Controlling methicillin-resistant Staphylococcus aureus (MRSA) in a hospital and the role of hydrogen peroxide decontamination: an interrupted time series analysis

Limited reduction in Clostridioides difficile and Methicillin-Resistant Staphylococcus aureus with the use of an aerosolized hydrogen peroxide disinfection system in tertiary health care facilities in Alberta, Canada

BACKGROUND

Nonmanual room disinfection systems may reduce the transmission of infections. A variety of systems have emerged; however, a paucity of evidence exists to make an evidence-informed decision for the implementation of a specific system. Alberta Health Services assessed one of these systems.

METHODS

A quasi-experimental prepost design assessed an aerosolized hydrogen peroxide disinfection system on 6 units at 3 acute care facilities in Alberta. To assess clinical effectiveness an interrupted time-series analysis with Poisson distribution compared changes in hospital-acquired Clostridioides difficile infection (HA-CDI) and hospital-acquired Methicillin-resistant Staphylococcus aureus (HA-MRSA) between preintervention, intervention, and postintervention periods. To assess operational feasibility cleaning turnaround time, time to operate, and utilization were considered. A participatory research framework was used to understand the benefits and challenges of operationalization.

RESULTS

Incidence rate ratio (IRR) of HA-CDI decreased by 25.7% on FMC-A and 6.9% on RAH-B. Following withdrawal, the IRR of HA-CDI continued to decrease. IRR of HA-MRSA decreased by 25.0% on RAH-B. Following withdrawal, the IRR of HA-MRSA continued to decrease. None of the results were statistically significant. The average time to operate was 3.2 hours. Utilization was between 1.7% and 25.6%. Most staff reported benefits and challenges.

DISCUSSION

None of the changes observed in HA-CDI and HA-MRSA after the introduction of the aerosolized hydrogen peroxide system were statistically significant. While most respondents reported multiple benefits and challenges in using the system, the core challenge was delays in inpatient admissions due to the time operate the system.

CONCLUSION

Successful implementation of a nonmanual room disinfection system as an addition to standard cleaning and disinfection requires significant investment and must consider a variety of factors.

Single intratracheal administration toxicity study on safety of vapor inhalation of electrolyzed reduced water in rats

The effects of acute intratracheal administration of electrolyzed reduced water (ERW; alkaline electrolyzed water) were investigated in rats. In this study, no deaths or near-deaths were recorded in either group, namely those treated with ERW or purified water (maximum doses of 900 mg/kg). The main symptoms observed in the rats were decreased spontaneous movements and abnormal breath sounds, which were considered to be transient symptoms caused by intratracheal administration. In addition, low values of alkaline phosphatase, total protein and lactate dehydrogenase were found in BALF tests, but these values were considered to be of low toxicological significance, since they are usually high in the presence of lung inflammation or cellular damage. This suggests that the alkalinity of ERW partially contributes to broken peptide bonds in proteins. There were no significant increases in bronchoalveolar lavage fluid protein in either group. ERW did not cause an increase in the influx of neutrophils, eosinophils, basophils, or lymphocytes, suggesting that intratracheal administration of ERW did not cause lung inflammation. ERW did not cause abnormalities in the body or pathological changes in the lungs. Aggregates of alveolar macrophages, as a measure of inflammation, were observed in both groups. These may be transient symptoms due to intratracheal administration, not due to ERW toxicity. This study confirmed the safety of intratracheal ERW infusion and demonstrated the low risk of acute toxicity for inhalation exposure to ERW aerosol or vapor. Therefore, ERW may be an effective air purifier against viruses or bacteria.

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.

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.

Results of an international pilot survey on health care environmental hygiene at the facility level

BACKGROUND

Health care-associated infections (HAIs) are a major threat to patient safety worldwide. The importance of the health care environment in patient care is not always adequately addressed. Currently, no overview exists of how health care environmental hygiene (HEH) is performed around the world.

METHODS

Our pilot survey tested a preliminary version of a framework for HEH self-assessment. It aimed to gather data to improve the framework as well as evaluate the strengths and challenges in HEH programs around the world, and across resource levels. The survey was developed by a group of experts, and based on the hand hygiene multimodal improvement strategy. The online survey was sent to 743 health care facilities (HCFs) from all of the World Bank income levels, aiming for at least 4 participants from each level. Overall responses were analyzed as a group as well as stratified per income level using OpenEpi.

RESULTS

Overall, 51 HCFs from 35 countries participated. Almost all HCFs surveyed (50/51, 98%) were found lacking in some or all of the 5 components of the WHO multimodal strategy independent of income level. The results demonstrate the widespread challenges in HEH institutions are facing around the world.

CONCLUSION

The feedback from survey participants allowed for the improvement of the self-assessment tool. There is a clear need for more focus on and investment in HEH programs in HCFs worldwide.

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.

Evaluation of an aerosolized hydrogen peroxide disinfection system for the reduction of Clostridioides difficile hospital infection rates over a 10 year period

BACKGROUND

Clostridioides difficile infections (CDI) cause significant morbidity and mortality in healthcare facilities worldwide. We examined the use of an aerosolized hydrogen peroxide (aHP) disinfection system for reduction of CDI rates.

METHODS

We conducted a retrospective analysis of CDI rates at an acute care facility over a 10-year period. The first 5-year period investigated the before and after implementation of an aHP system followed by another 5-year period of continued use on CDI rates.

RESULTS

The before and after period showed a reduction in CDI rates from 4.6 per 10,000 patient days down to 2.7 per 10,000 patient days after implementation (P < .001). The second study period for the continued aHP use exhibited a consistent decrease in CDI rates to 1.4 per 10,000 patient days at the end of the study.

CONCLUSIONS

The addition of a touchless aHP whole room disinfection system as part of terminal cleaning resulted in a significant reduction in CDI rates that have been sustained year after year.

Impact of environmental hygiene interventions on healthcare-associated infections and patient colonization: a systematic review

BACKGROUND

Healthcare-associated infections (HAI) are one of the gravest threats to patient safety worldwide. The importance of the hospital environment has recently been revalued in infection prevention and control. Though the literature is evolving rapidly, many institutions still do not consider healthcare environmental hygiene (HEH) very important for patient safety. The evidence for interventions in the healthcare environment on patient colonization and HAI with multidrug-resistant microorganisms (MDROs) or other epidemiologically relevant pathogens was reviewed.

METHODS

We performed a systematic review according to the PRISMA guidelines using the PubMed and Web of Science databases. All original studies were eligible if published before December 31, 2019, and if the effect of an HEH intervention on HAI or patient colonization was measured. Studies were not eligible if they were conducted in vitro, did not include patient colonization or HAI as an outcome, were bundled with hand hygiene interventions, included a complete structural rebuild of the healthcare facility or were implemented during an outbreak. The primary outcome was the comparison of the intervention on patient colonization or HAI compared to baseline or control. Interventions were categorized by mechanical, chemical, human factors, or bundles. Study quality was assessed using a specifically-designed tool that considered study design, sample size, control, confounders, and issues with reporting. The effect of HEH interventions on environmental bioburden was studied as a secondary outcome.

FINDINGS

After deduplication, 952 records were scrutinized, of which 44 were included for full text assessment. A total of 26 articles were included in the review and analyzed. Most studies demonstrated a reduction of patient colonization or HAI, and all that analyzed bioburden demonstrated a reduction following the HEH intervention. Studies tested mechanical interventions (n = 8), chemical interventions (n = 7), human factors interventions (n = 3), and bundled interventions (n = 8). The majority of studies (21/26, 81%) analyzed either S. aureus, C. difficile, and/or vancomycin-resistant enterococci. Most studies (23/26, 88%) reported a decrease of MDRO-colonization or HAI for at least one of the tested organisms, while 58% reported a significant decrease of MDRO-colonization or HAI for all tested microorganisms. Forty-two percent were of good quality according to the scoring system. The majority (21/26, 81%) of study interventions were recommended for application by the authors. Studies were often not powered adequately to measure statistically significant reductions.

INTERPRETATION

Improving HEH helps keep patients safe. Most studies demonstrated that interventions in the hospital environment were related with lower HAI and/or patient colonization. Most of the studies were not of high quality; additional adequately-powered, high-quality studies are needed. Systematic registration number: CRD42020204909.

Genotypic and Phenotypic Characterizations of Methicillin-Resistant Staphylococcus aureus (MRSA) on Frequently Touched Sites from Public Hospitals in South Africa

The hospital environment acts as a reservoir in the transmission of pathogens, such as MRSA, which may cause hospital-acquired infections. This study aimed to ascertain the prevalence, genetic relatedness, antibiotic resistance, and virulence profile of MRSA on some frequently touched hospital sites in South Africa. A total of 777 swabs were randomly collected from 11 frequently touched sites in the hospital environment of three wards of four public hospitals in the KwaZulu-Natal province of South Africa. Isolation of S. aureus and confirmation were done using genotypic and phenotypic methods. Antibiotic susceptibility testing was performed using the Kirby–Bauer disk-diffusion method. MRSA isolates were determined by the presence of the mecA gene. Virulence and resistance genes were detected using a standard monoplex PCR assay. ERIC-PCR was conducted to evaluate the genetic relatedness. An overall prevalence of 12.7% for S. aureus isolates was obtained. Out of these, 89.9% (89/99) were confirmed to be MRSA. The sites with the highest prevalence were the occupied beds (16.2% (16/99)), unoccupied beds (16.2% (16/99)), patient files (14.1% (14/99)), ward phones (13.1% (13/99)), and nurses' tables (14.1% (14/99)). The virulence genes with the highest observed frequency were hld (87 (87.9%)) and LukS/F-PV (53 (53.5%)). The resistance genes with the highest frequency were the tetM and tetK genes detected in 60 (60.6%) and 57 (57.6%) isolates, respectively. The ERIC-PCR results obtained indicated a high level of genetic diversity; however, intraclonal (within a hospital) and interclonal (between hospitals) clusters of MRSA were observed. The study showed that MRSA can contaminate various surfaces, and this persistence allows for the dissemination of bacteria within the hospital environment. This highlights the need for improved infection prevention and control (IPC) strategies in public hospitals in the country to curb their potential transmission risks.

Evidence Map and Systematic Review of Disinfection Efficacy on Environmental Surfaces in Healthcare Facilities

Healthcare-associated infections (HAIs) contribute to patient morbidity and mortality with an estimated 1.7 million infections and 99,000 deaths costing USD $28-34 billion annually in the United States alone. There is little understanding as to if current environmental surface disinfection practices reduce pathogen load, and subsequently HAIs, in critical care settings. This evidence map includes a systematic review on the efficacy of disinfecting environmental surfaces in healthcare facilities. We screened 17,064 abstracts, 635 full texts, and included 181 articles for data extraction and study quality assessment. We reviewed ten disinfectant types and compared disinfectants with respect to study design, outcome organism, and fourteen indictors of study quality. We found important areas for improvement and gaps in the research related to study design, implementation, and analysis. Implementation of disinfection, a determinant of disinfection outcomes, was not measured in most studies and few studies assessed fungi or viruses. Assessing and comparing disinfection efficacy was impeded by study heterogeneity; however, we catalogued the outcomes and results for each disinfection type. We concluded that guidelines for disinfectant use are primarily based on laboratory data rather than a systematic review of in situ disinfection efficacy. It is critically important for practitioners and researchers to consider system-level efficacy and not just the efficacy of the disinfectant.

Environmental dynamics of hospital microbiome upon transfer from a major hospital to a new facility

BACKGROUND

Infection control is critical to safe hospital care. However, how bacteria within nosocomial environments relate to space utilisation and occupancy remains poorly understood. Our aim was to characterise the hospital microbiome in the context of the closure of a tertiary hospital and the opening of a new facility.

METHODS

Environmental swabs were collected from common and inpatient areas in the old and new hospitals during a 12-month transition period. Microbiota characteristics were determined by 16S rRNA gene sequencing and quantitative (q)PCR. Targeted assays were used to detect Methicillin-resistant Staphylococcus aureus (MRSA) and vanB-positive Vancomycin-Resistant Enterococci (VRE).

RESULTS

The transition to full occupancy in the new facility was associated with an increase in bacterial load (inpatient areas, 3 months p = 0.001; common areas, 6 months p = 0.039) and a change in microbiota composition (baseline-12 months, PERMANOVA p = 0.002). These changes were characterised by an increase in human microbiota-associated taxa, including Acinetobacter and Veillonella. Closure of the existing facility was associated with a decrease in bacterial load (p = 0.040). Detection of MRSA did not differ significantly between sites.

CONCLUSIONS

Occupancy is a major determinant of bacterial dispersion within hospital environments. Steady-state bacterial levels and microbiota composition provide a basis for assessment of infection control measures.

Effectiveness of Plasma-Treated Hydrogen Peroxide Mist Disinfection in Various Hospital Environments

Hospital environments are associated with a high risk of infection. As plasma-treated hydrogen peroxide mist disinfection has a higher disinfection efficacy, we tested the efficacy of plasma-treated hydrogen peroxide mist disinfection on several surfaces in various hospital environments. Disinfection was performed in 23 rooms across different hospital environments, including hospital wards, outpatient departments (OPDs), and emergency rooms. A total of 459 surfaces were swabbed before/after disinfection. Surfaces were also divided into plastic, metal, wood, leather, ceramic, silicone, and glass for further analyses. Only gram-positive bacteria were statistically analyzed because the number of gram-negative bacteria and mold was insufficient. Most colony-forming units (CFUs) of gram-positive bacteria were observed in OPDs and on leather materials before disinfection. The proportion of surfaces that showed a percentage decrease in CFU values of more than 90% after disinfection were as follows: OPDs (85%), hospital wards (99%), and emergency rooms (100%); plastic (97%), metal (83%), wood (84%), leather (81%), and others (87%). Plasma-treated hydrogen peroxide mist disinfection resulted in a significant decrease in the CFU values of gram-positive bacteria in various environments. Plasma-treated hydrogen peroxide mist disinfection is an effective and efficient method of disinfecting various hospital environments.

Preliminary Study on Light-Activated Antimicrobial Agents as Photocatalytic Method for Protection of Surfaces with Increased Risk of Infections

Preventing and controlling the spread of multidrug-resistant (MDR) bacteria implicated in healthcare-associated infections is the greatest challenge of the health systems. In recent decades, research has shown the need for passive antibacterial protection of surfaces in order to reduce the microbial load and microbial biofilm development, frequently associated with transmission of infections. The aim of the present study is to analyze the efficiency of photocatalytic antimicrobial protection methods of surfaces using the new photocatalytic paint activated by light in the visible spectrum. The new composition is characterized by a wide range of analytical methods, such as UV-VIS spectroscopy, electron microscopy (SEM), X-ray powder diffraction (PXRD) or X-ray photoelectron spectroscopy (XPS). The photocatalytic activity in the UV-A was compared with the one in the visible light spectrum using an internal method developed on the basis of DIN 52980: 2008-10 standard and ISO 10678—2010 standard. Migration of metal ions in the composition was tested based on SR EN1186-3: 2003 standard. The new photocatalytic antimicrobial method uses a type of photocatalytic paint that is active in the visible spectral range and generates reactive oxygen species with inhibitory effect against all tested microbial strains.

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.

Efficacy of aerosolized hydrogen peroxide (Deprox) cleaning compared to physical cleaning in a Burns Unit

BACKGROUND

The performance of Deprox aerosolized hydrogen peroxide (aHP) has not been extensively studied in real-world clinical settings. A comparative study of aHP terminal disinfection was conducted in a Burns Unit and its performance compared to physical cleaning alone.

METHODS

Environmental surfaces were sampled pre-cleaning, post-cleaning and post-aHP disinfection. Samples were cultured for MRSA, VRE, Gram-negative multi-resistant organisms and other Gram-negative bacilli.

RESULTS

310 sites were sampled. There was a reduction in the rates of contaminated surfaces post-aHP, though pathogens were still recoverable in most cases, except for VRE. There was a marked reduction in MRSA contamination of soft surfaces (12% post-clean vs 6% post-aHP), and patient room surfaces (8.3% post-clean vs 2.8% post-aHP). It does not work as well for MRSA in bathrooms: 7% of surfaces were positive post-clean, and 9% post-aHP. There was a reduction in multiresistant Gram-negative bacteria (7%-3%), mostly due to drains (33%-13%).

CONCLUSION

aHP is a useful method of environmental disinfection, especially for Gram-negative pathogens in drains and MRSA on hard and soft surfaces. Where ongoing acquisition of MRSA is a problem, an adjunctive method of terminal disinfection in bathrooms could be considered.

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.

Microbiological Air Quality in Heating, Ventilation and Air Conditioning Systems of Surgical and Intensive Care Areas: The Application of a Disinfection Procedure for Dehumidification Devices

International literature data report that the increase of infectious risk may be due to heating, ventilation and air conditioning (HVAC) systems contaminated by airborne pathogens. Moreover, the presence of complex rotating dehumidification wheels (RDWs) may complicate the cleaning and disinfection procedures of the HVAC systems. We evaluated the efficacy of a disinfection strategy applied to the RDW of two hospitals’ HVAC systems. Hospitals have four RDW systems related to the surgical areas (SA1 and SA2) and to the intensive and sub-intensive care (IC and sIC) units. Microbiological air and surface analyses were performed in HVAC systems, before and after the disinfection treatment. Hydrogen peroxide (12%) with silver ions (10 mg/L) was aerosolized in all the air sampling points, located close to the RDW device. After the air disinfection procedure, reductions of total microbial counts at 22 °C and molds were achieved in SA2 and IC HVAC systems. An Aspergillus fumigatus contamination (6 CFU/500 L), detected in one air sample collected in the IC HVAC system, was eradicated after the disinfection. The surface samples proved to be of good microbiological quality. The results suggest the need for a disinfection procedure to improve the microbiological quality of the complex HVAC systems, mostly in surgical and intensive care areas.

'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.

No-Touch Disinfection Methods to Decrease Multidrug-Resistant Organism Infections: A Systematic Review and Meta-analysis

BACKGROUND Recent studies have shown that using no-touch disinfection technologies (ie, ultraviolet light [UVL] or hydrogen peroxide vapor [HPV] systems) can limit the transmission of nosocomial pathogens and prevent healthcare-associated infections (HAIs). To investigate these findings further, we performed a systematic literature review and meta-analysis on the impact of no-touch disinfection methods to decrease HAIs. METHODS We searched PubMed, CINAHL, CDSR, DARE and EMBASE through April 2017 for studies evaluating no-touch disinfection technology and the nosocomial infection rates for Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and other multidrug-resistant organisms (MDROs). We employed random-effect models to obtain pooled risk ratio (pRR) estimates. Heterogeneity was evaluated with I2 estimation and the Cochran Q statistic. Pooled risk ratios for C. difficile, MRSA, VRE, and MDRO were assessed separately. RESULTS In total, 20 studies were included in the final review: 13 studies using UVL systems and 7 studies using HPV systems. When the results of the UVL studies were pooled, statistically significant reduction ins C. difficile infection (CDI) (pRR, 0.64; 95% confidence interval [CI], 0.49-0.84) and VRE infection rates (pRR, 0.42; 95% CI, 0.28-0.65) were observed. No differences were found in rates of MRSA or gram-negative multidrug-resistant pathogens. CONCLUSIONS Ultraviolet light no-touch disinfection technology may be effective in preventing CDI and VRE infection. Infect Control Hosp Epidemiol 2018;39:20-31.

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.

A unified framework for developing effective hygiene procedures for hands, environmental surfaces and laundry in healthcare, domestic, food handling and other settings

Hygiene procedures for hands, surfaces and fabrics are central to preventing spread of infection in settings including healthcare, food production, catering, agriculture, public settings, and home and everyday life. They are used in situations including hand hygiene, clinical procedures, decontamination of environmental surfaces, respiratory hygiene, food handling, laundry hygiene, toilet hygiene and so on. Although the principles are common to all, approaches currently used in different settings are inconsistent. A concern is the use of inconsistent terminology which is misleading, especially to people we need to communicate with such as the public or cleaning professionals. This paper reviews the data on current approaches, alongside new insights to developing hygiene procedures. Using this data, we propose a more scientifically-grounded framework for developing procedures that maximize protection against infection, based on consistent principles and terminology, and applicable across all settings. A key feature is use of test models which assess the state of surfaces after treatment rather than product performance alone. This allows procedures that rely on removal of microbes to be compared with those employing chemical or thermal inactivation. This makes it possible to ensure that a consistent "safety target level" is achieved regardless of the type of procedure used, and allows us deliver maximum health benefit whilst ensuring prudent usage of antimicrobial agents, detergents, water and energy.

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.

Modern technologies for improving cleaning and disinfection of environmental surfaces in hospitals

Experts agree that careful cleaning and disinfection of environmental surfaces are essential elements of effective infection prevention programs. However, traditional manual cleaning and disinfection practices in hospitals are often suboptimal. This is often due in part to a variety of personnel issues that many Environmental Services departments encounter. Failure to follow manufacturer’s recommendations for disinfectant use and lack of antimicrobial activity of some disinfectants against healthcare-associated pathogens may also affect the efficacy of disinfection practices.

Improved hydrogen peroxide-based liquid surface disinfectants and a combination product containing peracetic acid and hydrogen peroxide are effective alternatives to disinfectants currently in widespread use, and electrolyzed water (hypochlorous acid) and cold atmospheric pressure plasma show potential for use in hospitals. Creating “self-disinfecting” surfaces by coating medical equipment with metals such as copper or silver, or applying liquid compounds that have persistent antimicrobial activity surfaces are additional strategies that require further investigation.

Newer “no-touch” (automated) decontamination technologies include aerosol and vaporized hydrogen peroxide, mobile devices that emit continuous ultraviolet (UV-C) light, a pulsed-xenon UV light system, and use of high-intensity narrow-spectrum (405 nm) light. These “no-touch” technologies have been shown to reduce bacterial contamination of surfaces. A micro-condensation hydrogen peroxide system has been associated in multiple studies with reductions in healthcare-associated colonization or infection, while there is more limited evidence of infection reduction by the pulsed-xenon system. A recently completed prospective, randomized controlled trial of continuous UV-C light should help determine the extent to which this technology can reduce healthcare-associated colonization and infections.

In conclusion, continued efforts to improve traditional manual disinfection of surfaces are needed. In addition, Environmental Services departments should consider the use of newer disinfectants and no-touch decontamination technologies to improve disinfection of surfaces in healthcare.

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.

Review of a two-year methicillin-resistant Staphylococcus aureus screening program and cost-effectiveness analysis in Singapore

Background

Methicillin-resistant Staphylococcus aureus (MRSA) poses an increasingly large disease and economic burden worldwide. The effectiveness of screening programs in the tropics is poorly understood. The aims of this study are: (i) to analyze the factors affecting MRSA colonization at admission and acquisition during hospitalization and (ii) to evaluate the cost-effectiveness of a screening program which aims to control MRSA incidence during hospitalization.

Methods

We conducted a retrospective case–control study of patients admitted to the Communicable Disease Centre (CDC) in Singapore between Jan 2009 and Dec 2010 when there was an ongoing selective screening and isolation program. Risk factors contributing to MRSA colonization on admission and acquisition during hospital stay were evaluated using a logistic regression model. In addition, a cost-effectiveness analysis was conducted to determine the cost per disability-adjusted life year (DALY) averted due to implementing the screening and isolation program.

Results

The average prevalence rate of screened patients at admission and the average acquisition rate at discharge during the study period were 12.1 and 4.8 % respectively. Logistic regression models showed that older age (adjusted odds ratio (OR) 1.03, 95 % CI 1.02–1.04, p < 0.001) and dermatological conditions (adjusted OR 1.49, 95 % CI 1.11–1.20, p = 0.008) were independently associated with an increased risk of MRSA colonization at admission. Age (adjusted OR 1.02, 95 % CI 1.01–1.03, p = 0.002) and length of stay in hospital (adjusted OR 1.04, 95 % CI 1.03–1.06, p < 0.001) were independent factors associated with MRSA acquisition during hospitalization. The screening and isolation program reduced the acquisition rate by 1.6 % and was found to be cost saving. For the whole study period, the program cost US$129,916, while it offset hospitalization costs of US$103,869 and loss of productivity costs of US$50,453 with −400 $/DALY averted.

Discussion

This study is the first to our knowledge that evaluates the cost-effectiveness of screeningand isolation of MRSA patients in a tropical country. Another unique feature of the analysis is the evaluationof acquisition rates among specific types of patients (dermatological, HIV and infectious disease patients)and the comparison of the cost-effectiveness of screening and isolation between them.

Conclusions

Overall our results indicate high MRSA prevalence that can be cost effectively reduced by selective screening and isolation programs in Singapore.

Controlling hospital-acquired infection: focus on the role of the environment and new technologies for decontamination

There is increasing interest in the role of cleaning for managing hospital-acquired infections (HAI). Pathogens such as vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA), multiresistant Gram-negative bacilli, norovirus, and Clostridium difficile persist in the health care environment for days. Both detergent- and disinfectant-based cleaning can help control these pathogens, although difficulties with measuring cleanliness have compromised the quality of published evidence. Traditional cleaning methods are notoriously inefficient for decontamination, and new approaches have been proposed, including disinfectants, steam, automated dispersal systems, and antimicrobial surfaces. These methods are difficult to evaluate for cost-effectiveness because environmental data are not usually modeled against patient outcome. Recent studies have reported the value of physically removing soil using detergent, compared with more expensive (and toxic) disinfectants. Simple cleaning methods should be evaluated against nonmanual disinfection using standardized sampling and surveillance. Given worldwide concern over escalating antimicrobial resistance, it is clear that more studies on health care decontamination are required. Cleaning schedules should be adapted to reflect clinical risk, location, type of site, and hand touch frequency and should be evaluated for cost versus benefit for both routine and outbreak situations. Forthcoming evidence on the role of antimicrobial surfaces could supplement infection prevention strategies for health care environments, including those targeting multidrug-resistant pathogens.