1. Environmental Cleaning: MRSA Dr. Michelle J. Alfa, FCCM Medical Director Clinical Microbiology Discipline, Diagnostic Services of Manitoba

2. Overview Evidence that environment plays a role in transmission of AROs in healthcare Cross-transmission in healthcare: How does it occur? Environmental cleaning - visibly clean - compliance of housekeeping - micro-fibre cloths - agent used Summary: What can be done??

3. Infection Transmission: Environmental role AROs such as VRE, MRSA, ESBLs, C.difficile, Acinetobacter spp, Improvements; reduce all AROs “A culture report should not dictate the practice of Standard Precautions” (Bartley et al 2008)

4. Microbial survival on surfaces Survives Years ** **Prolonged survival when suspended in dust/organic debris of up to six months to a year has been reported (Dancer 2007, Hardy 2007)

5. Distribution of S.aureus in General population and Nasal Carriers Dancer S. Importance of the environment in MRSA acquisition: the case for hospital cleaning. http://infection.thelancetlcom 2007 DOI:10.1016/S1473-3099(07)70241-4http://infection.thelancetlcom General Population:S.aureus nasal (+):

6. Environmental detection: MRSA in Stool of patient with diarrhea Bedside rails: 100% Blood pressure cuff: 88% Television remote: 75% Bedside Table: 63% Toilets: 63% Boyce J Hosp Infect 2007;65:50-54, Dancer Infection.thelancet 2007 If MRSA (+) but not in stool; ~ 30% environmental contamination “High-touch sites”

7. Do caregivers acquire MRSA from environment? 42% of 12 nurses contaminated gloves with MRSA by touching objects in room of patients with MRSA in wound or urine WITHOUT ANY PATIENT CONTACT! Boyce J Environmental contamination makes an important contribution to hospital infection J Hosp Infect 2007;65:50-54.

8. Chain of Cross-Transmission Patient shedding ARO - Bedrails, blood pressure cuff, etc Caregiver: transient acquisition - from patient - from environment Second patient: acquires ARO - environment contact (in same room as patient with ARO) - caregiver; transient carrier

9. How to Eliminate Chain of Transmission? - Environmental cleaning/disinfection - Hand hygiene Sounds Easy!! Why isn’t it working??? ENSURE:

10. Hand-hygiene vs Environmental Cleaning* Compliance with Hand-hygiene critical but hard to achieve Reducing environmental sources of MRSA, VRE and C.difficile does reduce healthcare associated infection (& colonization) * Boyce J Environmental contamination makes an important contribution to hospital infection J Hosp Infect 2007;65:50-54.

11. Environmental Cleaning: Visibly Clean: NOT ADEQUATE Housekeeping compliance - how to know if cleaning done? - ?adequate staffing/time Alfa et al BMC-Infectious Diseases 2008 (3) (0) UVM Score:

12. Audit of Cleaning Compliance UV Marker: - Carling et al 2008: 49% of surfaces clean after “terminal cleaning” - Alfa et al 2008: 20 – 50% of toilets clean after routine cleaning - Carling 2008: 57.1% of ICU surfaces clean after patient discharge ATP: - Cooper: < 500 RLU /cm 2 - Griffith et al 2007: 0 – 14% of surfaces “clean” after routine cleaning Viable count: - Dancer 2004: < 5 cfu/cm 2 - Griffith 2007: 50 – 90% of surfaces “clean” after routine cleaning

13. New Audit Tools Visibly clean: INADEQUATE UV marker  useful; indicates if surface wiped or not ATP  useful; detects presence of organic and microbial residues Need to provide positive feedback and ensure Housekeeping are part of the Infection Control TEAM!!

14. Microfibre cloths for cleaning? Rutala et al 2007: - String mops not as effective as microfibre mops for microbial removal - Microfibre effective without disinfectant Moore et al 2006: - Microfibre cloths vary in efficiency - Some microfibre cloths transfer organisms and re-contaminate surface during cleaning

15. Agent used for cleaning & disinfection Two-step? One-step with agent that cleans and disinfects? Detergents (most) at their use-dilution and usual contact times have little to no microbial killing ability Transfer/recontamination of surfaces during cleaning reduced if agent has killing ability

16. Room Fogging: VHP vapour Works  but rapidly re-contaminated (both MRSA and other bacteria) Hardy K et al Rapid recontamination with MRSA of the environment of an intensive care unit after decontamation with hydrogen peroxide vapour. J Hosp Infect 2007;66:360-368

17. Environmental cleaning Cleaning: remove organic material as well as microorganisms Re-contamination from patient etc occurs rapidly; need to have ongoing consistent cleaning process Disinfection as well as cleaning is needed Focus added cleaning efforts on “High-touch” areas for greatest impact for MRSA

18. SUMMARY: Environment does play a role in infection transmission of many AROs “visibly clean” is NOT adequate as a measure of proper cleaning Audit tools for housekeeping compliance valuable Microfibre good – but not all of equal efficiency Cleaning agent with microbial kill Housekeeping is CRITICAL PART OF THE INFECTION CONTROL TEAM!!!

19. References 1. Rutala et al Microbiologic evaluation of microfiber mops for surface disinfection AJIC 2007:35:569-73. 2. Moore G et al A laboratory evaluation of the decontamination properties of microfibre cloths J Hosp Infect 2006;64:379-385 3. Bartley et al Reservoirs of pathogens causing health care associated infections in the 21 st centurey: is renewed attention to inanimate surfaces warranted? Clin Micro Newletter 2—8;30:113-117 4. Dancer et al MRSA acquisition in an intensive care unit. AJIC 2006;34:10-17 5. Boyce Environmental contamination makes an important contribution to hospital infection J Hosp Infect 2007;65:50-54 6. Carling et al Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals ICHE 2008:29:1-7 7. Carling et al Intensive care unit environmental cleaning: an evaluation of sicteen hospitals using a novel assessment tool J Hosp Infect 2008;68:39-44 8. Cooper et al Monitoring the effectiveness of cleaning in four British hospitals AJIC 2007;35:338-41 9. Dancer Importance of the environment in MRSA acquisition: the case for hospital cleaning 10. Hardy et al Rapid recontamination with MRSA of environment of an ICU after decontamination with hydrogen peroxide vapour. J Hosp Infect 2007;66:360-68 11. Griffith et al The effectiveness of existing and modified cleaning regimens in a Welsh hospital J Hosp Infect 2007;66:352-359