Your hospital room can make you sick! How

Your hospital room can make you sick! How

Your hospital room can make you sick! How improved cleaning and disinfection can help 16/02/16 Jon Otter, PhD FRCPath Imperial College Healthcare NHS Trust Blog: www.ReflectionsIPC.com Twitter: @jonotter Email: [email protected] 2x Room A Room B The room lotto Patient infected or colonised with a pathogen (e.g. C. difficile, MRSA, VRE, A. baumannii or P. aeruginosa) Patient is discharged and the room is cleaned / disinfected; surfaces in the room remain contaminated with the pathogen The next room occupant is at an

increased risk of acquiring the pathogen Increased risk from the prior room occupant Nseir A. baumannii Shaughnessy C. difficile Drees VRE Drees VRE (2 weeks) Nseir P. aeruginosa Huang VRE Huang MRSA 0 1 2 Odds ratio Otter et al. Am J Infect Control 2013;41(5 Suppl):S6-11. 3 4 Taking the lotto out of the room

Datta VRE Datta MRSA Passaretti MDR-GNR Passaretti MRSA Passaretti C. difficile Passaretti VRE 0 1 Odds ratio Datta et al. Arch Intern Med 2011;171:491-494. Passaretti et al. Clin Infect Dis 2013;56:27-35. 2 Transmission routes Otter et al. Infect Control Hosp Epidemiol 2011;32:687-699. 86% 58% 93%

85% 59% Ltd (2010). All rights reserved. French et al. J Hosp Infect 2004;57:31-37. Bioquell UK96% Surface survival Organism Survival time Clostridium difficile (spores) 5 months Acinetobacter spp. 3 days to 5 months Enterococcus spp. including VRE 5 days 4 years (!)1 Pseudomonas aeruginosa

6 hours 16 months Klebsiella spp. 2 hours to > 30 months Staphylococcus aureus, inc. MRSA 7 days 7 months Norovirus (and feline calicivirus) 8 hours to > 2 weeks2 SARS Coronavirus 72 hours to >28 days3 Influenza Hours to several days4 Adapted from Kramer et al. BMC Infect Dis 2006;6:130. 1. 2.

3. 4. Wagenvoort et al. J Hosp Infect 2011;77:282-283. Doultree et al. J Hosp Infect 1999;41:51-57. Rabenau et al. Med Microbiol Immunol 2005;194:1-6. Bean et al. J Infect Dis 1982;146:47-51. Conventional terminal cleaning Percentage of MRSA swabs positive 100 90 80 70 90% of 124 sites 60 50 26% reductio n

66% of 124 sites 40 30 20 10 (8 rooms; 2 four-bed bays previously occupied by MRSA patients) 0 Before cleaning French et al. J Hosp Infect 2004;57:31-37. After cleaning Pathogens can be transferred from hospital surfaces to HCW hands without direct patient contact1-2 1.

2. 3. 4. 5. 6. 52% of 23 HCW acquired VRE on their hands3 Contact with patient or surface = ~10% risk of acquiring VRE3 45% of 50 HCW acquired MRSA on their hands4 40% of 50 HCW acquired MRSA on their hands4 50% of 30 HCW acquired C. difficile on their hands5 50% of 30 HCW acquired C. difficile on their hands5 Compliance with hand hygiene: 50%6

Compliance with hand hygiene: 80%6 Boyce et al. Infect Control Hosp Epidemiol 1997;18:622-627. Bhalla et al. Infect Cont Hosp Epidemiol 2004;25:164-167. Hayden et al. Infect Control Hosp Epidemiol 2008;29:149-154. Stiefel et al. Infect Control Hosp Epidemiol 2011;32:185-187. Guerrero et al. Am J Infect Control 2012;40:556-558. Randle et al. J Hosp Infect 2010;76:252-255. Learning objectives 1. Understand the key data supporting the role of contaminated surfaces in the transmission of hospital pathogens 2. Become familiar with the various methods to improve the efficacy of hospital disinfection: Tools such as ATP assays and fluorescent markers to evaluate the thoroughness of the cleaning process; Methods to improve the education and training of cleaning staff. 3. Discuss the results of improved cleaning and disinfection in reducing transmission of pathogens 4. Understand other and emerging approaches including: Measures to reduce and contain shedding more effectively; New disinfectants, cleaning materials and consideration of

automated systems; Antimicrobial surfaces; Improved design to improve cleanability. Improve existing procedures Try something new! Improve existing procedures Try something new! Improve existing procedures Education & training

Question Answer What to clean? Focus of high-touch sites seems sensible Who cleans what? Checklists can help What agent(s) to use? Depends on the situation; sporicidal agent for C. difficile What materials to use? Microfibre may help Wipes have pros and cons Bucket method most effective How to educate staff?

More than we currently do! Difficult task Daily cleaning: how often? Evidence for daily or twice daily Terminal cleaning: optimal protocols? More stringent protocol should be used for terminal disinfection Improve existing procedures Try something new! Improve existing procedures Why bother? Baseline cleaning rates of high-risk objects in 36 acute US hospitals, as determined by removal of a fluorescent marker.

Carling et al. Infect Control Hosp Epidemiol 2008;29:1035-1041. Improve existing procedures Why bother? The time taken to clean a room does not correlate with the thoroughness of cleaning, as determined by removal of a fluorescent marker Rupp et al. Infect Control Hosp Epidemiol 2013;34:100-102. Improve existing procedures Visual assessment Visual assessment of hospital cleaning is performed by measuring the apparent cleanliness of a room against a checklist.1,2 A room needs to be visually clean to be acceptable to the current and subsequent occupant.

Visual assessment of hygiene does not correlate with microbial contamination, and can thus be a misleading measure of cleanliness3-5 1. 2. 3. 4. 5. Sherlock et al. J Hosp Infect 2009;72:140-146. Mulvey et al. J Hosp Infect 2011;77:25-30. Griffith et al. J Hosp Infect 2007;66:352-359. Cooper et al. Am J Infect Control 2007;66:352-359. Griffith et al. J Hosp Infect 2000;45:19-28. Improve existing procedures Microbiological samples Microbiological surface cultures can be qualitative (pathogen presence or absence) or quantitative (aerobic colony counts) Several different sampling methods available; usually swabs (with or

without enrichment) or contact plates Quality standards for both aerobic colony counts (<2.5 cfu / cm2) and specific indicator organisms (<1 cfu / cm 2) have been proposed.1,2 Cost and practicality mean that routine microbiological sampling is rarely performed 1. Mulvey et al. J Hosp Infect 2011;77:25-30. 2. Malik et al. Am J Infect Control 2003;31:181-187. Improve existing procedures ATP assessment Adenosine triphosphate (ATP) is the energy currency of all living cells. Surfaces can be swabbed and a hand-held sensor can give a real-time quantitative measurement of ATP from the surface. Several quality standards have been set as relative light unit (RLU) thresholds, ranging from 100-500.1-3

There is no direct correlation between RLU and microbial contamination, but hygiene fails determined by aerobic colony count and ATP do correlate1,2 1. Boyce et al. Infect Control Hosp Epidemiol 2011;32:1187-1189. 2. Mulvey et al. J Hosp Infect 2011;77:25-30. 3. Whiteley et al. Healthcare Infection 2012;17:91-97. Improve existing procedures Fluorescent markers Fluorescent material in the form of gel, powder or lotion can be applied to a surface and its removal assessed by a black light The % removal of the spots is used to evaluate cleaning performance.1,2 Educational interventions can improve significantly the removal of the marked spots.2-3 The removal of marked spots has been shown to correlate with microbial contamination in some studies;2-3 cleaning staff may get wise to the location of the spots and preferentially target them4

1. 2. 3. 4. Boyce et al. Infect Control Hosp Epidemiol 2011;32:1187-1189. Carling et al. Infect Control Hosp Epidemiol 2008; 29:1035-1041. Munoz-Price et al. Infect Control Hosp Epidemiol 2012;33:897-904. Rutala et al. Infect Control Hosp Epidemiol 2011;32:743-747. Improve existing procedures Method comparison Visual Micro ATP Fluorescent Ease of use

High Low-Moderate High High Quantitative No Yes/No Yes No Poor Accurate Indirect Indirect

No Yes/No No No Risk of gaming by staff Low Low Low Moderate Identifies dirty surfaces* Yes No

Yes No Published evidence of attributable clinical impact No Yes No No Correlation with microbial contamination Identifies pathogens * Non-microbial soiling Improve existing procedures Method comparison

5 sites in 100 patient rooms assessed before and after terminal clean Clean defined as <2.5 cfu/cm2, complete removal of fluorescent marker and ATP score of <250 RLU Boyce et al. Infect Control Hosp Epidemiol 2011;32:1187-1189. Improve existing procedures Method comparison 5 sites in 50 patient rooms assessed before and after terminal clean Gold standard = <2.5 cfu/cm2 compared with complete removal of fluorescent marker and ATP score of <250 RLU Overall N = 250 Baseline dirty n = 103 Test

Sensitivity Specificity PPV (%) (%) (%) NPV (%) Dazo 68 50 90 19 ATP 78 38 90 20

Visual 95 9 9 23 Dazo 75 40 84 28 ATP 76

35 83 26 Visual 94 10 81 29 Luick et al. Am J Infect Control 2013 in press. Impact of environmental hygiene intervention on VRE incidence % patients Research staff monitored cleaners work overtly, using a checklist. Cleaners were given immediate, specific feedback about their performance, e.g., You missed the bedrail.

Baseline Intervention Washout Hayden et al. Clin Infect Dis 2006;42:1552-1560. HH intervention Improve existing procedures Try something new! Try something new! Source control Daily bathing of patients using chlorhexidine reduces the acquisition of MDROs,1,2 including C. difficile.3 Figure from Vernon et al.2

1. Climo et al. N Engl J Med 2013;368:533-542. 2. Vernon et al. Arch Intern Med 2006;166:306-312. 3. Rupp et al. Infect Control Hosp Epidemiol 2012;33:1094-1100. Try something new! Source control Proportion of MRSA bloodstream infections caused by CC22 (blue) and CC30 (red) Carriage of qacA CC22 (blue), CC30 (red) and other (green) clones Otter et al. J Antimicrob Chemother 2013;68:992-999. Try something new! Air control MRSA contamination of settle plates in multiple locations in the rooms of three patients with MRSA 180

160 140 % settle plates growing MRSA 120 Mean MRSA cfu per plate 100 80 60 40 20 0 HEPA off HEPA on Boswell & Fox. J Hosp Infect 2006;63:47-54. Antimicrobial surfaces Try something new!

Candidate Pros Cons Metal Copper Rapidly microbicidal Reduces acquisition ? Sporicidal Acceptability / retrofitting Silver Rapidly microbicidal ? Sporicidal Tolerance development Chemical Organosilane

Easy to apply Limited microbicidal activity Durability Light-activated Broadly microbicidal ? Sporicidal Topography Liquid glass Reduces deposition Improves cleanability Not microbicidal Sharklet pattern Reduces deposition Reduced biofilms Not microbicidal

Page et al. J Mat Chem 2009 Copper Try something new! 614 pts in 3 hospitals randomised to copper or non-copper ICU rooms % patients who acquired 14 12 HAI or MRSA / VRE colonisation 10 HAI only -44% p=0.020 2

Bedrails Overbed tables IV poles Visitor chair arms Nurse call button* Computer mouse* Computer palm rest* Rim of monitor* 0 (* = some rooms only) 8 6 -58% p=0.013 4 Non copper Copper

Salgado et al. Infect Control Hosp Epidemiol 2013;34:479-486. Improve existing procedures Try something new! Try something new! Wipes Evaluated hydrogen peroxide impregnated wipes by sampling 10 sites in 72 rooms before and after cleaning. 99% of sites <2.5 cfu/cm2 75% of sites no growth after cleaning (figure) Boyce & Havill. Infect Control Hosp Epidemiol 2013;34:521-523. Given the choice of improving technology or improving human behavior, technology

is the better choice. Dr Bob Weinstein Weinstein RA. Emerg Infect Dis 1998;4:416-420. Try something new! Hydrogen peroxide vapour (HPV) No touch disinfection Ultraviolet Aerosolised hydrogen peroxide radiation C (UVC) (aHP) Otter et al. J Hosp Infect 2013;83:1-13. Pulsedxenon UV (PX-UV) % s it e s c o n t a m in a t e d

Try something new! Reduce contamination 14 % sites contaminated with A. baumannii % 140 samples from 9 rooms sites contaminated with afterMRSA 2xbleach 12 10 8 6 5705 samples from 312 rooms after 4xbleach

2680 sites from 134 rooms after HPV 4 2 0 HPV Manian et al. Infect Control Hosp Epidemiol 2011;32:667-672. Try something new! H2O2 systems Aerosolised hydrogen peroxide (AHP) Hydrogen peroxide vapour (HPV) 5% H2O2 delivered by an aerosol 35% H2O2 delivered as a vapour Cycle time >2 hrs, single room

Cycle time < 2 hrs, single room Reduction in contamination but not elimination of pathogens; problems with catalase-positive bacteria Elimination of pathogens Incomplete distribution Homogeneous distribution No published controlled studies demonstrating a reduction in acquisition Several published studies showing reduced acquisition Otter et al. J Hosp Infect 2013;83:1-13. % s it e s c o n t a m in a t e d w it h C lo s t r id iu m d 30

25 20 15 Boyce et al. 89% reduction 100% reduction Before Barbut et al. 85% reduction Shapey et al. After Best et al. 52 % reduction

86% reduction Try something new! H2O2 systems 10 5 0 Yui et al. R a te / 1 0 0 0 p a tie n t d a y s Try something new! HPV clinical impact Patients admitted to rooms decontaminated using HPV were 64% less likely to acquire any MDRO (incidence rate ratio [IRR]=0.36, CI=0.19-0.70, p<0.001) 64% reduction in the rate of

MDRO acquisition 12 10 8 6 4 2 0 Standard cleaning / 1 disinfection Passaretti et al. Clin Infect Dis 2013;56:27-35. HPV 2 decontamination Try something new! UV systems

UVC PX-UV Continuous UVC (254nm) Pulsed broad spectrum (200-320nm) UV May control dose using feedback loop No feedback loop Single or dual room location Multiple room locations (usually 3) Cycle time range from ~15 to 90 min Cycle time ~15 mins 1-3 log in C. difficle and 3-4 log reduction in MRSA and VRE;1-5 incomplete inactivation of pathogens on hospital surfaces.1,4,6

Limited efficacy data published7 Significantly less effective out of direct line of sight1-5 No published data, but likely to be less effective out of direct line of sight Emerging evidence of clinical impact. Evidence of reduction of CDI8 1. 2. 3. 4. 5. 6. 7. 8. Nerandzic et al. BMC Infect Dis 2010;10:197. Mahida et al. J Hosp Infect 2013 in press. Boyce et al. Infect Control Hosp Epidemiol 2011;32:737-742. Rutala et al. Infect Control Hosp Epidemiol 2010;31:1025-1029.

Havill et al. Infect Control Hosp Epidemiol 2012;33:507-512. Anderson et al. Infect Control Hosp Epidemiol 2013;34:466-471. Stibich et al. Infect Control Hosp Epidemiol 2011;32:286-288. Levin et al. Am J Infect Control in press. Try something new! UVC v PX-UV Log reduction Log reductions achieved by a UVC (Tru-D) device and PX-UV (Xenex) when run for 10 mins from the same point in the room 4ft from the coupons. 4 3.5 3 2.5 Xenex UVC 2 1.5 1 0.5

0 C. difficile MRSA VRE Nerandzic et al. Infect Control Hosp Epidemiol 2015 in press. Try something new! UVC clinical impact Randomised study over >2 years across 9 hospitals including >25,000 exposed patients (admitted into a room where the previous occupant was known to have an MDRO). Each hospital performed a randomised sequence of different terminal room disinfection approaches: quaternary ammonium compound (QAC) disinfection (control group), bleach, QAC+UVC, and bleach+UVC. The primary outcome was the acquisition rate of a composite group of MDROs (MRSA, VRE, C. difficile, and MDR Acinetobacter species). Compared with the control group, patients admitted into a room decontaminated using UVC were significantly less likely to acquire an MDRO; this difference was 37% (p=0.03) when rooms were pre-cleaned

using QAC, and 32% (p=0.01) when rooms were pre-cleaned using bleach. Surprisingly, patients admitted to rooms disinfected using bleach were not significantly less likely to acquire MDROs compared with the control group (p=0.08). Anderson et al. ID Week 2015. Try something new! HPV vs UV Characteristics Cycle time (for single room) HPV 90 mins UV systems 15 mins to >1hr Practicalities Door and air vent sealing and leak detection required

No door and air vent sealing or leak detection required Distribution Microbiological efficacy Homogeneous Elimination of pathogens from surfaces; 6-log sporicidal reduction Affected by line of sight Does not eliminate pathogens from surfaces; 1-3 log sporicidal reduction Evidence of clinical impact Cost Published evidence Lower purchase cost;

higher running costs Emerging evidence Higher purchase cost; lower running costs Otter et al. J Hosp Infect 2013;83:1-13. Improve existing procedures Try something new! Try something new! Design The surface finish of 6 hospital bedrails; ease of cleaning was inversely proportional to the transfer of S. aureus from the surfaces Ali et al. J Hosp Infect 2012;80:192-198. Try something new! Design bugs out!

Design Bugs Out Product Evaluation Report. The Healthcare Associated Infection Technology Innovation Programme. UK Department of Health. 2011. Improve existing procedures Try something new! Learning objectives 1. Understand the key data supporting the role of contaminated surfaces in the transmission of hospital pathogens 2. Become familiar with the various methods to improve the efficacy of hospital disinfection: Tools such as ATP assays and fluorescent markers to evaluate the thoroughness of the cleaning process; Methods to improve the education and training of cleaning staff. 3. Discuss the results of improved cleaning and disinfection in reducing transmission of pathogens 4. Understand other and emerging approaches including: Measures to reduce and contain shedding more effectively; New disinfectants, cleaning materials and consideration of automated systems;

Antimicrobial surfaces; Improved design to improve cleanability.

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