APIC Greater NY Chapter 13 Journal Club Session November 16, 2016 Evaluation of Hospital Floors as a Potential Source of Pathogen Dissemination Using a Nonpathogenic Virus as a Surrogate Marker; ICHE 11/2016 by Steven Bock RN BSN CIC FAPIC Line 2 “For New RNs – 2013” Infection Prevention and Control Department 212-263-5454

ICHE – November 2016

Infectious Risks of Hospital Floors ICHE Nov 2016 Article Goals Describe how floor contamination of a non-pathogenic viral agent can spread throughout a patient care environment Begin a professional discussion about the role floors may play in dispersion of actual infectious agents to patients and staff in a healthcare setting Study done at a large VAMC in Cleveland, OH. Hospital is about 670 beds, high acuity full service VA hospital Brief report style article; some typical details in journal articles are lacking Only 10 references provided, all but two are current literature

Infectious Risks of Hospital Floors ICHE Nov 2016 Study Design 1 Place aliquots of a non-pathogenic virus (Bacteriophage MS2 15597-B1) on the floors of patient rooms MS2 bacteriophages are single-stranded RNA viruses that infect only certain strains of enteric bacteria, like E. coli, They do not infect human cells. Patients agreed to have the floors of their rooms intentionally contaminated, but they did not know exactly where Staff were not told of the study Initial studies showed recovery of the virus from rooms on day 1, 2, and 3, with small reduction in log counts due to desiccation 27 nm

Infectious Risks of Hospital Floors ICHE Nov 2016 Study Design 2 Ten rooms on 4 different wards were inoculated with 10^8 Plaque-forming units in 2 ml of sterile water All patients were on Contact Precautions, with either C. difficile infection or MRSA infection/colonization; all were ambulatory On days 1, 2, and 3 after room inoculation, swabs were taken of the patient’s hands, soles of footwear, and surfaces in the room, which were divided into two groups; those less than 3 feet and those more than 3 feet from the patient’s bed. Other sites swabbed included environmental surfaces in the adjacent patient rooms and nursing station on the test unit Swabs were then cultured to determine if and how much bacteriophage was recovered

Infectious Risks of Hospital Floors ICHE Nov 2016 Study Design 3 Negative controls were also collected in each patient room by opening a sterile swab but not touching anything. All negative controls came up negative for bacteriophage recovery. Daily room cleaning included high touch surfaces using bleach wipes; floors were only cleaned if visibly soiled Fluorescent marker validation of room cleaning was >85% compliant during the study period

Infectious Risks of Hospital Floors ICHE Nov 2016 Results More test sites were contaminated when less than 3 feet from the patient than greater than 3 feet from the patient, on each day There were higher concentrations of bacteriophage on surfaces less than 3 feet from the patient on days 1 and 3 (was the same on day 2) Contamination was commonly detected in the nursing station and in adjacent patient rooms Levels of contamination decreased over time in many sites, but persisted at the same level at other sites

Infectious Risks of Hospital Floors ICHE Nov 2016 Conclusions Bacteriophage contamination of a patient room, starting on the floor, can be readily spread to many sites in the room and in adjacent rooms and work areas Patients (and presumably staff) readily become contaminated with the floor organism and then spread it to other surfaces For patients with CDI/MDROs, should we do special foot cleaning or take steps to make sure footwear is not put in the bed?

Infectious Risks of Hospital Floors ICHE Nov 2016 Questions Can all microorganisms be transmitted from the floor to other areas or surfaces like a bacteriophage? While the viruses that got spread were pathogenic (they created PFUs which is how the contamination was detected), will all pathogenic bacteria on floors remain viable/pathogenic when transmitted from the floor to other surfaces and then to patients and/or staff? What role did the infrequent floor cleaning have on this study’s result? What would happen if floors were cleaned with a sporicidal cleaner/disinfectant regularly? Does it matter the patients were on Contact Precautions? Does this study suggest top-down cleaning may not be the best method of room cleaning?

Infectious Risks of Hospital Floors ICHE Nov 2016 Limitations One hospital site Very small sample size One test organism High viral titers were used, created a “worst-case” scenario Different flooring surfaces may give different results No floor cleaning was routinely performed Could have used actual organism patient had, but would run into IRB issues if study involved adding more of the patient’s own organism to her or his environment Negative controls could have included surfaces in the same rooms before room inoculation