William A. Rutala, PhD, MPH Director, Hospital Epidemiology, Occupational Health and Safety; Research Professor of Medicine and Director, Statewide Program for Infection Control and Epidemiology University of North Carolina at Chapel Hill and UNC Health Care, Chapel Hill, NC Monitoring and Improving the Effectiveness of Surface Cleaning/Disinfection

DISCLOSURES Consultation ASP (Advanced Sterilization Products)-2014 Clorox-2014, 2015 Honoraria (2014, 2015)  3M, ASP, Clorox Grants CDC, CMS

LECTURE OBJECTIVES Consider contribution of the environment to disease transmission Discuss available options for evaluating/monitoring environmental cleaning/disinfection Discuss methods for improving cleaning/disinfection to include supplemental “no touch” room decontamination

ENVIRONMENTAL CONTAMINATION LEADS TO HAIs There is increasing evidence to support the contribution of the environment to disease transmission This supports comprehensive disinfecting regimens (goal is not sterilization) to reduce the risk of acquiring a pathogen from the healthcare environment/equipment

KEY PATHOGENS WHERE ENVIRONMENTIAL SURFACES PLAY A ROLE IN TRANSMISSION MRSA VRE Acinetobacter spp. Clostridium difficile Norovirus Rotavirus SARS

ACQUISITION OF MRSA ON HANDS AFTER CONTACT WITH ENVIRONMENTAL SITES

ACQUISITION OF MRSA ON HANDS/GLOVES AFTER CONTACT WITH CONTAMINATED EQUIPMENT

TRANSFER OF MRSA FROM PATIENT OR ENVIRONMENT TO IV DEVICE AND TRANSMISSON OF PATHOGEN

ACQUISITION OF C. difficile ON PATIENT HANDS AFTER CONTACT WITH ENVIRONMENTAL SITES AND THEN INOCULATION OF MOUTH

“ High touch” objects only recently defined (no significant differences in microbial contamination of different surfaces) and “high risk” objects not epidemiologically defined. ALL “TOUCHABLE” (HAND CONTACT) SURFACES SHOULD BE WIPED WITH DISINFECTANT

Effective Surface Decontamination Product and Practice = Perfection

LOW-LEVEL DISINFECTION FOR NONCRITICAL EQUIPMENT AND SURFACES Exposure time > 1 min Germicide Use Concentration Ethyl or isopropyl alcohol70-90% Chlorine100ppm (1:500 dilution) Phenolic UD Iodophor UD Quaternary ammonium UD Improved hydrogen peroxide0.5%, 1.4% ____________________________________________________ UD=Manufacturer’s recommended use dilution

Does Improving Surface Cleaning and Disinfection Reduce Healthcare-Associated Infections? Donskey CJ. AJIC 2013;41:S12-S19 “As reviewed here, during the past decade a growing body of evidence has accumulated suggesting that improvements in environmental disinfection may prevent transmission of pathogens and reduce HAIs. Although, the quality of much of the evidence remains suboptimal, a number of high-quality investigations now support environmental disinfection as a control strategy”

Alfa et al. AJIC 2015;43:

Use of a Daily Disinfectant Cleaner Instead of a Daily Cleaner Reduced HAI Rates Alfa et al. AJIC : Method: Improved hydrogen peroxide disposable wipe was used once per day for all high-touch surfaces to replace cleaner Result: When cleaning compliance was ≥ 80%, there was a significant reduction in cases/10,000 patient days for MRSA, VRE and C. difficile Conclusion: Daily use of disinfectant applied to environmental surfaces with a 80% compliance was superior to a cleaner because it resulted in significantly reduced rates of HAIs caused by C. difficile, MRSA, VRE

Pathogen Transfer by Detergent Wipes Ramm et al, AJIC 2015 epubl All detergent wipes repeatedly transferred significant amounts of MRSA and C. difficile over 3 consecutive surfaces, although the percentage of total pathogens transferred from the wipes after wiping was low

Effective Surface Decontamination Product and Practice = Perfection

ENVIRONMENTAL CONTAMINATION LEADS TO HAIs Suboptimal Cleaning There is increasing evidence to support the contribution of the environment to disease transmission This supports comprehensive disinfecting regimens (goal is not sterilization) to reduce the risk of acquiring a pathogen from the healthcare environment

Thoroughness of Environmental Cleaning Carling P. AJIC 2013;41:S20-S25 Mean = 32% >110,000 Objects

Terminal cleaning methods ineffective (products effective practices deficient [surfaces not wiped]) in eliminating epidemiologically important pathogens Mean proportion of surfaces disinfected at terminal cleaning is 32%

Monitoring the Effectiveness of Surface Cleaning/Disinfection

MONITORING THE EFFECTIVENESS OF CLEANING Cooper et al. AJIC 2007;35:338; Carling P AJIC 2013;41:S20-S25 Visual assessment-not a reliable indicator of surface cleanliness ATP bioluminescence-measures organic debris (each unit has own reading scale, < RLU) Microbiological methods-<2.5CFUs/cm 2 -pass; can be costly and pathogen specific Fluorescent marker-transparent, easily cleaned, environmentally stable marking solution that fluoresces when exposed to an ultraviolet light (applied by IP unbeknown to EVS, after EVS cleaning, markings are reassessed)

SURFACE EVALUATION USING ATP BIOLUMINESCENCE Swab surface luciferace tagging of ATP Hand held luminometer Used in the commercial food preparation industry to evaluate surface cleaning before reuse and as an educational tool for more than 30 years.

DAZO Solution (AKA – Goo)

Target After Marking

TARGET ENHANCED

TERMINAL ROOM CLEANING: DEMONSTRATION OF IMPROVED CLEANING Evaluated cleaning before and after an intervention to improve cleaning 36 US acute care hospitals Assessed cleaning using a fluorescent dye Interventions Increased education of environmental service workers Feedback to environmental service workers †Regularly change “dotted” items to prevent targeting objects Carling PC, et al. ICHE 2008;29:

Comparison of Four Methods to Assess Cleanliness Rutala, Gergen, Sickbert-Bennett, Huslage, Weber Purpose: Compared four methods to assess cleanliness Methods: Study conducted at UNC Health Care using medical, surgical and pediatric wards (both ICU and non-ICU) Results: Compared to microbiological data (Rodac<62.5), 72% (90/125, CI %) were classified as clean with fluorescent markers, compared to 27% (34/126, CI 19-36%) were classified as clean according to ATP. 50% surfaces visually clean before cleaning. Conclusion: Fluorescent marker is a useful tool in determining how thoroughly a surface is wiped and mimics the microbiological data better than ATP (<500 RLU).

Percentage of Surfaces Clean by Different Measurement Methods Rutala, Gergen, Sickbert-Bennett, Huslage, Weber Fluorescent marker is a useful tool in determining how thoroughly a surface is wiped and mimics the microbiological data better than ATP

Improving the Effectiveness of Surface Cleaning/Disinfection

“ High touch” objects only recently defined (no significant differences in microbial contamination of different surfaces) and “high risk” objects not epidemiologically defined. ALL “TOUCHABLE” (HAND CONTACT) SURFACES SHOULD BE WIPED WITH DISINFECTANT

FREQUENCY (mean) OF HCP CONTACT FOR SURFACES IN AN ICU (N=28) AND WARD (N=24) ICUWARD Huslage K, Rutala WA, Sickbert-Bennett E, Weber DJ. ICHE 2010;31:

MICROBIAL BURDEN ON ROOM SURFACES AS A FUNCTION OF FREQUENCY OF TOUCHING Huslage K, Rutala WA, Weber DJ. ICHE. 2013;34: SurfacePrior to Cleaning Mean CFU/RODAC (95% CI) Post Cleaning (mean) Mean CFU/RODAC (95% CI) High71.9 ( )9.6 Medium44.2 ( )9.3 Low56.7 ( )5.7 The level of microbial contamination of room surfaces is similar regardless of how often they are touched both before and after cleaning Therefore, all surfaces that are touched must be cleaned and disinfected

Wipes Cotton, Disposable, Microfiber, Cellulose-Based, Nonwoven Spunlace Wipe should have sufficient wetness to achieve the disinfectant contact time (e.g. >1 minute)

LOW-LEVEL DISINFECTION FOR NONCRITICAL EQUIPMENT AND SURFACES Exposure time > 1 min Germicide Use Concentration Ethyl or isopropyl alcohol70-90% Chlorine100ppm (1:500 dilution) Phenolic UD Iodophor UD Quaternary ammonium UD Improved hydrogen peroxide0.5%, 1.4% ____________________________________________________ UD=Manufacturer’s recommended use dilution

Daily disinfection vs clean when soiled It appears that not only is disinfectant use important but how often is important

Daily Disinfection of High-Touch Surfaces Kundrapu et al. ICHE 2012;33:1039 Daily disinfection of high-touch surfaces (vs cleaned when soiled) with sporicidal disinfectant (PA) in rooms of patients with CDI and MRSA reduced acquisition of pathogens on hands after contact with surfaces and of hands caring for the patient

Thoroughness of Environmental Cleaning Carling P. AJIC 2013;41:S20-S25 Mean = 32% >110,000 Objects

Practice* NOT Product *surfaces not wiped

NEW “NO TOUCH” APPROACHES TO ROOM DECONTAMINATION

EFFECTIVENESS OF UV ROOM DECONTAMINATION Rutala WA, et al. Infect Control Hosp Epidemiol. 2010;31:

EFFECTIVENESS OF UV-C FOR ROOM DECONTAMINATION (Inoculated Surfaces) PathogensDose*Mean log 10 Reduction Line of Sight Mean log 10 Reduction Shadow TimeReference MRSA, VRE, MDR-A12, ~15 minRutala W, et al. 1 C. difficile 36, ~50 minRutala W, et al. 1 MRSA, VRE12,000>2-3NA~20 minNerandzic M, et al. 2 C. difficile 22,000>2-3NA~45 minNerandzic M, et al. 2 C. difficle 22, overall67.8 minBoyce J, et al. 3 MRSA, VRE, MDR-A, Asp 12, > > minMahida N, et al. 4 MRSA, VRE, MDR-A, Asp 22,000>4.0* minMahida N, et al. 4 C. difficile, G. stear spore 22, overall73 minHavill N et al 5 VRE, MRSA, MDR-A12, minAnderson et al 6 1 ICHE 2010;31:1025; 2 BMC 2010;10:197; 3 ICHE 2011;32:737; 4 JHI 2013;84:323l 5 ICHE 2012;33: ICHE 2013;34:466 *  Ws/cm 2 ; min = minutes; NA = not available

HYDROGEN PEROXIDE FOR DECONTAMINATION OF THE HOSPITAL ENVIRONMENT Falagas, et al. J Hosp Infect. 2011;78:171. Author, YearHP SystemPathogenBefore HPVAfter HPV% Reduction French, 2004VHPMRSA61/85-72%1/85-1% 98 Bates, 2005VHP Serratia 2/42-5%0/24-0%100 Jeanes, 2005VHPMRSA10/28-36%0/50-0%100 Hardy, 2007VHPMRSA7/29-24%0/29-0%100 Dryden, 2007VHPMRSA8/29-28%1/29-3% 88 Otter, 2007VHPMRSA18/30-60%1/30-3% 95 Boyce, 2008VHP C. difficile 11/43-26%0/37-0%100 Bartels, 2008HP dry mistMRSA4/14-29%0/14-0%100 Shapey, 2008HP dry mist C. difficile 48/203-24%7/203-3% 88 Barbut, 2009HP dry mist C. difficile 34/180-19%4/180-2% 88 Otter, 2010VHPGNR10/21-48%0/63-0%100

USE OF HPV TO REDUCE RISK OF ACQUISITION OF MDROs Design: 30 mo prospective cohort study with hydrogen peroxide vapor (HPV) intervention to assess risks of colonization or infection with MDROs Methods: 12 mo pre-intervention phase followed by HPV use on 3 units for terminal disinfection Results Prior room occupant colonized or infected with MDRO in 22% of cases Patients admitted to HPV decontaminated rooms 64% less likely to acquire any MDRO (95% CI, ) and 80% less likely to acquire VRE (95% CI, ) Risk of C. difficile, MRSA and MDR-GNRs individually reduced but not significantly Proportion of rooms environmentally contaminated with MDROs significantly reduced (RR, 0.65, P=0.03) Conclusion-HPV reduced the risk of acquiring MDROs compared to standard cleaning Passaretti CL, et al. Clin Infect Dis 2013;56:27-35

Retrospective Study on the Impact of UV on HA MDROs Plus C. difficile Haas et al. Am J Infect Control. 2014;42:S86-90 During the UV period (pulsed Xenon), significant decrease in HA MDRO plus C. difficile. UV used for 76% of Contact Precaution discharges. 20% decrease in HA MDRO plus C. difficile during the 22-m UV period compared to 30-m pre-UV period.

This technology should be considered for terminal room disinfection (e.g., after discharge of patients under CP, during outbreaks) if studies continue to demonstrate a benefit.

Visible Light Disinfection System Rutala, Gergen, Kanamori, Sickbert-Bennett, Weber Uses blue-violet range of visible light in nm region through light emitting diodes (LEDs); continuous Initiates a photoreaction with porphyrins in microbes which yield reactive oxygen Studies incomplete but have observed significant reductions with some microbes

LECTURE OBJECTIVES Consider contribution of the environment to disease transmission Discuss available options for evaluating/monitoring environmental cleaning/disinfection Discuss methods for improving cleaning/disinfection to include supplemental “no touch” room decontamination

Monitoring and Improving the Effectiveness of Surface Cleaning/Disinfection Conclusions The contaminated surface environment in hospital rooms is important in the transmission of healthcare-associated pathogens (MRSA, VRE, C. difficile, Acinetobacter ) Potential methods of reducing transmission of these pathogens include improved room cleaning/disinfection Thoroughness of cleaning should be monitored and a fluorescent marker is useful in determining how thoroughly a surface is wiped and mimics the microbiological data better then ATP UV and HP vapor/aerosol have been demonstrated to be effective against various HA pathogens (including C. difficile spores) and offer an option for room decontamination Since contamination of surfaces is common (although the microbial load is low), even after surface disinfection, this technology should be considered for terminal room disinfection (e.g., after discharge of patients under CP, during outbreaks) if studies continue to demonstrate a benefit

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