1. New Technology in Environmental Cleaning and Evaluation William A. Rutala, PhD, MPH Director, Hospital Epidemiology, Occupational Health and Safety; 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

2. DISCLOSURES Consultation and Honoraria ASP (Advanced Sterilization Products), Clorox Grants CDC, CMS

3. New Technology in Environmental Cleaning and Evaluation Objectives Understand the pathogens for which contaminated hospital surfaces play a role in transmission Review new technologies and practices to improve environmental disinfection Discuss available options for evaluating environmental cleaning Identify at least three ways infection prevention activities can reduce the contribution of environmental surfaces to HAIs

4. New Technology in Environmental Cleaning and Evaluation Objectives Understand the pathogens for which contaminated hospital surfaces play a role in transmission Review new technologies and practices to improve environmental disinfection Discuss available options for evaluating environmental cleaning Identify at least three ways infection prevention activities can reduce the contribution of environmental surfaces to HAIs

5. www.disinfectionandsterilization.org

7. 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

8. EVIDENCE TO SUPPORT THE CONTRIBUTION OF THE ENVIRONMENT TO HAIs Microbial persistence in the environment In vitro studies and environmental samples MRSA, VRE, Ab, Cd Frequent environmental contamination MRSA, VRE, Ab, Cd HCW hand contamination MRSA, VRE, Ab, Cd Relationship between level of environmental contamination and hand contamination Cd

9. EVIDENCE TO SUPPORT THE CONTRIBUTION OF THE ENVIRONMENT TO HAIs Person-to-person transmission Molecular link MRSA, VRE, Ab, Cd Housing in a room previously occupied by a patient with the pathogen of interest is a risk factor for disease MRSA, VRE, Cd, Ab Improved surface cleaning/disinfection reduces disease incidence MRSA, VRE, Cd

10. EVALUATION OF HOSPITAL ROOM ASSIGNMENT AND ACQUISITION OF CDI l Study design: Retrospective cohort analysis, 2005-2006 l Setting: Medical ICU at a tertiary care hospital l Methods: All patients evaluated for diagnosis of CDI 48 hours after ICU admission and within 30 days after ICU discharge l Results (acquisition of CDI) Admission to room previously occupied by CDI = 11.0% Admission to room not previously occupied by CDI = 4.6% (p=0.002) Shaughnessy MK, et al. ICHE 2011;32:201-206

11. RELATIVE RISK OF PATHOGEN ACQUISITION IF PRIOR ROOM OCCUPANT INFECTED * Prior room occupant infected; ^Any room occupant in prior 2 weeks infected. Otter, Yezli, French. ICHE. 2012;32:687-699

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

13. TRANSMISSION MECHANISMS INVOLVING THE SURFACE ENVIRONMENT Rutala WA, Weber DJ. In:”SHEA Practical Healthcare Epidemiology” (Lautenbach E, Woeltje KF, Malani PN, eds), 3 rd ed, 2010.

14. ENVIRONMENTAL CONTAMINATION ENDEMIC AND EPIDEMIC MRSA Dancer SJ et al. Lancet ID 2008;8(2):101-13

15. ENVIRONMENTAL SURVIVAL OF KEY PATHOGENS ON HOSPITAL SURFACES PathogenSurvival Time S. aureus (including MRSA) 7 days to >12 months Enterococcus spp. (including VRE) 5 days to >46 months Acinetobacter spp. 3 days to 11 months Clostridium difficile (spores) >5 months Norovirus (and feline calicivirus)8 hours to >2 weeks Pseudomonas aeruginosa 6 hours to 16 months Klebsiella spp. 2 hours to >30 months Adapted from Hota B, et al. Clin Infect Dis 2004;39:1182-9 and Kramer A, et al. BMC Infectious Diseases 2006;6:130

16. FREQUENCY OF ACQUISITION OF MRSA ON GLOVED HANDS AFTER CONTACT WITH SKIN AND ENVIRONMENTAL SITES No significant difference on contamination rates of gloved hands after contact with skin or environmental surfaces (40% vs 45%; p=0.59) Stiefel U, et al. ICHE 2011;32:185-187

17. ACQUISITION OF MRSA ON HANDS AFTER CONTACT WITH ENVIRONMENTAL SITES

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

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

20. TRANSMISSION MECHANISMS INVOLVING THE SURFACE ENVIRONMENT Rutala WA, Weber DJ. In:”SHEA Practical Healthcare Epidemiology” (Lautenbach E, Woeltje KF, Malani PN, eds), 3 rd ed, 2010.

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

22. New Technology in Environmental Cleaning and Evaluation Objectives Understand the pathogens for which contaminated hospital surfaces play a role in transmission Review new technologies and practices to improve environmental disinfection Discuss available options for evaluating environmental cleaning Identify at least three ways infection prevention activities can reduce the contribution of environmental surfaces to HAIs

23. TECHNOLOGIES TO IMPROVE DISINFECTION OF ENVIRONMENTAL SURFACES New surface disinfectants Improved hydrogen peroxide Electrochemically activated saline solution “No touch” terminal disinfection UV light: UV-C or pulsed xenon Hydrogen peroxide systems: Vapor or aerosol Portable devices: UV, steam “Self disinfecting” surfaces Heavy metal surface coatings: Silver, copper Sharklet pattern Germicide impregnated surfaces: Triclosan

24. TECHNOLOGIES TO IMPROVE DISINFECTION OF ENVIRONMENTAL SURFACES New surface disinfectants Improved hydrogen peroxide Electrochemically activated saline solution “No touch” terminal disinfection UV light: UV-C or pulsed xenon Hydrogen peroxide systems: Vapor or aerosol Portable devices: UV, steam “Self disinfecting” surfaces Heavy metal surface coatings: Silver, copper Sharklet pattern Germicide impregnated surfaces: Triclosan

25. 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 peroxide 0.5%, 1.4% ____________________________________________________ UD=Manufacturer’s recommended use dilution

26. IMPROVED HYDROGEN PEROXIDE (HP) SURFACE DISINFECTANT Advantages 30 sec -1 min bactericidal and virucidal claim (fastest non-bleach contact time) 5 min mycobactericidal claim Safe for workers (lowest EPA toxicity category, IV) Benign for the environment; noncorrosive; surface compatible One step cleaner-disinfectant No harsh chemical odor EPA registered (0.5% RTU, 1.4% RTU, wet wipe) Disadvantages More expensive than QUAT

27. BACTERICIDAL ACTIVITY OF DISINFECTANTS (log 10 reduction) WITH A CONTACT TIME OF 1m WITH/WITHOUT FCS. Rutala et al. ICHE. 2012;33:1159 OrganismIHP-0.5%0.5% HPIHP Cleaner-Dis 1.4% 1.4% HP3.0% HPQUAT MRSA>6.6<4.0>6.5<4.0 5.5 VRE>6.3<3.6>6.1<3.6 4.6 MDR- Ab >6.8<4.3>6.7<4.3 >6.8 MRSA, FCS>6.7NT>6.7NT<4.2 VRE, FCS>6.3NT>6.3NT<3.8 MDR- Ab, FCS >6.6NT>6.6NT<4.1>6.6 Improved hydrogen peroxide is significantly superior to standard HP at same concentration and superior or similar to the QUAT tested

28. Hospital Privacy Curtains (pre- and post-intervention study; sampled curtain, sprayed “grab area” 3x from 6-8” with 1.4% IHP and allowed 2 minute contact; sampled curtain)

29. Decontamination of Curtains with Activated HP (1.4%) Rutala, Gergen, Weber. 2012 MICU-CP for:Before Disinfection CFU/5 Rodacs (#Path) After Disinfection CFU/5 Rodacs (#Path) % Reduction MRSA330 (10 MRSA)21*(0 MRSA)93.6% MRSA186 (24 VRE)4* (0 VRE)97.9% MRSA108 (10 VRE)2* (0 VRE)98.2% VRE 75 (4 VRE)0 (0 VRE)100% VRE68 (2 MRSA)2* (0 MRSA)97.1% VRE98 (40 VRE)1* (0 VRE)99.0% MRSA618 (341 MRSA)1* (0 MRSA)99.8% MRSA55 (1 VRE)0 (0 MRSA)100% MRSA, VRE320 (0 MRSA, 0 VRE)1* (0 MRSA, 0 VRE)99.7% MRSA288 (0 MRSA)1* (0 MRSA)99.7% Mean2146/10=215 (432/10=43)33*/10=3 (0)98.5% * All isolates after disinfection were Bacillus sp; now treat CP patient curtains at discharge with IHP

30. Novel Methods of Room Disinfection

31. EFFECTIVENESS OF UV ROOM DECONTAMINATION Rutala WA, et al. Infect Control Hosp Epidemiol. 2010;31:1025-1029.

32. ROOM DECONTAMINATION WITH UV, HP Issues-Room decontamination time; where the occupancy is high and fast patient turnaround time is critical Room decontamination with UV is 25 minutes for vegetative bacteria and 50 minutes for C. difficile spores HP room decontamination takes approximately 2.5 hours

33. Rapid Hospital Room Decontamination Using UV Light With a Nanostructured Reflective Coating Assessed the time required to kill HAI pathogens in a room with standard white paint (3-7% UV reflective) versus walls coated with an agent formulated to be reflective to UV-C wavelengths (65% UV reflective) Coating/painted uses nanoscale metal oxides whose crystal structures are reflective to UV-C Coating is white in appearance and can be applied with a brush or roller in the same way as any common interior latex paint Cost to coat walls used in this study was estimated to be <$300.

34. ROOM DECONTAMINATION USING UV-C WITH A NANOSTRUCTURED UV-REFLECTIVE WALL COATING Rutala WA, Gergen MF, Weber DJ. ICHE 2013;34:527-529

35. EVALUATION OF A HAND HELD UV DEVICE FOR DECONTAMINATION Nerandzic MM, et al. BMC ID 2012;12 l Design: Assessed a handheld UV device (185-230nm) l Methods: Inoculated surfaces l Results: Lab surfaces: 100 mJ/cm 2 for ~5s reduced C. difficile spores by 4.4 CFU log 10, MRSA by 5.4 log 10 CFU and VRE by 6.9 log 10 CFU Keyboards and portable medical equipment: 100 mJ/cm 2 for ~5s reduced C. difficile spores by 3.2 CFU log 10, Presence of organic material reduced/eliminated lethal effect of far- UV l Conclusion: Rapidly kills HA pathogens but soil reduces efficacy

36. Room Decontamination with UV Rutala, Gergen, Weber. 2013 Objective: Determine the effectiveness of a UVC device Method: Study carried out in standard hospital room using Formica sheets contaminated with MRSA, C. difficile Results: The effectiveness of UVC radiation in reducing MRSA was more than >99.9% within 5 min and the reduction of C. difficile spores was >99% within 10 min Conclusion: This UVC device (UVDI) allowed room decontamination in 5-10 minutes

37. Room Decontamination with UV Rutala, Gergen, Weber. 2013 Organism (Decontamination Time) InoculumTotal Decontamination Log 10 Reduction Direct Decontamination Log 10 Reduction Indirect Decontamination Log 10 Reduction MRSA (5 min)4.803.56 (n=50)4.10 (n=30)2.74 (n=20) C. difficile spores (10 min) 3.692.78 (n=50)3.35 (n=30)1.80 (n=20) Delivers lethal dose of UV in 5-10 min

38. UV ROOM DECONTAMINATION: ADVANTAGES AND DISADVANTAGES l Advantages Reliable biocidal activity against a wide range of pathogens Surfaces and equipment decontaminated Room decontamination is rapid (5-25 min) for vegetative bacteria HVAC system does not need to be disabled and room does not need to be sealed UV is residual free and does not give rise to health and safety concerns No consumable products so operating costs are low (key cost = acquisition) l Disadvantages No studies evaluating whether use reduces HAIs Can only be done for terminal disinfection (i.e., not daily cleaning) All patients and staff must be removed from room Substantial capital equipment costs Does not remove dust and stains which are important to patients/visitors Sensitive use parameters (e.g., UV dose delivered) Rutala WA, Weber DJ. ICHE 2011;32:743-747

39. 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

40. ROOM DECONTAMINATION WITH HPV l Study design Before and after study of HPV l Outcome C. difficile incidence l Results HPV decreased environmental contamination with C. difficile (p<0.001), rates on high incidence floors from 2.28 to 1.28 cases per 1,000 pt days (p=0.047), and throughout the hospital from 1.36 to 0.84 cases per 1,000 pt days (p=0.26) Boyce JM, et al. Infect Control Hosp Epidemiol. 2008;29:723-729.

41. USE OF HPV TO DECONTAMINATE UNUSED MEDICAL SUPPLIES l Design: Before-after study (assessed hydrogen peroxide vapor) l Methods: 5 supply paired items removed patient room after discharge (one cultured before and one after HPV [items placed on metal rack in room]) l Results 7-9% supplies contaminated with 1 or more MDROs; 16% contaminated with potential pathogens None contaminated after exposure to HPV; projected cost savings (6 ICUs): $387,055.15 l Conclusion- HPV effectively disinfected the packaging of supply items Otter JA, et al. ICHE 2013;34:472-478

42. HP ROOM DECONTAMINATION: ADVANTAGES AND DISADVANTAGES l Advantages Reliable biocidal activity against a wide range of pathogens Surfaces and equipment decontaminated Demonstrated to decrease disease incidence ( C. difficile ) Residual free and does not give rise to health and safety concerns (aeration units convert HPV into oxygen and water) Useful for disinfecting complex equipment and furniture Does not require direct or indirect line of sight l Disadvantages Can only be done for terminal disinfection (i.e., not daily cleaning) All patients and staff must be removed from room Decontamination takes approximately 2-5 hours HVAC system must be disabled and the room sealed with tape Substantial capital equipment costs Does not remove dust and stains which are important to patients/visitors Sensitive use parameters (e.g., HP concentration) Rutala WA, Weber DJ. ICHE (In press)

43. SELF DISINFECTING SURFACES Sharklet Pattern Copper coated overbed table Antimicrobial effects of silver Triclosan pen

44. RCT DEMONSTRATING REDUCTION OF HAIs BY USE OF COPPER ALLOY SURFACES l Design: Randomized control trial in ICUs of 3 hospitals l Methods: Patients placed in rooms with or without copper alloy surfaces l Results: Rate of HAI and/or MRSA or VRE colonization was significantly lower than in standard ICU rooms (0.071 vs 0.123; P=0.020) Salgado CD, et al ICHE 2013;34:479

45. New Technology in Environmental Cleaning and Evaluation Objectives Understand the pathogens for which contaminated hospital surfaces play a role in transmission Review new technologies and practices to improve environmental disinfection Discuss available options for evaluating environmental cleaning Identify at least three ways infection prevention activities can reduce the contribution of environmental surfaces to HAIs

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

47. 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

48. New Technology in Environmental Cleaning and Evaluation Objectives Understand the pathogens for which contaminated hospital surfaces play a role in transmission Review new technologies and practices to improve environmental disinfection Discuss available options for evaluating environmental cleaning Identify at least three ways infection prevention activities can reduce the contribution of environmental surfaces to HAIs

49. Thoroughness of Environmental Cleaning Carling et al. ECCMID, Milan, Italy, May 2011 Mean = 32% >110,000 Objects

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

51. 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

52. MONITORING THE EFFECTIVENESS OF CLEANING Cooper et al. AJIC 2007;35:338 Visual assessment-not a reliable indicator of surface cleanliness ATP bioluminescence-measures organic debris (each unit has own reading scale, <250-500 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)

53. 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.

54. DAZO Solution (AKA – Goo)

55. Target After Marking

56. TARGET ENHANCED

57. TERMINAL ROOM CLEANING: DEMONSTRATION OF IMPROVED CLEANING l Evaluated cleaning before and after an intervention to improve cleaning l 36 US acute care hospitals l Assessed cleaning using a fluorescent dye l 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;29:1035-41

58. MONITORING THE EFFECTIVENESS OF CLEANING Cooper et al. AJIC 2007;35:338 Visual assessment-not a reliable indicator of surface cleanliness ATP bioluminescence-measures organic debris (each unit has own reading scale, <250-500 RLU) Microbiological methods-<2.5CFUs/cm 2 -pass; can be costly and pathogen specific Fluorescent marker

59. Comparison of Four Methods to Assess Cleanliness Rutala, Gergen, Sickbert-Bennett, Huslage, Weber. 2013 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: Per fluorescent markers, 72% (90/125, CI 63-79 %) were classified as clean (based on microbiological data-Rodac<62.5), 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).

60. Percentage of Surfaces Clean by Different Measurement Methods Rutala, Gergen, Sickbert-Bennett, Huslage, Weber. 2013 Fluorescent marker is a useful tool in determining how thoroughly a surface is wiped and mimics the microbiological data better than ATP

61. New Technology in Environmental Cleaning and Evaluation Objectives Understand the pathogens for which contaminated hospital surfaces play a role in transmission Review new technologies and practices to improve environmental disinfection Discuss available options for evaluating environmental cleaning Identify at least three ways infection prevention activities can reduce the contribution of environmental surfaces to HAIs

62. Number 1 Monitor and improve thoroughness of cleaning

63. Thoroughness of Environmental Cleaning Carling et al. ECCMID, Milan, Italy, May 2011 Mean = 32% >110,000 Objects

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

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

66. OPTIONS FOR EVALUATING ENVIRONMENTAL CLEANING Guh, Carling. December 2010. CDC Joint effort of ES and IC Responsibilities of ES staff and other staff for cleaning surfaces clearly defined Education of ES staff (must be trained, motivated and knowledgeable about IC) to define expectations Development of measures for monitoring Interventions to optimize cleaning Report results to ICC and facility leadership

67. INFECTION PREVENTION: WHAT THE CEO/COO NEEDS TO KNOW Environment contributes to HAIs. Leadership must understand the role of EVS in preventing HAIs. Improved thoroughness of cleaning results in : Decreased infections (improved patient outcomes) Decreased costs (HAIs often not reimbursable; 1 HAI equivalent to EVS FTE!) Improved patient satisfaction (patients equate dirty rooms with poor care) Meets CMS/TJC requirements

68. Number 2 Interventions to optimize cleaning/disinfecting

69. BEST PRACTICES FOR ROOM DISINFECTION Follow the CDC Guideline for Disinfection and Sterilization with regard to choosing an appropriate germicide and best practices for environmental disinfection Appropriately train environmental service workers on clean/disinfection of the environment (thoroughness. contact time, concentration, wipe change frequency, which product to use) and proper use of PPE Develop measures for monitoring thoroughness of cleaning (e.g., fluorescent dye, ATP, checklists) Assure that nursing and environmental service have agreed what items (e.g., sensitive equipment) are to be clean/disinfected by nursing and what items (e.g., environmental surfaces) are to be cleaned/disinfected by environmental service workers. Staff must have sufficient time. Increasing workload compromising infection control activities.

70. VALUE OF SEQUENTIAL INTERVENTIONS TO IMPROVE DISINFECTION OF C. difficile ROOMS l Design: Prospective intervention l Interventions 1. Fluorescent markers used to provide monitoring and feedback on cleaning 2. UV irradiation used for terminal disinfection of CDI rooms 3. Enhanced disinfection of CDI rooms including dedicated daily disinfection team l Results Cleaning improvement: 47%→87% Reduction CDI positive room cultures: 67% (baseline)→57% (1) →35% (2)→7% (3) Sitzlar B, et al. ICHE 2013;34:459-465

71. Number 3 Continue to evaluate “no-touch” methods to reduce HAIs

72. Novel Methods of Room Disinfection

73. 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, 0.19-0.70) and 80% less likely to acquire VRE (95% CI, 0.08-0.52) 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

74. HOW TO ASSESS WHETHER TO ADOPT A NEW TECHNOLOGY FOR DISINFECTION OF ROOM SURFACES Safe for patients and HCP Demonstration it reduces bioburden on room surfaces Vegetative bacteria (MRSA, VRE) Non-enveloped viruses (norovirus) and spore formers ( C. difficile ) Demonstration it reduces HAIs Cost effective (i.e., compared with other modalities as demonstrated by cost-effective analysis)

75. New Technology in Environmental Cleaning and Evaluation Objectives Understand the pathogens for which contaminated hospital surfaces play a role in transmission Review new technologies and practices to improve environmental disinfection Discuss available options for evaluating environmental cleaning Identify at least three ways infection prevention activities can reduce the contribution of environmental surfaces to HAIs

76. New Technology in Environmental Cleaning and Evaluation 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, “no-touch” methods, and ‘self-disinfecting” surfaces 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 Three ways to reduce contribution of the environment: improve thoroughness of cleaning; optimize cleaning/disinfecting; evaluate “no touch” methods “No touch” methods have been demonstrated to reduce HAIs in a few studies If data continue to show benefit, consider use of HP/UV during outbreaks, after CP patients

77. THANK YOU!

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