Wiping out infection Dr Mark Garvey Consultant Clinical Scientist Deputy Director of Infection Prevention and Control mark.garvey@uhb.nhs.uk or m.i.garvey@bham.ac.uk @drmarkgarvey @uhbipc

Overview Importance of cleaning Cleaning of multi-use patient equipment Wiping out MRSA Research at QEHB AMU cleaning UV

Problem – route of transmission The bugs themselves aren’t the problem Its where they can get to that is Healthcare is increasingly invasive and we are working with even more vulnerable patients as medical science progresses Kiernan M IPS 2018

Environmental survival of key pathogens on hospital surfaces Survival times S. aureus (including MRSA) 7 days to >12 months Enterococcus spp. (including VRE) 5 days to >48 months Acinetobacter spp. 3 days to 11 months Clostridium difficile (spore form) >5 months Norovirus 8 hours to 28 days (temperature dependent) Pseudomonas aeruginosa 6 hours to 16 months Klebsiella spp. 2 hours to >30 months Neisseria gonorrhoae 20 seconds Hota B et al., Clin Infect Dis 2011 Kramer A et al., BMC Infect Dis 2007 Dancer SJ et al. Clin Micro Rev 2014

Vickery K et al., J Hosp Infect 2012

Contamination of the environment and transmission of pathogens in healthcare settings Otter JA et al., ICHE 2011

Face touching S. aureus Adults touch their face 23 times per hour 44% mucous membrane 36% mouth 31% nose 27% eyes 6% all three Mouth 4x Nose 3x Eye 3x Kwok et al., AJIC 2015

MRSA and environment Doorknobs, bed rails, curtains, touchscreens, keyboards contaminated by hands which transmit to other surfaces MRSA on door handles of 19% of rooms housing MRSA & 7% of door handles of non-MRSA rooms Oie S et al., J Hosp Infect 2002 Staff often say ‘but I did not touch the patient’ 42% of nurses contaminated gloves with MRSA with no direct contact but by touching objects in rooms of MRSA patients Boyce JM et al., ICHE 1997

Evidence for organism transfer in clinical environments Inoculation of cauliflower mosaic virus DNA onto phone in an neonatal unit ICU cubicle Virus spread to 58% of ward sampling sites within 7 days of inoculation Spread to all five other cubicles Door handles in other cubicles became positive first Oelberg DG et al., Detection of pathogen transmission on neonatal nurseries using DNA markers as surrogate indicators pediatrics (2000)

Risk of transmission from previous room occupant Meta analysis of all studies with evidence of transmission Pooled acquisition odds for MRSA 1.89 for Gram positives (95% CI: 1.62-2.21) Mitchell B et al., J Hosp Infect 2015

Transmission of organisms Prospective cohort study in ICU Successive occupiers of a room at risk from organisms from previous occupants Quality audits showed 56% of rooms were not cleaned correctly Audits were visual only, failure in room door handles (45%), monitor screens (27%) and bedside tables (16%) Nseir et al., CMI 2010

Audit of equipment Many items of clinical equipment do not receive appropriate cleaning attention ATP score showed surfaces cleaned by professional cleaning staff was 64% lower than those by other staff (P=0.019) Nurses do not clean very well Of 27 items cleaned by clinical staff, 89% failed This is failure Training Allocation of responsibility Anderson RE et al., J Hosp Infect 2011

UV-visible marker demonstrates lack of compliance cleaning Canadian study focusing on extremely virulent strain Marker applied to toilets and commodes Inspected daily; sampled for C. difficile UV marker in 50% toilets and 75% commodes Commodes not cleaned at all on 3 in 4 days Toxigenic C. difficile found on 33.3% of toilets and 62% of commodes Alfa et al., BMC Infect Dis. 2008

Time spent cleaning does not show that it was done well…. Rupp ME et al., ICHE 2013

Who is doing the cleaning? Cleaning is either carried out by Low paid staff of low status who have been trained Well paid staff of higher status, who have not been trained Procedures for cleaning patient care environments Confusion about division of labour over cleaning responsibilities Systems to monitor cleaning are often ineffective (or absent) Housekeeping ‘yes’; clinical ‘no’ Dumigan DG et al., AJIC 2010

UHB cleaning

Nursing cleans - wipes

Wipes Over recent years, wipes have become firmly established in clinical areas in the UK and other countries Used on patients, equipment (from nasendoscopes to commodes) and the environment For cleaning and/or disinfection Advantages relate to human factors Convenient – can be placed at point of care Compare with alcohol hand rub Premixed and premeasured

Garvey et al., ICHE in press

Research CDU cleaning looking at cleans which we undertake in AMU – efficacy of green clean

AMU study Environmental samples taken by swabbing seven high-touch sites Sites were: Bed rail, patient arm chair, patient chair seat, patient table overside, patient table underside, patient locker, nurse call button Samples were taken before cleaning and after each subsequent stage of cleaning Polywipe sponges – neutralising broth Looked for: MRSA, CPE, ESBL and C. difficile GAMA educational training

Mean pre TVC Green – 5791.66 Amber – 22324.91 Red – 681.43 Mean post TVC Green – 604.68 Amber – 366.72 Red – 73.95 Mean log10 Reduction factor’s Green – 0.92 Amber – 0.60 Red – 0.77 GREEN CLEANS very effective However 7% of the time missed

Isolates No MRSA No CPE or ESBLs VRE isolated C. difficile? X23 times before green ~4% X3 times before amber ~2% 9.07 fold increase in probability for recovery of C. difficile in winter Green clean big reductions when cleaned high touch points such as PC seat and NCB Associated with lower C. difficile numbers during cleaning study

C. difficile Trust numbers Study

Research CDU cleaning looking at cleans which we undertake in AMU – efficacy of green clean Looking into new cleaning methodologies – UV clean

VRE UV

Final thoughts Cleaning is a Science Change the language Time to recognize it as such New RCT-level research on the use of UV-C showed clinically significant reductions in infections Anderson DJ et al., Lancet 2017 Change the language Don’t say ‘Has that been cleaned?’ say ‘is that room/piece of equipment safe?’ Value those that do the cleaning Simple change over to more practical wipes Importance of cleaning in AMU – C. difficile rates Can we help flow – quicker effective cleans using UV

Thank you Questions?