1. Wiping out infection Dr Mark Garvey Consultant Clinical Scientist
Deputy Director of Infection Prevention and Control or

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

3. 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

4. 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

5. Vickery K et al., J Hosp Infect 2012

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

7. 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

8. 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

9. 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)

10. 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: )
Mitchell B et al., J Hosp Infect 2015

11. 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

12. 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

13. 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

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

15. 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

16. UHB cleaning

17. Nursing cleans - wipes

18. 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

21. Garvey et al., ICHE in press

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

23. 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

24. Mean pre TVC
Green –
Amber –
Red –
Mean post TVC
Green –
Amber –
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

25. 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

28. C. difficile Trust numbers
Study

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

33. VRE UV

34. 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

36. Thank you
Questions?