Clinical, operational, and financial impact of an ultraviolet-C terminal disinfection intervention at a community hospital

Impact of high-speed nanodroplets on various pathogenic bacterial cell walls

Although the development of disinfection technologies with novel mechanisms has stagnated, we demonstrate the bactericidal effects and mechanisms of high-speed nanodroplet generation technology. The first development of this technology in 2017 gushes out a water droplet of 10 nm in size at 50 m/s; however, the target surface does not become completely wet. Nanodroplets were exposed to biofilm models of Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, and Serratia marcescens. This phenomenon was verified when the nanodroplets collide with the surface of the bacteria at an impact pressure of ~75 MPa. S. aureus was exposed to nanodroplets for 30 seconds at 75 MPa, which exploded the bacterial body and completely sterilized. Eighteen MPa damaged the bacterial surface, causing peptidoglycan leakage. S. aureus was repaired and survives in this state. In contrast, in Gram-negative bacteria, nanodroplets with 18 MPa penetrated some biofilm-forming bacteria but did not hit all of them, and the viable count was not significantly reduced. Although all three bacterial species were completely sterilized at 75 MPa, the disinfectant effect was affected by the biomass of the biofilm formed. In summary, our findings prove that nanodroplets at 18 MPa on the bacterial surface were ineffective in killing bacteria, whereas at 75 MPa, all four bacterial species were completely sterilized. The disinfection mechanism involved a high-velocity collision of nanodroplets with the bacteria, physically destroying them. Our results showed that disinfection using this technology could be an innovative method that is completely different from existing disinfection techniques.

IMPORTANCE

Although existing disinfection techniques demonstrate bactericidal effects through chemical reactions, concerns regarding human toxicity and environmental contamination have been raised. To the best of our knowledge, this study is the first in the world to reveal that the use of this technology, with nanodroplets of less than 100 nm, can destroy and sterilize bacterial cells by colliding with biofilm-forming bacteria at 75 MPa. Furthermore, because this technology uses only water, it can solve the problems of human toxicity and environmental contamination caused by existing disinfection techniques. Because of its minimal water usage, it can be employed for sanitation worldwide without being limited to specific regions. Our report proposes an unprecedented physical disinfection approach that utilizes a high-speed nanodroplet generation technology.

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.

úNo touch..Ñ methods for health care room disinfection: Focus on clinical trials

BACKGROUND

Hospital patient room surfaces are frequently contaminated with multidrug-resistant organisms. Since studies have demonstrated that inadequate terminal room disinfection commonly occurs, ..úno touch..Ñ methods of terminal room disinfection have been developed such as ultraviolet light (UV) devices and hydrogen peroxide (HP) systems.

METHODS

This paper reviews published clinical trials of ..úno touch..Ñ methods and ..úself-disinfecting..Ñ surfaces.

RESULTS

Multiple papers were identified including clinical trials of UV room disinfection devices (N.ß=.ß20), HP room disinfection systems (N.ß=.ß8), handheld UV devices (N.ß=.ß1), and copper-impregnated or coated surfaces (N.ß=.ß5). Most but not all clinical trials of UV devices and HP systems for terminal disinfection demonstrated a reduction of colonization/infection in patients subsequently housed in the room. Copper-coated surfaces were the only ..úself-disinfecting..Ñ technology evaluated by clinical trials. Results of these clinical trials were mixed.

DISCUSSION

Almost all clinical trials reviewed used a ..úweak..Ñ design (eg, before-after) and failed to assess potential confounders (eg, compliance with hand hygiene and environmental cleaning).

CONCLUSIONS

The evidence is strong enough to recommend the use of a ..úno-touch..Ñ method as an adjunct for outbreak control, mitigation strategy for high-consequence pathogens (eg, Candida auris or Ebola), or when there are an excessive endemic rates of multidrug-resistant organisms.

Using Protein Fingerprinting for Identifying and Discriminating Methicillin Resistant Staphylococcus aureus Isolates from Inpatient and Outpatient Clinics

In hospitals and other clinical settings, Methicillin-resistant Staphylococcus aureus (MRSA) is a particularly dangerous pathogen that can cause serious or even fatal infections. Thus, the detection and differentiation of MRSA has become an urgent matter in order to provide appropriate treatment and timely intervention in infection control. To ensure this, laboratories must have access to the most up-to-date testing methods and technology available. This study was conducted to determine whether protein fingerprinting technology could be used to identify and distinguish MRSA recovered from both inpatients and outpatients. A total of 326 S. aureus isolates were obtained from 2800 in- and outpatient samples collected from King Faisal Specialist Hospital and Research Centre in Riyadh, Saudi Arabia, from October 2018 to March 2021. For the phenotypic identification of 326 probable S. aureus cultures, microscopic analysis, Gram staining, a tube coagulase test, a Staph ID 32 API system, and a Vitek 2 Compact system were used. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS), referred to as protein fingerprinting, was performed on each bacterial isolate to determine its proteomic composition. As part of the analysis, Principal Component Analysis (PCA) and a single-peak analysis of MALDI-TOF MS software were also used to distinguish between Methicillin-sensitive Staphylococcus aureus (MSSA) and MRSA. According to the results, S. aureus isolates constituted 326 out of 2800 (11.64%) based on the culture technique. The Staph ID 32 API system and Vitek 2 Compact System were able to correctly identify 262 (80.7%) and 281 (86.2%) S. aureus strains, respectively. Based on the Oxacillin Disc Diffusion Method, 197 (62.23%) of 326 isolates of S. aureus exhibited a cefoxitin inhibition zone of less than 21 mm and an oxacillin inhibition zone of less than 10 mm, and were classified as MRSA under Clinical Laboratory Standards Institute guidelines. MALDI-TOF MS was able to correctly identify 100% of all S. aureus isolates with a score value equal to or greater than 2.00. In addition, a close relationship was found between S. aureus isolates and higher peak intensities in the mass ranges of 3990 Da, 4120 Da, and 5850 Da, which were found in MRSA isolates but absent in MSSA isolates. Therefore, protein fingerprinting has the potential to be used in clinical settings to rapidly detect and differentiate MRSA isolates, allowing for more targeted treatments and improved patient outcomes.

A systematic review of the germicidal effectiveness of ultraviolet disinfection across high-touch surfaces in the immediate patient environment

Background

There is not yet a consensus regarding the in-use effectiveness of ultraviolet irradiation (UV-C) as a supplementary tool for terminal room disinfection.

Aims and Objectives

To summarize and evaluate literature detailing the germicidal effectiveness of UV-C disinfection on high-touch surfaces in the patient environment.

Methods

A literature search was carried out utilizing PRISMA guidelines. Studies were included if intervention included UV-C after standard room disinfection in hospital rooms evaluated microbiologically by surface type.

Findings/Results

Twelve records met our criteria for inclusion. Studies predominantly focused on terminal disinfection of patient rooms, including five reports carried out in isolation rooms and three studies including operating room (OR) surfaces. Bedrails, remote controls, phones, tray tables, assist rails, floors, and toilets were the most commonly reported surfaces. Across study designs, surfaces, and room types, flat surfaces tended to showcase UV-C effectiveness best, particularly isolation room floors. In contrast, handheld surfaces (i.e., bed controls and assist bars) tended to show reduced efficacies (81-93%). In the OR, complex surfaces similarly demonstrated reduced UV-C effectiveness. Bathroom surfaces demonstrated 83% UV-C effectiveness overall, with surface characteristics uniquely impacted depending on the room type. Isolation room studies tended to include effectiveness comparison with standard treatment, reporting UV-C superiority most of the time.

Discussion

This review highlights the enhanced effectiveness of UV-C surface disinfection over standard protocols across various study designs and surfaces. However, surface and room characteristics do appear to play a role in the level of bacterial reduction.

Effectiveness of Ultraviolet-C Disinfection on Hospital-Onset Gram-Negative Rod Bloodstream Infection: A Nationwide Stepped-Wedge Time-Series Analysis

BACKGROUND

The effectiveness of enhanced terminal room cleaning with ultraviolet C (UV-C) disinfection in reducing gram-negative rod (GNR) infections has not been well evaluated. We assessed the association of implementation of UV-C disinfection systems with incidence rates of hospital-onset (HO) GNR bloodstream infection (BSI).

METHODS

We obtained information regarding UV-C use and the timing of implementation through a survey of all Veterans Health Administration (VHA) hospitals providing inpatient acute care. Episodes of HO-GNR BSI were identified between January 2010 and December 2018. Bed days of care (BDOC) was used as the denominator. Over-dispersed Poisson regression models were fitted with hospital-specific random intercept, UV-C disinfection use for each month, baseline trend, and seasonality as explanatory variables. Hospitals without UV-C use were also included to the analysis as a nonequivalent concurrent control group.

RESULTS

Among 128 VHA hospitals, 120 provided complete survey responses with 40 reporting implementations of UV-C systems. We identified 13 383 episodes of HO-GNR BSI and 24 141 378 BDOC. UV-C use was associated with a lower incidence rate of HO-GNR BSI (incidence rate ratio: 0.813; 95% confidence interval: .656-.969; P = .009). There was wide variability in the effect size of UV-C disinfection use among hospitals.

CONCLUSIONS

In this large quasi-experimental analysis within the VHA System, enhanced terminal room cleaning with UV-C disinfection was associated with an approximately 19% lower incidence of HO-GNR BSI, with wide variability in effectiveness among hospitals. Further studies are needed to identify the optimal implementation strategy to maximize the effectiveness of UV-C disinfection technology.

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.

Immersive ultraviolet disinfection of E. coli and MS2 phage on woven cotton textiles

Immersive ultraviolet disinfection provides a chemical-free technology for safer textiles, surfaces, and public spaces by inactivating communicable pathogens. This study examined immersive UV disinfection, using a disinfection cabinet, of E. coli and MS2 that was inoculated on white cotton T-shirts. The impact that porous materials have on UV disinfection is poorly understood with the majority of previous surface disinfection research focusing on hard, smooth surfaces. Several approaches were used in this study to characterize the light dynamics within the disinfection cabinet including colorimetric dosimetry coupons, biodosimetry, and spectroradiometry. Micro and macro geometry of porous surfaces are important factors to consider when using immersive UV technologies. The geometry of the cabinet impacted the distribution of emitted UV light within the disinfection cabinet and the physical properties of a porous material, such as the woven pattern of cotton, both contribute to UV disinfection efficiency. This work identified that light distribution is crucial for immersive UV technologies as the delivered fluence was highly variable within the disinfection cabinet and resulted in a difference of several logs of reduction for adjacent areas of T-shirt samples. Other inoculated areas achieved upwards of 1-log reductions values for MS2 and upwards of 2-log reductions for E. coli.

Ultraviolet-C radiation: A supplemental tool for disinfection

ABSTRACT

In response to the COVID-19 pandemic, healthcare facilities have purchased more ultraviolet-C (UVC) disinfection devices than in previous years. This article discusses the safety and efficacy of UVC disinfection in healthcare settings.

Hospital surface disinfection using ultraviolet germicidal irradiation technology: A review

Ultraviolet germicidal irradiation (UVGI) technologies have emerged as a promising alternative to biocides as a means of surface disinfection in hospitals and other healthcare settings. This paper reviews the methods used by researchers and clinicians in deploying and evaluating the efficacy of UVGI technology. The type of UVGI technology used, the clinical setting where the device was deployed, and the methods of environmental testing that the researchers followed are investigated. The findings suggest that clinical UVGI deployments have been growing steadily since 2010 and have increased dramatically since the start of the COVID-19 pandemic. Hardware platforms and operating procedures vary considerably between studies. Most studies measure efficacy of the technology based on the objective measurement of bacterial bioburden reduction; however, studies conducted over longer durations have examined the impact of UVGI on the reduction of healthcare associated infections (HCAIs). Future trends include increased automation and the use of UVGI technologies that are safer for use around people. Although existing evidence seems to support the efficacy of UVGI as a tool capable of reducing HCAIs, more research is needed to measure the magnitude of these effects and to establish recommended best practices.

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.

Effect of ultraviolet-C light disinfection at terminal patient discharge on hospital-acquired infections in bone marrow transplant and oncology units

We employed an interrupted time series analysis to assess the impact of ultraviolet-C light disinfection at terminal discharge in an oncology unit and a bone marrow transplant unit on the incidence of hospital-acquired infections. The deployment of ultraviolet-C light disinfection was associated with a significant decrease in the rate of Clostridioides difficile infections and a significant decrease in the rate of central line-associated blood stream infections in the bone marrow transplant unit.

Self-Disinfecting Copper Beds Sustain Terminal Cleaning and Disinfection Effects throughout Patient Care

Microbial burden associated with near-patient touch surfaces results in a greater risk of health care-associated infections (HAIs). Acute care beds may be a critical fomite, as traditional plastic surfaces harbor the highest concentrations of bacteria associated with high-touch surfaces in a hospital room's patient zone. Five high-touch intensive care unit (ICU) bed surfaces encountered by patients, health care workers, and visitors were monitored by routine culture to assess the effect U.S. Environmental Protection Agency (U.S. EPA)-registered antimicrobial copper materials have on the microbial burden. Despite both daily and discharge cleaning and disinfection, each control bed's plastic surfaces exceeded bacterial concentrations recommended subsequent to terminal cleaning and disinfection (TC&D) of 2.5 aerobic CFU/cm² Beds with self-disinfecting (copper) surfaces harbored significantly fewer bacteria throughout the patient stay than control beds, at levels below those considered to increase the likelihood of HAIs. With adherence to routine daily and terminal cleaning regimes throughout the study, the copper alloy surfaces neither tarnished nor required additional cleaning or special maintenance. Beds encapsulated with U.S. EPA-registered antimicrobial copper materials were found to sustain the microbial burden below the TC&D risk threshold levels throughout the patient stay, suggesting that outfitting acute care beds with such materials may be an important supplement to controlling the concentration of infectious agents and thereby potentially reducing the overall HAI risk.IMPORTANCE Despite cleaning efforts of environmental service teams and substantial compliance with hand hygiene best practices, the microbial burden in patient care settings often exceeds concentrations at which transfer to patients represents a substantial acquisition risk for health care-associated infections (HAIs). Approaches to limit HAI risk have relied on designing health care equipment and furnishings that are easier to clean and/or the use of no-touch disinfection interventions such as germicidal UV irradiation or vapor deposition of hydrogen peroxide. In a clinical trial evaluating the largest fomite in the patient care setting, the bed, a bed was encapsulated with continuously disinfecting antimicrobial copper surfaces, which reduced the bacteria on surfaces by 94% and sustained the microbial burden below the terminal cleaning and disinfection risk threshold throughout the patient's stay. Such an intervention, which continuously limits microbes on high-touch surfaces, should be studied in a broader range of health care settings to determine its potential long-range efficacy for reducing HAI.

Perceptions of Patients, Health Care Workers, and Environmental Services Staff Regarding Ultraviolet Light Room Decontamination Devices

BACKGROUND

Mobile ultraviolet C (UV-C) room decontamination devices are widely used in health care facilities; however, there is limited information on the perceptions of patients, health care workers (HCWs), and environmental services staff (EVS-staff) regarding their use for environmental decontamination.

METHODS

An anonymous questionnaire was administered to participants in 4 medical/surgical units of a tertiary care hospital where UV-C devices were deployed for a 6-month period. Survey questions assessed perceptions regarding the importance of environmental disinfection, effectiveness of UV-C decontamination, willingness to delay hospital admission in order to use UV-C, and safety of UV-C devices.

RESULTS

Questionnaires were completed by 102 patients, 130 HCWs, and 47 EVS-staff. All of the HCWs and EVS-staff and 99% of the patients agreed that environmental disinfection is important to reduce the risk of exposure from contaminated surfaces. Ninety-eight percent of the EVS-staff, 89% of the HCWs, and 96% of the patients felt that the use of UV-C as an adjunct to routine cleaning increased confidence that rooms are clean. Ninety-four percent of the EVS-staff, 85% of the HCWs, and 90% of the patients expressed a willingness to delay being admitted to a room in order to have UV-C decontamination completed. Seventy-nine percent of the EVS-staff, 76% of the HCWs, and 86% of the patients had no concerns about the safety of UV-C devices.

CONCLUSIONS

Patients, HCWs, and EVS-staff agreed that environmental disinfection is important and that UV-C devices are efficacious and safe. Educational tools are needed to allay safety concerns expressed by a minority of HCWs and EVS-staff.

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.