Do’sandDon’tsforhospitalcleaning

ProfessorStephanieDancerNHSScotland&EdinburghNapierUniversity

HostedbyProf. Jean-YvesMaillardCardiffUniversity,Wales

www.webbertraining.com April 25, 2017

A.DenverRussellMemorialTeleclassLecture

Howshouldweapproachcontrolofantimicrobial

resistance?

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...butpatientsacquireresistantpathogensfromthecontaminatednear-patientenvironment

SocontrollingAMRrequiresattentionon:i)vertical (direct)effectsbyantimicrobialdrugsii)horizontal (indirect)spreadcausedbyinfectionprevention&controldeficits

DancerSJ,‘TheeffectsofantibioticsonMRSA’,JAntimicrobialChemother(2008)

Antimicrobialstewardship?

Antimicrobialdrugsmightbeencouragingresistance..

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InvisibleAesthetic bias

Pathogen detection Evidence-based science?

No accepted measureWomens’ workFabric deficits

Costly

Low paid; low status; and dirty

WHY are we still debating the value of cleaning?

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SurvivaltimeInfectiousdose

MRSA 7daysto>7months4cfu’s

Acinetobacter 3daysto>5months250cfu’s

C.difficile >5months5spores

VRE 5daysto>4months<103cfu’s

E.coli 2hrsto16months102-106cfu’s

Klebsiella 2hrsto>30months102cfu’s

Norovirus 8hrsto7days<20virions

Kramer,BMCInfectDis,2006;DancerSJ,ClinMicrobiolRev2014

Propertiesofhospitalpathogens

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Increased risk associated with the prior room occupant. The figures of difference in risk are unadjusted based on raw data.

Otteretal,AmJInfectControl2013Mitchelletal,JHospInfect2015

Isriskrelatedtoenvironmentallongevity?

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Where are the pathogens in a hospital?

Hayden et al, SHEA 2004 7

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Adamsetal,JHospInfect201710

Fluorescent gel placed on chosen sites

After patient discharge, a site is considered cleaned if the fluorescent material is removed or disrupted

Carling et al, Am J Infect Control, 2006

Ecolab®

How do we measure hospital cleaning?

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Removal of marker may not correlate with cleaning of alternate sites on the same surface Sitzlar et al, ICHE 2013

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What’s the long term effect?

Maintenance of environmental services cleaning and disinfection in the ICU after a performance improvement project

Fitzgerald et al, AmJIC 201213

Howdowemeasurehospitalcleanliness?

Whatisclean?

“whatanindividualthinksitis”

82-91% Visually clean

10-24% ATP clean

30-45% Microbiologically clean

GriffithCJetal,JHospInfect200014

Surface evaluation using ATP bioluminescence

Swab surface luciferase tagging of ATP Luminometer

Used in the commercial food preparation industry to evaluate surface cleaning and as an educational tool for more than 30 years

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Site Before* After*Site Mean

ATP BeforeSite Mean

ATP After

Locker (M) RangeMean

15-316106

17-14847

120 69Locker (S) RangeMean

7-325134

5-20891

L Bed (M) RangeMean

4-243106

4-1512206

105 131L Bed (S) Range

Mean4-181103

32-11556

O/B Table (M) RangeMean

28-625116

13-7536

181 309O/B Table (S) RangeMean

33-550246

55-3846581

R Bed (M) RangeMean

3-409145

3-20060

132 57R Bed (S) RangeMean

0-266118

16-12854

ATP values (RLU’s) for sites on medical & surgical wards

Mulveyetal,JHospInfect2011*Benchmark=100RLU’s 16

ChanMC,LinTY,ChiuYH,etal.ApplyingATPbioluminescencetodesignandevaluateasuccessfulnewintensivecareunitcleaningprogramme.JHospInfect2015;90:344–346.

ATPsystemsencouragecleaningeffectiveness,buttheydonotnecessarilymeasuresurfacecleanliness.HighATPvaluesdonot

necessarilymeanpresenceofmicrobialpathogens!

WhateffectdoesATPmonitoringhave?

Studyin2ICUsinapublic1800-bedhospitalinTaiwan

CleaningefficacywasmonitoredbyATPbioluminescenceaftercleaning;<45%of221surfacespassed

Afteranewcleaningprotocol,88%of270surfaceswerecleanaccordingtoATPcriteria.CombinedHAIratesintheICUsapparentlydecreasedbyhalf!

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5 cfu/cm2 45 cfu/cm2

Slide from Chris Griffith

Would microbiological standards help?

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Standard1Thereshouldbe<1cfu/cm2 pathogen(MRSA;

C.difficile;VRE;etc)onhealthcaresurfaces

Standard2AerobicColonyCount(ACC)ortotalmicrobialgrowthlevelfrom

ahandtouch surfaceshouldbe<5cfu/cm2

Thesestandardsarebaseduponfoodindustrycountsasappliedtofoodpreparationsurfacesbutcouldbeutilisedfor

frequenthandtouchsurfacesinhospitals

DancerS,JHospInfect2004

Microbiologicalstandardsforsurfacehygieneinhospitals

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Istherearelationshipbetweenenvironmentalbioburdenandhospital-acquiredinfection?

White et al, AmJIC 2008

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.

Sowhichisthebestmethodformeasuringhowcleanahospitalis?

Aimforasystemwhichshowsmeasurablebenefitforpatients:aesthetics,cleaningfocus,cleanersurfaces,

andifyou’relucky,HAIrates;but….wouldn’titbenicetohaveasystemthatgivesusearly

warningofanimminentoutbreak?

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Correlatingcleaningeffectagainstsurfacecleanlinessindicators

Boyce et al, ICHE 2011

Fluorescent marker vs ACCs; how well have surfaces been cleaned

Fluorescent marker vs ATP; which surfaces need cleaning

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Correlatingcleaningeffectagainstsurfacecleanlinessindicators

Boyce et al, ICHE 2011

Fluorescent marker vs ACCs; how well have surfaces been cleaned

Fluorescent marker vs ATP; which surfaces need cleaning

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Whatistheevidenceforcleaningasaviablecontrolmechanismforhospital-acquiredinfections?

BBC website, 2008

Twomatchedwardsreceivedoneextracleaner(MondaytoFriday),witheachwardreceivingenhancedcleaningforsixmonthsinacross-overdesign;

Enhancedcleaningledtoa33%reductioninlevelsofmicrobialsoilathand-touchsites;and27%reductioninnewMRSAinfections,despitehigherbedoccupanciesandMRSAcolonisationpressures(p=0.032:95%CI7.7%,92.3%).

Dancer et al, BMC Med, 200924

Totalaerobiccolonycounts(ACC)fromhand-touchsitesontwomatchedwards;thecleanermovedfromWardAtoWardBatweek26

Danceretal,BMCMed,200925

Keepyourcleaningstaffin-house!

Toffoluttietal, SocialScience&Medicine2017;174:64–69

MRSA Incidence rate by type of cleaning service in 2010

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Clostridium difficile infection incidence for units A and B combined, before and after the intervention

HAI, hospital-acquired CDAD; INC, overall CDAD incidence; PD, patient days; PT, patient.

Orenstein et al, ICHE 2011

WipingOutClostridiumdifficile

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BasichygienemeasuresreducedVREincidence

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=Hand Hand-touch site

...isequalandoppositeDancerSJ,ICHE2010

The Hand-Touch equation:

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Onesurprising! findingwasthatpatienthandhygienewasassociatedwithreducedcontaminationofenvironmentalsurfaces………….

Sunkesulaetal,ICHE2016

ImpactofaHand-HygieneInterventiononContaminationofPatient’sHandswithHealthcare-AssociatedPathogens

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Dailycleaning?

TheTelegraph,UK,2008

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Contact plates from patient locker surfaceLeft to right: Pre clean, 1 hour, 2 hour, 3 hour assessment

MRSA rapidly recontaminates high-touch sites in ICU after H202 vapourHardyKJetal,JHI2007

Mike Rollins, Osprey

Howlongdohospitalsurfacesstay‘clean’?

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gg

Stewart et al, ICHE 2014

Effectofdetergent(blueline)anddisinfectant(redline)cleaningontotalACCathand-touchsitesover48hours

5cfu/cm2

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Stewart et al, ICHE 2014

EffectofdetergentanddisinfectantcleaningontotalMSSA/MRSAathand-touchsitesonone30bedwardover48hours

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Vickery et al, J Hosp Infect 2015

Dobiofilmsonhospitalsurfacesprotectviablepathogensfromcleaning?

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‘Chemzyme Plus’AsoupofBacillussubtilis!

Adisinfectantcontaininggoodbacteriareduced‘bad’bacteriaby1,000-foldcomparedwithstandardcleaning

PhagedisinfectantsBacteriophages thattargethospitalpathogenscanbeincorporatedintodisinfectants

NeutralElectrolysedwater

New disinfectants on the Block

http://www.phageworks.com

http://chemexuk.com

MeakinNetal,JHospInfect2012

Normaltapwaterwithaddedsaltthathashadanelectriccurrentpassedthroughit

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ElectrolysedwaterWhatisit?

Electrolysedwaterisnormaltapwaterwithaddedsaltexposedtoanelectriccurrent.Non-toxic!

Itismicrobiocidalduetothepresenceofhypochlorousacid.ThisacidisonlypresentinverylowconcentrationssothattheproducthasaneutralpH,thesameasordinarywater.

Howgoodadisinfectantisit?Isitbetterthanbleach?

Alsoeffectivefordecontaminatingsensitiveclinicalequipment

MeakinNetal,JHI2012;Danceretal,HealthcareInfection201537

ColdPlasmaTechnologyreducessurfacebacterialcounts

Multiple-jet air decontamination of patient tray tables over 8 weeks (n= 6; NS, non significant; *P< .05). Claro et al, Infect Control Hosp Epidemiol 2017

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Song et al, AmJIC 2012

EffectofbleachvssteamagainstE.coli biofilm

<1secondsteamachievesbetterdisinfectionthan10ppmsodiumhypochloritefor10-20minutes

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Antimicrobial surfaces

• Copper(toiletseats,sinks,handles,etc)• Silver(textiles,etc)• Triclosan(tootpaste,choppingboards,etc)• Paintscontainingpolyurethanes,epoxymaterials,styreneacrylics• Polymer‘conjugatedpoly-electrolyte’plusfluorescentlight• Nanocoating(nanotubespluslysostaphin)

PageetalJMaterChem2009

‘….antimicrobialcoatingsmustnotunderminetraditionalhygienemethodsandneithershouldconventionalcleaningberelaxedifantimicrobialcoatingsareemployed’

ChildT,www.allbusiness.com 2005 40

Failureofcopper-basedNanoCote/Aqua-Basedantimicrobialpaintinahospitalsetting

LaminatedwoodbedsidetablecoatedwithNanoCotefollowingwaterspillage

LaminatedwoodbedsidetablecoatedwithNanoCoteHD-WR(beforecuring).Close-upviewshowingunevendistributionafterapplication

Ramsdenetal,JBiologPhysChem,201641

Pailhoriès et al, ICHE 2016

FourMSSAandfourMRSA;Twodifferentorientationsofoakused

Potentialantimicrobialactivityofoak(Querceusspp.)wastestedagainstapanelofS.aureusisolates

Oakshowedantimicrobialactivitytowardsalltheisolatestested;BUT….diameterofthewoodendiscswas9mm,asopposedto2mmforastandardantibioticdisc

‘Oakinhospitals,theWorstEnemyofStaphylococcusaureus?’

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Disinfecteverything…..

DancerSJ,ClinMicroRev2014;

Po&Carling,ICHE201043

DoesH202 improvedisinfectionofICUrooms?

ProspectivecrossoverstudyinaFrenchhospital;roomswerecleanedwithquat&sodiumhypochlorite,followedbyeitherH2O2vapouroraerosolizedH2O2combinedwithperaceticacid;

BEFOREanyH202disinfection,only23(1.5%)of1,456sampledsurfacesand15(8%)of182roomswereMDRO-positiveafterpatientdischarge;

H2O2disinfectionreducedESBLsonly,sincenootherMDROswerefoundafterroutinecleaning;

TheseESBLswerefoundmostlyfromsinks..

BlazejewskiCetal,CritCare201544

ButtheriskofacquiringClostridiumdifficile,MRSAandmultidrug-resistantGram-negativebacilliwas‘notsignificantlyreduced’;

ThesignificancequotedfortheoverallresultcamefromtheVREdataonly.

Patientswere64%lesslikelytoacquireMDROsand80%lesslikelytoacquireVRE(P < 0.001)followingH202 terminalcleaning……...

Passarettietal.ClinInfectDis,56(2013):27–35

TerminaldecontaminationofroomsusingH202vapour

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AnEnvironmentalDisinfectionOdyssey:evaluationofsequentialinterventionstoimprovedisinfectionofC.difficileisolationrooms

Sitzlaretal,ICHE2013

35%ofroomsremainedculturepositiveforC.difficileafteruseofUVdevices46

Theeffectofdistanceontheefficacyofthe

PX-UVdevice

Nerandzicetal,ICHE2015

Good

Poor

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IncidenceofMDROsandClostridiumdifficile fromJanuary2009untilApril2013;pulsedUVlightintroducedMay2011

HaasJetal,AmJIC201448

IncidenceofMDROsandClostridiumdifficile fromJanuary2009untilApril2013;pulsedUVlightintroducedMay2011

HaasJetal,AmJIC2014

$$$

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Dancer et al, IJAA 2013

*

**

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Hydrogenperoxidecan’tpenetratelinen,pillowsorsoftfurnishings

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CanUVCwavesgoroundcorners?

That’saNO,then?52

Toxicity?

HumansSurfacesPlasticsPlantsAnimals

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Timetakenfordecontamination

Needtoremovethepatient;

NeedtototallysealoffaroombeforeH202exposure;NeedtorepositionUVCapparatusforuniformcoverage;

Needtotrainstaff;Needtoprepareroom;Needtoremovesoftfurnishings;

Can’tdoopenplan….

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..iscurrentevidenceonclinicalbenefitsufficientlyplentiful,andindeed,robust,toallocatescarcehealthcareresourcesforthesesystems?’ DancerSJ,FloorWarsletter,JHI2013

‘TheH202robotsystemcostsaboutUS$40,000;theUVlightsystemcostsmorethanUS$100,000……..

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Aggressivemarketingbyrobotcompaniesencourageshealthcaremanagerstochoosethesemethods…

…butnooneknowswhetherplainoldsoapandwatermightactuallydothejobjustaswell,formuchlesscostandminimaleffectonpeopleandenvironment

Buy my robot! It kills all known germs

My robot’s called Jim

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Man-agersaremorelikelytochoosepush-buttongadgetsratherthanreducebedoccupancyorengage

morecleaners

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true

59

true

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AlfaMJetal,BMCInfectDis2010,10:268

Theefficacyofanycleaning/disinfectantagenttestedisdependentonphysicalaction....

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Evenifalltheroomsaredecontaminatedbyrobots,westillneedstafftomanuallypickuplitter…

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Time to get PHYSICAL!C.difficile and cleaning – alternative options to using chlorine-releasing disinfectants……..could C.difficile be removed by routine physical cleaning?

Awadel-Kariem et al, J Hosp Infect 2011

PhysicalremovalofC.difficilesporesismoreimportantthansporicidalinactivation Rutala et al, ICHE 2012

A single clean can reduce contamination by around 90%.....

Speight et al, J Hosp Infect 2011

When surfaces are wiped 3 or more times, detergent wipes are just as effective as disinfectant wipes Berendt et al, AmJIC 2011

Detergent gives the same result as disinfectant for cleaning clinical equipment

Petti et al, AmJIC 2012

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CONCLUSION

DOvaluetraditionalcleaning

DOmonitorcleaners;cleaning;orwhatisleftbehind(howeveryoulike)

DO keepyourcleanersin-house!

Don’tprioritisehandhygieneovercleaning

Don’twastemoneyonrobotsorantimicrobialpaint

Don’t believeeverythingthatsalesmentellyou!64

NB.Nodisclosures

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