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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
CIDEIM
3
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
CIDEIM
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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
CIDEIM
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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
CIDEIM
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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
CIDEIM
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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
CIDEIM
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Chemical disinfectants
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)
CIDEIM
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Chemical disinfectants
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
CIDEIM
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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
CIDEIM
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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
Weber D, et al. Curr Opin Infect Dis 2016;29.
Otter JA, et al. J Hosp Infect 2013;83.CIDEIM
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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
Weber D, et al. Curr Opin Infect Dis 2016;29.
Otter JA, et al. J Hosp Infect 2013;83.CIDEIM
15
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.
Otter JA, et al. J Hosp Infect 2013;83.CIDEIM
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• Studies evaluating clinical outcomes
– Healthcare-associated infections (HAIs), multidrug-resistant organisms
(MDROs)
Automated no-touch technologies
Weber D, et al. Curr Opin Infect Dis 2016;29.
CIDEIM
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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.
CIDEIM
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Intervention
10
15
20
25
30
35
40
45
50
CD
I ra
te (
pe
r 10
,00
0 p
atien
t-da
ys)
Dec
13
Dec
14
Jan1
3
Feb13
Mar
13
Apr
13
May
13
Jun1
3
Jul1
3
Aug
13
Sep
13
Oct
13
Nov
13
Feb14
Mar
14
Apr
14
May
14
Jun1
4
Jul1
4
Aug
14
Sep
14
Oct
14
Nov
14
Jan1
5
Study month
Impact of UV irradiation on C. difficile in
hematology- oncology units
Overall reduction in CDI
incidence: 25% ↓
Pegues D, et al. Infect Control Hosp Epidemiol 2017;38.
CIDEIM
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Impact of UV irradiation on C. difficile in
hematology- oncology units
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
Pegues D, et al. Infect Control Hosp Epidemiol 2017;38.
CIDEIM
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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
Anderson D, et al. Lancet 2017; 389.2017;38.
CIDEIM
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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
Anderson D, et al. Lancet 2017; 389.2017;38.
CIDEIM
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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
Anderson D, et al. Lancet 2017; 389.2017;38.
CIDEIM
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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
Anderson D, et al. Lancet 2017; 389.2017;38.
CIDEIM
25
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
CIDEIM
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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.
CIDEIM
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Copper-coated surfaces
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.
CIDEIM
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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
Copper-coated surfaces
Salgado C, et al. Infect Control Hosp Epidemiol 2013;34.
CIDEIM
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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
CIDEIM