Evaluation of hydrogen peroxide vapor for the inactivation of nosocomial pathogens on porous and nonporous surfaces

Environmental cleaning and disinfection in the operating room: a systematic scoping review through a human factors and systems engineering lens

OBJECTIVE

To synthesize evidence and identify gaps in the literature on environmental cleaning and disinfection in the operating room based on a human factors and systems engineering approach guided by the Systems Engineering Initiative for Patient Safety (SEIPS) model.

DESIGN

A systematic scoping review.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched 4 databases (ie, PubMed, EMBASE, OVID, CINAHL) for empirical studies on operating-room cleaning and disinfection. Studies were categorized based on their objectives and designs and were coded using the SEIPS model. The quality of randomized controlled trials and quasi-experimental studies with a nonequivalent groups design was assessed using version 2 of the Cochrane risk-of-bias tool for randomized trials.

RESULTS

In total, 40 studies were reviewed and categorized into 3 groups: observational studies examining the effectiveness of operating-room cleaning and disinfections (11 studies), observational study assessing compliance with operating-room cleaning and disinfection (1 study), and interventional studies to improve operating-room cleaning and disinfection (28 studies). The SEIPS-based analysis only identified 3 observational studies examining individual work-system components influencing the effectiveness of operating-room cleaning and disinfection. Furthermore, most interventional studies addressed single work-system components, including tools and technologies (20 studies), tasks (3 studies), and organization (3 studies). Only 2 studies implemented interventions targeting multiple work-system components.

CONCLUSIONS

The existing literature shows suboptimal compliance and inconsistent effectiveness of operating-room cleaning and disinfection. Improvement efforts have been largely focused on cleaning and disinfection tools and technologies and staff monitoring and training. Future research is needed (1) to systematically examine work-system factors influencing operating-room cleaning and disinfection and (2) to redesign the entire work system to optimize operating-room cleaning and disinfection.

Effect of Improved Nursing Strategy on Prognosis of Immunosuppressed Patients With Pneumonia and Sepsis: A Prospective Cohort Study

Objectives: To investigate the effect of our improved nursing strategy on prognosis in immunosuppressed patients with pneumonia and sepsis. Methods: Immunosuppressed patients (absolute lymphocyte count <1000 cells/mm3) with pneumonia and sepsis were enrolled and divided into a control group and treatment group. The treatment group received the improved nursing strategy. The primary outcome in this study was 28-day mortality. Results: In accordance with the study criteria, 1019 patients were finally enrolled. Compared with patients in the control group, those in the treatment group had significantly fewer days on mechanical ventilation [5 (4, 7) versus 5 (4, 7) days, P = .03] and lower intensive care unit (ICU) mortality [21.1% (132 of 627) vs 28.8% (113 of 392); P = .005] and 28-day mortality [22.2% (139 of 627) vs 29.8% (117 of 392); P = .006]. The treatment group also had a shorter duration of ICU stay [9 (5, 15) vs 11 (6, 22) days, P = .0001] than the control group. The improved nursing strategy acted as an independent protective factor in 28-day mortality: odds ratio 0.645, 95% confidence interval: 0.449-0.927, P = .018. Conclusion: Our improved nursing strategy shortened the duration of mechanical ventilation and the ICU stay and decreased ICU mortality and 28-day mortality in immunosuppressed patients with pneumonia and sepsis. Trial registration: ChiCTR.org.cn, ChiCTR-ROC-17010750. Registered 28 February 2017.

Use of Hydrogen Peroxide Vapour for Microbiological Disinfection in Hospital Environments: A Review

Disinfection of nosocomial pathogens in hospitals is crucial to combat healthcare-acquired infections, which can be acquired by patients, visitors and healthcare workers. However, the presence of a wide range of pathogens and biofilms, combined with the indiscriminate use of antibiotics, presents infection control teams in healthcare facilities with ongoing challenges in the selection of biocides and application methods. This necessitates the development of biocides and innovative disinfection methods that overcome the shortcomings of conventional methods. This comprehensive review finds the use of hydrogen peroxide vapour to be a superior alternative to conventional methods. Motivated by observations in previous studies, herein, we provide a comprehensive overview on the utilisation of hydrogen peroxide vapour as a superior high-level disinfection alternative in hospital settings. This review finds hydrogen peroxide vapour to be very close to an ideal disinfectant due to its proven efficacy against a wide range of microorganisms, safety to use, lack of toxicity concerns and good material compatibility. The superiority of hydrogen peroxide vapour was recently demonstrated in the case of decontamination of N95/FFP2 masks for reuse to address the critical shortage caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the COVID-19 pandemic. Despite the significant number of studies demonstrating antimicrobial activity, there remains a need to critically understand the mechanism of action by performing studies that simultaneously measure damage to all bacterial cell components and assess the correlation of this damage with a reduction in viable cell count. This can lead to improvement in antimicrobial efficacy and foster the development of superior approaches.

Disinfection and sterilization: New technologies

BACKGROUND

Adherence to professional guidelines and/or manufacturer's instructions for use regarding proper disinfection and sterilization of medical devices is crucial to preventing cross transmission of pathogens between patients. Emerging pathogens (e.g., Candida auris) and complex medical devices provide new challenges.

METHODS

A search for published English articles on new disinfection and sterilization technologies was conducted by Google, Google scholar and PubMed.

RESULTS

Several new disinfection methods or products (e.g., electrostatic spraying, new sporicides, colorized disinfectants, "no touch" room decontamination, continuous room decontamination) and sterilization technologies (e.g., new sterilization technology for endoscopes) were identified.

CONCLUSIONS

These technologies should reduce patient risk.

Efficacy of Vaporized Hydrogen Peroxide Combined with Silver Ions against Multidrug-Resistant Gram-Negative and Gram-Positive Clinical Isolates

Antimicrobial resistance (AMR) is a serious public health problem that results in high morbidity and mortality rates. In particular, multidrug-resistant (MDR) strains circulating in hospital settings pose a major threat as they are associated with serious nosocomial infections. Therefore, regular cleaning and disinfection procedures, usually using chemical disinfectants, must be implemented in these facilities. Hydrogen peroxide (HP)-based disinfectants have proven high microbicidal activity and several comparative advantages over conventional disinfectants. We assessed the in vitro biocidal activity of an 8% HP solution combined with 30 mg/L silver ions (HP + Ag) against MDR clinical isolates of Klebsiella pneumoniae (MDRKp) and Pseudomonas aeruginosa (MDRPa), and methicillin-resistant Staphylococcus aureus (MRSA). Accordingly, the in vitro antibacterial activity was determined using the macrodilution method, and the efficacy was determined for 30 min in terms of (1) activity on bacteria in suspension and (2) activity on surfaces using vaporized HP + Ag on a 20 cm2 stainless steel surface. A strong bactericidal effect of HP + Ag was observed against MDRKp, MDRPa, and MRSA strains, with minimum inhibitory concentrations and minimum bactericidal concentrations between 362.5 and 5800 mg/L. A strong effect was observed during the 30 min of HP + Ag exposure to the resistant clinical isolates, with over 4-Log10 reduction in CFUs. Regarding the efficacy of the disinfectant on surfaces, bacterial load reductions of >99% were observed. These results suggest that HP + Ag is potentially useful as an effective disinfectant for decontaminating surfaces in hospital settings suspected of contamination with MDR bacteria.

The in situ efficacy of whole room disinfection devices: a literature review with practical recommendations for implementation

BACKGROUND

Terminal cleaning and disinfection of hospital patient rooms must be performed after discharge of a patient with a multidrug resistant micro-organism to eliminate pathogens from the environment. Terminal disinfection is often performed manually, which is prone to human errors and therefore poses an increased infection risk for the next patients. Automated whole room disinfection (WRD) replaces or adds on to the manual process of disinfection and can contribute to the quality of terminal disinfection. While the in vitro efficacy of WRD devices has been extensively investigated and reviewed, little is known about the in situ efficacy in a real-life hospital setting. In this review, we summarize available literature on the in situ efficacy of WRD devices in a hospital setting and compare findings to the in vitro efficacy of WRD devices. Moreover, we offer practical recommendations for the implementation of WRD devices.

METHODS

The in situ efficacy was summarized for four commonly used types of WRD devices: aerosolized hydrogen peroxide, H₂O₂ vapour, ultraviolet C and pulsed xenon ultraviolet. The in situ efficacy was based on environmental and clinical outcome measures. A systematic literature search was performed in PubMed in September 2021 to identify available literature. For each disinfection system, we summarized the available devices, practical information, in vitro efficacy and in situ efficacy.

RESULTS

In total, 54 articles were included. Articles reporting environmental outcomes of WRD devices had large variation in methodology, reported outcome measures, preparation of the patient room prior to environmental sampling, the location of sampling within the room and the moment of sampling. For the clinical outcome measures, all included articles reported the infection rate. Overall, these studies consistently showed that automated disinfection using any of the four types of WRD is effective in reducing environmental and clinical outcomes.

CONCLUSION

Despite the large variation in the included studies, the four automated WRD systems are effective in reducing the amount of pathogens present in a hospital environment, which was also in line with conclusions from in vitro studies. Therefore, the assessment of what WRD device would be most suitable in a specific healthcare setting mostly depends on practical considerations.

Using engineered water nanostructures (EWNS) for wound disinfection: Case study of Acinetobacter baumannii inactivation on skin and the inhibition of biofilm formation

Engineered water nanostructures (EWNS) were utilized to deliver a cocktail of nature derived antimicrobials, to assess their efficacy as a solution to the problem of wound infections. The wound related microorganism Acinetobacter baumannii was inoculated on stainless steel and porcine skin and treated with EWNS. EWNS were able to reduce A. baumannii on stainless steel by 4.79 logs in 15 min, and 2 logs in 30 min on porcine skin. The EWNS were able to reduce the strength of A. baumannii biofilm on stainless steel by 87.31% as measured with the XTT assay (P < .001) and 86.27% in cellular counts (P < .001), after two EWNS interventions of 30 min each. Total antimicrobial dose delivered to the surface was 1.42 ng. SEM of biofilms after EWNS treatment showed reduced biomass. These results indicate that the EWNS technology has potential for application in field of wound disinfection and healing.

Effect of five decontamination methods on face masks and filtering facepiece respirators contaminated with Staphylococcus aureus and Pseudomonas aeruginosa

Introduction. In the context of the global pandemic due to SARS-CoV-2, procurement of personal protective equipment during the crisis was problematic. The idea of reusing and decontaminating personal surgical masks in facilities was explored in order to avoid the accumulation of waste and overcome the lack of equipment.

Hypothesis. Our hypothesis is that this work will show the decontamination methods assessed are effective for bacteria, such as Staphylococcus aureus and Pseudomonas aeruginosa .

Aim. We aim to provide information about the effects of five decontamination procedures (UV treatment, dry heat, vaporized H2O2, ethanol treatment and blue methylene treatment) on S. aureus and P. aeruginosa . These bacteria are the main secondary bacterial pathogens responsible for lung infections in the hospital environment.

Methodology. The surgical masks and the filtering facepiece respirators were inoculated with two bacterial strains ( S. aureus ATCC 29213 and P. aeruginosa S0599) and submitted to five decontamination treatments: vaporized H2O2 (VHP), UV irradiation, dry heat treatment, ethanol bath treatment and blue methylene treatment. Direct and indirect microbiology assessments were performed on three positive controls, five treated masks and one negative control.

Results. The five decontaminations showed significant (P<0.05) but different degrees of reductions of S. aureus and P. aeruginosa . VHP, dry heat treatment and ethanol treatment adequately reduced the initial contamination. The 4 min UV treatment allowed only a reduction to five orders of magnitude for face mask respirators. The methylene blue treatment induced a reduction to two orders of magnitude.

Conclusions. The three methods that showed a log10 reduction factor of 6 were the dry heat method, VHP and ethanol bath treatment. These methods are effective and their establishment in the medical field are easy but require economic investment.

The Influence of Blue Light and the BlsA Photoreceptor on the Oxidative Stress Resistance Mechanisms of Acinetobacter baumannii

Acinetobacter baumannii is a catalase-positive Gram-negative bacterial pathogen that causes severe infections among compromised patients. Among its noteworthy regulatory mechanisms, this microorganism regulates its lifestyle through the blue light using flavin (BLUF) protein BlsA. This protein regulates a diverse set of cellular processes that include, but are not limited to, motility, biofilm formation, phenylacetic acid metabolism, iron uptake, and catalase activity. We set out to determine how A. baumannii regulates catalase activity and other related oxidative stress phenotypes in response to light. Notably, because A. baumannii ATCC 17978 encodes four catalase homologs – which we refer to as KatA, KatE, KatE2, and KatG – we also aimed to show which of these enzymes exhibit light- and BlsA-dependent activity. Our work not only provides insight into the general function of all four catalase homologs and the impact of light on these functions, but also directly identifies KatE as a BlsA-regulated enzyme. We further demonstrate that the regulation of KatE by BlsA is dependent on a lysine residue that we previously demonstrated to be necessary for the regulation of surface motility. Furthermore, we show that BlsA’s five most-C-terminal residues – previously considered dispensable for BlsA’s overall function – are necessary for the light-independent and light-dependent regulation of catalase and superoxide dismutase activities, respectively. We hypothesize that these identified critical residues are necessary for BlsA’s interaction with protein partners including the transcriptional regulators Fur and BfmR. Together these data expand the understanding regarding how A. baumannii uses light as a signal to control oxidative stress resistance mechanisms that are critical for its pathophysiology.

Evaluation of dry hydrogen peroxide in reducing microbial bioburden in a healthcare facility

BACKGROUND

Standard manual cleaning and disinfection practices are often inadequate. Persistent contamination in the environment poses an infection risk that may be mitigated by no-touch disinfection systems. This study evaluates the efficacy of dry hydrogen peroxide (DHP) on microbial air and surface contamination as an adjunct to routine cleaning and disinfection in a large urban hospital.

METHODS

Surface samples were collected in five different hospital units, two pediatric and three adult, after manual cleaning on multiple days before and after DHP implementation. Air samples were also collected in each unit pre- and post-DHP use. Data outcomes were reported as colony forming units (CFU) with species identification.

RESULTS

The overall mean surface microbial burden was reduced by 96.5 percent for all units post-DHP compared to baseline (P < 0.001), with the greatest reductions achieved on privacy curtains (99.5 %). Mean microbial air sample counts were also reduced post-DHP compared to pre-DHP.

CONCLUSIONS

This study demonstrates that DHP was effective in reducing both air and surface microbial contamination in a variety of settings within a large, tertiary care hospital.

A Systematic Review on the Efficacy of Vaporized Hydrogen Peroxide as a Non-Contact Decontamination System for Pathogens Associated with the Dental Environment

Aerosol generation and a wide range of pathogens originating from the oral cavity of the patient contaminate various surfaces of the dental clinic. The aim was to determine the efficacy of vaporized hydrogen peroxide fogging on pathogens related to the dental environment and its possible application in dentistry. PICOS statement (Population, Intervention, Comparison/Control, Outcome and Study design statement) was used in the review. Six electronic databases were searched for articles published from 2010 to 2020. Articles written in English reporting vaporized hydrogen peroxide on pathogens deemed to be relevant to the dental environment were assessed. The quality of the studies was assessed using the risk-of-bias assessment tool designed for the investigation of vaporized hydrogen peroxide application in dentistry. A total of 17 studies were included in the qualitative synthesis. The most commonly reported single bacterial pathogen was Methicillin-resistant Staphylococcus aureus in five studies, and the viruses Feline calicivirus, Human norovirus, and Murine norovirus were featured in three studies. The results of the studies reporting the log kill were sufficient for all authors to conclude that vaporized hydrogen peroxide generation was effective for the assessed pathogens. The studies that assessed aerosolized hydrogen peroxide found a greater log kill with the use of vaporized hydrogen peroxide generators. The overarching conclusion was that hydrogen peroxide delivered as vaporized hydrogen peroxide was an effective method to achieve large levels of log kill on the assessed pathogens. The hydrogen peroxide vapor generators can play a role in dental bio-decontamination. The parameters must be standardized and the efficacy assessed to perform bio-decontamination for the whole clinic. For vaporized hydrogen peroxide generators to be included in the dental bio-decontamination regimen, certain criteria should be met. These include the standardization and efficacy assessment of the vaporized hydrogen peroxide generators in dental clinics.

The implementation of an infection control bundle within a Total Care Burns Unit

AIM

To evaluate the impact of the implementation of a best practice infection prevention and control bundle on healthcare associated burn wound infections in a paediatric burns unit.

BACKGROUND

Burn patients are vulnerable to infection. For this patient population, infection is associated with increased morbidity and mortality, thereby representing a significant challenge for burns clinicians who care for them.

METHODS

An interrupted time series was used to compare healthcare associated burn wound infections in paediatric burn patients before and after implementation of an infection prevention and control bundle. Prospective surveillance of healthcare associated burn wound infections was conducted from 2012 to 2014. Other potential healthcare associated infection rates were also reviewed over the study period, including urinary tract infections, pneumonia, upper respiratory tract infections and sepsis. An infection prevention and control bundle developed in collaboration between the paediatric burn unit and infection control clinicians was implemented in 2013 in addition to previous standard practice.

RESULTS

During the study period a total of 626 patients were admitted to the paediatric burns unit. Healthcare associated burn wound infections reduced from 34 in 2012 to 0 in 2014 following the implementation of the infection prevention and control bundle. Pneumonia and sepsis also reduced to 0 in 2013 and 2014, however one upper respiratory tract infection occurred in 2013 and urinary tract infections persisted in 2013.

CONCLUSION

The implementation of an infection prevention and control bundle was effective in reducing healthcare associated burn wound infections, pneumonia and sepsis within our paediatric burns unit. Urinary tract infections remain a challenge for future improvement.

Chemical disinfection in healthcare settings: critical aspects for the development of global strategies

Chemical disinfection is an indispensable means of preventing infection. This holds true for healthcare settings, but also for all other settings where transmission of pathogens poses a potential health risk to humans and/or animals. Research on how to ensure effectiveness of disinfectants and the process of disinfection, as well as on when, how and where to implement disinfection precautions is an ongoing challenge requiring an interdisciplinary team effort. The valuable resources of active substances used for disinfection must be used wisely and their interaction with the target organisms and the environment should be evaluated and monitored closely, if we are to reliable reap the benefits of disinfection in future generations. In view of the global threat of communicable diseases and emerging and re-emerging pathogens and multidrug-resistant pathogens, the relevance of chemical disinfection is continually increasing. Although this consensus paper pinpoints crucial aspects for strategies of chemical disinfection in terms of the properties of disinfectant agents and disinfection practices in a particularly vulnerable group and setting, i.e., patients in healthcare settings, it takes a comprehensive, holistic approach to do justice to the complexity of the topic of disinfection.

Decontamination of microbiologically contaminated abiotic porous surfaces in an oral surgery clinic using vaporised hydrogen peroxide (VHP)

PURPOSE

The aims of the study were to identify microorganisms, including those in the VBNC state, inhabiting porous surfaces in oral surgery offices and to assess the biocidal effectiveness and impact of 300 ppm vaporised hydrogen peroxide (VHP) for 20 min on decontaminated materials.

METHODS

From the surfaces of textured armrests of dental chairs, pinewood doors and window frames and cotton medical aprons, 30 swabs were taken with moistened sponges. The identification of isolated microorganisms was performed using molecular methods with MALDI-TOF MS, DNA Sanger sequencer and Illumina MiSeq. To evaluate the impact of VHP decontamination (independent variable) on the number of microorganisms (response variable) ANOVA and LSD tests were used. After application of 10 processes of VHP decontamination, changes in the properties of the materials were assessed using FTIR spectroscopy, SEM microscopy and XPS spectrometry.

RESULTS

The concentration of microorganisms was 10¹-10⁴ CFU/100 cm² on the tested surfaces and 10² CFU/m³ in the air. Twenty species of bacteria, one yeast and 16 filamentous fungi were identified, with the predominance of Bacillus, Staphylococcus, Alternaria, Aspergillus and Penicillium. Moreover, Janthinobacterium, Acremonium, Aureobasidium, Coprinellus and Cosmospora in the VBNC state were metagenomically detected. VHP decontamination resulted in a reduction in the majority of tested microbial strains by a minimum of 3 log, and all tested mixed cultures inhabiting porous surfaces were above 98% and in the air, 100%. VHP decontamination did not affect the structural and morphological properties of cotton fibres, wood or stainless steel.

CONCLUSIONS

VHP decontamination at a concentration of 300 ppm for 20 min can be used for the holistic disinfection of air, surfaces and equipment in oral surgery offices.

Evaluation of Hydrogen Peroxide Fumigation and Heat Treatment for Standard Emergency Arthropod Inactivation in BSL-3 Insectaries

Climate change and global movements of people and goods have accelerated the spread of invasive species, including insects that vector infectious diseases, which threaten the health of more than half of the world’s population. Increasing research efforts to control these diseases include the study of vector – pathogen interactions, involving the handling of pathogen-infected vector insects under biosafety level (BSL) 2 and 3 conditions. Like microbiology BSL-3 laboratories, BSL-3 insectaries are usually subjected to fixed-term or emergency room decontamination using recognized methods such as hydrogen peroxide (H₂O₂) or formaldehyde fumigation. While these procedures have been standardized and approved for the inactivation of diverse pathogens on surfaces, to date, there are no current standards for effective room-wide inactivation of insects in BSL-3 facilities in case of an emergency such as the accidental release of a large number of infected vectors. As H₂O₂ is often used for standard room decontamination in BSL-3 facilities, we evaluated H₂O₂ fumigation as a potential standard method for the safe, room-wide deactivation of insects in BSL-3 insectaries in comparison to heat treatment. To account for physiological diversity in vector insect species, six species from three different orders were tested. For the H₂O₂ fumigation we observed a strong but also varying resilience across all species. Lethal exposure time for the tested dipterans ranged from nine to more than 24 h. Furthermore, the coleopteran, Tribolium castaneum, did not respond to continuous H₂O₂ exposure for 48 h under standard room decontamination conditions. In contrast, temperatures of 50°C effectively killed all the tested species within 2 to 10 min. The response to lower temperatures (40–48°C) again showed a strong variation between species. In summary, results suggest that H₂O₂ fumigation, especially in cases where a gas generator is part of the laboratory equipment, may be used for the inactivation of selected species but is not suitable as a general emergency insect inactivation method under normal room decontamination conditions. In contrast, heat treatment at 48 to 50°C has the potential to be developed as an approved standard procedure for the effective inactivation of insects in BSL-3 facilities.

Role of Hydrogen Peroxide Vapor (HPV) for the Disinfection of Hospital Surfaces Contaminated by Multiresistant Bacteria

The emergence of multiresistant bacterial strains as agents of healthcare-related infection in hospitals has prompted a review of the control techniques, with an added emphasis on preventive measures, namely good clinical practices, antimicrobial stewardship, and appropriate environmental cleaning. The latter item is about the choice of an appropriate disinfectant as a critical role due to the difficulties often encountered in obtaining a complete eradication of environmental contaminations and reservoirs of pathogens. The present review is focused on the effectiveness of hydrogen peroxide vapor, among the new environmental disinfectants that have been adopted. The method is based on a critical review of the available literature on this topic.

An overview of automated room disinfection systems: When to use them and how to choose them

Conventional disinfection methods are limited by reliance on the operator to ensure appropriate selection, formulation, distribution, and contact time of the agent. Automated room disinfection (ARD) systems remove or reduce reliance on operators and so they have the potential to improve the efficacy of terminal disinfection. The most commonly used systems are hydrogen peroxide vapor (H₂O₂ vapor), aerosolized hydrogen peroxide (aHP), and ultraviolet (UV) light. These systems have important differences in their active agent, delivery mechanism, efficacy, process time, and ease of use. The choice of ARD system should be influenced by the intended application, the evidence base for effectiveness, practicalities of implementation, and cost considerations.

Influence of a visible-light continuous environmental disinfection system on microbial contamination and surgical site infections in an orthopedic operating room

BACKGROUND

A growing body of research has demonstrated that manual cleaning and disinfection of the operating room (OR) is suboptimal. Residual environmental contamination may pose an infection risk to the surgical wound. This study evaluates the impact of a visible-light continuous environmental disinfection (CED) system on microbial surface contamination and surgical site infections (SSI) in an OR.

METHODS

Samples from 25 surfaces within 2 contiguous ORs sharing an air supply were obtained after manual cleaning on multiple days before and after a visible-light CED system installation in 1 of the ORs. Samples were incubated and enumerated as total colony-forming units. SSIs in both ORs, and a distant OR, were tracked for 1 year prior to and 1 year after the visible-light CED system installation.

RESULTS

There was an 81% (P = .017) and 49% (P = .015) reduction in total colony-forming units after the visible-light CED system installation in the OR in which the system was installed, and in the contiguous OR, respectively. In the OR with the visible-light CED system, SSIs decreased from 1.4% in the year prior to installation to 0.4% following installation (P = .029).

CONCLUSIONS

A visible-light CED system, used in conjunction with manual cleaning, resulted in significant reductions in both microbial surface contamination and SSIs in the OR.

Inactivation of common hospital acquired pathogens on surfaces and in air utilizing engineered water nanostructures (EWNS) based nano-sanitizers

Infectious diseases represent a major public health challenge worldwide. There are various modes for the transmission of these diseases, with surface and airborne transmission being two of the most important ones. The inefficiencies of current intervention methods have resulted in the emergence of nosocomial infections. Here, we report the use of a nanotechnology based antimicrobial platform using Engineered Water Nanostructures (EWNS) generated using a combined electrospray and ionization of an aqueous suspension of various active ingredients (AIs). These EWNS based nano-sanitizers were tested in terms of their ability to efficiently deliver AI and inactivate Acinetobacter baumannii and influenza H1N1/PR/8 on both surfaces and air. Results indicate a significant reduction in the concertation of the pathogens, while the delivered to pathogen AI doses required for inactivation were miniscule (nanogram level), indicating the viability of such nano-carrier platform as an intervention technology against infectious microorganisms.

Best practices for disinfection of noncritical environmental surfaces and equipment in health care facilities: A bundle approach

Over the past decade, there is excellent evidence in the scientific literature that contaminated environmental surfaces and noncritical patient care items play an important role in the transmission of several key health care-associated pathogens including methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, Acinetobacter, norovirus, and Clostridium difficile. Thus, surface disinfection of noncritical environmental surfaces and medical devices is one of the infection prevention strategies to prevent pathogen transmission. This article will discuss a bundle approach to facilitate effective surface cleaning and disinfection in health care facilities. A bundle is a set of evidence-based practices, generally 3-5, that when performed collectively and reliably have been proven to improve patient outcomes. This bundle has 5 components and the science associated with each component will be addressed. These components are: creating evidence-based policies and procedures; selection of appropriate cleaning and disinfecting products; educating staff to include environmental services, patient equipment, and nursing; monitoring compliance (eg, thoroughness of cleaning, product use) with feedback (ie, just in time coaching); and implementing a "no touch" room decontamination technology and to ensure compliance for patients on contact and enteric precautions. This article will also discuss new technologies (eg, continuous room decontamination technology) that may enhance our infection prevention strategies in the future.

PCR Prevalence of Murine Opportunistic Microbes and their Mitigation by Using Vaporized Hydrogen Peroxide

Exposing immunodeficient mice to opportunistic microbes introduces risks of data variability, morbidity, mortality, and the invalidation of studies involving unique human reagents, including the loss of primary human hematopoietic cells, patient-derived xenografts, and experimental therapeutics. The prevalence of 15 opportunistic microbes in a murine research facility was determined by yearlong PCR-based murine and IVC equipment surveillance comprising 1738 specimens. Of the 8 microbes detected, 3 organisms- Staphylococcus xylosus, Proteus mirabilis, and Pasteurella pneumotropica biotype Heyl-were most prevalent in both murine and IVC exhaust plenum specimens. Overall, the 8 detectable microbes were more readily PCR-detectable in IVC exhaust airways than in murine specimens, supporting the utility of PCR testing of IVC exhaust airways as a component of immunodeficient murine health surveillance. Vaporized hydrogen peroxide (VHP) exposure of IVC equipment left unassembled (that is, in a 'static-open' configuration) did not eliminate PCR detectable evidence of microbes. In contrast, VHP exposure of IVC equipment assembled 'active-closed' eliminated PCR-detectable evidence of all microbes. Ensuring data integrity and maintaining a topographically complex immunodeficient murine research environment is facilitated by knowing the prevalent opportunistic microbes to be monitored and by implementing a PCR-validated method of facility decontamination that mitigates opportunistic microbes and the risk of invalidation of studies involving immunodeficient mice.

Health care-associated infections - an overview

Health care-associated infections (HCAIs) are infections that occur while receiving health care, developed in a hospital or other health care facility that first appear 48 hours or more after hospital admission, or within 30 days after having received health care. Multiple studies indicate that the common types of adverse events affecting hospitalized patients are adverse drug events, HCAIs, and surgical complications. The US Center for Disease Control and Prevention identifies that nearly 1.7 million hospitalized patients annually acquire HCAIs while being treated for other health issues and that more than 98,000 patients (one in 17) die due to these. Several studies suggest that simple infection-control procedures such as cleaning hands with an alcohol-based hand rub can help prevent HCAIs and save lives, reduce morbidity, and minimize health care costs. Routine educational interventions for health care professionals can help change their hand-washing practices to prevent the spread of infection. In support of this, the WHO has produced guidelines to promote hand-washing practices among member countries.

Modelling vaporised hydrogen peroxide efficacy against mono-species biofilms

This pilot study investigates a novel approach towards efficacy testing of antimicrobial cleaning agents; focusing primarily on hydrogen peroxide vapour (HPV). Contaminated surfaces are recognised modes of pathogen transmission within healthcare environments and increase the risk of pathogen acquisition in newly admitted patients. Studies have shown these pathogens can survive on surfaces for extended periods of time in spite of cleaning. This resilience is characteristic of biofilm formation and recent publications have identified their presence in hospitals. In this study, biofilm models comprised of multidrug-resistant organisms (MDROs) were generated using a drip flow reactor and exposed to HPV decontamination. The MDROs included Acinetobacter baumannii, Enterococcus faecalis, Klebsiella pneumoniae, Pseudomonas aeruginosa and Staphylococcus aureus. Upon exposure, samples were periodically removed and enumerated to generate kill curves for each species. Consequently revealing any inherent resistances; such as catalase-producing organisms which expressed reduced susceptibility. Epifluorescence microscopy revealed an abundance of viable and non-viable microcolonies before and after decontamination, respectively. Greater than 6-Log₁₀ reduction was achieved within a 100 minutes exposure time. This pilot study puts forward a potential methodology for testing antimicrobial agents against biofilms and supports the efficacy of HPV.

Facility-wide Eradication of Corynebacterium bovis by using PCR-validated Vaporized Hydrogen Peroxide

Facility-wide Corynebacterium bovis eradication was established using vaporized hydrogen peroxide (VHP) decontamination guided by C. bovis PCR surveillance. Prior attempts limited to culling PCR-positive mice and decontaminating affected rooms were ineffective in preventing recurrence. Because research aims often require trafficking to and use of procedural cores, a 12-mo facility-wide C. bovis PCR surveillance of 2064 specimens was performed and documented that, despite the presence of few clinically hyperkeratotic mice, 35% of the murine housing and use space was contaminated by C. bovis. The airways of IVC racks and air-handling units (AHU) provided a substantive niche for C. bovis survival, comparable to the primary enclosure, with 26% of murine and 22% of airway specimens PCR-positive for C. bovis. Equipment airway VHP sterilization in a 'flex room' required an 'active-closed' setting with the IVC rack connected to the AHU set to the VHP cycle, because 12% of specimens from 'static-open' VHP-exposed airways remained PCR-positive for C. bovis, whereas 0% of specimens from active-closed VHP exposures were positive. VHP decontamination of the 29,931-ft2 facility was completed in 2 mo. C. bovis PCR testing of IVC exhaust plenums for 200 d in previously C. bovis-affected rooms confirmed that none of the 259 specimens tested were PCR-positive for the organism. Monthly surveillance identified a single recurrence during June 2017 (month 9), ensuring rapid culling of C. bovis PCR-positive mice and acute VHP decontamination of equipment and rooms. Molecular persistence of C. bovis was resolved in procedural and personnel areas, and no murine or housing specimens tested C. bovis PCR-positive during study months 11 and 12. Furthermore, since the conclusion of the 12-mo study, none of the 452 additional murine, cell biologic, environmental, and monthly equipment surveillance specimens tested were C. bovis PCR-positive, documenting an 11-mo period of facility-wide C. bovis eradication to date. Study invalidation due to C. bovis can be avoided through PCR surveillance for the organism, immediate culling of PCR-positive mice, and acute VHP decontamination of affected areas.

Investigation of Polyaniline and a Functionalised Derivative as Antimicrobial Additives to Create Contamination Resistant Surfaces

Antimicrobial surfaces can be applied to break transmission pathways in hospitals. Polyaniline (PANI) and poly(3-aminobenzoic acid) (P3ABA) are novel antimicrobial agents with potential as non-leaching additives to provide contamination resistant surfaces. The activity of PANI and P3ABA were investigated in suspension and as part of absorbent and non-absorbent surfaces. The effect of inoculum size and the presence of organic matter on surface activity was determined. PANI and P3ABA both demonstrated bactericidal activity against Escherichia coli and Staphylococcus aureus in suspension and as part of an absorbent surface. Only P3ABA showed antimicrobial activity in non-absorbent films. The results that are presented in this work support the use of P3ABA to create contamination resistant surfaces.

'No touch' technologies for environmental decontamination: focus on ultraviolet devices and hydrogen peroxide systems

PURPOSE OF REVIEW

This article reviews 'no touch' methods for disinfection of the contaminated surface environment of hospitalized patients' rooms. The focus is on studies that assessed the effectiveness of ultraviolet (UV) light devices, hydrogen peroxide systems, and self-disinfecting surfaces to reduce healthcare-associated infections (HAIs).

RECENT FINDINGS

The contaminated surface environment in hospitals plays an important role in the transmission of several key nosocomial pathogens including methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus spp., Clostridium difficile, Acinetobacter spp., and norovirus. Multiple clinical trials have now demonstrated the effectiveness of UV light devices and hydrogen peroxide systems to reduce HAIs. A limited number of studies have suggested that 'self-disinfecting' surfaces may also decrease HAIs.

SUMMARY

Many studies have demonstrated that terminal cleaning and disinfection with germicides is often inadequate and leaves environmental surfaces contaminated with important nosocomial pathogens. 'No touch' methods of room decontamination (i.e., UV devices and hydrogen peroxide systems) have been demonstrated to reduce key nosocomial pathogens on inoculated test surfaces and on environmental surfaces in actual patient rooms. Further UV devices and hydrogen peroxide systems have been demonstrated to reduce HAI. A validated 'no touch' device or system should be used for terminal room disinfection following discharge of patients on contact precautions. The use of a 'self-disinfecting' surface to reduce HAI has not been convincingly demonstrated.

Evaluating the efficacy of hydrogen peroxide vapour against foot-and-mouth disease virus within a BSL4 biosafety facility

An evaluation was made of the efficacy of 35% hydrogen peroxide vapour (HPV) against foot-and-mouth disease virus (FMDV) in a biosafety facility. Biological indicators (BIs) were produced using three serotypes of FMDV, all with a titre of ≥10⁶ TCID₅₀ per ml. Fifteen BIs of each serotype were distributed across five locations, throughout a 30-m³ airlock chamber, producing a total of 45 BIs. Thirty-five percent HPV was generated and applied using a Bioquell vaporization module located in the centre of the chamber. After a dwell period of 40 min, the HPV was removed via the enclosures air handling system and the BIs were collected. The surfaces of the BIs were recovered into Glasgow's modified Eagle's medium (GMEM), cultivated in BHK21 Cl13 cell culture and analysed for evidence of cytopathic effect (CPE). No CPE was detected in any BI sample. Positive controls showed CPE. The experimentation shows that FMDV is susceptible to HPV decontamination and presents a potential alternative to formaldehyde.

SIGNIFICANCE AND IMPACT OF THE STUDY

Foot-and-mouth disease virus (FMDV) is an important pathogen in terms of biosafety due to its infectious nature and wide range of host animals, such as cattle, sheep, goats and pigs. Outbreaks of FMDV can have a severe impact on livestock production, causing morbidity, mortality, reduced yields and trade embargoes. Laboratories studying FMDV must possess BSL4 robust bio-decontamination methods to prevent inadvertent release. Formaldehyde has been the primary agent for environmental decontamination, but its designation as a human carcinogen has led to a search for alternatives. This study shows 35% hydrogen peroxide vapour has the potential to be a rapid, effective, residue-free alternative.

Survival of bacteria of laboratory animal origin on cage bedding and inactivation by hydrogen peroxide vapour

This study aims to determine the ability of laboratory animal bacteria to resist desiccation and inactivation by hydrogen peroxide vapour (HPV) on paper bedding pieces. Bedding pieces were saturated with bacterial suspensions in water or 2% (w/v) bovine serum albumin (BSA) in water, and held in a mouse facility. Viable counts showed variable survival rates over time for the bacterial species used ([ Pasteurella] pneumotropica, Muribacter muris, Pseudomonas aeruginosa, Acinetobacter redioresistens, Escherichia coli, Klebsiella oxytoca, Bordetella bronchiseptica, Bordetella hinzii, Enterococcus faecalis, β-haemolytic Streptococcus spp., Staphylococcus aureus and Staphylococcus xylosus). Overall, BSA increased bacterial survival in the bedding pieces. The survival rates of Bacillus safensis were not influenced by BSA but depended on sporulation. When bedding pieces and Petri dishes inoculated with E. coli, P. aeruginosa and S. aureus were subjected to HPV disinfection, all bacterial species on the bedding pieces inoculated with bacterial suspensions in water were readily inactivated. By contrast, S. aureus and P. aeruginosa, but not E. coli cells survived HPV treatment in high numbers when inoculated on bedding pieces as a BSA suspension. Notably, all three bacterial species were readily inactivated by HPV even in the presence of BSA when smeared on smooth surfaces. In conclusion, the suspension medium and the carrier can influence the environmental survival and susceptibility of bacterial species to HPV. Our results may help to develop standard protocols that can be used to ensure the microbiological quality of experimental rodent housing.

Effectiveness of ultraviolet devices and hydrogen peroxide systems for terminal room decontamination: Focus on clinical trials

Over the last decade, substantial scientific evidence has accumulated that indicates contamination of environmental surfaces in hospital rooms plays an important role in the transmission of key health care-associated pathogens (eg, methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, Clostridium difficile, Acinetobacter spp). For example, a patient admitted to a room previously occupied by a patient colonized or infected with one of these pathogens has a higher risk for acquiring one of these pathogens than a patient admitted to a room whose previous occupant was not colonized or infected. This risk is not surprising because multiple studies have demonstrated that surfaces in hospital rooms are poorly cleaned during terminal cleaning. To reduce surface contamination after terminal cleaning, no touch methods of room disinfection have been developed. This article will review the no touch methods, ultraviolet light devices, and hydrogen peroxide systems, with a focus on clinical trials which have used patient colonization or infection as an outcome. Multiple studies have demonstrated that ultraviolet light devices and hydrogen peroxide systems have been shown to inactivate microbes experimentally plated on carrier materials and placed in hospital rooms and to decontaminate surfaces in hospital rooms naturally contaminated with multidrug-resistant pathogens. A growing number of clinical studies have demonstrated that ultraviolet devices and hydrogen peroxide systems when used for terminal disinfection can reduce colonization or health care-associated infections in patients admitted to these hospital rooms.

A study of the properties of chlorine dioxide gas as a fumigant

Chlorine dioxide (ClO2) is a strong oxidant that possesses an antimicrobial activity. We demonstrated here that ClO2 gas is easily generated by mixing 3.35% sodium chlorite solution (Purogene) and 85% phosphoric acid at a 10:1 volume ratio without using an expensive machine. In a test room (87 m(3)), experiments were carried out using various amounts of sodium chlorite solution (0.25 ml/m(3) to 20.0 ml/m(3)). The gas concentration increased in a sodium chlorite volume-dependent manner and reached peak values of from 0.8 ppm to 40.8 ppm at 2 h-3 h, and then gradually decreased. No differences in gas concentrations were observed between 0.1 and 2.5 m above the floor, indicating that the gas was evenly distributed. Under high-humidity (approximately 80% relative humidity), colony formation of both Staphylococcus aureus and Escherichia coli was completely inhibited by ClO2 gas exposure at 1.0 ml/m(3) sodium chlorite solution (mean maximal concentration of 3.0 ppm). Exposure at 4.0 ml/m(3) sodium chlorite solution (mean maximal concentration of 10.6 ppm) achieved complete inactivation of Bacillus atrophaeus spores. In contrast, without humidification, the efficacy of ClO2 gas was apparently attenuated, suggesting that the atmospheric moisture is indispensable. Delicate electronic devices (computer, camera, etc.) operated normally, even after being subjected to more than 20 times of fumigation. Considering that our method for gas generation is simple, reproducible, and highly effective at decontaminating microbes, our approach is expected to serve as an inexpensive alternative method for cleaning and disinfecting animal facilities.