Reducing Environmental Contamination and Trans-mission of Healthcare Associated Infections With Single-Use, Absorbent Cleaning Cloths.
AbstractHealthcare-associated infections cost the Australian healthcare system $AUD 950 million every year. Prop-er environmental cleaning resulting in a clean and dry surface seems like an obvious and easily achieved outcome. Unfortunately, however current guidelines and cleaning practice vary widely. As a consequence, environmental reservoirs of potentially pathogenic organisms are common. There is also suggestion that the European and UN tests used by authorities to assess the efficacy of various impregnated single wipes do not truly emulate the typical clinical environment. The problem of inappropriate cleaning is particularly concerning given the increasingly concerning global issue of multiple drug resistant organisms. Perhaps rather than embracing new, fancy technologies and cleaning products decision makers need to better un-derstand and appreciate the critical role a cleaning cloth plays in infection prevention. These issues under-pin this white paper.
AuthorCathryn Murphy, RN B Photog MPH PhD CIC CICP-E., CEO – Infection Control Plus Pty Ltd, Honor-ary Adjunct Associate Professor, School of Medicine, Bond University, Queensland, Australia© 2018. This white paper is the property of Kimberly Clark Professional.Infection Control Plus (ICP) Pty Ltd has partnered with commercial and clinical clients since it began trading in 2004. ICP provides unique insights about the infection prevention and control (IP&C) risks and/or benefits associated with specific clinical practices, medical devices, equipment and formula-tions. ICP is well respected among the Australian and international IP&C communities and recognised for its unique ability to help clinicians and end-users to better understand and apply evidence to remediate, evaluate and/or innovate their organisation’s IP&C program.
IntroductionHealthcare-associated infections (HAIs) are estimat-ed to affect between 83,0001 and 200,0002 Austra-lians each year. The annual cost of HAIs to the Aus-tralian healthcare system is estimated to be as much as $AUD 950 million3 with public hospitals only re-cently being subject to financial penalty in the event of specific HAIs.4 In efforts to reduce both the harm to patients and costs of these infections healthcare organisations, including acute hospitals and long-term residential aged-care facilities are constant-ly trying to maintain clean and safe environments. Typically, these environments are managed through routine processes of regular environmental and sur-face cleaning. In the event of a patient known to be positive for some specific bacterial infections such as Clostridium difficile or other multiple-drug resis-tant organisms (MDROs) or viral conditions such as norovirus, routine cleaning is often supplemented by a disinfection process. In Australia this most often involves the use of liquid disinfectants rather than waterless methods of disinfection such as ultraviolet and
other light spectrums. Recent evidence confirms that patients occupying a room previously occupied by an MDRO-positive patient are at substantial in-creased risk of also acquiring the same organism(s).5,6
Due to the absence of well-designed, high quality research to date reports of HAI directly attributable to contaminated or improperly cleaned environ-mental surfaces are sparse. The ability to demon-strate a causal link is further complicated by wide variations in healthcare worker (HCW) compliance with recommended actions such as hand hygiene, use of gloves and protective clothing which are part of basic Standard Precautions and applied routinely in healthcare settings. Variation in the ability of po-tential pathogens (including bacteria, viruses, and fungi) to survive on the many different surfaces and shapes in the inanimate healthcare environment fur-ther complicates our understanding of the criticality of cleaning as an infection prevention strategy.7,8
1Reducing Environmental Contamination and Transmission of Healthcare Associated Infections With Single-Use, Absorbent Cleaning Cloths.
However, experts are now willing to acknowledge that ineffective cleaning and/or disinfection of en-vironmental surfaces contributes to increased HAI risk.9-13 Additionally, other experts have demonstrat-ed significant difference in thoroughness of cleaning in hospitals around the world,14-17 including in Aus-tralia.18 Unfortunately, this problem is further com-plicated by lack of agreement regarding the most effective methods of performing and evaluating en-vironmental cleaning in patient-care areas.10-13,19-21
Our understanding of the importance and impact of environmental cleaning in healthcare has been further challenged by the emergence of new tech-nologies and innovations such as micro-fibre cloths, waterless disinfection systems, impregnated single use wipes and one-step systems of cleaning and disinfection.9,11,13,19,22,23 Variations in training, practice, compliance and technique among environmental services staff is widespread and difficult to address. In Australia, there is also variation among the inclu-sions and recommendations contained in various state and national guidelines. As a result environ-mental cleaning including products used is not stan-dardised in Australia.24
The purpose of this white paper is to review available scientific and grey literature to explore issues relating to the use of cloths in cleaning of the clinical envi-ronment. Its specific aim is to better understand any relationship between residual moisture after clean-ing and increased risk of HAI transmission. Areas considered include pathogen survival on inanimate surfaces, general and guideline recommendations regarding cleaning technique, potential for re-con-tamination of inanimate surfaces and future chal-lenges in cleaning of clinical environments.
Pathogen Survival on Inanimate Surfaces In 2002 Kramer published a seminal publication ad-dressing organism persistence in inanimate environ-ments.7 Although Kramer reported the various times for persistence of bacteria on dry not wet or moist inanimate surfaces, his work is a salient reminder of the ability of potential pathogens to survive in some cases up to several years in clinical settings there-by functioning as a “continuous source of transmis-sion”p1.
The US Centers For Disease Control and Prevention’s
The US Centers For Disease Control and Prevention’s2003 Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Ad-visory Committee (HICPAC)25 are an early but high level piece of guidance for those involved in clean-ing of hospital environments. The guideline reminds readers that “…Microorganisms are present in great numbers in moist, organic environments, but some also can persist under dry conditions…” p.17. It also discusses the general requirement of gram-negative bacteria for a moist environment to support their persistence and growth.25 Specifically it highlights the preference of Acinetobacter spp. and Entero-bacter spp for moist environments. In the years after the CDC’s guideline, both have become organisms of major concern in regard to their ability to become multiple drug resistant. In doing so they are often re-sponsible for serious HAI outbreaks.
Other potentially pathogenic organisms associated with or dependent on moisture include Aspergillus spp and Pseudomonas aeruginosa. There are report-ed cases of probable indirect transfer of Pseudomo-nas aeruginosa from moist environmental surfaces via hands of health-care workers.26 Other outbreak reports show the ability of pathogens to contami-nate solutions (including disinfectant solutions) and moist equipment, including reusable cleaning cloths, used in clinical care.13 Moisture and water, especially contaminated water, used in environmental clean-ing, can easily serve as a medium for spreading mi-crobes around the environment.13 To varying extents this knowledge of the potential for moisture to con-tribute to environmental spread of pathogenic or-ganisms has informed current cleaning Australian recommendations as discussed in the next section.
General and Guideline Recommendations Regard-ing Cleaning Technique Australian national infection control guidelines and cleaning guidelines from New South Wales, South Australia and Victoria were reviewed in the writing of this paper. None detailed the importance of elim-inating all moisture from cleaned surfaces to reduce potential spread of HAI-causing pathogens.
2Reducing Environmental Contamination and Transmission of Healthcare Associated Infections With Single-Use, Absorbent Cleaning Cloths.
Rather they focussed on the importance of changing reusable cleaning items (including cloths) after each use and washing and rinsing each of them prior to drying and storage. The one exception was the Na-tional Health and Medical Research Council’s 2010 guideline2 which included advice that “…Allowing the cleaned surface to dry is an important aspect of cleaning…”p69. To predict what the revised version of this national guideline (due for release in Novem-ber 2018) may recommend the most recent public-ly available draft version (April 2018) was reviewed. There was no alternate or additional recommenda-tion regarding drying of environmental surfaces.
The absence of specific guidance in regard to clean-ing and advice regarding cleaning equipment ex-plains the wide variation in cleaning product use in Australian hospitals reported recently by Mitchell and colleagues.24 It is also likely a good representation of the low priority Australian clinicians have to-date attributed to the possible relationship between en-vironmental contamination, cleaning and HAI trans-mission risk. The disconnect appears to be very real. The problem of non-uniform cleaning also appears to be a global issue with a recent study reporting wide variation in cleaning practice and product.10
Undoubtably the lack of uniform, well-recognised best practice in surface cleaning and disinfection contributes to poor and perhaps even unneces-sary and/or unsafe cleaning practices. The lack of agreement on the extent to which environmental contamination contributes to HAIs also impedes best practice cleaning.22 The added reliance on hu-man behavioural factors for manual cleaning further complicates the issue.22
Additionally, the draft NHMRC Guidelines indicate a preference for disinfection of contaminated sites and surfaces with sodium hypochlorite. The draft guideline is generally silent or vague regarding issues of adequate contact-time, coverage, influence of type and characteristics, including composition, of the cleaning cloths used.
Potential For Re-Contamination Of Inanimate Surfaces The available literature includes discussion of used cleaning solution and cloths either separately or in combination becoming a source of organism distri-bution rather than removal.13 Dancer suggests that this is a particular problem with reusable microfibre cloths and more importantly can involve Enterococ-ci including Vancomycin-resistant enterococci (VRE) which is a major problem for Australian hospitals.
Siani5 also addresses the issue of wipes and in a dou-ble-crossover study reported pre-impregnated wipes contributed to significantly decreasing microbial bio burden from a number of high touch surfaces. Siani also reports contravention by staff of the “one wipe-one direction-one surface recommendation” which is an informal recommendation designed to reduce overuse of single use cloths and misuse of reusable cloths.
Regardless of whether disposable wipes or re-usable cloths are used they must achieve sufficient wetness to meet the relevant manufacturer’s instructions for use for any cleaning or disinfection agent.11 Ideally, the cleaning cloth is also compatible with the agents used. For reusable cloths it is not uncommon for cloths, including microfibre cloths, to be affected and even degraded by certain agents. It has even been suggested that typical hospital laundering practices are not sufficient to remove all viable microorgan-isms and spores from cleaning towels thereby ren-dering them as potential reservoirs for dissemination of possible pathogens.27-29 The burden and perhaps even the safety of using, changing, rinsing, launder-ing, drying and storing reusable cloths in a place and manner where they are not re-contaminated can be substantial. In these situations, impregnated wipes may seem more convenient, simple and effective. However, recent literature suggests that the current European and US tests against which the perfor-mance of impregnated wipes are assessed are inad-equate representations of the clinical environment. Importantly, “…wipes need to be assessed for their ability to remove and transfer microbes…”.30
Dancer also recognises the apparent convenience of disposable impregnated wipes however she also cautions that they may leave excess moisture or res-idues on surfaces, which can attract additional soil and ultimately spoil the finished appearance.13
Reducing Environmental Contamination and Transmission of Healthcare Associated Infections With Single-Use, Absorbent Cleaning Cloths.
Ramm and colleagues suggest that in the case of im-pregnated detergent wipes their performance may be influenced by the type of nonwoven, quality of the raw materials and nonwoven, liquid to wiper ra-tio, and even the packaging of the product.30 This example suggests that it may be prudent for users to more carefully consider the needs of their clinical organisation also taking into account that the needs may vary across various settings within an organisa-tion.5,9,19,30
In a recent article Satar eloquently raises concerns regarding the “crucial” role of wiping in decontam-ination of high-touch environmental surfaces.31 His work highlights how the physical properties of a towelette influence the degree of contact it makes with the surface as well as its cleaning/abrasion of that surface and the capacity it has to pick up and hold soils, microbes, and particles as a surface is wiped. Satar also highlights that pathogen survival on an inanimate surface is dependent on its biolo-gy, growth phase, environmental conditions such as relative humidity (RH) and air temperature, nature of the surface, and type and level of the associated soil.31 His work further considers the importance of the human factors associated with cleaning and the requirement for diligence to ensure efficacy of the process. He, like others, warns that incorrect wiping can be counterproductive by spreading localized contamination over a greater area.29,31
Future Challenges in Cleaning Of Clinical EnvironmentsJust as with many other areas of infection preven-tion, significant innovation and technological im-provements in cleaning potentially offer previously unattainable levels of efficacy and safety. Unfortu-nately, the challenges we face in infection preven-tion continue to be more complex and difficult. The most difficult and potentially catastrophic would seem to be the worldwide increase in MDROs.
The importance of adequate environmental cleaning as an essential element of any organisation’s infec-tion prevention and control programme is undis-puted. Early indications suggest that rather than hav-ing insufficient options, future offerings for cleaning will be plentiful. The real challenge will be accurately assessing their efficacy, their ease of use and their suitability. As part of that process the ability of any innovation to inadvertently contribute to greater HAI risk rather than greater safety should be considered. This process is not necessarily complex, in fact it may even be as simple as thinking about how well a cloth removes moisture thereby leaving a surface truly clean and dry. DisclaimerAssoc. Prof Cath Murphy RN, B. Photog, MPH, CIC, CICP-E, FAPIC, FSHEA, PhD is a consultant to mul-tiple medical manufacturers globally including Kim-berly Clark Professional, Australia. Views expressed in this white paper are the author’s own based on comprehensive review of available scientific litera-ture.
To learn more about the critical role hand towels and wipers can play in healthcare hygiene, visit
References 1. Mitchell BG, Shaban RZ, MacBeth D, Wood C-J, Russo PL. The burden of healthcare-associated infec-tion in Australian hospitals: A systematic review of the literature. Infection, Disease & Health. 2017;22(3):117-128.2. National Health and Medical Research Council. Australian Guidelines for The Prevention and Control of Infection in Healthcare. In. Canberra: Commonwealth of Australia; 2010.3. Duckett S, Jorm C, Moran G, and , Parsonage H. Safer care saves money: How to improve patient care and save public money at the same time. Melbourne: Grattan Institute;2018.4. Magid B, Murphy C, Lankiewicz J, Lawandi N, Poulton A. Pricing for safety and quality in healthcare: A discussion paper. Infection, Disease & Health. 2018;23(1):49-53.5. Siani H, Wesgate R, Maillard J-Y. Impact of antimicrobial wipes compared with hypochlorite solution on environmental surface contamination in a health care setting: A double-crossover study. American Journal of Infection Control. 2018.6. Huang SS, Datta R, Platt R. Risk of acquiring antibiotic-resistant bacteria from prior room occupants. Arch Intern Med. 2006;166(18):1945-1951.7. Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis. 2006;6:130.8. Dancer SJ. Hospital cleaning in the 21st century. European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology. 2011;30(12):1473-1481.9. Rutala WA, Weber DJ. Surface Disinfection: Treatment Time (Wipes and Sprays) Versus Contact Time (Liquids). Infect Control Hosp Epidemiol. 2018;39(3):329-331.10. Kenters N, Gottlieb T, Hopman J, et al. An international survey of cleaning and disinfection practices in the healthcare environment. Journal of Hospital Infection. 2018.11. Rutala WA, Weber DJ. Monitoring and improving the effectiveness of surface cleaning and disinfection. American Journal of Infection Control. 2016;44(5, Supplement):e69-e76.12. Carling PC. Optimizing Health Care Environmental Hygiene. Infectious Disease Clinics of North America. 2016;30(3):639-660.13. Dancer SJ. Controlling Hospital-Acquired Infection: Focus on the Role of the Environment and New Technologies for Decontamination. Clinical Microbiology Reviews. 2014;27(4):665.14. Carling PC, Bartley JM. Evaluating hygienic cleaning in health care settings: what you do not know can harm your patients. Am J Infect Control. 2010;38(5 Suppl 1):S41-50.15. Carling PC, Parry MF, Von Beheren SM. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(1):1-7.16. Carling PC, Parry MM, Rupp ME, Po JL, Dick B, Von Beheren S. Improving cleaning of the environment surrounding patients in 36 acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(11):1035-1041.17. Carling PC, Von Beheren S, Kim P, Woods C. Intensive care unit environmental cleaning: an evaluation in sixteen hospitals using a novel assessment tool. J Hosp Infect. 2008;68(1):39-44.18. Murphy CL, Macbeth DA, Derrington P, et al. An assessment of high touch object cleaning thoroughness using a fluorescent marker in two Australian hospitals. Healthcare Infection. 2012;16(4):156-163.19. Kenters N, Huijskens EGW, de Wit SCJ, van Rosmalen J, Voss A. Effectiveness of cleaning-disinfec-tion wipes and sprays against multidrug-resistant outbreak strains. American Journal of Infection Control. 2017;45(8):e69-e73.20. Ellis O, Godwin H, David M, Morse DJ, Humphries R, Uslan DZ. How to better monitor and clean irregu-lar surfaces in operating rooms: Insights gained by using both ATP luminescence and RODAC assays. American Journal of Infection Control. 2018;46(8):906-912.21. Mitchell BG, Wilson F, Dancer SJ, McGregor A. Methods to evaluate environmental cleanliness in health-care facilities. Healthcare Infection. 2013;18(1):23-30.22. Doll M, Stevens M, Bearman G. Environmental cleaning and disinfection of patient areas. International Journal of Infectious Diseases. 2018;67:52-57.23. Gillespie E, Wilson J, Lovegrove A, et al. Environment cleaning without chemicals in clinical settings. American Journal of Infection Control. 2013;41(5):461-463.24. Mitchell BG, Farrington A, Allen M, et al. Variation in hospital cleaning practice and process in Australian
5Reducing Environmental Contamination and Transmission of Healthcare Associated Infections With Single-Use, Absorbent Cleaning Cloths.
24. Mitchell BG, Farrington A, Allen M, et al. Variation in hospital cleaning practice and process in Australian hospitals: A structured mapping exercise. Infection, Disease & Health. 2017;22(4):195-202.25. Sehulster L, Chinn RY, Cdc, Hicpac. Guidelines for environmental infection control in health-care facil-ities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recommendations and reports : Morbidity and mortality weekly report Recommendations and reports. 2003;52(RR-10):1-42.26. Widmer AF, Wenzel RP, Trilla A, Bale MJ, Jones RN, Doebbeling BN. Outbreak of Pseudomonas aerugi-nosa infections in a surgical intensive care unit: probable transmission via hands of a health care worker. Clin Infect Dis. 1993;16(3):372-376.27. Sifuentes LY, Gerba CP, Weart I, Engelbrecht K, Koenig DW. Microbial contamination of hospital reusable cleaning towels. American Journal of Infection Control. 2013;41(10):912-915.28. Oie S, Arakawa J, Furukawa H, Matsumoto S, Matsuda N, Wakamatsu H. Microbial contamination of a disinfectant-soaked unwoven cleaning cloth. Journal of Hospital Infection. 2012;82(1):61-63.29. Bergen LK, Meyer M, Høg M, Rubenhagen B, Andersen LP. Spread of bacteria on surfaces when cleaning with microfibre cloths. Journal of Hospital Infection. 2009;71(2):132-137.30. Ramm L, Siani H, Wesgate R, Maillard J-Y. Pathogen transfer and high variability in pathogen removal by detergent wipes. American Journal of Infection Control. 2015;43(7):724-728.31. Sattar SA, Maillard J-Y. The crucial role of wiping in decontamination of high-touch environmental sur-faces: Review of current status and directions for the future. American Journal of Infection Control. 2013;41(5, Supplement):S97-S104.
6Reducing Environmental Contamination and Transmission of Healthcare Associated Infections With Single-Use, Absorbent Cleaning Cloths.