1. Evaluation of Discharge Room Cleaning using UV Technology: Focus on Clostridium difficile
Alison Gibson D.O.
Fellow, Pediatric Infectious Diseases
University of Michigan

2. Disclosures
This study was funded by a $12,000 award from the Patient Safety Committee of University of Michigan Health System
Both of the UV devices used in our study were provided to the institution by Xenex and iPT during the outcomes study, the Xenex device was then rented to complete the environmental culturing study
I have no other conflicts of interest or relationships with industry
This is a confidential Quality Improvement and Assurance/peer review document of the University of Michigan Hospitals and Health Centers.  Unauthorized disclosure or duplication is absolutely prohibited.  This document is protected from disclosure pursuant to the provisions of MCL ; MCL ; MCL ; MCL or such other statutes that may be applicable.

3. Objectives How does UV work?
What literature do we have to support the use of UV?
Why did UofM choose to pursue UV and how did we utilize it?
Outcomes study
Environmental culturing study
Future Directions

4. Automated Room Disinfection
Ultraviolet (UV)
UV-C (mercury bulbs)
PPX-UV (pulsed xenon bulbs)
Hydrogen peroxide vapor (HPV)
Neither of these technologies replace manual cleaning, and therefore both add additional time before room turnover

5. Xenex (PPX-UV) Bioquell (HPV) Tru-D Lumalier (UV-C)

6. UV – Science
Breaks DNA bonds by inducing pyrimidine or thymine dimers (1,2,3,4,5)

7. UV – Safety No health or safety concerns returning to room
Direct prolonged light exposure can cause temporary corneal and conjunctival irritation (1,2,3,4,5)

8. UV – Utilization Easy to use, no room modifications
Shorter treatment time (depending on device and room size, compared to HPV)
Expenses associated with machine and bulb replacement
Safe with electronic room devices and other room materials (1,2,3,4,5)

9. UV - Efficacy 2-4 log10 reduction of spores
May allow resistant organisms to develop due to sub-lethal dose
Efficacy dependent on intensity of emitted light (old bulb vs. new bulb), exposure time, placement/obstructions, air movement
Less effective out of direct line of sight
Less effective further from the source (cannot use in large areas) (1,2,3,4,5)

10. UV-C (Ex. Tru-D Lumalier, iPT)
UV-C vs. PPX-UV
UV-C (Ex. Tru-D Lumalier, iPT)
PPX-UV (Ex. Xenex)
nm, Tru-D emits at 254nm
Breaks DNA bonds but not at the ideal wavelength (265nm), so occurs more slowly
Continuous dose at germicidal wavelength
Longer treatment times (34-100min per cycle) (1,2,4,5)
nm broad spectrum
More efficient (faster) because more broad spectrum
Additional benefits of photosplitting, photohydration, and photocrosslinking, all of which contributes to faster treatment times
Pulse dose at broad wavelength including germicidal range
Shorter treatment times (5-10 min per cycle) (1,2,5)

11. Published UV Data Study Device Cleaning Method Culture Method Results
Anderson et al. (2013)6
Tru-D Lumalier UV
Rodac touch plates
1.16 log reduction in colony counts
Boyce et al. (2011)7
Pre-inoculated plates
log reduction in colony counts
Sitzlar et al. (2013)8
Routine cleaning followed by UV
Surface swabbing
Reduction in positive cultures from 57% to 35%
Levin et al. (2013)9
PPX-UV
Bleach followed by UV
None
Reduction in HO-CDI rate from 9.46 to 4.45/10,000 PDs

12. Why did we choose to pursue use of a UV system?
C. difficile rates are above the national and state averages
Tried to implement daily bleach cleans of high-touch surfaces
Appeal of a device less vulnerable to human error

13. UV light trials
Trialed two different lights [PPX-UV (Xenex) and UV-C (iPT)] on three units each and followed HO-CDI rates
Trial 1 was 5 months
Trial 2 was 10 months

14. UV Utilization Adjunct to bleach for discharge room cleans
2 - 4 cycles per room, 5-10 min each plus set up and take down
Device was operated by EVS personnel trained by our institution
Spot cleaning of public areas/work areas (family rooms, bathrooms, etc.)

15. iPT (UV-C) Xenex (PPX-UV)

18. UV Utilization

19. Barriers to UV Utilization
Prolonged room turnover time
Only can be used at discharge in single occupant rooms
Burden of initial investment to provide sufficient machines to cover all C.diff or contact isolation or every discharge
Burden of training and maintaining additional EVS personnel to run the devices

20. Why we chose to pursue this study
No improvement in C. difficile outcomes after utilizing UV technology
Were we utilizing the device correctly?
Were enough rooms being treated?
Was it actually decreasing environmental C. difficile burden?
Is environmental contamination at discharge our primary issue?

21. The Study
Our goal was to compare the effectiveness of manual cleaning with quaternary ammonium cleaner (Virex), manual cleaning with bleach, and PPX-UV cleaning both separately and in combination
Obtained cultures from confirmed C. difficile positive rooms at discharge and throughout the cleaning process
Bed rail
Tray table
Remote
Toilet seat
Toilet rim
Sink faucet
Light switch
Keyboard

22. Soiled Room Bleach Clean QA Clean PPX-UV Clean Ready for Admission
Culture #1
Bleach Clean
QA Clean
PPX-UV Clean
Ready for Admission
Culture #2
Culture #3

23. Technicalities of swabbing and culturing
Sites were swabbed using pre-moistened sterile swabs (EnviroMax Plus)
Swabs were inoculated in enrichment broth (TCCFB) and incubated anaerobically for hours
Broth was plated on selective media (CCFA-HT) and incubated anaerobically for hours
Multiple colonies which were morphologically similar to/consistent with C.difficile were selected from each plate for PCR
PCR was used to detect toxin genes tcdA, tcdB, cdtA/cdtB
Representative isolates from each room were PCR ribotyped

24. C. difficile Reduction with Bleach Followed by PPX-UV

25. C. difficile Reduction with QA Followed By PPX-UV

26. Conclusions
Bleach effectively eradicated C. difficile from multiple surfaces (p = .011)
PPX-UV light could not show an additive benefit when utilized after bleach cleaning (p = .343)
Manual cleaning with a QA product followed by PPX-UV did reduce positive C. difficile cultures (p = .008)
Manual cleaning with a QA product followed by PPX-UV is possibly not as effective for C. difficile eradication as bleach alone (p = .063)

27. In the Meantime… Nerandzic et al. (2015):
Xenex (PPX-UV) device and Tru-D Lumalier (UV-C) device
C. diff, MRSA, and VRE from pre-inoculated plates
Pathogen load did not impact killing, but distance from source did
C. diff at 4ft was only 0.5 log10 reduction with PPX-UV
UV-C was superior to PPX-UV for reduction of all 3 organisms with the same concentrations of organisms and distance from source (1 log10 for C. diff)
Room contamination
Tested PPX-UV alone and bleach + PPX-UV
Saw statistically significant reductions in culture positivity with PPX-UV, but not with bleach + PPX-UV, and did not assess for statistically significant difference between the two methods (10)

28. In the Meantime… Ghantoji et al. (2015): Xenex PPX-UV device
Environmental cultures were collected before and after environmental cleaning with activated hydrogen peroxide followed by bleach (26/74  18/74)
And with activated hydrogen peroxide followed by PPX-UV (29/70  16/70)
No statistically significant difference in C. difficile positive cultures, z = (11)

29. Comparing Our Study Study Positive cultures pre-bleach (%)
Positive cultures post-bleach (%)
Gibson et al.
17/80 (21%)
1/80 (1%)
Ghantoji et al.11
26/74 (35%)
18/74 (24%)a
Nerandzic et al. 10
22/113 (19%)
9/113 (8%)b
aCultures were obtained pre- and post- combination of activated hydrogen peroxide followed by bleach
bCultures were obtained pre- and post- combination of standard clean including bleach followed by PPX-UV

30. Remaining Questions
Is environmental contamination at discharge a primary contributor to C. difficile transmission at our institution?
Does UV-C/PPX-UV have a place in an infection prevention program?
What amount of bacterial environmental burden is permissible?

31. Future Directions
When an excessive number of cases occur on a unit (5 in a rolling 4 week period), multi-pronged approach including:
bleach cleaning
ATP assessment
contact precautions re-enforcement and monitoring
Possible utilization of hydrogen peroxide vapor (Bioquell)
Focusing on other aspects of C. difficile prevention besides the terminal clean

32. Thanks
Patient Safety Committee of the University of Michigan Health System
The Young Lab
Kavitha Santhosh
Vincent Young MD, PhD
Krishna Rao MD
Infection Prevention
Amanda Valyko MPH, CIC
Laraine Washer MD
Terri Stillwell MD, MPH

33. References
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6. Anderson DJ, Gergen MF, Smathers E, et al. “Decontamination of targeted pathogens from patient rooms using an automated ultraviolet-C-emitting device.” Infect Control Hosp Epidemiol May;34(5):
7. Boyce JM, Havill NL, Moore BA. “Terminal decontamination of patient rooms using an automated mobile UV light unit.” Infect Control Hosp Epidemiol Aug;32(8):
8. Sitzlar B, Deshpande A, Fertelli D, et al. “An environmental disinfection odyssey: evaluation of sequential interventions to improve disinfection of Clostridium difficile isolation rooms.” Infect Control Hosp Epidemiol May;34(5):
9. Levin J, Riley LS, Parrish C, et al. “The effect of portable pulsed xenon ultraviolet light after terminal cleaning on hospital-associated Clostridium difficile infection in a community hospital.” Am J Infect Control Aug;41(8):746-8.
10. Nerandzic MM, Thota P, Sankar T, et al. “Evaluation of a pulsed xenon ultraviolet disinfection system for reduction of healthcare-associated pathogens in hospital rooms.” Infect Control Hosp Epidemiol Feb;36(2):192-7.
11. Ghantoji SS, Stibich M, Stachowiak J, et al. “Non-inferiority of pulsed xenon UV light versus bleach for reducing environmental Clostridium difficile contamination on high-touch surfaces in Clostridium difficile infection isolation rooms.” J Med Microbiol Feb;64(Pt 2):191-4.