New Technologies in Environmental Cleaning and Disinfection€¦ · 789-bed, academic hospital, 3...

New Technologies in Environmental

Cleaning and Disinfection

March 16, 2017

Jennifer Han, MD, MSCE

Assistant Professor of Medicine and Epidemiology

Division of Infectious Diseases

Associate Healthcare Epidemiologist

Hospital of the University of Pennsylvania

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Disclosures

Nothing to Disclose

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Objectives

Overview of contamination of the hospital

environment

Discuss environmental cleaning and infection

prevention

Review commonly used environmental cleaning

disinfectants

Discuss new technologies for environmental

cleaning

• Automated, no-touch technologies

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Contamination of the hospital environment

• Frequent contamination of the hospital environment with

multidrug-resistant organisms

• MRSA, VRE, Acinetobacter baumanii, Clostridium difficile

• Organisms can remain viable for weeks to months

• Spread directly via contaminated surfaces to other patients

and indirectly via healthcare worker hands

Weber DJ, Anderson D, Rutala WA. Curr Opin Infect Dis 2013;26.

Weber DJ, Rutala WA, Miller MB, et al. Am J Infect Control 2010;38S

Kramer A, Schwebke I, Kampf G. BMC Infect Dis. 2006.CIDEIM

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Contamination of high touch objects (HTOs)

Bed rail TV remote Bathroom hand rail

Tray table Room sink Bathroom light

Chair Call box/button Toilet flush handle

IV pole Room doorknob Bathroom sink

Room light switch Bedside telephone Toilet/commode seat

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EC effectiveness↓ transmission of

MDROs

• Disinfectants

• Automated, no-touch modalities

• Heavy metal surface coatings

• Visual monitoring

• ATP bioluminescence

• Microbiologic sampling

• UV fluorescent markers • Education

• Audit and feedback

• Staffing structure

• Setting

Cleaning/disinfection

Monitoring interventions

Implementation

Environmental cleaning effectiveness

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Principles of Effective Cleaning and Disinfection

Physical action of cleaning

• Manual cleaning to remove organic and inorganic debris

• Associated with patient satisfaction

Disinfectant selection

• Organisms being targeted

• Type of surface – e.g., porous vs. non-porous

• Cost and ease of use

• Safety for environmental services personnel

Disinfectant application

• Appropriate concentration, temperature

• Correct surface contact time

• Real-world hospital environment

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Disinfectants and new technologies

Chemical disinfectants

• Review of commonly used disinfectants in hospital

setting

• Accelerated hydrogen peroxide

Automated, “no-touch” technologies

• Ultraviolet light systems

• Hydrogen peroxide-producing systems

Self-disinfecting surfaces

• Copper surfaces

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Han JH, Sullivan N, Leas BF, et al. Ann Intern Med 2015; 163.

Summary Considerations

Quarternary

ammonium

compounds (QACs)

▪ Commonly used for routine daily and

terminal disinfection, generally surface-

compatible

▪ Bactericidal, virucidal (enveloped

viruses), fungicidal

▪ Some persistent antimicrobial activity

on surfaces

▪ Not sporicidal, mycobactericidal

▪ High water hardness and certain

materials (e.g., cotton) can

diminish activity

▪ Case reports of occupational

asthma w/ benzalkonium chloride

Hypochlorite/bleach ▪ Commonly used for routine daily and

terminal disinfection, blood spills

▪ Bactericidal, virucidal, fungicidal

▪ Mycobactericidal and sporicidal (C.

difficile)

▪ Not affected by water hardness, stable

and fast-acting

▪ Specific concentrations and

contact times depending on

surface

▪ Dilutions need to be freshly

prepared

▪ Can cause skin and eye irritation

▪ Surfaces need to be effectively

precleaned (↓ activity with organic

matter)

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Han JH, Sullivan N, Leas BF, et al. Ann Intern Med 2015; 163.

Summary Considerations

Phenolics ▪ Less commonly used, inexpensive

▪ Bactericidal, virucidal, fungicidal,

mycobactericidal

▪ Not sporicidal

▪ Absorption by porous materials

▪ Residual product can irritate

tissue

▪ Depigmentation of skin

*Accelerated

hydrogen peroxide

▪ Recently introduced

▪ Bactericidal, virucidal, fungicidal,

mycobactericidal and sporicidal (C.

difficile)

▪ Short contact time (~1 minute

bactericidal, ~5 minutes

mycobactericidal)

▪ Generally safe, surface compatible,

not affected by organic material

▪ Expensive

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setting






• Copper surfaces

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UV automated systems

Used during terminal cleaning

Automated mobile UV light unit

• UV-C (200-270 nm range)

• Germicidal, breaking of DNA molecular bonds

• Microbicidal activity against wide range of

healthcare-associate pathogens

• Vegetative and non-vegetative bacteria

Testing in patient rooms after discharge

• Multiple studies have shown reduction in frequency of positive

surfaces sites post-treatment

Weber D, et al. Curr Opin Infect Dis 2016;29.

Otter JA, et al. J Hosp Infect 2013;83.CIDEIM

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UV automated systems

Advantages

• Microbicidal activity against a wide range of pathogens,

including C. difficile

• Turnaround time is rapid (~5-15 min) for vegetative bacteria,

Residual free, safe

Disadvantages

• Significant cost to healthcare system

• Room has to be vacated, only for terminal cleaning

• Equipment/furniture needs to be moved away from walls to

prevent shadowing

– Need direct or indirect line of sight

• Significant turnaround time for C. difficile (~50-100 minutes)

Han JH, et al. Ann Intern Med 2015; 163



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Hydrogen peroxide automated systems

Used during terminal cleaning

Different systems available

• Vapor systems - heat to produce vapor ~30% H2O2

• Aerosolized/mist systems – Pressure or ultrasonic

nebulization ~5% H2O2

• Microbicidal activity against wide range of

healthcare-associate pathogens

• Vegetative and non-vegetative bacteria

Testing in patient rooms after discharge

• Several studies have shown reduction in

rate of positive surfaces for bacteria after treatment



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Hydrogen peroxide automated systems

Advantages

• Microbicidal activity against a wide range of pathogens,

including C. difficile

• Automated dispersal, does not require moving of

equipment/furniture

Disadvantages

• Significant cost to healthcare system

• Room has to be vacated, only used for terminal cleaning

• Higher-level training needed to operate

– Sealing of vents, doors, windows

• Significant turnaround time, ~1.5-2.5 hours

Han JH, et al. Ann Intern Med 2015; 163

Weber D, et al. Curr Opin Infect Dis 2016.


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• Studies evaluating clinical outcomes

– Healthcare-associated infections (HAIs), multidrug-resistant organisms

(MDROs)

Automated no-touch technologies


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Impact of UV irradiation on C. difficile in

hematology- oncology units

789-bed, academic hospital, 3 heme-onc units with high rates

of C. difficile infection (CDI)

Use of bleach for routine daily and terminal cleaning of rooms

of patients with CDI

UV device deployed for all rooms after terminal room cleaning

Intervention period: February 1, 2014 - January 1, 2015

Comparison period: January 1, 2013 - December 31, 2013

Control units (remainder of hospital)

Weekly reporting of UV deployment to environmental services

staff

Pegues D, et al. Infect Control Hosp Epidemiol 2017;38.

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Intervention

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Study month



Overall reduction in CDI

incidence: 25% ↓


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Study units: Incidence rate ratio (IRR) 0.49 (95% CI, 0.26-

0.94), P=0.03.

No significant change in CDI incidence rates on non-

study units hospital-wide

No significant differences in broad-spectrum antibiotic

consumption, visual assessment scores, hand hygiene

rates

Annual direct cost averted: US $348,528 to US $1,537,000


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Benefits of Enhanced Terminal Room

Disinfection (BETR) study

Multicenter, cluster-randomized crossover trial

Nine U.S. hospitals, April 2012 – July 2014

Targeted rooms – single patient rooms from which a patient on

contact precautions was discharged

Four terminal disinfection strategies

• Standard – QACs for all rooms except bleach for C. difficile rooms

• UV – UV disinfection of C. difficile rooms

• Bleach – bleach for all targeted rooms

• UV/bleach – UV + bleach for all targeted rooms

7 month study arms

• 1 month wash-in, 6 months data collection

Anderson D, et al. Lancet 2017; 389.2017;38.

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BETR study

Primary outcome – Incidence of target organism among patients subsequently

admitted to target rooms

• C. difficile, multidrug-resistant Acinetobacter spp., MRSA, VRE

Primary outcome – Incidence of C. difficile among patients subsequently

admitted to target rooms


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BETR study

Addition of UV: ↓ reduction in target organism incidence rate:

• 51.3 per 10,000 exposure days to 33.9 per 10,000 exposure

days

Relative risk: 0.70 (95% CI, 0.50 – 0.98), P = 0.036

No difference with bleach group or bleach+UV group compared

to standard


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BETR study

Addition of UV to bleach: no change in C. difficile incidence

rate:

• 31.6 per 10,000 exposure days to 30.4 per 10,000 exposure

days

Relative risk: 1.0 (95% CI, 0.57 – 1.75), P = 0.997


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Benefits of Enhanced Terminal Room Disinfection (BETR) study

First RCT to demonstrate reduction in acquisition of important

healthcare-associated pathogens with an enhanced

disinfection strategy

Largest risk reduction with UV-C device added

Post-hoc analysis: significant risk reduction with UV+bleach

when C. difficile removed from primary outcome

No difference with addition of UV to bleach (standard) for C.

difficile outcome

• Compliance w/ cleaning in reference group ~90%

• Smaller sample size for this stratum

• ↓ effectiveness of UV-C in room shadows

• UV device not placed in bathrooms


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setting






• Copper surfaces

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Copper-coated surfaces

Copper generally toxic to most microorganisms

• Generation of reactive oxygen species → cell death

Laboratory killing of pathogens such as MRSA, E. coli,

Enterococcus spp.

Coating of high touch surfaces

• Bed rails, IV poles

• “Self-disinfecting”

• Textiles – bed sheets, gowns

Adjunct to routine room disinfection

Limited real-world data on reduction of HAIs or MDROs

Rutala W, Weber D. Am J Infect Control 2013;41S.

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Randomized controlled trial

3 U.S. intensive care units (ICUs)

• Each ICU: 8 copper, 8 non-copper rooms

Hard surfaces made from copper alloys

• E.g., bed rails, overbed tables, IV poles

Primary outcome – rate of HAIs and/or MRSA and VRE

colonization

Salgado C, et al. Infect Control Hosp Epidemiol 2013;34.

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41 events in non-copper arm vs 21 events in copper arm

Proportion 0.123 versus 0.071, P=0.02

Limitations

Unclear baseline rate of HAIs in both arms

Unable to have healthcare workers, EVS associates blinded to

copper surfaces

53.4% of patients in copper rooms had at least one item

removed

13.4% of patients in non-copper rooms were exposed to

copper items


Salgado C, et al. Infect Control Hosp Epidemiol 2013;34.

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Summary

Environmental cleaning and disinfection is an important part

of infection prevention

Selection of disinfectant needs to take into account surfaces,

organisms targeted, appropriate usage

Automated no-touch technologies show promise in reducing

HAIs and MDROs

Need more evidence for copper surfaces as an adjunct to

disinfection

Future research directions include comparative RCTs for

adjunct disinfection technologies to reduce HAIs

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Thank you!

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New Technologies in Environmental Cleaning and Disinfection€¦ · 789-bed, academic hospital, 3...

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