New Technologies in Environmental Cleaning

New Technologies in Environmental CleaningDr. Moustapha Ahmed RamadanHead of Infection Control Department Al-Adan HospitalMarch 20161

Environmental Contamination

There is excellent evidence in the scientific literature that environmental contamination plays an important role in the transmission of several key healthcare-associated pathogens.

Including methicillin-resistant Staphylococcus aureus [MRSA] , vancomycin-resistant Enterococcus [VRE], Acinetobacter, norovirus, and Clostridium difficile.2

Environmental Contamination

Admission to a room previously occupied by a patient colonized or infected with certain nosocomial pathogens increases the risk of acquisition by subsequent occupants.

Studies showed that inadequate terminal cleaning of rooms, patients acquire the organism directly from contaminated surfacesfrom HCWs who contaminate their hands in the room

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Environmental Contamination

While routine cleaning can reduce the microbiological burden in a patient room it does not always eliminate the presence of bacteria and hence risk of infection.

Traditional cleaning strategies do not remove all environmental MDROs.

The complications of room topology, and the presence of dust, grime or biofilm significantly increase the resistance of bacteria to decontamination methods.

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Housekeepers and nursing staff often do not agree on who should clean whatHousekeepers do not always understandWhich detergent/disinfectant to useWhat concentration should be used

Other contributing factorsStaff shortages and frequent turnover of personnel with demands for fast room.

Environmental Contamination

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5Factors Contributing to Suboptimal Cleaning/Disinfection Practices

Environmental Contamination

* Prior room occupant infected; ^Any room occupant in prior 2 weeks infected. Relative Risk of pathogen acquisition if prior room occupant infected

Otter , Yezli, French. ICHE. 2012;32:687-699

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Environmental Contamination

PathogenSurvival TimeS. aureus (including MRSA)7 days to >12 monthsEnterococcus spp. (including VRE)5 days to >46 monthsAcinetobacter spp.3 days to 11 monthsClostridium difficile (spores)>5 monthsNorovirus (and feline calicivirus)8 hours to >2 weeksPseudomonas aeruginosa6 hours to 16 monthsKlebsiella spp.2 hours to >30 months

Environmental survival of key pathogens on hospital surfaces

Hota B, et al. Clin Infect Dis 2004;39:1182-9 and Kramer A, et al. BMC Infectious Diseases 2006;6:130

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Environmental Contamination

Items frequently contaminated near patients include:Bed railsBed linenOverbed tablesBlood pressure cuffsIntravenous pumpsNurse call buttonsUrinary collection bags

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Environmental Contamination

It has long been recommended that environmental surfaces in patient rooms should be cleaned/ disinfected on a regular basis, when surfaces are visibly soiled, and following patient discharge (terminal cleaning).

Studies have demonstrated that adequate environment cleaning is frequently lacking.9

Carling et al. found that only 49% of surfaces targeted for terminal cleaning had been cleaned.

Overbed Table Overbed TableBefore Cleaning After CleaningVRE on call button after cleaningEnvironmental Contamination

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10Carling PC et al. Clin Infect Dis 2006;42:385The overall thoroughness of cleaning, expressed as a percent of surfaces evaluated, was 49% (range for all hospitals, 35%-81%). Further, while interventions aimed at improving cleaning thoroughness have demonstrated effectiveness, many surfaces remain inadequately cleaned and therefore potentially contaminated.

Environmental Contamination

A number of studies have shown that improved cleaning and disinfection of environmental surfaces can reduce transmission of pathogens such as C. difficile, vancomycin-resistant enterococci (VRE), and methicillin-resistant S. aureus (MRSA)11

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Environmental Contamination

Environmental cleaning rate increased significantlyVRE environmental contamination decreased significantlyVRE acquisitions by patients decreased significantly

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12Hayden MK et al. Clin Infect Dis 2006;42:1552, Prospective, 9-month study in an MICU includedAdmission and daily screening of patientsEnvironmental and HCW hand cultures twice weeklyStudy design includedBaseline period (1)Education/monitoring/feedback for housekeepers (2)Wash-out period with no specific intervention (3)Multimodal hand hygiene intervention (4)

Level of Disinfection/Cleaning for Patient Care EquipmentSpaulding Classification of ObjectsApplicationLevel of Germicidal Action RequiredCriticalEntry or penetration into sterile tissue, cavity or bloodstreamSterilizationSemi-criticalContact with mucous membranes, or non-intact skin High-level DisinfectionNon-criticalContact with intact skinLow-level Disinfection

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Common Agents Used for Disinfection of Environmental Surfaces Chlorine and Chlorine compoundsEthyl or isopropyl alcohol (70-90%)Quaternary ammonium germicidal solutionsPhenolic germicidal detergent solutionsIodophor germicidal solutionsPeracetic and hydrogen peroxide

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Advantages and Disadvantages of Common DisinfectantsDisinfectantAdvantagesDisadvantagesSodium hypochlorite(household bleach)InexpensiveFast-actingWidely availableActive against bacteria, spores, Mtb, virusesOdor can be irritatingCorrosive to metals Inactivated by organic materialMay discolor fabricsEthyl or isopropyl alcohol (70-90%)InexpensiveWidely availableRapidly effectiveActive against bacteria, Mtb, virusesNot effective against bacterial sporesNot for large surfaces

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Advantages and Disadvantages of Common DisinfectantsDisinfectantAdvantagesDisadvantagesQuaternary ammonium compoundsNot too expensiveWidely availableGood cleaning agentsNot effective against bacterial spores, Mtb, non-enveloped virusesMay become contaminatedPhenolicsWidely availableMay be toxic to infantsPoor activity againstbacterial spores and non-enveloped viruses

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Sodium hypochlorite (5.25 6.15% solutions) household bleachPreparationParts per million (ppm) available chlorineComments1:10 dilution of household bleach 5,250 - 6,150Active against C. difficile spores 1:50 dilution of household bleach 1,050 - 1,230Active against Mtb, Norovirus1:500 dilution of household bleach 105 - 123Active against vegetative bacteria

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Improving Cleaning/Disinfection PracticesDevelop policies regarding which patient-care equipment and environmental surfaces are to be cleaned by housekeepers and by nursing staff

Educate and train housekeepers regarding recommended cleaning practices and the importance of following hospital cleaning policies18

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Improving Cleaning/Disinfection PracticesEnsure and audit compliance of cleaning and disinfection procedures

Develop and apply new technologies/ devices for environmental cleaning and equipment disinfection.19

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Methods for Assessing Cleaning PracticesVisual inspectionCheck list to assure surfaces have been wipedMarking surfaces with fluorescent dye, and checking to see if marker was removed during cleaning

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Methods for Assessing Cleaning PracticesCulturing surfaces (aerobic colony counts)Contact agar plates or moistened swab culturesATP bioluminescence assays to measure cleanliness

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Advantages and Disadvantages of Methods for Assessing Cleaning PracticesMethodAdvantagesDisadvantagesVisual inspectionSimpleDoes not provide reliable assessment of cleanlinessFluorescent marker systemInexpensiveMinimal equipment neededMust mark surfaces before cleaning, and check them after cleaningAerobic colony countsRelatively simpleDetects presence of pathogensMore expensive Results not available for 48 hrs laterATP bioluminescence assay systemsProvides quantitative measure of cleanlinessQuick results More expensiveRequires special equipment

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NEW TECHNOLOGIES TO IMPROVE DISINFECTION OF ENVIRONMENTAL SURFACES 23

No touch terminal disinfectionUV light: UV-C or pulsed xenonHydrogen peroxide systems: Vapor or aerosolPortable devices: UV, steam

Self disinfecting surfacesHeavy metal surface coatings: Silver, copperSharklet patternGermicide impregnated surfaces: Triclosan24

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NTD/ UV-CMobile UV unit.

Emits UVC (254nm), which damages DNA.

Some systems control the dose of UV according to room topology.

Some have the option for multiple emitters.

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NTD/ UV-CThe efficacy of UV irradiation is a function of many different parameters such as intensity, exposure time, lamp placement, and air movement patterns.

Multiple room locations recommended.

Single room cycle times range from ~30 mins to >90 mins depending on setting

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NTD/UV-CResults/ Findings:

UV-C system is capable of reducing (MRSA, VRE, Acinetobacter baumannii) by >3-4-log10 in 15-20 minutes, and C. difficile by >1.7-4-log10 in 35-100 minutes.

Significantly less effective out of direct line of sight, e.g. only 1 log reduction in C. difficile and Aspergillus sp.

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NTD/ Pulsed Xenon UVMobile UV unit.

Produces flashes of UV light in the 200-320nm range which causes cellular damage

Cycles are fast: 15 minutes (process times 60 mins for standard methods vs. 50 mins for PX-UV including pre-cleaning)

Limited published data

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by 4 methods (photohydration, photosplitting, photodiemerization, photocrosslinking) 30

NTD/ Pulsed Xenon UVSites contaminated with MRSA

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Evaluation of a pulsed-xenon ultraviolet room disinfection device for impact on contamination levels of methicillin-resistant Staphylococcus aureusJinadatha C et al BMC Infect Dis. 2014 Apr 7;14:18731

NTD/ Pulsed Xenon UVMean contaminated samples with C.difficile

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Non-inferiority of pulsed xenon UV light versus bleach for reducing environmental Clostridium difficile contamination on high-touch surfaces in Clostridium difficile infection isolation rooms.Ghantoji SS1,et al J Med Microbiol. 2015 Feb;64(Pt 2):191-4.

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NTD/ Pulsed Xenon UVC. difficile transmission

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Miller et al December 1, 2015Volume 43, Issue 12, Pages13501353 Utilization and impact of a pulsed-xenon ultraviolet room disinfection system and multidisciplinary care team on Clostridium difficile in a long-term acute care facility

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Pros and Cons of UV systemAdvantages:Reliable biocidal activity against a wide range of healthcare-associated pathogens as room surfaces and equipment decontaminated (but not eliminated)

Room decontamination is rapid (~15-25 minutes) for vegetative bacteria

Effective against Clostridium difficile, although requires longer exposure (~50 minutes)35

Pros and Cons of UV systemAdvantages:HVAC (heating, ventilation and air conditioning) system does not need to be disabled and the room does not need to be sealed

UV is residual free and does not give rise to health or safety concerns

No consumable products so costs include only capital equipment and staff time36

Pros and Cons of UV systemDisadvantages:All patients and staff must be removed from the room prior to decontamination

Decontamination can only be accomplished at terminal disinfection (i.e., cannot be used for daily disinfection) as room must be emptied of people

Hence cleaning must precede UV decontamination

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Pros and Cons of UV systemDisadvantages:Sensitive to use parameters (e.g., wavelength, UV dose delivered)

Requires that equipment and furniture be moved away from the walls

Less effective out of direct line of sight

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UV-C Vs Pulsed Xenon UVUV-CPX-UVEfficacy3-4 log reduction in vegetative bacteria2-3 log reduction in C. difficile4-5 log reduction inVegetative bacteria Limited published data for C. difficileReduce but do not eliminate pathogensDistributionLess effective out of direct line of sightEase of useSingle or multiple locationsMultiple locationsCycle time15-50 mins15 mins

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NTD/ HPVPortable HPV generator + aeration unit for the healthcare settings.

Produces HPV from a 30%-35% H2O2 liquid solution.

Distributed as a vapour (gas) then condenses on surfaces.

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NTD/ HPVThe process also generate hydroxyl free radicals (OH-) which kill microorganisms.

At the end of the process HPV is catalytically broken down to water vapor and O2.

Compatible with hospital materials including sensitive electronics.

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NTD/ HPVResults/finding:

Passaretti et al. demonstrated that environmental decontamination with HPV reduced the risk of a patient admitted to a room previously occupied by a colonized or infected patient with a MDRO from acquiring an MDRO by 64% compared to using standard disinfection methods

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NTD/ HPV

p= 0.04743

Boyce et al. Infect Cont Hosp Epidemiol2008;29:723-729.

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NTD/ aPVPortable H2O2 aerosolizes.

5-6% hydrogen peroxide and 50-60ppm silver plus stabilisers.

Aerosolized (droplets not gas) particles

Passive aeration, H2O2 left to degrade naturally.

Cycle time >2 hour for a single room.

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NTD/ aPVResults/finding:

Exposure to 0.35 ml-aHP/ft3 achieved a 2.5-log reduction in Norovirus, 4.3, and 3.4-log reduction Feline Calcivirus and Tulane virus respectively.

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Efficacy of a Portable Aerosolized Hydrogen Peroxide Delivery Method for Inactivating Human Norovirus and Its SurrogatesClyde Manuel, et al .46

NTD/ aPVLog10 reduction under aPV of two C. difficile strains(without organic soiling)

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Effect of airborne hydrogen peroxide on spores of Clostridium difficileGeorg Steindl Anita Fiedler Steliana Huhulescu Gnther Wewalka Franz Allerberger47

NTD/ aPVLog10 reduction under aPV of two C. difficile strains(with organic soiling)

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Effect of airborne hydrogen peroxide on spores of Clostridium difficileGeorg Steindl Anita Fiedler Steliana Huhulescu Gnther Wewalka Franz Allerberger48

Effects of conventional cleaning method vs H2O2 system against MDRO surface contamination in ICU p= 0.371 p= 0.00449

Efficiency of hydrogen peroxide in improving disinfection of ICU roomsCarolineBlazejewski1, et al Critical Care201519:30

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HPV vs aHP for C. difficile decontamination% of sites contaminated with C. difficile p 2 hours Passive aeration

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Hydrogen peroxide Vs Ultra Violet500 bed hospital (15 patient rooms at random from 8 wards)

5 high touch surfaces cultured for Aerobic colony counts

Steel discs loaded with 6 log10 C. difficile sporesplaced in 5 areas close to high touch surfaces

Biological indicators with 4 log10 and 6 log10 G. stearothermophilus56

Hydrogen peroxide Vs Ultra VioletDirect line of sightNumbers of sites positiveIndirect line of sight57

Hydrogen peroxide Vs Ultra VioletHPVUV-CACC93%52%C. Difficile reduction6 log 10< 2 log10BI Killed99-100%0-22%Hour cycle2.5-3 hours0.6-1.7 hour

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Which to be used?HPVaPVUV-CPX-UVEfficacy11-233-4Distribution1243Ease of use4312Cycle time3421Running cost3211

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Heavy metals coatingsAntimicrobial copper works on two steps

First step is a direct interaction between the surface and the bacterial outer membrane, causing the membrane to rupture.

Second is related to the holes in the outer membrane, through which the cell loses vital nutrients and water, causing a general weakening of the cell.63

Heavy metals coatingsAntimicrobial Copper is designed to cover high touch surfaces.

More studies are needed.

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Heavy metals coatings

The antimicrobial effects of silver are through protein inactivation, DNA association and penetrating the cell.

Mainly used for medical devices and equipment as in silicone based medical devices.65

Germicide impregnated surfacesNot designed to protect users from disease causing microorganisms.

Protects against stain and odors.

Not recommended any more in several settings.

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Sharklet pattern New technology aims to inhibit bacterial growth through physical surface modification alone.

The surface topography is made of millions of microscopic diamonds that disrupt the ability for bacteria to aggregate, colonize, and develop into biofilms.

High touch surfaces/ medical equipment

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ConclusionThe surface environment in rooms of colonized or infected patients is frequently contaminated with pathogens.

These pathogens are capable of surviving on hospital room surfaces and medical equipment for a prolonged period of time.

Contact with hospital room surfaces or medical equipment by healthcare personnel frequently leads to contamination of hands and/or gloves.

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ConclusionPatient admitted to a room previously occupied by a patient colonized or infected with a pathogen has an increased likelihood of developing colonization or infection with that pathogen

The frequency with which room surfaces are contaminated correlates with the frequency of hand and/or glove contamination of healthcare personnel

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(eg, methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, Clostridium difficile, and Acinetobacter)69

Conclusion

Clonal outbreaks of pathogens contaminating the room surfaces of colonized or infected patients are demonstrated to be due to person-to-person transmission or shared medical equipment

Improved terminal cleaning and disinfection of rooms leads to a decreased rate of infections70

ConclusionThese technologies supplement, but do not replace, standard cleaning and disinfection because surfaces must be physically cleaned of dirt and debris.

Additionally, these methods can only be used for terminal or discharge room decontamination (i.e., cannot be used for daily room decontamination) because the room must be emptied of people.71

THANK YOU

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