/27/2018] [Accepted: 03/27/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Antimicrobial wipes are increasingly used in health care settings. This study evaluates, in a clinical setting, the efficacy of sporicidal wipes versus a cloth soaked in a 1,000 ppm chlorine solution. INTERVENTION A double-crossover study was performed on 2 different surgical and cardiovascular wards in a 1,000-bed teaching hospital over 29 weeks. The intervention period that consisted of surface decontamination with the preimpregnated wipe or cloth soaked in chlorine followed a 5-week baseline assessment of microbial bioburden on surfaces. Environmental samples from 11 surfaces were analyzed weekly for their microbial content. RESULTS A total of 1,566 environmental samples and 1,591 ATP swabs were analyzed during the trial. Overall, there were significant differences in the recovery of total aerobic bacteria (P < .001), total anaerobic bacteria (P < .001), and ATP measurement (P < .001) between wards and between the different parts of the crossover study. Generally, the use of wipes produced the largest reduction in the total aerobic and anaerobic counts when compared with the baseline data or the use of 1,000 ppm chlorine. Collectively, the introduction of training plus daily wipe disinfection significantly reduced multidrug-resistant organisms recovered from surfaces. Reversion to using 1,000 ppm chlorine resulted in the number of sites positive for multidrug-resistant organisms rising again. CONCLUSIONS This double-crossover study is the first controlled field trial comparison of using preimpregnated wipes versus cotton cloth dipped into a bucket of hypochlorite to decrease surface microbial bioburden. The results demonstrate the superiority of the preimpregnated wipes in significantly decreasing microbial bioburden from high-touch surfaces.
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Affiliation(s)
- Harsha Siani
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK
| | - Rebecca Wesgate
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK
| | - Jean-Yves Maillard
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK.
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Wesgate R, Robertson A, Barrell M, Teska P, Maillard JY. Impact of test protocols and material binding on the efficacy of antimicrobial wipes. J Hosp Infect 2018; 103:e25-e32. [PMID: 30273639 DOI: 10.1016/j.jhin.2018.09.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/24/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND The use of effective cleaning/disinfectant products is important to control pathogens on healthcare surfaces. With the increasing number of wipe products available, there is a concern that combination of a formulation with the wrong material will decrease the efficacy of the product. This study aimed to use a range of efficacy test protocols to determine the efficacy of four formulations before and after binding to three commonly used wiping materials. METHODS Two quaternary ammonium (QAC)-based products, one hydrogen-peroxide-based product and one neutral cleaner were combined with microfibre, cotton or non-woven materials and tested for efficacy against Pseudomonas aeruginosa and Staphylococcus aureus with two surface tests (ASTM E2197-17 and EN13697-15) and two 'product' tests (ASTM E2967-15 and EN16615-15). FINDINGS Overall, the impact of using different materials on formulation efficacy was limited, except for an alkyl(C12-16)dimethylbenzylammonium chloride-based product used at 0.5% v/v. The hydrogen peroxide product was the most efficacious regardless of the material used. The results from wipe test ASTM E2967-15 were consistent with those from the surface tests, but not with EN16615-15 which was far less stringent. CONCLUSIONS The use of different wiping cloth materials may not impact severely on the efficacy of potent disinfectants, despite the absorption of different volumes of formulation by the materials. QAC-based formulations may be at higher risk when a low concentration is used. There were large differences in efficacy depending on the standard test performed, highlighting the need for more stringency in choosing the test to make a product claim on label.
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Affiliation(s)
- R Wesgate
- Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK
| | - A Robertson
- Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK
| | - M Barrell
- Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK
| | - P Teska
- Diversey Inc., Charlotte, NC, USA
| | - J-Y Maillard
- Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK.
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Saeb A, Mody L, Gibson K. How are nursing homes cleaned? Results of a survey of 6 nursing homes in Southeast Michigan. Am J Infect Control 2017; 45:e119-e122. [PMID: 28958448 DOI: 10.1016/j.ajic.2017.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 08/15/2017] [Accepted: 08/15/2017] [Indexed: 11/30/2022]
Abstract
This brief report details 2 surveys that were conducted to better understand current cleaning practices in 6 nursing home facilities in Southeast Michigan. Each facility's environmental services supervisor answered questions regarding cleaning policy and procedures, roles and responsibilities of the staff, and frequency of education and training; one environmental services employee from each facility answered questions addressing education and training, employer evaluation and feedback, and workload. We identify gaps in knowledge and behaviors and note substantial variations in cleaning practices.
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Affiliation(s)
- Aya Saeb
- Division of Geriatric and Palliative Care Medicine, University of Michigan Medical School, Ann Arbor, MI; Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Lona Mody
- Division of Geriatric and Palliative Care Medicine, University of Michigan Medical School, Ann Arbor, MI; Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Kristen Gibson
- Division of Geriatric and Palliative Care Medicine, University of Michigan Medical School, Ann Arbor, MI.
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Lei H, Li Y, Xiao S, Yang X, Lin C, Norris SL, Wei D, Hu Z, Ji S. Logistic growth of a surface contamination network and its role in disease spread. Sci Rep 2017; 7:14826. [PMID: 29093534 PMCID: PMC5665872 DOI: 10.1038/s41598-017-13840-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 10/02/2017] [Indexed: 12/15/2022] Open
Abstract
Surfaces and objects surround us, and touching them is integral to everyday life. Pathogen contaminated surfaces (fomites) are known to transmit diseases. However, little is known about the ways and speed at which surfaces become contaminated. We found that under certain conditions, the number of contaminated surfaces grows logistically, corresponding to possible rapid transmission of infection. In such a surface network, pathogen can be transmitted great distances quickly-as far as people move. We found that the surface contamination network in aircraft cabins exhibits a community structure, with small communities connected by the aisle seatback surfaces and toilets, which are high-touch surfaces. In less than two to three hours, most high-touch surfaces in the cabin are contaminated, and within five to six hours nearly all touchable surfaces are contaminated. During short haul flight, aisle passengers have higher fomite exposure. This closely matches the spatial infection pattern of one reported inflight norovirus outbreaks. Our model is generally applicable to other crowded settings. The commonly repeated advice to "wash hands frequently" may be replaced in future by more strategic advice such as "clean surfaces right now", or advice based on who should wash their hands, and when.
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Affiliation(s)
- Hao Lei
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, SAR, China
| | - Yuguo Li
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, SAR, China.
| | - Shenglan Xiao
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, SAR, China
| | - Xinyan Yang
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, SAR, China
| | - ChaoHsin Lin
- Environmental Control Systems, Boeing Commercial Airplanes, Everett, WA, USA
| | - Sharon L Norris
- Environmental Control Systems, Boeing Commercial Airplanes, Everett, WA, USA
| | - Daniel Wei
- Environmental Control Systems, Boeing Commercial Airplanes, Everett, WA, USA
| | - Zhongmin Hu
- Beijing Aeronautical Science & Technology Research Institute of COMAC, Beijing, China
| | - Shengcheng Ji
- Beijing Aeronautical Science & Technology Research Institute of COMAC, Beijing, China
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Abstract
PURPOSE OF REVIEW Cleaning and disinfection in healthcare facilities is essential to ensure patient safety. This review examines practical strategies used to assess and improve the effectiveness of daily and post-discharge manual cleaning in healthcare facilities. RECENT FINDINGS Effective implementation of cleaning interventions requires objective monitoring of staff performance with regular feedback on performance. Use of fluorescent markers to assess thoroughness of cleaning and measurement of residual ATP can provide rapid and objective feedback to personnel and have been associated with improved cleaning. Direct observation of cleaning and interviews with front-line staff are useful to identify variations and deficiencies in practice that may not be detected by other methods. Although not recommended for routine monitoring, cultures can be helpful for outbreak investigations. Monitoring and feedback can be effective in improving cleaning and disinfection in healthcare facilities. Ongoing commitment within institutions is needed to sustain successful cleaning and disinfection programs.
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Affiliation(s)
- Abhishek Deshpande
- Department of Medicine, Medicine Institute Center for Value Based Care Research, Cleveland Clinic, Cleveland, OH, 44195, USA. .,Department of Infectious Disease, Cleveland Clinic, Cleveland, OH, 44195, USA.
| | - Curtis J Donskey
- Geriatric Research, Education and Clinical Center, Cleveland Veterans Affairs Medical Center, Cleveland, OH, 44106, USA
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Affiliation(s)
- Philip C Carling
- Department of Infectious Diseases, Carney Hospital, 2100 Dorchester Avenue, Boston, MA 02124, USA.
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Affiliation(s)
- Geeta Sood
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Mason F. Lord Building Center Tower, 3rd Floor, 5200 Eastern Avenue, Baltimore, MD 21224, USA.
| | - Trish M Perl
- Bloomberg School of Public Health, Johns Hopkins School of Medicine, 725 North Wolfe Street, Suite 228 PCTB, Baltimore, MD 21205, USA
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Barker A, Ngam C, Musuuza J, Vaughn VM, Safdar N. Reducing Clostridium difficile in the Inpatient Setting: A Systematic Review of the Adherence to and Effectiveness of C. difficile Prevention Bundles. Infect Control Hosp Epidemiol 2017; 38:639-650. [PMID: 28343455 PMCID: PMC5654380 DOI: 10.1017/ice.2017.7] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is the most common infectious cause of nosocomial diarrhea, and its prevention is an urgent public health priority. However, reduction of CDI is challenging because of its complex pathogenesis, large reservoirs of colonized patients, and the persistence of infectious spores. The literature lacks high-quality evidence for evaluating interventions, and many hospitals have implemented bundled interventions to reduce CDI with variable results. Thus, we conducted a systematic review to examine the components of CDI bundles, their implementation processes, and their impact on CDI rates. METHODS We conducted a comprehensive literature search of multiple computerized databases from their date of inception through April 30, 2016. The protocol was registered in PROSPERO, an international prospective register of systematic reviews. Bundle effectiveness, adherence, and study quality were assessed for each study meeting our criteria for inclusion. RESULTS In the 26 studies that met the inclusion criteria for this review, implementation and adherence factors to interventions were variably and incompletely reported, making study reproducibility and replicability challenging. Despite contextual differences and the variety of bundle components utilized, all 26 studies reported an improvement in CDI rates. However, given the lack of randomized controlled trials in the literature, assessing a causal relationship between bundled interventions and CDI rates is currently impossible. CONCLUSION Cluster randomized trials that include a rigorous assessment of the implementation of bundled interventions are urgently needed to causally test the effect of intervention bundles on CDI rates. Infect Control Hosp Epidemiol 2017;38:639-650.
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Affiliation(s)
- Anna Barker
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Caitlyn Ngam
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jackson Musuuza
- Institute of Clinical and Translational Research, University of Wisconsin, Madison, WI, USA
| | - Valerie M. Vaughn
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- The Patient Safety Enhancement Program, University of Michigan and VA Ann Arbor Health System, Ann Arbor, MI, USA
| | - Nasia Safdar
- William S. Middleton Memorial Veterans Affairs Hospital, Madison, WI, USA
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Infection Control, University of Wisconsin Hospital and Clinics, Madison, WI, USA
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Ray AJ, Deshpande A, Fertelli D, Sitzlar BM, Thota P, Sankar C T, Jencson AL, Cadnum JL, Salata RA, Watkins RR, Sethi AK, Carling PC, Wilson BM, Donskey CJ. A Multicenter Randomized Trial to Determine the Effect of an Environmental Disinfection Intervention on the Incidence of Healthcare-Associated Clostridium difficile Infection. Infect Control Hosp Epidemiol 2017; 38:777-83. [DOI: 10.1017/ice.2017.76] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVETo determine the impact of an environmental disinfection intervention on the incidence of healthcare-associated Clostridium difficile infection (CDI).DESIGNA multicenter randomized trial.SETTINGIn total,16 acute-care hospitals in northeastern Ohio participated in the study.INTERVENTIONWe conducted a 12-month randomized trial to compare standard cleaning to enhanced cleaning that included monitoring of environmental services (EVS) personnel performance with feedback to EVS and infection control staff. We assessed the thoroughness of cleaning based on fluorescent marker removal from high-touch surfaces and the effectiveness of disinfection based on environmental cultures for C. difficile. A linear mixed model was used to compare CDI rates in the intervention and postintervention periods for control and intervention hospitals. The primary outcome was the incidence of healthcare-associated CDI.RESULTSOverall, 7 intervention hospitals and 8 control hospitals completed the study. The intervention resulted in significantly increased fluorescent marker removal in CDI and non-CDI rooms and decreased recovery of C. difficile from high-touch surfaces in CDI rooms. However, no reduction was observed in the incidence of healthcare-associated CDI in the intervention hospitals during the intervention and postintervention periods. Moreover, there was no correlation between the percentage of positive cultures after cleaning of CDI or non-CDI rooms and the incidence of healthcare-associated CDI.CONCLUSIONSAn environmental disinfection intervention improved the thoroughness and effectiveness of cleaning but did not reduce the incidence of healthcare-associated CDI. Thus, interventions that focus only on improving cleaning may not be sufficient to control healthcare-associated CDI.Infect Control Hosp Epidemiol 2017;38:777–783
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Lei H, Jones RM, Li Y. Exploring surface cleaning strategies in hospital to prevent contact transmission of methicillin-resistant Staphylococcus aureus. BMC Infect Dis 2017; 17:85. [PMID: 28100179 PMCID: PMC5242018 DOI: 10.1186/s12879-016-2120-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 12/14/2016] [Indexed: 01/20/2023] Open
Abstract
Background Cleaning of environmental surfaces in hospitals is important for the control of methicillin-resistant Staphylococcus aureus (MRSA) and other hospital-acquired infections transmitted by the contact route. Guidance regarding the best approaches for cleaning, however, is limited. Methods In this study, a mathematical model based on ordinary differential equations was constructed to study MRSA concentration dynamics on high-touch and low-touch surfaces, and on the hands and noses of two patients (in two hospitals rooms) and a health care worker in a hypothetical hospital environment. Two cleaning interventions – whole room cleaning and wipe cleaning of touched surfaces – were considered. The performance of the cleaning interventions was indicated by a reduction in MRSA on the nose of a susceptible patient, relative to no intervention. Results Whole room cleaning just before first patient care activities of the day was more effective than whole room cleaning at other times, but even with 100% efficiency, whole room cleaning only reduced the number of MRSA transmitted to the susceptible patient by 54%. Frequent wipe cleaning of touched surfaces was shown to be more effective that whole room cleaning because surfaces are rapidly re-contaminated with MRSA after cleaning. Wipe cleaning high-touch surfaces was more effective than wipe cleaning low-touch surfaces for the same frequency of cleaning. For low wipe cleaning frequency (≤3 times per hour), high-touch surfaces should be targeted, but for high wipe cleaning frequency (>3 times per hour), cleaning should target high- and low-touch surfaces in proportion to the surface touch frequency. This study reproduces the observations from a field study of room cleaning, which provides support for the validity of our findings. Conclusions Daily whole room cleaning, even with 100% cleaning efficiency, provides limited reduction in the number of MRSA transmitted to susceptible patients via the contact route; and should be supplemented with frequent targeted cleaning of high-touch surfaces, such as by a wipe or cloth containing disinfectant. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-2120-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hao Lei
- Department of Mechanical Engineering, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China.
| | - Rachael M Jones
- Division of Environmental and Occupational Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Yuguo Li
- Department of Mechanical Engineering, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China
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Jullian-Desayes I, Landelle C, Mallaret MR, Brun-Buisson C, Barbut F. Clostridium difficile contamination of health care workers' hands and its potential contribution to the spread of infection: Review of the literature. Am J Infect Control 2017; 45:51-58. [PMID: 28065332 DOI: 10.1016/j.ajic.2016.08.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/18/2016] [Accepted: 08/18/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) can be transmitted from patient to patient by the hands of health care workers (HCWs); however, the relative importance of this route in the spread of C difficile in the hospital is currently unknown. Our aim was to review studies examining HCWs' hand carriage and its potential role in CDI transmission. METHODS First, English-speaking references addressing HCWs' hand sampling obtained from the PubMed database were reviewed. Second, C difficile outbreaks definitely or probably implicating HCWs were retrieved from the Outbreak Database Web site (www.outbreak-database.com). Finally, cases of C difficile occurring in HCWs after contact with an infected patient were retrieved from PubMed. RESULTS A total of 11 studies dealing with HCWs' hand carriage were selected and reviewed. Between 0% and 59% of HCWs' hands were found contaminated with C difficile after caring for a patient with CDI. There were several differences between studies regarding site of hands sampling, timing after contact, and bacteriologic methods. Only 2 C difficile outbreaks implicating HCWs and 6 series of cases of transmission from patients to HCWs have been reported. CONCLUSIONS This review shows that HCWs' hands could play an important role in the transmission of C difficile. Hand hygiene and reduction of environmental contamination are essential to control C difficile transmission.
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Weber DJ, Rutala WA. Response to letter to the editor regarding "Occupational health risks associated with the use of germicides in health care". Am J Infect Control 2017; 45:97-98. [PMID: 27856071 DOI: 10.1016/j.ajic.2016.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 09/24/2016] [Indexed: 11/29/2022]
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
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Zelikoff AJ, Dellit TH, Lynch J, McNamara EA, Makarewicz VA. Cleaning practices in the hospital setting: Are high-touch surfaces in isolation and standard precaution patient rooms cleaned to the same standard? Am J Infect Control 2016; 44:1399-1400. [PMID: 27317406 DOI: 10.1016/j.ajic.2016.04.220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 04/25/2016] [Accepted: 04/25/2016] [Indexed: 11/29/2022]
Abstract
The purpose of this quality improvement project was to identify differences in cleaning practices between isolation rooms and standard precaution rooms in the hospital setting. An ultravoilet marking system was used to evaluate high-touch surfaces throughout the patient environment. Results reveal the importance of refining training systems to reflect staff perceptions and improve evaluation processes across systems in an effort to reduce health care-associated infections.
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Affiliation(s)
| | - Timothy H Dellit
- Infection Prevention & Control, Harborview Medical Center, Seattle, WA
| | - John Lynch
- Infection Prevention & Control, Harborview Medical Center, Seattle, WA
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Abstract
Clostridium difficile is one of the foremost nosocomial pathogens. Preventing infection is particularly challenging. Effective prevention efforts typically require a multifaceted bundled approach. A variety of infection control procedures may be advantageous, including strict hand decontamination with soap and water, contact precautions, and using chlorine-containing decontamination agents. Additionally, risk factor reduction can help reduce the burden of disease. The risk factor modification is principally accomplished though antibiotic stewardship programs. Unfortunately, most of the current evidence for prevention is in acute care settings. This review focuses on preventative approaches to reduce the incidence of Clostridium difficile infection in healthcare settings.
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Affiliation(s)
- Christopher C Cooper
- Division of Infectious Diseases, Wayne State University, 3990 John R. Street, 5 Hudson, Detroit, MI 48201, USA
| | - Robin L P Jump
- Infectious Disease Section, Medical Division, Geriatric Research Education and Clinical Center (GRECC), Louis Stokes Cleveland Veterans Affairs Medical Center, 10701 East Boulevard, Cleveland, OH 44106, USA; Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Teena Chopra
- Division of Infectious Diseases, Wayne State University, 3990 John R. Street, 5 Hudson, Detroit, MI 48201, USA.
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Rutala WA, Weber DJ. Monitoring and improving the effectiveness of surface cleaning and disinfection. Am J Infect Control 2016; 44:e69-76. [PMID: 27131138 DOI: 10.1016/j.ajic.2015.10.039] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 10/28/2015] [Indexed: 02/08/2023]
Abstract
Disinfection of noncritical environmental surfaces and equipment is an essential component of an infection prevention program. Noncritical environmental surfaces and noncritical medical equipment surfaces may become contaminated with infectious agents and may contribute to cross-transmission by acquisition of transient hand carriage by health care personnel. Disinfection should render surfaces and equipment free of pathogens in sufficient numbers to prevent human disease (ie, hygienically clean).
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Tomas ME, Nerandzic MM, Cadnum JL, Mana TSC, Jencson A, Sunskesula V, Kundrapu S, Wilson BM, Donskey CJ. A Novel, Sporicidal Formulation of Ethanol for Glove Decontamination to Prevent Clostridium difficile Hand Contamination During Glove Removal. Infect Control Hosp Epidemiol 2016; 37:337-9. [DOI: 10.1017/ice.2015.289] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Decontamination of gloves before removal could reduce the risk for contamination of hands of personnel caring for patients with Clostridium difficile infection. We demonstrated that a novel sporicidal formulation of ethanol rapidly reduced C. difficile spores on gloved hands without adverse odor, respiratory irritation, or staining of clothing.Infect. Control Hosp. Epidemiol. 2016;37(3):337–339
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Han JH, Sullivan N, Leas BF, Pegues DA, Kaczmarek JL, Umscheid CA. Cleaning Hospital Room Surfaces to Prevent Health Care-Associated Infections: A Technical Brief. Ann Intern Med 2015; 163:598-607. [PMID: 26258903 PMCID: PMC4812669 DOI: 10.7326/m15-1192] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
The cleaning of hard surfaces in hospital rooms is critical for reducing health care-associated infections. This review describes the evidence examining current methods of cleaning, disinfecting, and monitoring cleanliness of patient rooms, as well as contextual factors that may affect implementation and effectiveness. Key informants were interviewed, and a systematic search for publications since 1990 was done with the use of several bibliographic and gray literature resources. Studies examining surface contamination, colonization, or infection with Clostridium difficile, methicillin-resistant Staphylococcus aureus, or vancomycin-resistant enterococci were included. Eighty studies were identified-76 primary studies and 4 systematic reviews. Forty-nine studies examined cleaning methods, 14 evaluated monitoring strategies, and 17 addressed challenges or facilitators to implementation. Only 5 studies were randomized, controlled trials, and surface contamination was the most commonly assessed outcome. Comparative effectiveness studies of disinfecting methods and monitoring strategies were uncommon. Future research should evaluate and compare newly emerging strategies, such as self-disinfecting coatings for disinfecting and adenosine triphosphate and ultraviolet/fluorescent surface markers for monitoring. Studies should also assess patient-centered outcomes, such as infection, when possible. Other challenges include identifying high-touch surfaces that confer the greatest risk for pathogen transmission; developing standard thresholds for defining cleanliness; and using methods to adjust for confounders, such as hand hygiene, when examining the effect of disinfecting methods.
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Affiliation(s)
- Jennifer H. Han
- From Perelman School of Medicine, University of Pennsylvania, and Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, and ECRI Institute–Penn Medicine Evidence-based Practice Center, Plymouth Meeting, Pennsylvania
| | - Nancy Sullivan
- From Perelman School of Medicine, University of Pennsylvania, and Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, and ECRI Institute–Penn Medicine Evidence-based Practice Center, Plymouth Meeting, Pennsylvania
| | - Brian F. Leas
- From Perelman School of Medicine, University of Pennsylvania, and Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, and ECRI Institute–Penn Medicine Evidence-based Practice Center, Plymouth Meeting, Pennsylvania
| | - David A. Pegues
- From Perelman School of Medicine, University of Pennsylvania, and Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, and ECRI Institute–Penn Medicine Evidence-based Practice Center, Plymouth Meeting, Pennsylvania
| | - Janice L. Kaczmarek
- From Perelman School of Medicine, University of Pennsylvania, and Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, and ECRI Institute–Penn Medicine Evidence-based Practice Center, Plymouth Meeting, Pennsylvania
| | - Craig A. Umscheid
- From Perelman School of Medicine, University of Pennsylvania, and Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, and ECRI Institute–Penn Medicine Evidence-based Practice Center, Plymouth Meeting, Pennsylvania
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