Environmental approaches to controlling Clostridioides difficile infection in healthcare settings

As today's most prevalent and costly healthcare-associated infection, hospital-onset Clostridioides difficile infection (HO-CDI) represents a major threat to patient safety world-wide. This review will discuss how new insights into the epidemiology of CDI have quantified the prevalence of C. difficile (CD) spore contamination of the patient-zone as well as the role of asymptomatically colonized patients who unavoidable contaminate their near and distant environments with resilient spores. Clarification of the epidemiology of CD in parallel with the development of a new generation of sporicidal agents which can be used on a daily basis without damaging surfaces, equipment, or the environment, led to the research discussed in this review. These advances underscore the potential for significantly mitigating HO-CDI when combined with ongoing programs for optimizing the thoroughness of cleaning as well as disinfection. The consequence of this paradigm-shift in environmental hygiene practice, particularly when combined with advances in hand hygiene practice, has the potential for significantly improving patient safety in hospitals globally by mitigating the acquisition of CD spores and, quite plausibly, other environmentally transmitted healthcare-associated pathogens.

Health Care Environmental Hygiene: New Insights and Centers for Disease Control and Prevention Guidance

Recent research has significantly clarified the impact of optimizing patient-zone environmental hygiene. New insights into the environmental microbial epidemiology of many hospital-associated pathogens, especially Clostridioides difficile, have clarified and quantified the role of ongoing occult pathogen transmission from the near-patient environment. The recent development of safe, broadly effective surface chemical disinfectants has led to new opportunities to broadly enhance environmental hygiene in all health care settings. The Centers for Disease Control and Prevention has recently developed a detailed guidance to assist all health care settings in implementing optimized programs to mitigate health care-associated pathogen transmission from the near-patient surfaces.

Factors associated with environmental service worker cleaning practices in health care settings: A systematic review of the literature

INTRODUCTION

Health care-associated infections can be reduced through better environmental disinfection practices. Central to effective disinfection is the environmental service worker (ESW). The aim of this systematic literature review was to identify factors associated with the disinfection practices of ESWs in health care settings.

METHODS

A systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses principles. Ten online databases and search engines were selected for the review of English-language studies published between 2000 and 2019.

RESULTS

Thirty-one (31) eligible studies were identified. Environmental disinfection was associated with many factors (eg, knowledge, perceptions) as well as ESW exposure to education/training sessions. When education/training was combined with performance evaluation/feedback, significant improvement in ESW disinfection practices was reported.

CONCLUSIONS

To sustain improvements in disinfection practices, education/training sessions need to be continuous. The long-term commitment of an organization is also essential for continuous improvement in disinfection outcomes. While knowledge transfer is critical for behavior change, education/training also needs to focus on the skills and perceptions of ESWs. Future studies need to use a randomized controlled design with larger sample sizes to determine a true effect.

Fluorescent tagging for environmental surface cleaning surveillance in a veterinary hospital

OBJECTIVES

To evaluate the use of fluorescent tagging for environmental surface cleaning surveillance in a small animal veterinary hospital and identify factors associated with tag removal.

MATERIALS AND METHODS

Over 5.5 weeks, a commercial fluorescent dye (Glo Germ) was used to tag (mark) surfaces in a small animal veterinary teaching hospital. Twenty-four hours after tagging, cleaning was assessed with a black light (UV-A source). Surfaces were recorded as cleaned based on complete removal of fluorescent tagging at assessment. Proportions cleaned were calculated overall and by predictors (i.e. surface location/type, primary nature of surface contact - animal/human, week of study).

RESULTS

A total of 4984 surfaces were tagged and assessed. Overall cleaning was 50%. Cleaning varied by surface/object (range: 2 to 100%) and hospital location (4 to 78%). Surfaces designated as having primarily animal contact were cleaned more frequently than those with primarily human contact (75%, 42%; P<0.001). Cleaning varied over the study period (range by week: 45 to 54%;); a significant trend was not identified.

CLINICAL SIGNIFICANCE

Key surfaces in the small animal veterinary practice environment are unlikely to be adequately cleaned, posing a concern for animal and human health. Commercial products can be effectively used to asses environmental cleaning with findings used to target clinic-specific barriers to improve cleaning and reduce hospital-associated infections.

Antibacterial Metallic Touch Surfaces

Our aim is to present a comprehensive review of the development of modern antibacterial metallic materials as touch surfaces in healthcare settings. Initially we compare Japanese, European and US standards for the assessment of antimicrobial activity. The variations in methodologies defined in these standards are highlighted. Our review will also cover the most relevant factors that define the antimicrobial performance of metals, namely, the effect of humidity, material geometry, chemistry, physical properties and oxidation of the material. The state of the art in contact-killing materials will be described. Finally, the effect of cleaning products, including disinfectants, on the antimicrobial performance, either by direct contact or by altering the touch surface chemistry on which the microbes attach, will be discussed. We offer our outlook, identifying research areas that require further development and an overview of potential future directions of this exciting field.

Researching effective approaches to cleaning in hospitals: protocol of the REACH study, a multi-site stepped-wedge randomised trial

Background

The Researching Effective Approaches to Cleaning in Hospitals (REACH) study will generate evidence about the effectiveness and cost-effectiveness of a novel cleaning initiative that aims to improve the environmental cleanliness of hospitals. The initiative is an environmental cleaning bundle, with five interdependent, evidence-based components (training, technique, product, audit and communication) implemented with environmental services staff to enhance hospital cleaning practices.

Methods/design

The REACH study will use a stepped-wedge randomised controlled design to test the study intervention, an environmental cleaning bundle, in 11 Australian hospitals. All trial hospitals will receive the intervention and act as their own control, with analysis undertaken of the change within each hospital based on data collected in the control and intervention periods. Each site will be randomised to one of the 11 intervention timings with staggered commencement dates in 2016 and an intervention period between 20 and 50 weeks. All sites complete the trial at the same time in 2017. The inclusion criteria allow for a purposive sample of both public and private hospitals that have higher-risk patient populations for healthcare-associated infections (HAIs). The primary outcome (objective one) is the monthly number of Staphylococcus aureus bacteraemias (SABs), Clostridium difficile infections (CDIs) and vancomycin resistant enterococci (VRE) infections, per 10,000 bed days. Secondary outcomes for objective one include the thoroughness of hospital cleaning assessed using fluorescent marker technology, the bio-burden of frequent touch surfaces post cleaning and changes in staff knowledge and attitudes about environmental cleaning. A cost-effectiveness analysis will determine the second key outcome (objective two): the incremental cost-effectiveness ratio from implementation of the cleaning bundle.

The study uses the integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework to support the tailored implementation of the environmental cleaning bundle in each hospital.

Discussion

Evidence from the REACH trial will contribute to future policy and practice guidelines about hospital environmental cleaning. It will be used by healthcare leaders and clinicians to inform decision-making and implementation of best-practice infection prevention strategies to reduce HAIs in hospitals.

Trial registration

Australia New Zealand Clinical Trial Registry ACTRN12615000325505

Cleaning Hospital Room Surfaces to Prevent Health Care-Associated Infections: A Technical Brief

The cleaning of hard surfaces in hospital rooms is critical for reducing health care-associated infections. This review describes the evidence examining current methods of cleaning, disinfecting, and monitoring cleanliness of patient rooms, as well as contextual factors that may affect implementation and effectiveness. Key informants were interviewed, and a systematic search for publications since 1990 was done with the use of several bibliographic and gray literature resources. Studies examining surface contamination, colonization, or infection with Clostridium difficile, methicillin-resistant Staphylococcus aureus, or vancomycin-resistant enterococci were included. Eighty studies were identified-76 primary studies and 4 systematic reviews. Forty-nine studies examined cleaning methods, 14 evaluated monitoring strategies, and 17 addressed challenges or facilitators to implementation. Only 5 studies were randomized, controlled trials, and surface contamination was the most commonly assessed outcome. Comparative effectiveness studies of disinfecting methods and monitoring strategies were uncommon. Future research should evaluate and compare newly emerging strategies, such as self-disinfecting coatings for disinfecting and adenosine triphosphate and ultraviolet/fluorescent surface markers for monitoring. Studies should also assess patient-centered outcomes, such as infection, when possible. Other challenges include identifying high-touch surfaces that confer the greatest risk for pathogen transmission; developing standard thresholds for defining cleanliness; and using methods to adjust for confounders, such as hand hygiene, when examining the effect of disinfecting methods.

Methods for assessing the adequacy of practice and improving room disinfection

The value of objectively monitoring and improving environmental cleaning in health care settings is becoming increasingly recognized as an important component of interventions to mitigate the transmission of health care-associated pathogens. Whereas the 2010 Centers for Disease Control and Prevention tool kit "Options for Evaluating Environmental Cleaning" provides detailed guidance related to implementing such programs, there is a need to clearly understand the value and limitations of various environmental cleaning monitoring approaches to ensure the favorable impact of such activities.