Monitoring Cleaning and Disinfection Practices John M. Boyce, MD Director, Hospital Epidemiology & Infection Control Yale-New Haven Hospital and Clinical Professor of Medicine Yale University School of Medicine New Haven, CT Disclosures: Consultant to Clorox Corporation, 3M Corporation, BIOQUELL PLC. Honoraria from Clorox, 3M. Research support from 3M, Clorox, Crothall

Advances in Environmental Cleaning/Disinfection Approaches to monitoring cleaning practices Coating surfaces with antimicrobial metals Applying products with long-term antimicrobial activity to suppress contamination of surfaces

Role of Environment in Transmission of Healthcare-Associated Pathogens Numerous investigators have provided evidence that contaminated environmental surfaces can contribute to transmission of healthcare-associated infections Hota B Clin Infect Dis 2004;39:1182 Boyce JM J Hosp Infect 2007;65 (Suppl 2):50 Weber DJ et al. Am J Infect Control 2010;38 (5 Suppl 1):S25 Weber DJ and Rutala WA Infect Control Hosp Epidemiol 2011;32:207 Otter JA et al. Infect Control Hosp Epidemiol 2011;32:687 Weber DJ et al. Curr Opin Infect Dis 2013;26:338

Improving Cleaning/Disinfection Practices Pay close attention to cleaning and disinfection of high-touch surfaces in patient-care areas Ensure compliance by housekeeping staff with cleaning and disinfection procedures Disinfect (or clean) environmental surfaces on a regular basis, and when surfaces are visibly soiled Sehulster L et al. MMWR Recomm Rep 2003;52(RR-10):1 Rutala WA, Weber DJ et al. HICPAC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008

Methods for Assessing Cleaning Practices Visual inspection of surfaces Check lists sometimes used Observation of housekeeper technique Fluorescent marker system Aerobic colony counts ATP bioluminescence assays Griffith CJ et al. J Hosp Infect 2000;45:19 Cooper RA et al. Am J Infect Control 2007;35:338 Dancer SJ J Hosp Infect 2009;73:378 Luick L et al. Am J Infect Control 2013;41:751

Check lists to Improve Cleaning Practices http://www.cdc.gov/hai/toolkits/evaluating-environmental-cleaning.html

Visual Inspection of Surfaces Simple, can be conducted in any facility Usually performed by housekeeping managers Assess surfaces to detect visible dirt/stains Problem: Surfaces that appeared clean by visual inspection often failed to pass criteria for cleanliness when tested by objective measures: aerobic colony counts or ATP bioluminescence Griffith CJ et al. J Hosp Infect 2000;45:19 Cooper RA et al. AJIC 2007;35:338 Luick L et al. AJIC 2013;41:751

Observation of Housekeeper Technique Covert or overt observation of housekeepers during routine cleaning/disinfection activities Establish variations in amount of time spent cleaning or disinfecting high-touch objects Determine number of disinfectant wipes used/room Detect which surfaces are not wiped adequately Establish if housekeepers are allowing disinfectant to remain on surfaces for appropriate contact time Hayden MK et al. Clin Infect Dis 2006;42:1552 Boyce JM et al. ICHE 2010;31:99 Guerrero D et al. 2010 Decennial conference, Abstr 60

Observation and Supervision of Housekeeper Performance Investigators applied C. difficile spores (non-toxigenic) to 3 high-touch surfaces in mulitple rooms before terminal cleaning Phase 1: housekeepers were not observed and were unaware Phase 2: Housekeeper education and direct monitoring of practice Phase 3: Direct supervision by investigator, reinforcement of education and real-time feedback Results: Education and passive observation sigificantly improved disinfection Further significant reduction in contamination occurred with direct supervision and real-time feedback significantly improved disinfection Percent of inoculated surfaces positive for C. difficile after cleaning, with different interventions Guerrero DM et al. ICHE 2013;34:524

Aerobic Colony Counts Methods of culturing environmental surfaces Moistened swab inoculated onto agar +/- broth enrichment Most useful for irregularly shaped surfaces Agar contact plates (Rodac) Recommended for flat surfaces Yield number of colonies per square inch or centimeter Currently, no standard methods for how to obtain & to process specimens for aerobic colony counts Provide data on contamination by important pathogens No accepted criteria for defining a surface as “clean” by using aerobic colony counts Sehulster L et al. MMWR Recomm Rep 2003;52(RR-10):1 Dancer SJ J Hosp Infect 2004;56:10

Moistened Swab with Direct Plating Use moistened swab to sample surfaces If defined area not sampled; results are at best semi-quatitative If a defined area is sampled using a template, results are quantitative (CFUs/cm2); preferable Moistening (wetting) agents include normal saline, broth media (most common), or broth containing disinfectant neutralizer(s) Swab is used to directly inoculate non-selective or selective media, followed by incubation x 48 hrs Useful for sampling irregularly shaped objects, medical equipment, hard to reach areas, HCP hands VRE on Bedside Rail Lemmen SW et al. Int J Hyg Environ Health 2001;203:245 Duckro AN et al. Arch Intern Med 2005;165:302 Donskey CJ et al. N Engl J Med 2009;360:e3 Hand imprint culture

Aerobic Colony Counts Using RODAC Plates RODAC plates are small petri plates filled with agar in order to provide convex surface for sampling flat environmental surfaces Agar surface is pressed against a flat surface, plate is incubated Advantages: Very easy to perform; more standardized approach than others Results can be expressed as CFUs/cm2 (quantitative result) May be preferable for detecting Gram-positive bacteria (e.g., MRSA) Neutralizer – containing media (Dey-Engley) are available Disadvantages: Greater cost; limited media available; sample small area per plate Obee P et al. J Hosp Infect 2007;65:35 Rutala WA et al. ICHE 2010;31:1025 Galvin S et al. J Hosp Infect 2012;82:143 Havill NL Am J Infect Control 2013;41:S26 Anderson DJ et al. ICHE 2013;34:466

RODAC Plates Before Cleaning After Cleaning Cultures of Overbed Table Before Cleaning After Cleaning Boyce JM et al. SHEA 2011, Abstr 4711

Fluorescent Marker System for Monitoring Cleaning Practices Prospective study conducted in 3 hospitals 12 high-touch objects in patient rooms were marked with invisible fluorescent solution after terminal cleaning Marks moistened by disinfectant spray could be removed by wiping surface for 5 seconds with light pressure After at least 2 patients had occupied the rooms and rooms were terminally cleaned, target surfaces were evaluated using a portable UV light to see if the marker had been wiped off Intervention: education and feedback given to cleaning staff Carling PC et al. J Hosp Infect 2008;68:3

Improving Cleaning Practices by Using Fluorescent Marker System 1404 objects were evaluated before the intervention 744 objects were evaluated after the intervention Proportion of objects cleaned Before intervention: 47% After interventions: 76 - 92% Technique improved in all 3 hospitals (p < 0.001) This method has been used to improve cleaning practices in several larger studies Carling PC et al. Clin Infect Dis 2006;42:385 Carling PC et al. Infect Control Hosp Epidemiol 2008;29:1 Carling PC et al. Crit Care Med 2010;38:1054

Improving Cleaning Practices by Using Fluorescent Marker System Prospective study in 36 acute-care hospitals Hospital size: 25 to 721 beds Fluorescent markers applied to 14 types of objects before terminal room disinfection 20,646 surfaces checked after terminal cleaning Intervention included providing housekeepers with performance feedback Carling PC et al. ICHE 2008;29:1035

Evaluating Cleaning Measures in an ICU Using Fluorescent Marker System Prospective study of the impact of cleaning interventions on environmental contamination by MRSA and VRE Intervention consisted of Change from use of pour bottles to bucket immersion of cleaning cloths Educational campaign for housekeepers Feedback regarding adequacy of terminal room cleaning 15 surfaces in rooms were marked with a fluorescent dye, and 6 surfaces in patient rooms were cultured for MRSA and VRE Results: Removal of fluorescent dye occurred on 44% of surfaces during baseline period 71% of surfaces during intervention period Cultures (+) for MRSA or VRE decreased from 45% at baseline to 27% Goodman ER et al. Infect Control Hosp Epidemiol 2008;29:593

Evaluating Cleaning Measures in an ICU Using Fluorescent Marker System Goodman ER et al. Infect Control Hosp Epidemiol 2008;29:593

Monitoring Hospital Cleanliness Using ATP Bioluminescence Assays ATP bioluminescence assays have been used to monitor cleanliness of surfaces in hospitals Daily cleaning or terminal cleaning Assess variations in housekeeper performance Griffith CL et al. J Hosp Infect 2000;45:19 Malik RE et al. AJIC 2003;31:181 Cooper RA et al. AJIC 2007;35:338 Lewis T et al. J Hosp Infect 2008;69:156 Boyce JM et al. Infect Control Hosp Epidemiol 2009;30:678 Boyce JM et al. Infect Control Hosp Epidemiol 2010;31:99 Moore G et al. AJIC 2010;38:617 Havill NL et al. AJIC 2011;39:602 Anderson RE et al. J Hosp Infect 2011;78:178

ATP Bioluminescence Method Step 1 Step 2 Step 3 Use special swab Place swab in Place tube in luminometer to sample surface reaction tube Results: Relative Light Units

Assessing Terminal Cleaning Practices Using 3 Methods Prospective study to compare how many surfaces would be considered clean, based on Aerobic colony counts obtained by agar contact plates Fluorescent marker method ATP bioluminescence assay system 5 high-touch surfaces were sampled in a convenience sample of 100 hospital rooms Adjacent surfaces on 5 high-touch surfaces were sampled before and after terminal cleaning Boyce JM et al. ICHE 2011;32:1187

Assessing Terminal Cleaning Practices Using 3 Methods Main outcome measures expressed as percent of surfaces sampled after cleaning with: Aerobic colony count < 2.5 cfu/cm2 Most or all of fluorescent marker removed ATP reading of < 250 Relative Light Units

Proportion of 500 High-Touch Surfaces Classified as Having Been Cleaned by Fluorescent Marker, or as “Clean” by ACC or ATP Criteria After Terminal Cleaning P < 0.0001 P = 0.65

Proportion of 382 High-Touch Surfaces Classified as Having Been Cleaned by Fluorescent Marker, or Clean by ATP After Terminal Cleaning P < 0.0001 Rooms Classified as Clean BEFORE terminal cleaning by ATP were excluded

382 High-Touch Surfaces Classified as Not Clean Before Terminal Cleaning, Results for Fluorescent Marker and ATP (53.6%) (34.7%) (6.7%) N = 168 N = 124 N = 90 Boyce JM et al. ICHE 2011;32:1187

Cleaning by housekeepers, using Quat disinfectant Re-Evaluating Cutoffs for Defining Cleanliness, ATP Bioluminescence and Aerobic Colony Counts Cleaning by housekeepers, using Quat disinfectant Note: Each graph represents 1000 data points Boyce JM et al. APIC Annual meeting, 2013, Poster 1705

Re-Evaluating Cutoffs for Defining Cleanliness, ATP Bioluminescence and Aerobic Colony Counts Cleaning by infection preventionist, using peroxide-based disinfectant Note: Each graph includes 720 data points (data are for after cleaning only)

ATP Bioluminescence for Evaluating Disinfection of C ATP Bioluminescence for Evaluating Disinfection of C. difficile Isolation Rooms 140 high-touch sites in 50 rooms were cultured for C. difficile and sampled using an ATP assay after terminal or daily cleaning using bleach-based disinfectant Surfaces with ATP < 250 RLU were considered to be clean 3% of 71 sites with ATP readings of < 250 RLU had positive culture 19% of 69 sites with ATP readings > 250 RLU had positive culture Measuring ATP on surfaces could be a useful & rapid method to assess cleaning of C. difficile rooms Deshpande A et al. Infect Control Hosp Epidemiol 2013;34:865

Comparison of Visual Inspection, Fluorescent Marker, Aerobic Colony Counts and ATP Bioluminescence 250 environmental surfaces in 50 rooms were sampled after terminal cleaning using three monitoring methods Aerobic colony counts [ACC] (before & after cleaning) Fluorescent markers (checked for complete removal after cleaning) ATP bioluminescence assay system (before & after cleaning) Results: 93% of surfaces had no visible contamination after cleaning 76% were considered clean by ATP method after cleaning 87% were considered clean by ACC after cleaning Sensitivity, specificity and NPV of methods, compared to ACC Fluorescent marker: sensitivity = 75%, specificity = 40%, NPV = 28% ATP: sensitivity = 76%, specificity = 35%, NPV = 26% Conclusion: Fluorescent marker and ATP are better than visual assessment. Both may be useful for monitoring cleaning Luick L et al. AJIC 2013;41:751

Caveats on Using ATP Bioluminescence to Monitor Environmental Cleaning No standard, evidence-based criteria for defining surfaces as clean by ATP bioluminescence is currently available Cut-offs used to classify surfaces as clean by ATP assays depends on the brand of assay used Some systems classify surfaces with < 250 RLU as clean Other systems classify surfaces with < 100 RLU as clean Sensitivity and specificity of different luminometers and assay systems differ Consider manufacturer’s recommendations for cut-off Further research is needed to refine criteria for cleanliness, both by ATP assays and by aerobic colony counts Mulvey D et al. J Hosp Infect 2011;77:25 Aiken ZA et al. Infect Control Hosp Epidemiol 2011;32:507 Shama G et al. Int J Hyg Environmental Health 2013;216:115

Advantages and Disadvantages of Methods for Monitoring Cleaning and Disinfection Practices Housekeepers may “game” system Havill NL Am J Infect Control 2013;41:S26

Sequential Interventions and Use of Two Monitoring Methods Improved Disinfection of C. difficile Isolation Rooms 21-month prospective intervention trial was conducted to evaluate methods for disinfection of C. difficile isolation rooms Phase 1) Fluorescent markers + education and feedback to housekeepers Phase 2) Addition of automated UV light units for adjunctive disinfection Phase 3) Use of dedicated daily disinfection team, and requiring rooms to be “cleared” by housekeeper supervisor or infection preventionist using visual assessment and ATP bioluminescence assay of 3 sites in each room Surfaces were cultured for presence of C. difficile Results: Percent of rooms with positive C.difficile cultures: Baseline: 67% Phase 1: 57% Phase 2: 35% Phase 3: 7% Sitzlar B et al. Infect Control Hosp Epidemiol 2013;34:459

Sequential Interventions and Use of Two Monitoring Methods to Improve Disinfection of C. difficile Isolation Rooms Sitzlar B et al. Infect Control Hosp Epidemiol 2013;34:459

Conclusions Contaminated environmental surfaces can contribute to transmission of healthcare-associated pathogens Monitoring cleaning and disinfection of environmental surfaces is recommended in national guidelines Visual inspection correlates poorly with objective methods Fluorescent marker methods and ATP bioluminescence are being used increasingly to monitoring cleaning Each method has advantages and limitations Can be used in combination Aerobic colony counts are more expensive and require more time, but provide unique information Have been used during outbreaks and for research purposes

Coating Surfaces with Antimicrobial Metals Coating medical equipment with metals which have antimicrobial activity is a new strategy for reducing environmental contamination Examples include: Copper alloys (studied most extensively) Silver or nano-silver particles + titanium dioxide Zinc Dancer SJ Eur J Clin Microbiol Infect Dis 2011;30:1473 Weber DJ et al. ICHE 2012;33:10

Copper Alloys as Antimicrobial Surfaces Environmental surfaces or medical equipment coated with copper alloys have been shown to Have sustained antimicrobial activity Reduce levels of bacterial contamination of surfaces in clinical settings when compared with usual equipment Effective against a variety of pathogens Less effective against MRSA and C. difficile Noyce JO et al. J Hosp Infect 2006;63:289 Wheeldon et al. J Antimicrob Chemother 2008;62:522 Casey AL et al. J Hosp Infect 2010;74:72 Grass G et al. Appl Environ Microbiol 2011;77:1541 Karpanen TJ et al. ICHE 2012;33:3

Antimicrobial (Self-Disinfecting) Surfaces Are Promising, But Require Further Study Many of the proposed products yielded only modest killing of pathogens Not proven to be effective against some important pathogens (e.g. C. difficile) Cost of installing metal-coated equipment and of products applied to usual equipment not clear Durability of antimicrobial activity of such products has not been established No data on impact of such strategies on HAIs Weber DJ et al. ICHE 2012;33:10

Applying of Compounds with Long-Term Antimicrobial Activity to Surfaces Silver iodide-based compound Triclosan Quaternary ammonium salt-based surfactant Organosilane compounds Quaternary ammonium + silicone-based compound Effective in a few trials, but not in another Light-activated antimicrobial coatings Toluidine blue O + rose Bengal Weber DJ et al. ICHE 2012;33:10 Havill NL & Boyce JM (unpublished)