Evaluation of Discharge Room Cleaning using UV Technology: Focus on Clostridium difficile Alison Gibson D.O. Fellow, Pediatric Infectious Diseases University of Michigan

Disclosures This study was funded by a $12,000 award from the Patient Safety Committee of University of Michigan Health System Both of the UV devices used in our study were provided to the institution by Xenex and iPT during the outcomes study, the Xenex device was then rented to complete the environmental culturing study I have no other conflicts of interest or relationships with industry This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers.  Unauthorized disclosure or duplication is absolutely prohibited.  This document is protected from disclosure pursuant to the provisions of MCL 333.20175; MCL 333.21515; MCL 331.531; MCL 331.533 or such other statutes that may be applicable.

Objectives How does UV work? What literature do we have to support the use of UV? Why did UofM choose to pursue UV and how did we utilize it? Outcomes study Environmental culturing study Future Directions

Automated Room Disinfection Ultraviolet (UV) UV-C (mercury bulbs) PPX-UV (pulsed xenon bulbs) Hydrogen peroxide vapor (HPV) Neither of these technologies replace manual cleaning, and therefore both add additional time before room turnover

Xenex (PPX-UV) Bioquell (HPV) Tru-D Lumalier (UV-C) http://www.hpnonline.com/inside/2011-09/1109-CS-RoomDisinfection.html http://bionews-tx.com/wp-content/uploads/2013/04/xenex-device.jpg http://www.bioquell.com/en-us/markets/product-selector/bioquell-q10/

UV – Science Breaks DNA bonds by inducing pyrimidine or thymine dimers (1,2,3,4,5) http://mashable.com/category/dna/

UV – Safety No health or safety concerns returning to room Direct prolonged light exposure can cause temporary corneal and conjunctival irritation (1,2,3,4,5) http://www.clinicaladvisor.com/what-to-do-when-the-eyes-have-it/article/121816/

UV – Utilization Easy to use, no room modifications Shorter treatment time (depending on device and room size, compared to HPV) Expenses associated with machine and bulb replacement Safe with electronic room devices and other room materials (1,2,3,4,5)

UV - Efficacy 2-4 log10 reduction of spores May allow resistant organisms to develop due to sub-lethal dose Efficacy dependent on intensity of emitted light (old bulb vs. new bulb), exposure time, placement/obstructions, air movement Less effective out of direct line of sight Less effective further from the source (cannot use in large areas) (1,2,3,4,5)

UV-C (Ex. Tru-D Lumalier, iPT) UV-C vs. PPX-UV UV-C (Ex. Tru-D Lumalier, iPT) PPX-UV (Ex. Xenex) 200-280nm, Tru-D emits at 254nm Breaks DNA bonds but not at the ideal wavelength (265nm), so occurs more slowly Continuous dose at germicidal wavelength Longer treatment times (34-100min per cycle) (1,2,4,5) 200-320nm broad spectrum More efficient (faster) because more broad spectrum Additional benefits of photosplitting, photohydration, and photocrosslinking, all of which contributes to faster treatment times Pulse dose at broad wavelength including germicidal range Shorter treatment times (5-10 min per cycle) (1,2,5)

Published UV Data Study Device Cleaning Method Culture Method Results Anderson et al. (2013)6 Tru-D Lumalier UV Rodac touch plates 1.16 log reduction in colony counts Boyce et al. (2011)7 Pre-inoculated plates 1.7-2.9 log reduction in colony counts Sitzlar et al. (2013)8 Routine cleaning followed by UV Surface swabbing Reduction in positive cultures from 57% to 35% Levin et al. (2013)9 PPX-UV Bleach followed by UV None Reduction in HO-CDI rate from 9.46 to 4.45/10,000 PDs

Why did we choose to pursue use of a UV system? C. difficile rates are above the national and state averages Tried to implement daily bleach cleans of high-touch surfaces Appeal of a device less vulnerable to human error

UV light trials Trialed two different lights [PPX-UV (Xenex) and UV-C (iPT)] on three units each and followed HO-CDI rates Trial 1 was 5 months Trial 2 was 10 months

UV Utilization Adjunct to bleach for discharge room cleans 2 - 4 cycles per room, 5-10 min each plus set up and take down Device was operated by EVS personnel trained by our institution Spot cleaning of public areas/work areas (family rooms, bathrooms, etc.) http://bionews-tx.com/news/2014/10/08/xenex-uv-emitting-room-disinfection-robots-ready-to-tackle-ebola-and-other-contamination/

iPT (UV-C) Xenex (PPX-UV) http://www.infectionpreventiontechnologies.com/irsModel3200m.php http://bionews-tx.com/wp-content/uploads/2013/04/xenex-device.jpg

UV Utilization

Barriers to UV Utilization Prolonged room turnover time Only can be used at discharge in single occupant rooms Burden of initial investment to provide sufficient machines to cover all C.diff or contact isolation or every discharge Burden of training and maintaining additional EVS personnel to run the devices

Why we chose to pursue this study No improvement in C. difficile outcomes after utilizing UV technology Were we utilizing the device correctly? Were enough rooms being treated? Was it actually decreasing environmental C. difficile burden? Is environmental contamination at discharge our primary issue?

The Study Our goal was to compare the effectiveness of manual cleaning with quaternary ammonium cleaner (Virex), manual cleaning with bleach, and PPX-UV cleaning both separately and in combination Obtained cultures from confirmed C. difficile positive rooms at discharge and throughout the cleaning process Bed rail Tray table Remote Toilet seat Toilet rim Sink faucet Light switch Keyboard

Soiled Room Bleach Clean QA Clean PPX-UV Clean Ready for Admission Culture #1 Bleach Clean QA Clean PPX-UV Clean Ready for Admission Culture #2 Culture #3

Technicalities of swabbing and culturing Sites were swabbed using pre-moistened sterile swabs (EnviroMax Plus) Swabs were inoculated in enrichment broth (TCCFB) and incubated anaerobically for 24-48 hours Broth was plated on selective media (CCFA-HT) and incubated anaerobically for 24-48 hours Multiple colonies which were morphologically similar to/consistent with C.difficile were selected from each plate for PCR PCR was used to detect toxin genes tcdA, tcdB, cdtA/cdtB Representative isolates from each room were PCR ribotyped

C. difficile Reduction with Bleach Followed by PPX-UV

C. difficile Reduction with QA Followed By PPX-UV

Conclusions Bleach effectively eradicated C. difficile from multiple surfaces (p = .011) PPX-UV light could not show an additive benefit when utilized after bleach cleaning (p = .343) Manual cleaning with a QA product followed by PPX-UV did reduce positive C. difficile cultures (p = .008) Manual cleaning with a QA product followed by PPX-UV is possibly not as effective for C. difficile eradication as bleach alone (p = .063)

In the Meantime… Nerandzic et al. (2015): Xenex (PPX-UV) device and Tru-D Lumalier (UV-C) device C. diff, MRSA, and VRE from pre-inoculated plates Pathogen load did not impact killing, but distance from source did C. diff at 4ft was only 0.5 log10 reduction with PPX-UV UV-C was superior to PPX-UV for reduction of all 3 organisms with the same concentrations of organisms and distance from source (1 log10 for C. diff) Room contamination Tested PPX-UV alone and bleach + PPX-UV Saw statistically significant reductions in culture positivity with PPX-UV, but not with bleach + PPX-UV, and did not assess for statistically significant difference between the two methods (10)

In the Meantime… Ghantoji et al. (2015): Xenex PPX-UV device Environmental cultures were collected before and after environmental cleaning with activated hydrogen peroxide followed by bleach (26/74  18/74) And with activated hydrogen peroxide followed by PPX-UV (29/70  16/70) No statistically significant difference in C. difficile positive cultures, z = 0.058 (11)

Comparing Our Study Study Positive cultures pre-bleach (%) Positive cultures post-bleach (%) Gibson et al. 17/80 (21%) 1/80 (1%) Ghantoji et al.11 26/74 (35%) 18/74 (24%)a Nerandzic et al. 10 22/113 (19%) 9/113 (8%)b aCultures were obtained pre- and post- combination of activated hydrogen peroxide followed by bleach bCultures were obtained pre- and post- combination of standard clean including bleach followed by PPX-UV

Remaining Questions Is environmental contamination at discharge a primary contributor to C. difficile transmission at our institution? Does UV-C/PPX-UV have a place in an infection prevention program? What amount of bacterial environmental burden is permissible?

Future Directions When an excessive number of cases occur on a unit (5 in a rolling 4 week period), multi-pronged approach including: bleach cleaning ATP assessment contact precautions re-enforcement and monitoring Possible utilization of hydrogen peroxide vapor (Bioquell) Focusing on other aspects of C. difficile prevention besides the terminal clean

Thanks Patient Safety Committee of the University of Michigan Health System The Young Lab Kavitha Santhosh Vincent Young MD, PhD Krishna Rao MD Infection Prevention Amanda Valyko MPH, CIC Laraine Washer MD Terri Stillwell MD, MPH

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