Hospital cleaning in the 21st century

Infection Prevention and Control Strategies According to the Type of Multidrug-Resistant Bacteria and Candida auris in Intensive Care Units: A Pragmatic Resume including Pathogens R0 and a Cost-Effectiveness Analysis

Multidrug-resistant organism (MDRO) outbreaks have been steadily increasing in intensive care units (ICUs). Still, healthcare institutions and workers (HCWs) have not reached unanimity on how and when to implement infection prevention and control (IPC) strategies. We aimed to provide a pragmatic physician practice-oriented resume of strategies towards different MDRO outbreaks in ICUs. We performed a narrative review on IPC in ICUs, investigating patient-to-staff ratios; education, isolation, decolonization, screening, and hygiene practices; outbreak reporting; cost-effectiveness; reproduction numbers (R0); and future perspectives. The most effective IPC strategy remains unknown. Most studies focus on a specific pathogen or disease, making the clinician lose sight of the big picture. IPC strategies have proven their cost-effectiveness regardless of typology, country, and pathogen. A standardized, universal, pragmatic protocol for HCW education should be elaborated. Likewise, the elaboration of a rapid outbreak recognition tool (i.e., an easy-to-use mathematical model) would improve early diagnosis and prevent spreading. Further studies are needed to express views in favor or against MDRO decolonization. New promising strategies are emerging and need to be tested in the field. The lack of IPC strategy application has made and still makes ICUs major MDRO reservoirs in the community. In a not-too-distant future, genetic engineering and phage therapies could represent a plot twist in MDRO IPC strategies.

Investigating the effect of enhanced cleaning and disinfection of shared medical equipment on health-care-associated infections in Australia (CLEEN): a stepped-wedge, cluster randomised, controlled trial

BACKGROUND

There is a paucity of high-quality evidence based on clinical endpoints for routine cleaning of shared medical equipment. We assessed the effect of enhanced cleaning and disinfection of shared medical equipment on health-care-associated infections (HAIs) in hospitalised patients.

METHODS

We conducted a stepped-wedge, cluster randomised, controlled trial in ten wards of a single hospital located on the central coast of New South Wales, Australia. Hospitals were eligible for inclusion if they were classified as public acute group A according to the Australian Institute of Health and Welfare, were located in New South Wales, had an intensive care unit, had a minimum of ten wards, and provided care for patients aged 18 years or older. Each cluster consisted of two randomly allocated wards (by use of simple randomisation), with a new cluster beginning the intervention every 6 weeks. Wards were informed of their allocation 2 weeks before commencement of intervention exposure, and the researcher collecting primary outcome data and audit data was masked to treatment sequence allocation. In the control phase, there was no change to environmental cleaning practices. In the intervention phase, a multimodal cleaning bundle included an additional 3 h per weekday for the dedicated cleaning and disinfection of shared medical equipment by 21 dedicated cleaning staff, with ongoing education, audit, and feedback. The primary outcome was the number of confirmed cases of HAI, as assessed by a fortnightly point prevalence survey and measured in all patients admitted to the wards during the study period. The completed trial is registered with Australia New Zealand Clinical Trials Registry (ACTRN12622001143718).

FINDINGS

The hospital was recruited on July 31, 2022, and the study was conducted between March 20 and Nov 24, 2023. We assessed 220 hospitals for eligibility, of which five were invited to participate, and the first hospital to formally respond was enrolled. 5002 patients were included in the study (2524 [50·5%] women and 2478 [49·5%] men). In unadjusted results, 433 confirmed HAI cases occurred in 2497 patients (17·3%, 95% CI 15·9 to 18·8) in the control phase and 301 confirmed HAI cases occurred in 2508 patients (12·0%, 10·7 to 13·3) in the intervention phase. In adjusted results, there was a relative reduction of -34·5% (-50·3 to -17·5) in HAIs following the intervention (odds ratio 0·62, 95% CI 0·45 to 0·80; p=0·0006), corresponding to an absolute reduction equal to -5·2% (-8·2 to -2·3). No adverse effects were reported.

INTERPRETATION

Improving the cleaning and disinfection of shared medical equipment significantly reduced HAIs, underscoring the crucial role of cleaning in improving patient outcomes. Findings emphasise the need for dedicated approaches for cleaning shared equipment.

FUNDING

National Health and Medical Research Council.

16S rRNA amplicon sequencing and antimicrobial resistance profile of intensive care units environment in 41 Brazilian hospitals

Introduction

Infections acquired during healthcare setting stay pose significant public health threats. These infections are known as Healthcare-Associated Infections (HAI), mostly caused by pathogenic bacteria, which exhibit a wide range of antimicrobial resistance. Currently, there is no knowledge about the global cleaning process of hospitals and the bacterial diversity found in ICUs of Brazilian hospitals contributing to HAI.

Objective

Characterize the microbiome and common antimicrobial resistance genes present in high-touch Intensive Care Unit (ICU) surfaces, and to identify the potential contamination of the sanitizers/processes used to clean hospital surfaces.

Methods

In this national, multicenter, observational, and prospective cohort, bacterial profiles and several antimicrobial resistance genes from 41 hospitals across 16 Brazilian states were evaluated. Using high-throughput 16S rRNA amplicon sequencing and real-time PCR, the bacterial abundance and resistance genes presence were analyzed in both ICU environments and cleaning products.

Results

We identified a wide diversity of microbial populations with a recurring presence of HAI-related bacteria among most of the hospitals. The median bacterial positivity rate in surface samples was high (88.24%), varying from 21.62 to 100% in different hospitals. Hospitals with the highest bacterial load in samples were also the ones with highest HAI-related abundances. Streptococcus spp., Corynebacterium spp., Staphylococcus spp., Bacillus spp., Acinetobacter spp., and bacteria from the Flavobacteriaceae family were the microorganisms most found across all hospitals. Despite each hospital particularities in bacterial composition, clustering profiles were found for surfaces and locations in the ICU. Antimicrobial resistance genes mecA, bla KPC-like, bla NDM-like, and bla OXA-23-like were the most frequently detected in surface samples. A wide variety of sanitizers were collected, with 19 different active principles in-use, and 21% of the solutions collected showed viable bacterial growth with antimicrobial resistance genes detected.

Conclusion

This study demonstrated a diverse and spread pattern of bacteria and antimicrobial resistance genes covering a large part of the national territory in ICU surface samples and in sanitizers solutions. This data should contribute to the adoption of surveillance programs to improve HAI control strategies and demonstrate that large-scale epidemiology studies must be performed to further understand the implications of bacterial contamination in hospital surfaces and sanitizer solutions.

The role of decontamination in reducing healthcare-associated infections

Effective decontamination is a vital aspect of infection prevention and control, and has a crucial role in reducing healthcare-associated infections (HCAIs). Various decontamination methods can be used in healthcare settings to ensure that medical devices, equipment and the clinical environment are safe. It is essential for nurses and other healthcare staff to have adequate knowledge of the decontamination methods and infection prevention and control practices required to prevent HCAIs. This article discusses the most common HCAIs, decontamination methods that can be used, and relevant UK legislation, policies and guidance. It also outlines nurses' responsibilities in relation to infection prevention and control and the importance of education and training in this area, with a particular focus on integrating human factors.

Plasma-activated liquid as a potential decontaminant in healthcare: assessment of antibacterial activity and use with cleaning cloths

BACKGROUND

Cold air plasma (CAP) can generate plasma-activated liquids (PALs) with high concentrations of reactive oxygen (ROS) and nitrogen species (RNS), e.g., nitrites, with antimicrobial properties.

AIM

We investigated the concentrations of ROS and RNS in saline PAL. We assessed planktonic bacterial inactivation by PAL and the decontamination of contaminated cleaning cloths.

METHODS

Phosphate-buffered saline (PBS) was treated with an air-driven CAP jet for 90 or 300 s to generate PAL. The ROS and RNS were measured using quantitative fluorescent (2,7-dichlorofluorescin diacetate) and colourimetric (Greiss) assays. Isolates of MRSA and Escherichia coli were incubated in PAL overnight and inactivation measured through colony forming unit (cfu) assays. Sections of cleaning cloths were incubated with MRSA and E. coli, and treated with PAL for 1 h. Bacterial inactivation was measured through resazurin reduction assays.

RESULTS

Nitrites increased from 0.1 μM in untreated PBS to 49.1 μM and to 94.0 μM in 90- and 300-s CAP-treated PAL, respectively. ROS increased from 30 μM in untreated PBS to 75 μM and to 103 μM in 90- and 300-s CAP-treated PAL, respectively. 90-s PAL reduced MRSA and E. coli viability (P<0.05) and 300-s PAL resulted in more than a 7-log reduction of both. One-hour treatment of contaminated cleaning cloths in PAL resulted in a 55% and 73% reduction in viable MRSA and E. coli, respectively (P<0.05).

CONCLUSION

Inactivation of planktonic bacteria correlated with ROS and RNS concentrations. PAL reduced bacteria contaminated cleaning cloths. PAL has potential as a hospital disinfectant, including cleaning cloths.

Surface decontamination effectiveness at the "Université des Montagnes" Teaching Hospital: Monitoring in the biomedical analysis laboratory

Background

Many infections in healthcare facilities are associated with the microbiological quality of the work environment, generally due to poor sanitation.

Aim

In order to evaluate the effectiveness of a decontamination protocol (cleaning + disinfection) applied at the "Université des Montagnes" Teaching Hospital, the present study assessed the variation of bacterial loads on surfaces subsequent to decontamination. Susceptibility of bacteria to disinfectants was also evaluated in the same frame.

Methodology

This work was conducted with an adjusted bacterial detection/enumeration and susceptibility test protocols and standard bacterial identification protocols. Sampling on surfaces was performed by wet swabbing before cleaning, between cleaning and disinfection and after disinfection.

Results

Major findings revealed the predominance of Staphylococcus (75.5%) on target surfaces. High bacterial loads recorded on these surfaces before decontamination became undetectable after cleaning with the detergent "Pax lemon". The majority of isolates (98%) were susceptible to the disinfectants tested, (Surfanios® 0.25% and sodium hypochlorite 0.12%).

Conclusion

Overall, these findings indicated process effectiveness on the subjected bacterial populations and suggest the use of either Surfanios® (0.25%) or sodium hypochlorite (0.12%) for work surfaces hygiene, justifying the use of these products in this department for surface decontamination. Also, cleaning with the detergent "Pax lemon" and disinfection with sodium hypochlorite may be sufficient for the types of surfaces subjected in the present research.

Effectiveness of a combined UV-C and ozone treatment in reducing healthcare-associated infections in hospital facilities

BACKGROUND

Hospital-acquired infections pose an ongoing threat to patient safety due to the presence of multi-drug-resistant organisms (MDROs) and other pathogens such as Clostridioides difficile which are dependent on thorough and effective cleaning and disinfection by personnel.

METHODS

This study evaluated the influence of UV-C air treatment: the air in the room was sanitized by UV-C and redirected into the room. In addition, ozone was released into the room to treat actual surfaces in low-risk areas such as hospital gyms, and high- to medium-risk areas such as hospital rooms. To this aim, a portable device designed for treating the environment air was tested against nine bacterial strains including Aspergillus spp. and Clostridioides spp.

RESULTS

The use of UV-C air treatment during daily operations and ozone treatment achieved at least a 2-log10 pathogen reduction except for Clostridioides spp.

CONCLUSION

Effective prevention of C. difficile normally requires the use of combined approaches that include chemical compounds and disinfection agents whose toxicity can be harmful not only to patients but also to healthcare personnel. Thus, the proposed no-touch device may be evaluated in future research to assess the needed requirements for its possible and full implementation in hospitals.

Multimodal environmental cleaning strategies to prevent healthcare-associated infections

Infection transmission in healthcare is multifaceted and by in large involves the complex interplay between a pathogen, a host and their environment. To prevent transmission, infection prevention strategies must also consider these complexities and incorporate targeted interventions aimed at all possible transmission pathways. One strategy to prevent and control infection is environmental cleaning. There are many aspects to an environmental cleaning strategy. We believe the key to successfully reducing the risk of healthcare-associated infections through the environment, is to design and implement a multimodal intervention. This paper aims to provide an overview of important considerations for designing a meaningful and sustainable environmental program for healthcare facilities.

Hospital cleaning: past, present, and future

INTRODUCTION

The importance of hospital cleaning for controlling healthcare-associated infection (HAI) has taken years to acknowledge. This is mainly because the removal of dirt is inextricably entwined with gender and social status, along with lack of evidence and confusion over HAI definitions. Reducing so-called endogenous infection due to human carriage entails patient screening, decolonisation and/or prophylaxis, whereas adequate ventilation, plumbing and cleaning are needed to reduce exogenous infection. These infection types remain difficult to separate and quantitate. Patients themselves demonstrate wide-ranging vulnerability to infection, which further complicates attempted ranking of control interventions, including cleaning. There has been disproportionate attention towards endogenous infection with less interest in managing environmental reservoirs.

QUANTIFYING CLEANING AND CLEANLINESS

Finding evidence for cleaning is compromised by the fact that modelling HAI rates against arbitrary measurements of cleaning/cleanliness requires universal standards and these are not yet established. Furthermore, the distinction between cleaning (soil removal) and cleanliness (soil remaining) is usually overlooked. Tangible bench marking for both cleaning methods and all surface types within different units, with modification according to patient status, would be invaluable for domestic planning, monitoring and specification.

AIMS AND OBJECTIVES

This narrative review will focus on recent history and current status of cleaning in hospitals. While its importance is now generally accepted, cleaning practices still need attention in order to determine how, when and where to clean. Renewed interest in removal and monitoring of surface bioburden would help to embed risk-based practice in hospitals across the world.

Bioinspired nanoflakes with antifouling and mechano-bactericidal capacity

Pathogenic bacteria contamination ubiquitously occurs on high-contact surfaces in hospitals and has long been a threat to public health, inducing severe nosocomial infections that cause multiple organ dysfunction and increased hospital mortality. Recently, nanostructured surfaces with mechano-bactericidal properties have shown potential for modifying material surfaces to fight against the spread of pathogenic microorganisms without the risk of triggering antibacterial resistance. Nevertheless, these surfaces are readily contaminated by bacterial attachment or inanimate pollutants like solid dust or common fluids, which has greatly weakened their antibacterial capabilities. In this work, we discovered that the nonwetting Amorpha fruticosa leaf surfaces are equipped with mechano-bactericidal capacity by means of their randomly-arranged nanoflakes. Inspired by this discovery, we reported an artificial superhydrophobic surface with similar nanofeatures and superior antibacterial abilities. Compared to conventional bactericidal surfaces, this bioinspired antibacterial surface was synergistically accompanied by antifouling performances, which significantly prevent either initial bacterial attachment or inanimate pollutants like dust covering and fluid contaminants. Overall, the bioinspired antifouling nanoflakes surface holds promise as the design of next-generation high-touch surface modification that effectively reduces the transmission of nosocomial infections.

Evaluating the environmental microbiota across four National Health Service hospitals within England

Hospital surfaces contaminated with microbial soiling, such as dry surface biofilms (DSBs), can act as a reservoir for pathogenic micro-organisms, and inhibit their detection and removal during routine cleaning. Studies have recognized that such increases in bioburden can hinder the impact of disinfectants and mask the detection of potential pathogens. Cleanliness within healthcare settings is often determined through routine culture-based analysis, whereby surfaces that exhibit >2.5 colony-forming units (CFU) per cm² pose a risk to patient health; therefore, any underestimation could have detrimental effects. This study quantified microbial growth on high-touch surfaces in four hospitals in England over 19 months. This was achieved using environmental swabs to sample a variety of surfaces within close proximity of the patient, and plating these on to non-specific low nutrient detection agar. The presence of DSBs on surfaces physically removed from the environment was confirmed using real-time imaging through episcopic differential interference contrast microscopy combined with epifluorescence. Approximately two-thirds of surfaces tested exceeded the limit for cleanliness (median 2230 CFU/cm²), whilst 83% of surfaces imaged with BacLight LIVE/DEAD staining confirmed traces of biofilm. Differences in infection control methods, such as choice of surface disinfectants and cleaning personnel, were not reflected in the microbial variation observed and resulting risk to patients. This highlights a potential limitation in the effectiveness of the current standards for all hospital cleaning, and further development using representative clinical data is required to overcome this limitation.

Comparison of conventionally and digitally completed patient consent-anamnesis forms in terms of surface contamination

BACKGROUND

With the development of modern technology, the use of software-based applications in the field of health has become increasingly widespread. For this reason, computer-assisted personal registration forms have been developed using software programs.

OBJECTIVE

The aim of this study was to compare surface contamination during the filling of orthodontic anamnesis-consent forms, traditionally on paper and digitally on a tablet equipped with a software application, measured in confined spaces using the 3M Clean-Trace Luminometer device.

METHODS

In order for the participants to complete the orthodontic anamnesis-consent forms, two separate identical cabins with standard flat surfaces were prepared. In the first cabin, the participants conventionally completed these forms on paper (conventional group), while in the second cabin, the other group used a tablet equipped with a software program for this purpose (digital group). After the form completion process, surface pollution of the predetermined areas was measured in both cabins using a 3M Clean-Trace Luminometer device.

RESULTS

Surface contamination was found to be statistically significantly higher in all measurement areas in the conventional group than in the digital group. Despite a statistically significant difference between the two groups in relation to the measurements performed using the pens (conventional or electronic), this was not as strong as those found for the remaining surfaces.

CONCLUSION

The completion of orthodontic anamnesis-consent forms over tablets significantly reduced surface contamination in the close environment. This study reflects the importance of digitization - which has become beneficial in many fields - in reducing the spread of infections.

Comparison of Floor Cleaning and Disinfection Processes in a Research Animal Facility

Floor cleaning and disinfection are essential components of maintaining animal health status and meeting regulatory requirements in research vivaria. However, best practices for method, frequency, and evaluation techniques have not been established. Reuse of cotton string mop and bucket systems has been implicated in spreading contamination in the human hospital setting. We evaluated 4 different combinations of disinfectant and mop systems commonly used in rodent vivaria. Eight housing rooms were mopped a total of 4 times using one of the following methods: quaternary ammonium compound (QUAT) and cotton string mop (QC), QUAT and microfiber mop (QM), hydrogen peroxide disinfectant (HPD) and cotton string mop (HC), or HPD and microfiber mop (HM). ATP and RODAC samples of the floor were taken before and after mopping. The time to mop each room, floor drying time, and the amount of disinfectant used were recorded. The QC method was associated with significantly more bacterial contamination while all other methods significantly reduced bacterial contamination. The QC method performed significantly worse in reducing bacterial contamination as compared with all other methods when cotton mop heads were reused. All methods except QC significantly reduced ATP levels, with the HC and HM methods being significantly more effective at reducing ATP levels than the QC and QM methods. Costs were similar for the QC, QM, and HM methods. The results of this study indicate that reuse of cotton string mop heads with QUAT increases floor contamination while HPD is effective for up to 3 reuses. Single use microfiber mops were effective with both QUAT and HPD but did not result in more effective cleaning or disinfection than cotton string mops.

Technologies to decontaminate bacterial biofilm on hospital surfaces: a potential new role for cold plasma?

Healthcare-associated infections (HCAIs) are a major challenge and the near patient surface is important in harbouring causes such as methicillin-resistant Staphylococcus aureus (MRSA) and Clostridioides difficile. Current approaches to decontamination are sub-optimal and many studies have demonstrated that microbial causes of HCAIs may persist with onward transmission. This may be due to the capacity of these microbes to survive in biofilms on surfaces. New technologies to enhance hospital decontamination may have a role in addressing this challenge. We have reviewed current technologies such as UV light and hydrogen peroxide and also assessed the potential use of cold atmospheric pressure plasma (CAPP) in surface decontamination. The antimicrobial mechanisms of CAPP are not fully understood but the production of reactive oxygen and other species is believed to be important. CAPP systems have been shown to partially or completely remove a variety of biofilms including those caused by Candida albicans, and multi-drug-resistant bacteria such as MRSA. There are some studies that suggest promise for CAPP in the challenge of surface decontamination in the healthcare setting. However, further work is required to define better the mechanism of action. We need to know what surfaces are most amenable to treatment, how microbial components and the maturity of biofilms may affect successful treatment, and how would CAPP be used in the clinical setting.

A Qualitative Study of Factors Influencing Unsafe Work Behaviors Among Environmental Service Workers: Perspectives of Workers, and Safety Managers: The Case of Government Hospitals in Addis Ababa, Ethiopia

BACKGROUND

Environmental Service (EVS) is a term that refers to cleaning in healthcare facilities. EVS personnel are exposed to a variety of hazards, including physical, chemical, ergonomic, cognitive, and biological hazards that contribute to the development of diseases and disabilities. Recognizing the conditions that promote unsafe behavior is the first step in reducing such hazards. The purpose of this study was to (a) investigate the attitudes and perceptions of safety among employees and safety managers in Addis Ababa hospitals, and (b) figure out what factors inhibit healthy work behaviors.

METHODS

The data for this study was gathered using 2 qualitative data gathering methods: key informant interviews and individual in-depth interviews. About 25 personnel from 3 Coronavirus treatment hospitals were interviewed to understand more about the factors that make safe behavior challenging. The interviews were recorded, transcribed, and then translated into English. Open Code 4.02 was used for thematic analysis.

RESULTS

Poor safety management and supervision, a hazardous working environment, and employee perceptions, skills, and training levels were all identified as key factors in the preponderance of unsafe work behaviors among environmental service workers.

CONCLUSIONS

Different types of personal and environmental factors were reported to affect safe work behavior among environmental service personnel. Individual responsibility is vital in reducing or eliminating these risk factors for unsafe behaviors, but management's involvement in providing resources for safe work behavior is critical.

Artificial Human Sweat as a Novel Growth Condition for Clinically Relevant Pathogens on Hospital Surfaces

The emergence of biofilms on dry hospital surfaces has led to the development of numerous models designed to challenge the efficacious properties of common antimicrobial agents used in cleaning. This is in spite of limited research defining how dry surfaces are able to facilitate biofilm growth and formation in such desiccating and nutrient-deprived environments. While it is well established that the phenotypical response of biofilms is dependent on the conditions in which they are formed, most models incorporate a nutrient-enriched, hydrated environment dissimilar to the clinical setting. In this study, we piloted a novel culture medium, artificial human sweat (AHS), which is perceived to be more indicative of the nutrient sources available on hospital surfaces, particularly those in close proximity to patients. AHS was capable of sustaining the proliferation of four clinically relevant multidrug-resistant pathogens (Acinetobacter baumannii, Staphylococcus aureus, Enterococcus faecalis, and Pseudomonas aeruginosa) and achieved biofilm formation at concentration levels equivalent to those found in situ (average, 6.00 log₁₀ CFU/cm²) with similar visual characteristics upon microscopy. The AHS model presented here could be used for downstream applications, including efficacy testing of hospital cleaning products, due to its resemblance to clinical biofilms on dry surfaces. This may contribute to a better understanding of the true impact these products have on surface hygiene. IMPORTANCE Precise modeling of dry surface biofilms in hospitals is critical for understanding their role in hospital-acquired infection transmission and surface contamination. Using a representative culture condition which includes a nutrient source is key to developing a phenotypically accurate biofilm community. This will enable accurate laboratory testing of cleaning products and their efficacy against dry surface biofilms.

Brought to Light: How Ultraviolet Disinfection Can Prevent the Nosocomial Transmission of COVID-19 and Other Infectious Diseases

The novel coronavirus disease 2019 (COVID-19) pandemic has brought to light the role of environmental hygiene in controlling disease transmission. Healthcare facilities are hot spots for infectious pathogens where physical distancing and personal protective equipment (PPE) are not always sufficient to prevent disease transmission. Healthcare facilities need to consider adjunct strategies to prevent transmission of infectious pathogens. In combination with current infection control procedures, many healthcare facilities are incorporating ultraviolet (UV) disinfection into their routines. This review considers how pathogens are transmitted in healthcare facilities, the mechanism of UV microbial inactivation and the documented activity of UV against clinical pathogens. Emphasis is placed on the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) as well as multidrug resistant organisms (MDROs) that are commonly transmitted in healthcare facilities. The potential benefits and limitations of UV technologies are discussed to help inform healthcare workers, including clinical studies where UV technology is used in healthcare facilities.

Synthesis of silver nanoparticles using Plantago lanceolata extract and assessing their antibacterial and antioxidant activities

Silver nanoparticles (Ag. NPs) have shown a biological activity range, synthesized under different environment-friendly approaches. Ag. NPs were synthesized using aqueous crude extract (ACE) isolated from Plantago lanceolata. The ACE and Ag. NPs were characterized and assessed their biological and antioxidant activities. The existence of nanoparticles (NPs) was confirmed by color shift, atomic force microscopy (AFM), and UV-Vis's spectroscopy. The FT-IR analysis indicated the association of biomolecules (phenolic acid and flavonoids) to reduce silver (Ag⁺) ions. The SEM study demonstrated a sphere-shaped and mean size in the range of 30 ± 4 nm. The EDX spectrum revealed that the Ag. NPs were composed of 54.87% Ag with 20 nm size as identified by SEM and TEM. AFM has ended up being exceptionally useful in deciding morphological elements and the distance across of Ag. NPs in the scope of 23-30 nm. The TEM image showed aggregations of NPs and physical interaction. Ag. NPs formation also confirmed by XPS, DRS and BET studies. Ag. NPs showed efficient activity as compared to ACE, and finally, the bacterial growth was impaired by biogenic NPs. The lethal dose (LD₅₀) of Ag. NPs against Agrobacterium tumefaciens, Proteus vulgaris, Staphylococcus aureus, and Escherichia coli were 45.66%, 139.71%, 332.87%, and 45.54%, with IC50 (08.02 ± 0.68), (55.78 ± 1.01), (12.34 ± 1.35) and (11.68 ± 1.42) respectively, suppressing the growth as compared to ACE. The antioxidant capacity, i.e., 2,2-diphenyl-1-picrylhydrazyl (DPPH) of Ag. NPs were assayed. ACE and Ag. NPs achieved a peak antioxidant capacity of 62.43 ± 2.4 and 16.85 ± 0.4 μg mL^-1, compared to standard (69.60 ± 1.1 at 100 μg mL^-1) with IC₅₀ (369.5 ± 13.42 and 159.5 ± 10.52 respectively). Finally, the Ag. NPs synthesized by P. lanceolata extract have an excellent source of bioactive natural products (NP). Outstanding antioxidant, antibacterial activities have been shown by NPs and can be used in various biological techniques in future research.

Guidelines in Practice: Environmental Cleaning

All perioperative personnel are responsible for providing a clean environment for patients undergoing operative or other invasive procedures. A contaminated environment can contribute to the incidence of surgical site infections when a patient's skin contacts a contaminated surface or personnel touch a contaminated surface and then transmit microbes to the patient. Airborne contaminants may settle on the sterile field or in the surgical wound. The AORN "Guideline for environmental cleaning" provides guidance on cleaning product selection, cleaning procedures, personnel education, competency verification, and monitoring cleanliness through performance improvement processes. This article discusses guideline recommendations for cleaning procedures and cleaning of operating and procedure rooms. A scenario describes how an ambulatory surgery center team identifies gaps in cleaning processes and modifies the cleaning checklist to improve these processes. Perioperative RNs should review the entire guideline for additional information when creating and updating policies and procedures for environmental cleaning.

Safety culture implications on safe work practices and work place exposure incidents in Operation Theater

BACKGROUND & OBJECTIVES

The study was undertaken to estimate the prevalence of body and blood fluid exposure incidents such as needle stick injuries, direct contact, splashes, and cuts among health care personnel (HCP) in operation theaters (OTs). The study objective was to investigate perception of safety culture and potential challenges faced by HCP in Pakistani context.

METHODS

An analytical cross-sectional survey was conducted in four tertiary care hospitals of Rawalpindi and Islamabad that were Akbar Niazi Teaching Hospital (ANTH), Fauji Foundation Hospital (FFH), Benazir Bhutto Hospital (BBH) and Holy Family Hospital (HFH) during March, 2019 to June, 2019. The data of the current study was collected from surgical staff in OTs at four tertiary care teaching hospitals including nurses, house officers, post graduate trainees, registrars, consultants, and technicians in the twin cities i.e., Rawalpindi and Islamabad.

RESULTS

In our findings (N=367) there was a high prevalence of exposure incidents in past six months, 45% had had got a needle injury, 36% have got a splash, 28.8% had direct contact and 35.6% had a cut once respectively in past six months, the occurrence of exposure incidents twice, thrice and more is also enormous.

CONCLUSION

The study reflected a dire need of trainings at hospitals so that very strategically the importance of safety being a priority and value of HCP is inculcated on daily basis.

A novel methodology to study antimicrobial properties of high-touch surfaces used for indoor hygiene applications-A study on Cu metal

Metal-based high-touch surfaces used for indoor applications such as doorknobs, light switches, handles and desks need to remain their antimicrobial properties even when tarnished or degraded. A novel laboratory methodology of relevance for indoor atmospheric conditions and fingerprint contact has therefore been elaborated for combined studies of both tarnishing/corrosion and antimicrobial properties of such high-touch surfaces. Cu metal was used as a benchmark material. The protocol includes pre-tarnishing/corrosion of the high touch surface for different time periods in a climatic chamber at repeated dry/wet conditions and artificial sweat deposition followed by the introduction of bacteria onto the surfaces via artificial sweat droplets. This methodology provides a more realistic and reproducible approach compared with other reported procedures to determine the antimicrobial efficiency of high-touch surfaces. It provides further a possibility to link the antimicrobial characteristics to physical and chemical properties such as surface composition, chemical reactivity, tarnishing/corrosion, surface roughness and surface wettability. The results elucidate that bacteria interactions as well as differences in extent of tarnishing can alter the physical properties (e.g. surface wettability, surface roughness) as well as the extent of metal release. The results clearly elucidate the importance to consider changes in chemical and physical properties of indoor hygiene surfaces when assessing their antimicrobial properties.

Systematic review on use, cost and clinical efficacy of automated decontamination devices

BACKGROUND

More evidence is emerging on the role of surface decontamination for reducing hospital-acquired infection (HAI). Timely and adequate removal of environmental pathogens leads to measurable clinical benefit in both routine and outbreak situations.

OBJECTIVES

This systematic review aimed to evaluate published studies describing the effect of automated technologies delivering hydrogen peroxide (H202) or ultra-violet (UV) light on HAI rates.

METHODS

A systematic review was performed using relevant search terms. Databases were scanned from January 2005 to March 2020 for studies reporting clinical outcome after use of automated devices on healthcare surfaces. Information collected included device type, overall findings; hospital and ward data; study location, length and size; antimicrobial consumption; domestic monitoring; and infection control interventions. Study sponsorship and duplicate publications were also noted.

RESULTS

While there are clear benefits from non-touch devices in vitro, we found insufficient objective assessment of patient outcome due to the before-and-after nature of 36 of 43 (84%) studies. Of 43 studies, 20 (47%) used hydrogen peroxide (14 for outbreaks) and 23 (53%) used UV technology (none for outbreaks). The most popular pathogen targeted, either alone or in combination with others, was Clostridium difficile (27 of 43 studies: 63%), followed by methicillin-resistant Staphylococcus aureus (MRSA) (16 of 43: 37%). Many owed funding and/or personnel to industry sponsorship (28 of 43: 65%) and most were confounded by concurrent infection control, antimicrobial stewardship and/or cleaning audit initiatives. Few contained data on device costs and rarely on comparable costs (1 of 43: 2%). There were expected relationships between the country hosting the study and location of device companies. None mentioned the potential for environmental damage, including effects on microbial survivors.

CONCLUSION

There were mixed results for patient benefit from this review of automated devices using H202 or UV for surface decontamination. Most non-outbreak studies lacked an appropriate control group and were potentially compromised by industry sponsorship. Concern over HAI encourages delivery of powerful disinfectants for eliminating pathogens without appreciating toxicity or cost benefit. Routine use of these devices requires justification from standardized and controlled studies to understand how best to manage contaminated healthcare environments.

Biogenic Gold Nanoparticles Decrease Methylene Blue Photobleaching and Enhance Antimicrobial Photodynamic Therapy

Antibiotic resistance is a growing concern that is driving the exploration of alternative ways of killing bacteria. Here we show that gold nanoparticles synthesized by the mycelium of Mucor plumbeus are an effective medium for antimicrobial photodynamic therapy (PDT). These particles are spherical in shape, uniformly distributed without any significant agglomeration, and show a single plasmon band at 522–523 nm. The nanoparticle sizes range from 13 to 25 nm, and possess an average size of 17 ± 4 nm. In PDT, light (from a source consisting of nine LEDs with a peak wavelength of 640 nm and FWMH 20 nm arranged in a 3 × 3 array), a photosensitiser (methylene blue), and oxygen are used to kill undesired cells. We show that the biogenic nanoparticles enhance the effectiveness of the photosensitiser, methylene blue, and so can be used to kill both Gram-positive (Staphylococcus aureus) and Gram-negative (Escherichia coli) bacteria. The enhanced effectiveness means that we could kill these bacteria with a simple, small LED-based light source. We show that the biogenic gold nanoparticles prevent fast photobleaching, thereby enhancing the photoactivity of the methylene blue (MB) molecules and their bactericidal effect.

Evaluating bio-burden of frequently touched surfaces using Adenosine Triphosphate bioluminescence (ATP): Results from the Researching Effective Approaches to Cleaning in Hospitals (REACH) trial

BACKGROUND

Environmental cleaning is an important approach to reducing healthcare-associated infection. The aim of this short research paper is to describe changes in the efficacy of post-discharge cleaning by examining the amount of bio-burden on frequent touch points (FTPs) in patient areas, using a validated Adenosine Triphosphate (ATP) bioluminescence sampling method. In so doing, we present findings from a secondary outcome of a recent trial, the Researching Effective Approaches to Cleaning in Hospitals (REACH) study.

METHODS

The REACH study used a prospective, stepped-wedge randomised cluster design. Cross sectional ATP sampling was conducted at three of the 11 participating hospitals. At each hospital, during the control and intervention phase of the study, six Frequent Touch Points (FTPs) were sampled: toilet flush, bathroom tap, inside bathroom door handle, patient call button, over bed tray table, and bed rails.

RESULTS

Across the three hospitals, 519 surfaces in 49 rooms (control phase) and 2856 surfaces in 251 rooms (intervention phase) were sampled. Bedroom FTP cleaning improved across all three hospitals. The cleaning of bathroom FTPs was generally high from the outset and remained consistent throughout the whole study period. Average cleaning outcomes for bathroom FTPs were consistently high during the control period however outcomes varied between individual FTP. Changes in cleaning performance over time reflected variation in intervention effectiveness at the hospital level.

CONCLUSION

Findings confirm improvement in cleaning in the FTPs in bedrooms, demonstrating improvements in discharge cleaning aligned with the improvements seen when using fluorescent marking technology as a marker of performance.

Building upon current knowledge and techniques of indoor microbiology to construct the next era of theory into microorganisms, health, and the built environment

In the constructed habitat in which we spend up to 90% of our time, architectural design influences occupants' behavioral patterns, interactions with objects, surfaces, rituals, the outside environment, and each other. Within this built environment, human behavior and building design contribute to the accrual and dispersal of microorganisms; it is a collection of fomites that transfer microorganisms; reservoirs that collect biomass; structures that induce human or air movement patterns; and space types that encourage proximity or isolation between humans whose personal microbial clouds disperse cells into buildings. There have been recent calls to incorporate building microbiology into occupant health and exposure research and standards, yet the built environment is largely viewed as a repository for microorganisms which are to be eliminated, instead of a habitat which is inexorably linked to the microbial influences of building inhabitants. Health sectors have re-evaluated the role of microorganisms in health, incorporating microorganisms into prevention and treatment protocols, yet no paradigm shift has occurred with respect to microbiology of the built environment, despite calls to do so. Technological and logistical constraints often preclude our ability to link health outcomes to indoor microbiology, yet sufficient study exists to inform the theory and implementation of the next era of research and intervention in the built environment. This review presents built environment characteristics in relation to human health and disease, explores some of the current experimental strategies and interventions which explore health in the built environment, and discusses an emerging model for fostering indoor microbiology rather than fearing it.

Effectiveness of a structured, framework-based approach to implementation: the Researching Effective Approaches to Cleaning in Hospitals (REACH) Trial

BACKGROUND

Implementing sustainable practice change in hospital cleaning has proven to be an ongoing challenge in reducing healthcare associated infections. The purpose of this study was to develop a reliable framework-based approach to implement and quantitatively evaluate the implementation of evidence-based practice change in hospital cleaning.

DESIGN/METHODS

The Researching Effective Approaches to Cleaning in Hospitals (REACH) trial was a pragmatic, stepped-wedge randomised trial of an environmental cleaning bundle implemented in 11 Australian hospitals from 2016 to 2017. Using a structured multi-step approach, we adapted the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to support rigorous and tailored implementation of the cleaning bundle intervention in eleven diverse and complex settings. To evaluate the effectiveness of this strategy we examined post-intervention cleaning bundle alignment calculated as a score (an implementation measure) and cleaning performance audit data collected using ultraviolet (UV) gel markers (an outcome measure).

RESULTS

We successfully implemented the bundle and observed improvements in cleaning practice and performance, regardless of hospital size, intervention duration and contextual issues such as staff and organisational readiness at baseline. There was a positive association between bundle alignment scores and cleaning performance at baseline. This diminished over the duration of the intervention, as hospitals with lower baseline scores were able to implement practice change successfully.

CONCLUSION

Using a structured framework-based approach allows for pragmatic and successful implementation of clinical trials across diverse settings, and assists with quantitative evaluation of practice change.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry ACTRN12615000325505, registered on 4 September 2015.

Profile of environmental service managers and workers in Brazilian hospitals

INTRODUCTION

Contamination through the hands of professionals and surfaces is one of the main agents involved in health care-associated infections in health services. Flaws in the execution of hospital housekeeping can lead to the contamination of surfaces and health equipment though, representing a risk for patient safety and highlighting the need to maximize the quality of cleaning processes in these institutions.

OBJECTIVE

To describe the profile of managers and environmental service workers (ESWs) in Brazilian hospitals.

METHODS

A cross-sectional study was undertaken in January 2018, involving 155 participants, being 12 managers and 143 workers from the housekeeping team of two health institutions, being one private and the other public.

RESULTS

Most participants were female (86%), with a mean age of 45 years and primary education level, 52% being outsourced workers. The participants positively assessed their job satisfaction, satisfaction with training, basic knowledge and performance; nevertheless, situations were identified that were perceived as risks for patient safety and occupational health. The questions involving motivational incentives received the lowest scores.

CONCLUSION

Inconsistencies were found in the housekeeping professionals'. Preparation, indicating that the institutions studied do not value this type of service and that an investment policy in these workers' motivation is lacking.

Comparison of steam technology and a two-step cleaning (water/detergent) and disinfecting (1,000 resp. 5,000 ppm hypochlorite) method using microfiber cloth for environmental control of multidrug-resistant organisms in an intensive care unit

Aim: The aim of this prospective observational study was to evaluate the impact of two cleaning and disinfecting methods and the use of steam against methicillin-resistant Staphyl ococcus aureus, vancomycin-resistant Enterococcus faecalis, carbapenem-resistant Pseudomonas aeruginosa and multidrug-resistant (MDR) Acinetobacter baumannii in a tertiary referral hospital. Methods: McFarland 0.5 suspensions (content 1.5 x 10⁸ cfu/ml) of four challenge bacterial species were prepared and used to inoculate different sites in three ICU rooms. One of the following methods was used in each room: steam technology (Tecnovap Evo 304) resp. cleaning with microfiber cloths, soaked with detergent and water, thereafter disinfection with 1,000 ppm hypochlorite or the same procedure with 5,000 ppm hypochlorite. Qualitative microbiology and ATP bioluminescence were performed before and after cleaning with each method. The Wilcoxon test was used for paired samples to check for ordinal variables. The cost of each cleaning method was analyzed. Results: Environmental cleaning with steam technology was found to be as effective against MDR microorganisms as a two-step cleaning process (water/detergent and disinfecting with 1,000 resp. 5,000 ppm hypochlorite) in ICUs. No bacterial growth was detected after any of the three cleaning methods. Steam technology was 76% and 91% cheaper than using 5,000 ppm and 1,000 ppm hypochlorite, respectively. Conclusions: When compared to, steam technology was found to have an advantage over the 2-step procedure with cleaning and disinfection, because it avoids the use of chemicals, reduces water consumption, labor time and costs for cleaning.

The Use of Copper as an Antimicrobial Agent in Health Care, Including Obstetrics and Gynecology

Health care-associated infections (HAIs) are a global problem associated with significant morbidity and mortality. Controlling the spread of antimicrobial-resistant bacteria is a major public health challenge, and antimicrobial resistance has become one of the most important global problems in current times. The antimicrobial effect of copper has been known for centuries, and ongoing research is being conducted on the use of copper-coated hard and soft surfaces for reduction of microbial contamination and, subsequently, reduction of HAIs. This review provides an overview of the historical and current evidence of the antimicrobial and wound-healing properties of copper and explores its possible utility in obstetrics and gynecology.

Rapid metagenomics analysis of EMS vehicles for monitoring pathogen load using nanopore DNA sequencing

Pathogen monitoring, detection and removal are essential to public health and outbreak management. Systems are in place for monitoring the microbial load of hospitals and public health facilities with strategies to mitigate pathogen spread. However, no such strategies are in place for ambulances, which are tasked with transporting at-risk individuals in immunocompromised states. As standard culturing techniques require a laboratory setting, and are time consuming and labour intensive, our approach was designed to be portable, inexpensive and easy to use based on the MinION third-generation sequencing platform from Oxford Nanopore Technologies. We developed a transferable sampling-to-analysis pipeline to characterize the microbial community in emergency medical service vehicles. Our approach identified over sixty-eight organisms in ambulances to the genera level, with a proportion of these being connected with health-care associated infections, such as Clostridium spp. and Staphylococcus spp. We also monitored the microbiome of different locations across three ambulances over time, and examined the dynamic community of microorganisms found in emergency medical service vehicles. Observed differences identified hot spots, which may require heightened monitoring and extensive cleaning. Through metagenomics analysis it is also possible to identify how microorganisms spread between patients and colonize an ambulance over time. The sequencing results aid in the development of practices to mitigate disease spread, while also providing a useful tool for outbreak prediction through ongoing analysis of the ambulance microbiome to identify new and emerging pathogens. Overall, this pipeline allows for the tracking and monitoring of pathogenic microorganisms of epidemiological interest, including those related to health-care associated infections.

Bacterial Contamination of Hemodialysis Devices in Hospital Dialysis Wards

Chronic care patients undergoing hemodialysis for treatment of end-stage renal failure experience higher rates of bloodstream-associated infection due to the patients' compromised immune system and management of the bloodstream through catheters. Staphylococcus species are acommon cause of hemodialysis catheterrelated bloodstream infections. We investigated environmental bacterial contamination of dialysis wards and contamination of hemodialysis devices to determine the source of bacteria for these infections. All bacterial samples were collected by the swab method and the agarose stamp method. And which bacterium were identified by BBL CRYSTAL Kit or 16s rRNA sequences. In our data, bacterial cell number of hemodialysis device was lower than environment of patient surrounds. But Staphylococcus spp. were found predominantly on the hemodialysis device (46.8%), especially on areas frequently touched by healthcare-workers (such as Touch screen). Among Staphylococcus spp., Staphylococcus epidermidis was most frequently observed (42.1% of Staphylococcus spp.), and more surprising, 48.2% of the Staphylococcus spp. indicated high resistance for methicillin. Our finding suggests that hemodialysis device highly contaminated with bloodstream infection associated bacteria. This study can be used as a source to assess the risk of contamination-related infection and to develop the cleaning system for the better prevention for bloodstream infections in patients with hemodialysis. J. Med. Invest. 66 : 148-152, February, 2019.

An environmental cleaning bundle and health-care-associated infections in hospitals (REACH): a multicentre, randomised trial

BACKGROUND

The hospital environment is a reservoir for the transmission of microorganisms. The effect of improved cleaning on patient-centred outcomes remains unclear. We aimed to evaluate the effectiveness of an environmental cleaning bundle to reduce health care-associated infections in hospitals.

METHODS

The REACH study was a pragmatic, multicentre, randomised trial done in 11 acute care hospitals in Australia. Eligible hospitals had an intensive care unit, were classified by the National Health Performance Authority as a major hospital (public hospitals) or having more than 200 inpatient beds (private hospitals), and had a health-care-associated infection surveillance programme. The stepped-wedge design meant intervention periods varied from 20 weeks to 50 weeks. We introduced the REACH cleaning bundle, a multimodal intervention, focusing on optimising product use, technique, staff training, auditing with feedback, and communication, for routine cleaning. The primary outcomes were incidences of health-care-associated Staphylococcus aureus bacteraemia, Clostridium difficile infection, and vancomycin-resistant enterococci infection. The secondary outcome was the thoroughness of cleaning of frequent touch points, assessed by a fluorescent marking gel. This study is registered with the Australian and New Zealand Clinical Trial Registry, number ACTRN12615000325505.

FINDINGS

Between May 9, 2016, and July 30, 2017, we implemented the cleaning bundle in 11 hospitals. In the pre-intervention phase, there were 230 cases of vancomycin-resistant enterococci infection, 362 of S aureus bacteraemia, and 968 C difficile infections, for 3 534 439 occupied bed-days. During intervention, there were 50 cases of vancomycin-resistant enterococci infection, 109 of S aureus bacteraemia, and 278 C difficile infections, for 1 267 134 occupied bed-days. After the intervention, vancomycin-resistant enterococci infections reduced from 0·35 to 0·22 per 10 000 occupied bed-days (relative risk 0·63, 95% CI 0·41-0·97, p=0·0340). The incidences of S aureus bacteraemia (0·97 to 0·80 per 10 000 occupied bed-days; 0·82, 0·60-1·12, p=0·2180) and C difficile infections (2·34 to 2·52 per 10 000 occupied bed-days; 1·07, 0·88-1·30, p=0·4655) did not change significantly. The intervention increased the percentage of frequent touch points cleaned in bathrooms from 55% to 76% (odds ratio 2·07, 1·83-2·34, p<0·0001) and bedrooms from 64% to 86% (1·87, 1·68-2·09, p<0·0001).

INTERPRETATION

The REACH cleaning bundle was successful at improving cleaning thoroughness and showed great promise in reducing vancomycin-resistant enterococci infections. Our work will inform hospital cleaning policy and practice, highlighting the value of investment in both routine and discharge cleaning practice.

FUNDING

National Health and Medical Research Council (Australia).

Four steps to clean hospitals: LOOK, PLAN, CLEAN and DRY

BACKGROUND

Now that cleaning and decontamination are recognized as integral to infection control, it is timely to examine the process in more detail. This is because cleaning practices vary widely within healthcare districts, and it is likely that both time and energy are needlessly wasted with ill-defined duties. Furthermore, inadequate cleaning will not reduce the risk of infection but may even enhance it. The process would benefit from a systematic appraisal, with each component placed within an evidence-based and ordered protocol.

METHODS

A literary search was performed on 'hospital cleaning', focusing on manual aspects of cleaning, pathogen reservoirs and transmission, hand hygiene, staff responsibilities and patient comfort.

RESULTS

No articles providing an evidence-based practical approach to systematic cleaning in hospitals were identified. This review therefore proposes a simple four-step guide for daily cleaning of the occupied bed space. Step 1 (LOOK) describes a visual assessment of the area to be cleaned; Step 2 (PLAN) argues why the bed space needs preparation before cleaning; Step 3 (CLEAN) covers surface cleaning/decontamination; and Step 4 (DRY) is the final stage whereby surfaces are allowed to dry.

CONCLUSION

Given the lack of articles providing practical cleaning guidance, this review proposes a four-step protocol based on evidence if available, or justified where not. Each step is presented, discussed and risk-assessed. It is likely that a systematic cleaning process would reduce the risk of healthcare-associated infection for everyone, including outbreaks, in addition to heightened confidence in overall quality of care.

ATP bioluminescence assay for evaluating cleaning practices in operating theatres: applicability and limitations

Background

Environmental cleaning practice plays an important role in reducing microbial contamination in hospital surfaces and contributes to prevent Healthcare Associated Infections. Adenosine Triphosphate (ATP) bioluminescence assay is a commonly used method for assessing environmental cleanliness on healthcare surfaces. This study tested the feasibility of using ATP-bioluminescence assay for evaluating the efficiency of cleaning procedures in the operating theatre settings, comparing the ATP-bioluminescence test with the traditional culture method.

Methods

The surfaces of 10 operating rooms of two public hospitals (140 samples in total) were examined “at rest”, in two moments of the same daily session: before the first scheduled operation (Pre), and before the second, after a clean environment was re-established (Post). Surface contamination was assessed using the cultural method to detect Total Viable Counts (TVC36°C) and ATP-bioluminescence assay (RLU).

Results

The examined surfaces presented very low TVCs (geometric means: 1.8 CFU/plate; IC95%: 1.6–2.0), always compliant with the relative reference standards. No statistical correlation was found between ATP values and TVCs. However, considering the results in terms of general evaluation of hygienic quality of surfaces, the two methods were consistent in identifying the most contaminated areas (Hospital A > Hospital B; Pre > Post; most contaminated surfaces: scialytic lamp). Furthermore, the ATP mean values showed a progressive increase from surfaces with TVC = 0 to surfaces with TVC > 15 CFU/plate.

Conclusions

Although not an alternative to cultural methods, the ATP-bioluminescence-assay can be a useful tool to measure the efficiency of cleaning procedures also in environments with very low microbial counts. Each health facility should identify appropriate reference values, depending on the devices used and on the basis of the analysis of the data collected through spatial and temporal sampling series. By providing a rapid feedback, the ATP-assay helps to increase the awareness of operators and allows immediate action to be taken in critical situations.

Impact of test protocols and material binding on the efficacy of antimicrobial wipes

BACKGROUND

The use of effective cleaning/disinfectant products is important to control pathogens on healthcare surfaces. With the increasing number of wipe products available, there is a concern that combination of a formulation with the wrong material will decrease the efficacy of the product. This study aimed to use a range of efficacy test protocols to determine the efficacy of four formulations before and after binding to three commonly used wiping materials.

METHODS

Two quaternary ammonium (QAC)-based products, one hydrogen-peroxide-based product and one neutral cleaner were combined with microfibre, cotton or non-woven materials and tested for efficacy against Pseudomonas aeruginosa and Staphylococcus aureus with two surface tests (ASTM E2197-17 and EN13697-15) and two 'product' tests (ASTM E2967-15 and EN16615-15).

FINDINGS

Overall, the impact of using different materials on formulation efficacy was limited, except for an alkyl(C_12-16)dimethylbenzylammonium chloride-based product used at 0.5% v/v. The hydrogen peroxide product was the most efficacious regardless of the material used. The results from wipe test ASTM E2967-15 were consistent with those from the surface tests, but not with EN16615-15 which was far less stringent.

CONCLUSIONS

The use of different wiping cloth materials may not impact severely on the efficacy of potent disinfectants, despite the absorption of different volumes of formulation by the materials. QAC-based formulations may be at higher risk when a low concentration is used. There were large differences in efficacy depending on the standard test performed, highlighting the need for more stringency in choosing the test to make a product claim on label.

"How Can the Patients Remain Safe, If We Are Not Safe and Protected from the Infections"? A Qualitative Exploration among Health-Care Workers about Challenges of Maintaining Hospital Cleanliness in a Resource Limited Tertiary Setting in Rural India

Background: Health care-associated infections (HAIs) result in treatment delays as well as failures and financial losses not only to patients but also to the treating hospital and overall health-care delivery system. Due to hospital-acquired infections, there are problems of increase in morbidity and mortality, additional diagnostic and therapeutic interventions and ultimately antimicrobial resistance. Proper understanding among health-care workers about the ill effects of HAIs is very important to address this issue. The present study is a qualitative exploration aimed at understanding various aspects of hospital environmental hygiene and Infection prevention control program, by exploring the staff perception regarding the challenges, facilitators and barriers as well as feasible measures towards improvement in a rural tertiary teaching hospital in central India. Method: A qualitative study was conducted using 10 focus group discussions (FGDs) among five different professional groups, which included hospital administrators, doctors, nurses, environmental cleaning staff, and undergraduate medical students. The FGD guide included the following topics: (1) opinion about the status of cleanliness, (2) concepts and actual practices prevailing of hospital environmental hygiene, (3) Barriers, constraints, and problems in maintaining hospital environmental hygiene, (4) Suggestions for improvements. The data were analyzed manually using the content (thematic) analysis method. Results: Two themes were identified: Theme 1: “Prevailing practices and problems related to hospital surface/object contamination and hospital infection control”. Theme 2: “Measures suggested for improving hospital cleanliness within the existing constraints”. The participants emphasized the influence of resource constraints and needed inputs. They brought up the consequent prevailing practices and problems related, on one hand, to various stakeholders (service consumers, hospital personnel including the management), on the other, to specific infection prevention and control processes. They also suggested various measures for improvement. Conclusions: The study has revealed prevailing practices, problems, and suggested measures related to hospital environmental hygiene, particularly hospital cleanliness and HAI prevention and control processes. These insights and assertions are important for developing future behavioral and structural interventions in resource-limited settings. This study recommends a nationwide reliable HAI surveillance system and a robust infection prevention and control program in each health-care institution.

Cleaning and disinfection of surfaces in hospitals. Improvement in quality of structure, process and outcome in the hospitals in Frankfurt/Main, Germany, in 2016 compared to 2014

The cleaning and disinfection of surfaces in hospitals is becoming increasingly important in the multi-barrier approach for preventing infection, in addition to hand hygiene and proper reprocessing of medical devices. Therefore, in 2014, the quality of structure, process and outcome of surface preparation was checked in all hospitals in Frankfurt/Main, Germany. Because of great need for improvements, this monitoring was repeated in 2016. The data are presented in comparison to those in 2014.

Methods: All 16 hospitals provided information on the quality of structure. Data on quality of process was obtained through direct observation during cleaning and disinfection of rooms and their bathrooms. Data on quality of result was acquired using the fluorescence method, i.e., marking surfaces with a fluorescent liquid and testing whether this mark has been sufficiently removed by cleaning. The results are compared to those of the 17 hospitals monitored in 2014, before the closing of one of the hospitals.

Results: Quality of structure [data from 2014]: In all hospitals, the employees were trained regularly. In 14 (88%) [12; 71%] of those, the foremen had the required qualifications. In 1 (6%) [6; 35%] hospitals, some uncertainty remained concerning the interface of the cleaning and nursing care services. A complete cleaning was reported to take place in 12 (75%) [12; 70%] hospitals on Saturdays and in 4 (25%) [2; 11%] hospitals on Sundays. Quality of process: During process monitoring, the different surfaces with frequent hand or skin contact were prepared to different extents (91–100%) [70–100%]. Quality of result: 88% [75%] of fluorescent marks were appropriately removed.

Conclusion: Compared to 2014, a clear improvement were seen in 2016, especially in the qualification of the foremen and in terms of clearly defining the interface between cleaning and care services as well as the quality of process and outcome. Nevertheless, regarding the growing importance of proper reprocessing of hospital surfaces for prevention of infections and/or colonizations, further improvements are mandatory, including a program for better education of the cleaning staff.

An international survey of cleaning and disinfection practices in the healthcare environment

BACKGROUND

Antimicrobial resistance has become an urgent global health priority. Basic hygiene practices and cleaning and disinfection of the hospital environment are key in preventing pathogen cross-transmission.

AIM

To our knowledge no studies have assessed the worldwide differences in cleaning and disinfection practices in healthcare facilities. The electronic survey described here was developed in order to evaluate differences in healthcare facility cleaning practices around the world.

METHODS

The International Society of Antimicrobial Chemotherapy (ISAC, formerly ISC), Infection Prevention and Control work group developed a survey with 30 multiple-choice questions. The questions were designed to assess the current cleaning practices in healthcare settings around the world.

FINDINGS

A total of 110 healthcare professionals, representing 23 countries, participated in the online survey. In 96% of the facilities a written cleaning policy was present. Training of cleaning staff occurred in 70% of the facilities at the start of employment. Cleaning practices and monitoring of these practices varied.

CONCLUSIONS

The survey enabled assessment and recognition of widely differing global practices in approaches to environmental cleaning and disinfection. Development of guideline recommendations for cleaning and disinfection could improve practices and set minimum standards worldwide.

Controlling infectious disease outbreaks in low-income and middle-income countries

When an infectious disease outbreak is detected or suspected, a healthcare facility's infection control personnel should be notified and an outbreak control team formed that is pertinent to the size and severity of the outbreak and healthcare facility. Management of an infectious disease outbreak in a middle- or low-income country is challenging. Cost-effective recommendations that are easy to carry out and that have been stratified according to the type of infection and prevention and control intervention used are provided in this paper and constitute basic practices.

Long-term metabolic persistence of gram-positive bacteria on health care-relevant plastic

BACKGROUND

Health care-associated opportunistic pathogens Staphylococcus aureus and Enterococcus faecium persist on dry environments and can contribute to organism transmission through contact. These organisms can be monitored on surfaces by culture, molecular methods, or metabolic assays. This study was designed to determine the kinetics of bacterial persistence on acrylonitrile butadiene styrene, a plastic commonly used in the manufacture of bedrails.

MATERIALS AND METHODS

Polymerase chain reaction for genomic DNA was used to confirm the presence of bacteria cells on this plastic irrespective of viability. Bacterial viability was measured by culture, ATP quantification, and a metabolic assay at time points up to and longer than 1 year.

RESULTS

Polymerase chain reaction confirmed the presence of bacteria on the plastic for the entire time period studied. However, S aureus culturability was reduced after 3 and 7 weeks; neither organism was culturable after 1 year. At 7 weeks, ATP levels were reduced for both organisms, paralleling S aureus culturability but indicating that ATP quantification did not predict E faecium culturability. S aureus-reducing potential was reduced after 7 weeks, whereas E faecium-reducing potential reached the level of fresh inoculum after 12 hours in broth culture. Low but significant levels of metabolic activity were detected for each organism after 1 year.

CONCLUSIONS

S aureus and E faecium cells may retain viability on plastic for longer than 1 year.

Effectiveness of cleaning-disinfection wipes and sprays against multidrug-resistant outbreak strains

BACKGROUND

Hospital rooms play an important role in the transmission of several health care-associated pathogens. During the last few years, a number of innovative cleaning-disinfecting products have been brought to market. In this study, commercially available products combining cleaning and disinfection were compared, using 2 different application methods. The aim was to determine which product was most effective in simultaneous cleaning and disinfection of surfaces.

METHODS

Seven cleaning-disinfecting wipes and sprays based on different active ingredients were tested for their efficacy in removal of microbial burden and proteins. Efficacy was tested with known Dutch outbreak strains: vancomycin-resistant enterococci (VRE), Klebsiella pneumoniae OXA-48, or Acinetobacter baumannii.

RESULTS

For all bacteria, ready-to-use cleaning-disinfecting products reduced the microbial count with a log₁₀ reduction >5 with a 5-minute exposure time, with the exception of a spray based on hydrogen peroxide. Omitting the aforementioned hydrogen peroxide spray, there were no significant differences between use of a wipe or spray in bacterial load reduction. Using adenosine triphosphate (ATP) measurements, a significant difference in log₁₀ relative light units (RLU) reduction between various bacteria (P ≤ .001) was observed.

CONCLUSIONS

In general, a >5 log₁₀ reduction of colony forming units (CFU) for tested wipes and sprays was obtained for all tested bacteria strains, with exception of hydrogen peroxide spray and VRE. Although ATP may show a difference between pre- and postcleaning, RLU reduction does not correlate with actual CFU reductions.

Hygiene: microbial strategies to reduce pathogens and drug resistance in clinical settings

Healthcare‐associated infections (HAIs) are a global concern, affecting all western hospitals, and profoundly impairing the clinical outcome of up to 15% of all hospitalized patients. Persistent microbial contamination of hospital surfaces has been suggested to contribute to HAIs onset, representing a reservoir for hospital pathogens. On the other hand, conventional chemicals‐based sanitation do not prevent recontamination and can select drug‐resistant strains, resulting in over 50% of surfaces persistently contaminated. There is therefore an urgent need for alternative sustainable and effective ways to control pathogens contamination and transmission. Toward this goal, we recently reported that a probiotic‐based sanitation can stably decrease surface pathogens up to 90% more than conventional disinfectants, without selecting resistant species. This paper summarizes some of our most significant results.

Reduction of Environmental Contamination With Multidrug-Resistant Bacteria by Copper-Alloy Coating of Surfaces in a Highly Endemic Setting

OBJECTIVE To evaluate the efficacy of copper-coating in reducing environmental colonization in an intensive-care unit (ICU) with multidrug-resistant-organism (MDRO) endemicity DESIGN Interventional, comparative crossover trial SETTING The general ICU of Attikon University hospital in Athens, Greece PATIENTS Those admitted to ICU compartments A and B during the study period METHODS Before any intervention (phase 1), the optimum sampling method using 2 nylon swabs was validated. In phase 2, 6 copper-coated beds (ie, with coated upper, lower, and side rails) and accessories (ie, coated side table, intravenous [i.v.] pole stands, side-cart handles, and manual antiseptic dispenser cover) were introduced as follows: During phase 2a (September 2011 to February 2012), coated items were placed next to noncoated ones (controls) in both compartments A and B; during phase 2b (May 2012 to January 2013), all copper-coated items were placed in compartment A, and all noncoated ones (controls) in compartment B. Patients were randomly assigned to available beds. Environmental samples were cultured quantitatively for clinically important bacteria. Clinical and demographic data were collected from medical records. RESULTS Copper coating significantly reduced the percentage of colonized surfaces (55.6% vs 72.5%; P<.0001), the percentage of surfaces colonized by MDR gram-negative bacteria (13.8% vs 22.7%; P=.003) or by enterococci (4% vs 17%; P=.014), the total bioburden (2,858 vs 7,631 cfu/100 cm2; P=.008), and the bioburden of gram-negative isolates, specifically (261 vs 1,266 cfu/100 cm2; P=.049). This effect was more pronounced when the ratio of coated surfaces around the patient was increased (phase 2b). CONCLUSIONS Copper-coated items in an ICU setting with endemic high antimicrobial resistance reduced environmental colonization by MDROs. Infect Control Hosp Epidemiol 2017;38:765-771.

High-touch surfaces: microbial neighbours at hand

Despite considerable efforts, healthcare-associated infections (HAIs) continue to be globally responsible for serious morbidity, increased costs and prolonged length of stay. Among potentially preventable sources of microbial pathogens causing HAIs, patient care items and environmental surfaces frequently touched play an important role in the chain of transmission. Microorganisms contaminating such high-touch surfaces include Gram-positive and Gram-negative bacteria, viruses, yeasts and parasites, with improved cleaning and disinfection effectively decreasing the rate of HAIs. Manual and automated surface cleaning strategies used in the control of infectious outbreaks are discussed and current trends concerning the prevention of contamination by the use of antimicrobial surfaces are taken into consideration in this manuscript.

Transmission of health care-associated infections from roommates and prior room occupants: a systematic review

Pathogens that cause health care-associated infections (HAIs) are known to survive on surfaces and equipment in health care environments despite routine cleaning. As a result, the infection status of prior room occupants and roommates may play a role in HAI transmission. We performed a systematic review of the literature evaluating the association between patients' exposure to infected/colonized hospital roommates or prior room occupants and their risk of infection/colonization with the same organism. A PubMed search for English articles published in 1990-2014 yielded 330 studies, which were screened by three reviewers. Eighteen articles met our inclusion criteria. Multiple studies reported positive associations between infection and exposure to roommates with influenza and group A streptococcus, but no associations were found for Clostridium difficile, methicillin-resistant Staphylococcus aureus, Cryptosporidium parvum, or Pseudomonas cepacia; findings were mixed for vancomycin-resistant enterococci (VRE). Positive associations were found between infection/colonization and exposure to rooms previously occupied by patients with Pseudomonas aeruginosa and Acinetobacter baumannii, but no associations were found for resistant Gram-negative organisms; findings were mixed for C. difficile, methicillin-resistant S. aureus, and VRE. Although the majority of studies suggest a link between exposure to infected/colonized roommates and prior room occupants, methodological improvements such as increasing the statistical power and conducting universal screening for colonization would provide more definitive evidence needed to establish causality.

Cleaning the grey zones of hospitals: A prospective, crossover, interventional study

BACKGROUND

Environmental cleaning is a fundamental principle of infection prevention in hospitals, but its role in reducing transmission of health care-acquired pathogens has been difficult to prove experimentally. In this study we analyze the influence of cleaning previously uncleaned patient care items, grey zones (GZ), on health care-acquired transmission rates.

METHODS

The intervention consisted of specific GZ cleaning by an extra cleaner (in addition to routine cleaning) on 2 structurally different acute care medical wards for a period of 6 months each, in a crossover design. Data on health care-acquired transmissions of vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus, and Clostridium difficile were collected during both periods. Adjusted incidence rate ratios (IRRs) using Poisson regression were calculated to compare transmission of pathogens between both periods on both wards.

RESULTS

During the intervention VRE transmission was significantly decreased (2-fold) on the ward where patients had fewer roommates; cleaning of GZ did not have any effect on the ward with multiple-occupancy rooms. There was no impact on methicillin-resistant S aureus transmission and only a nonsignificant decrease in transmission of C difficile.

CONCLUSIONS

Our data provide evidence that targeted cleaning interventions can reduce VRE transmission when rooming conditions are optimized; such interventions can be cost-effective when the burden of VRE is significant. Enhanced cleaning interventions are less beneficial in the context of room sharing where many other factors contribute to transmission of pathogens.