1. Safer Healthcare Environments for Infection Prevention 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, USA

2. DISCLOSURES Consultation Advanced Sterilization Products, Clorox Honoraria (speaking) Advanced Sterilization Products, 3M Grants CDC

3. Safer Healthcare Environments for Infection Prevention Describe how products, practices, principles and technology in the healthcare environment (air, water, surfaces and disinfection and sterilization) have been and continue to be integrated into practice to prevent patient exposure to pathogens Discuss new technologies for the healthcare environment as well as future opportunities and challenges

4. Safer Healthcare Environments for Infection Prevention New Technologies and Future Challenges Reprocessing reusable medical/surgical instruments Hospital surfaces Water Air

5. disinfectionandsterilization.org

6. Safer Healthcare Environments for Infection Prevention New Technologies and Future Challenges Reprocessing reusable medical/surgical instruments Hospital surfaces Water Air

7. DISINFECTION AND STERILIZATION EH Spaulding believed that how an object will be disinfected depended on the object’s intended use CRITICAL - objects which enter normally sterile tissue or the vascular system or through which blood flows should be sterile SEMICRITICAL - objects that touch mucous membranes or skin that is not intact require a disinfection process (high-level disinfection[HLD]) that kills all microorganisms but high numbers of bacterial spores NONCRITICAL - objects that touch only intact skin require low- level disinfection

9. New Trends in Sterilization of Patient Equipment Alternatives to ETO-CFC ETO-CO 2, ETO-HCFC, 100% ETO New Low Temperature Sterilization Technology Hydrogen Peroxide Gas Plasma-most common Vaporized hydrogen peroxide-limited clinical use Ozone-limited clinical use

10. Rapid Readout BIs for Steam Now Require a 1-3h Readout Compared to 24-48h

11. Attest™ Super Rapid Readout Biological Indicators Commercially available in early 2013 1491 BI (blue cap) Monitors 270°F and 275°F gravity –displacement steam sterilization cycles 30 minute result (from 1 hour) 1492V BI (brown cap) Monitors 270°F and 275°F dynamic-air-removal (pre-vacuum) steam sterilization cycles 1 hour result (from 3 hours)

12. DISINFECTION AND STERILIZATION EH Spaulding believed that how an object will be disinfected depended on the object’s intended use CRITICAL - objects which enter normally sterile tissue or the vascular system or through which blood flows should be sterile SEMICRITICAL - objects that touch mucous membranes or skin that is not intact require a disinfection process (high-level disinfection[HLD]) that kills all microorganisms but high numbers of bacterial spores NONCRITICAL - objects that touch only intact skin require low- level disinfection

13. High-Level Disinfection of “Semicritical Objects” Exposure Time > 8m-45m (US), 20 o C Germicide Concentration_____ Glutaraldehyde > 2.0% Ortho-phthalaldehyde 0.55% Hydrogen peroxide* 7.5% Hydrogen peroxide and peracetic acid* 1.0%/0.08% Hydrogen peroxide and peracetic acid* 7.5%/0.23% Hypochlorite (free chlorine)* 650-675 ppm Accelerated hydrogen peroxide 2.0% Peracetic acid 0.2% Glut and isopropanol 3.4%/26% Glut and phenol/phenate** 1.21%/1.93%___ * May cause cosmetic and functional damage; **efficacy not verified

14. Automated Endoscope Reprocessors with Cleaning Claim l Product Definition: Integrated double-bay AER Eliminates manual cleaning Uses New High-Level Disinfectant (HLD) with IP protection Single-shot HLD Automated testing of endoscope channels and minimum effective concentration of HLD Incorporates additional features (LAN, LCD display) Eliminates soil and microbes equivalent to optimal manual cleaning. BMC ID 2010; 10:200

15. DISINFECTION AND STERILIZATION Rutala, Weber, HICPAC. 2008. www.cdc.gov EH Spaulding believed that how an object will be disinfected depended on the object’s intended use CRITICAL - objects which enter normally sterile tissue or the vascular system or through which blood flows should be sterile SEMICRITICAL - objects that touch mucous membranes or skin that is not intact require a disinfection process (high-level disinfection[HLD]) that kills all microorganisms but high numbers of bacterial spores NONCRITICAL - objects that touch only intact skin require low- level disinfection

16. 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 (HP) 0.5%, 1.4% ____________________________________________________ UD=Manufacturer’s recommended use dilution

17. 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

18. BACTERICIDAL ACTIVITY OF DISINFECTANTS (log 10 reduction) WITH A CONTACT TIME OF 1m WITH/WITHOUT FCS. Rutala et al. ICHE. In press 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

20. Hospital Privacy Curtains (sprayed “grab area” 3x from 6-8” with 1.4% IHP and allowed 2 minute contact; sampled)

21. Decontamination of Curtains with Activated HP (1.4%) Rutala, Gergen, Weber. 2012 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=44)33*/10=3 (0)98.5% * All isolates after disinfection were Bacillus sp

22. Safer Healthcare Environments for Infection Prevention New Technologies and Future Challenges Reprocessing reusable medical/surgical instruments Hospital surfaces (increasing evidence to support the contribution of the environment to disease transmission) Water Air

23. HAZARDS IN THE HOSPITAL Weinstein RA. Am J Med 1991;91(suppl 3B):179S MRSA, VRE, C. difficile, Acinetobacter spp., norovirus Endogenous flora 40-60% Cross-infection (hands): 20-40% Antibiotic driven: 20-25% Other (environment): 20%

24. THE ROLE OF THE ENVIRONMENT IN DISEASE TRANSMISSION Over the past decade there has been a growing appreciation that environmental contamination makes a contribution to HAI with MRSA, VRE, Acinetobacter, norovirus and C. difficile Surface disinfection practices are currently not effective in eliminating environmental contamination Inadequate terminal cleaning of rooms occupied by patients with MDR pathogens places the next patients in these rooms at increased risk of acquiring these organisms

25. 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.

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

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

28. ENVIRONMENTAL CONTAMINATION LEADS TO HAIs Weber, Rutala, Miller et al. AJIC 2010;38:S25 Microbial persistence in the environment In vitro studies and environmental samples MRSA, VRE, AB, CDI Frequent environmental contamination MRSA, VRE, AB, CDI HCW hand contamination MRSA, VRE, AB, CDI Relationship between level of environmental contamination and hand contamination CDI

29. ENVIRONMENTAL CONTAMINATION LEADS TO HAIs Weber, Rutala, Miller et al. AJIC 2010;38:S25 Person-to-person transmission Molecular link MRSA, VRE, AB, CDI Housing in a room previously occupied by a patient with the pathogen of interest is a risk factor for disease MRSA, VRE, CDI Improved surface cleaning/disinfection reduces disease incidence MRSA, VRE, CDI

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

31. C. difficile Environmental Contamination Rutala, Weber. SHEA. 3 rd Edition. 2010 Frequency of sites found contaminated~10->50% from 13 studies-stethoscopes, bed frames/rails, call buttons, sinks, hospital charts, toys, floors, windowsills, commodes, toilets, bedsheets, scales, blood pressure cuffs, phones, door handles, electronic thermometers, flow-control devices for IV catheter, feeding tube equipment, bedpan hoppers C. difficile spore load is low-7 studies assessed the spore load and most found 100; one reported a range of “1->200” and one study sampled several sites with a sponge and found 1,300 colonies C. difficile.

32. 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

33. Risk of Acquiring MRSA and VRE from Prior Room Occupants Admission to a room previously occupied by an MRSA-positive patient or VRE-positive patient significantly increased the odds of acquisition for MRSA and VRE (although this route is a minor contributor to overall transmission). Arch Intern Med 2006;166:1945. Prior environmental contamination, whether measured via environmental cultures or prior room occupancy by VRE-colonized patients, increases the risk of acquisition of VRE. Clin Infect Dis 2008;46:678. Prior room occupant with CDAD is a significant risk for CDAD acquisition. Shaughnessy et al. ICHE 2011;32:201

34. A Targeted Strategy for C. difficile Orenstein et al. 2011. ICHE;32:1137 Daily cleaning with bleach wipes on high incidence wards reduced CDI 85% (24.2 to 3.6 cases/10,000 patient days and prolonged median time between HA CDI from 8 to 80 days

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

36. Wipes Cotton, Disposable, Microfiber Wipe should have sufficient wetness to achieve the disinfectant contact time. Discontinue use of a disposable wipe if it no longer leaves the surface visibly wet for > 1m

37. SURFACE DISINFECTION Effectiveness of Different Methods, Rutala et al. 2012 Technique (with cotton)MRSA Log 10 Reduction (QUAT) Saturated cloth4.41 Spray (10s) and wipe4.41 Spray, wipe, spray (1m), wipe4.41 Spray4.41 Spray, wipe, spray (until dry)4.41 Disposable wipe with QUAT4.55 Control: detergent2.88

38. EFFECTIVENESS OF DISINFECTANTS AGAINST MRSA AND VRE Rutala WA, et al. Infect Control Hosp Epidemiol 2000;21:33-38.

39. 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

40. 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

41. 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

42. 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

43. NEW APPROACHES TO ROOM DECONTAMINATION

44. ROOM DECONTAMINATION UNITS Rutala, Weber. ICHE. 2011;32:743

45. UV Room Decontamination Fully automated, self calibrates, activated by hand-held remote Room ventilation does not need to be modified Uses UV-C (254 nm range) to decontaminate surfaces Measures UV reflected from walls, ceilings, floors or other treated areas and calculates the operation time to deliver the programmed lethal dose for pathogens. UV sensors determines and targets highly-shadowed areas to deliver measured dose of UV energy (12,000µWs/cm 2 bacteria) After UV dose delivered, will power-down and audibly notify the operator Reduces colony counts of pathogens by >99.9% within 20-25m

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

47. HP SYSTEMS FOR ROOM DECONTAMINATION

48. HP SYSTEMS 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%; 77/203-3%; 0.4 88 Barbut, 2009HP dry mist C. difficile 34/180-19%4/180-2% 88 Otter, 2010VHPGNR10/21-48%0/63-0%100 Reliable biocidal activity against a wide range of pathogens

49. 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.

50. 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 (~15 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

51. 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 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 3-5 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)

53. 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 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.

54. UV Reflective Coating Rutala, Gergen, Tande, Weber. 2012 Line-of-SightMRSA w/coatingMRSA no coating C. difficile w/coating C. difficile no coating Cycle Time5m03s25m13s9m24s43m42s Direct4.70 (n=42)4.72 (n=33)3.28 (n=39)3.42 (n=33) Indirect4.45 (n=28)4.30 (n=27)2.42 (n=31)2.01 (n=27) Total4.60 (n=70)4.53 (n=60)2.91 (n=70)2.78 (n=60) With the nanoscale reflective coating, cycle times were 5-10m (~80% reduction) which would substantially reduce the turnover time of the room

55. METHODS TO IMPROVE DISINFECTION OF ENVIRONMENTAL SURFACES Enhanced environmental cleaning and disinfection Improved education of environmental service workers Use of checklists Monitoring of cleaning with fluorescent dye, ATPase, aerobic plate counts “No touch” terminal disinfection UV light Hydrogen peroxide: Vapor or aerosol Portable steam dispensers Self disinfecting surfaces (or persistent antimicrobials)

56. RATIONALE FOR DEVELOPMENT OF SELF DISINFECTING SURFACES Unlike improved environmental cleaning does not require a ongoing behavior change or education of personnel Self-sustaining once in place Allows continued disinfection (may eliminate the problem of recontamination), unlike no touch methods which can only be used for terminal disinfection Most hospital surfaces have a low bioburden of pathogens (i.e., <100 per cm 2 ) Once purchased might not have a maintenance cost

57. SELF DISINFECTING SURFACES Surface impregnated with a “heavy” metal Silver Copper Surface impregnated with a germicide Triclosan Antimicrobial surfactant/quaternary ammonium salt? Organosilane products? Altered topography Sharklet pattern Light-activated antimicrobial coating Weber DJ, Rutala WA. ICHE 2012;33:10-13

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

59. IN VITRO EFFECTIVENESS OF A SILVER COATING AGAINST BACTERIAL CHALLENGE l Study design: In vitro study l Study agent: Surfacine (~10  g/cm 2 silver iodide) l Methods: Surface coated with Surfacine and then challenged with VRE l Results: Antimicrobial activity retained despite repeated dry wiping or wiping with a QUAT Rutala WA, Weber DJ. Emerg Infect Dis 2001;7:348

60. Role of Copper in Reducing Hospital Environmental Contamination Casey et al. 2010: 74:72-77

61. COPPER VERSUS STANDARD ITEMS: A CROSS-OVER STUDY OF CONTAMINATION l Study: To assess antimicrobial activity of copper coated objects l Method: Cross-over study on an acute medical ward l Results: Copper reduced aerobic counts by 90-100% l Toilet seat 87 v 2/ cm 2 ; push plate 2 v 0/cm 2 ; hot water tap handle 7.5 v 0/cm 2 Casey AL, et al. J Hosp Infect 2010;74:72-77

62. Efficacy of Copper Alloy in Clinical Environment Copper surfaces demonstrated to be cidal to HA pathogen Limitations Cost of purchasing and installing copper items Reduction of microbial contamination is modest (i.e., 1 log 10 ) How soiling, cleaning, etc affect properties not studied Impractical/impossible to coat all environmental surfaces and medical devices that could lead to hand contamination No studies whether use reduces HAI rates

63. SURFACE DISINFECTANTS: PERSISTENCE Surface disinfectantPersistence PhenolicNo Quaternary ammonium compoundYes (with caveats) AlcoholNo HypochloriteNo Hydrogen peroxideNo

64. QUATS AS SURFACE DISINFECTANTS WITH PERSISTENT ACTIVITY l Study of computer keyboards: Challenge with VRE or P. aeruginosa l Keys wiped with alcohol or quats (CaviWipes, Clorox Disinfecting Wipes, or Sani- Cloth Plus) l Persistent activity when undisturbed any contact will result in removal of the Quat and loss of persistent activity Rutala WA, White MS, Gergen MF, Weber DJ. ICHE 2006;27:372-77.

65. EFFICACY OF LIGHT-ACTIVATED ANTIMICROBIAL COATING l Germicide: Silicone polymers containing photosensitizer methylene blue (MB) and Au nanoparticles l Results (exposure to 28W light): Panel A: Mean number of MRSA recovered after 24hr incubation Panel B: Mean number of MRSA recovered after 6hr incubation Reduction MB = 99.33% AU = 99.99% Reduction MB = 56.51% AU = 92.30% Ismail S, et al. ICHE 2011;32:1130-32

66. ADVANTAGES AND DISADVANTAGES OF SELF DISINFECTING SURFACES Advantages Passive (i.e., requires no additional maintenance once installed) Effective throughout patient occupancy (i.e., not just at terminal disinfection) Prevents recontamination Depending on method may be manufactured in or applied by dipping, brushing or spraying Disadvantages No studies evaluating whether use reduces HAIs Impossible to coat/cover all frequently touched surfaces with antimicrobial coating (e.g., medical equipment, television remote, curtains) Reduces but does not eliminate pathogenic microorganisms Durability? Cost? (unknown) Development of resistant pathogens (i.e., copper, silver)

67. Safer Healthcare Environments for Infection Prevention New Technologies and Future Challenges Reprocessing reusable medical/surgical instruments Hospital surfaces (increasing evidence to support the contribution of the environment to disease transmission) Water Air

68. Water and Healthcare Multiple Uses CDC

69. Water-Related Pathogens and Their Disease Transmission Pathways Exner et al. AJIC 33:S26-40; 2005

70. WATER RESERVOIRS Rutala, Weber. ICHE 1997;18:609

71. Water Wall Fountains and Electronic Faucets

72. Water Walls Linked to Legionnaires’ Palmore et al. ICHE 2009;30:764 2 immunocompromised patients exposed to decorative fountain in radiation oncology; isolates from patients and fountain identical; disinfection with ozone, filter and weekly cleaning Houpt et al. ICHE 2012;33:185 Lab-confirmed Legionnaires disease was dx in 8 patients; 6 had exposure to decorative fountain (near main entrance to hospital); high counts of Legionella pneumophila 1 despite disinfection and maintenance

73. Water Walls and Decorative Water Fountains Present unacceptable risk in hospitals serving immunocompromised patients (even with standard maintenance and sanitizing methods)

74. Electronic Faucets A Possible Source of Nosocomial Infection?

75. Electronic Faucets Conserve water Conserve energy Hygienic Hands free Barrier free

76. Electronic (E) vs Handle-Operated (HO) Faucets 100% E vs 30% HO Legionella (no cases). Halabi et al. JHI 2001:49:117 Significant difference HPC levels between brand A (32%) and B (8%) E compared to HO (11%). Hargreaves et al. 2001; 22:202 No difference in P. aeruginosa. Assadian et al. ICHE. 2002;23:44. 73% E samples did not meet water std vs 0% HO 29% of water samples from E and 1% from HO yielded P. aeruginosa. Merrer et al. Intensive Care Med 2005;31:1715 95% E grew Legionella compared to 45% HO (water-disruption events). Syndor et al. ICHE; 33:235

77. Issues Associated with Electronic Faucets A longer distance between the valve and the tap, resulting in a longer column of stagnant, warm water, which favors production of biofilms Reduced water flow; reduced flushing effect (growth favored) Valves and pipes made of plastic (enhances adhesion P. aeruginosa )

78. Prevention Measures Electronic faucets constructed so they do not promote the growth of microorganisms A potential source of nosocomial pathogens No guideline (but some have recommended) to remove electronic faucets from at-risk patient care areas (BMTU) Some have recommended periodic monitoring of water samples for growth of Legionella More data are needed to establish role in HAIs

79. Safer Healthcare Environments for Infection Prevention New Technologies and Future Challenges Reprocessing reusable medical/surgical instruments Hospital surfaces (increasing evidence to support the contribution of the environment to disease transmission) Water Air

82. MOST COMMON PATHOGENS ASSOCIATED WITH CONSTRUCTION OR RENOVATION OUTBREAKS Aspergillus spp. (by far most important) Zygomycetes Other fungi Miscellaneous

83. No. of PatientsMortality (%) Hematologic malignancy29957.6 Solid organ transplant l Renal transplant l Liver transplant 36 8 55.9 Other immunocompromised l High-dose steroid therapy l Neonates l Other malignancy l Chronic lung disease l ICU patients (“high-risk”) l No exact classification possible 15 5 4 2 49 52.3 Patients without severe immunodeficiency l Thoracic surgery l Cataract surgery l ICU patients (“low risk”) l Other surgery patients 25 5 3 39.4 TOTAL45855.0 UNDERLYING CONDITIONS IN PATIENTS WITH NOSOCOMIAL ASPERGILLOSIS

84. NOSOCOMIAL ASPERGILLOSIS IN OUTBREAK SETTINGS Vonberg R-P, Gastmeier P. J Hosp Infect 2006;63:246-54

85. RELEVANT GUIDELINES 2003: Guidelines for preventing health-care-associated pneumonia (HICPAC) 2003: Guidelines for environmental infection control in health-care facilities (CDC, HICPAC) 2000: Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients (CDC, IDSA, ASBMT) American Institute of Architects Academy of Architecture for Health. Guidelines for Design and Construction of Hospital and Health Care Facilities, 2006. (telephone #: 888-272-4115) Construction and Renovation, 3rd Edition,and Infection Prevention for Construction DVD, Association for Professionals in Infection Control and Epidemiology, 2007 ($173 member price ) APIC store: www.apic.org/www.apic.org/ APIC Text of Infection Control and Epidemiology, 3 rd ed. Association for Professionals in Infection Control and Epidemiology, 2009. www.apic.org/www.apic.org/ ASHRAE - American Society of Heating, Refrigeration and Air Conditioning Engineers

86. INFECTION CONTROL RISK ASSESSMENT (ICRA) ICRA is an multidisciplinary, organizational, documented process that after considering the facility’s patient population and type of construction project (non-invasive to major demolition): Focuses on reduction of risk from infection Acts through phases of facility planning, design, construction, renovation, facility maintenance and Coordinates and weights knowledge about infection, infectious agents, type of construction project and care environment permitting the organization to anticipate potential impact

87. STEP 1: IDENTIFY TYPE OF CONSTRUCTION PROJECT http://www.premierinc.com/quality-safety/tools-services/safety/topics/construction/downloads/ICRA- MatrixColorRevised-091109.pdf

88. STEP 1: IDENTIFY TYPE OF CONSTRUCTION PROJECT

89. STEP 2: IDENTIFY PATIENT RISK

90. STEP 3: MATCH RISK GROUP WITH CONSTRUCTION TYPE

91. INFECTION CONTROL BY CLASS

92. During construction After construction

93. INFECTION CONTROL BY CLASS During construction After construction

94. Portable HEPA Units Rutala et al. ICHE 1995;16:391 Can rapidly reduce levels of airborne particles (0.3µ, for example, 90% in ~5 m); used in construction worksite and reduce risk to TB exposure.

96. Safer Healthcare Environments for Infection Prevention New Technologies and Future Challenges Reprocessing reusable medical/surgical instruments Hospital surfaces Water Air

97. CONCLUSIONS New sterilization, high-level disinfection and low-level disinfection technologies/practices/products are effective The contaminated surface environment in hospital rooms is important in the transmission of healthcare-associated pathogens (MRSA, VRE, C. difficile ) Effective surface disinfection essential to eliminate the environment as a source for transmission of HA pathogens. New methods of reducing transmission of these pathogens may include: improved room cleaning/disinfection, “no-touch” methods (UV, HP), and self-disinfecting surfaces Water reservoirs of HA pathogens (e.g., water walls) may present unacceptable risk to high-risk patients Use of Infection Control Risk Assessment is a logical method to reduce risks associated with construction and renovation projects

98. disinfectionandsterilization.org

99. THANK YOU!