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

Effective elimination of bacteria on hard surfaces by the combined use of bacteriophages and chemical disinfectants

Hospital-acquired infections (HAIs) represent one of the significant causes of morbidity and mortality worldwide, and controlling pathogens in the hospital environment is of great importance. Currently, the standard disinfection method in the hospital environment is chemical disinfection. However, disinfectants are usually not used strictly according to the label, making them less effective in disinfection. Therefore, there is an emergent need to find a better approach that can be used in hospitals to control pathogenic bacteria in the clinical environment. Bacteriophages (phages) are effective in killing bacteria and have been applied in the treatment of bacterial infections but have not received enough attention regarding the control of contamination in the clinical environment. In this study, we found that various phages remain active in the presence of chemical disinfectants. Moreover, the combined use of specific phages and chemical disinfectants is more effective in removing bacterial biofilms and eliminating bacteria on hard surfaces. Thus, this proof-of-concept study indicates that adding phages directly to chemical disinfectants might be an effective and economical approach to enhance clinical environment disinfection.

IMPORTANCE

In this study, we investigated whether the combination of bacteriophages and chemical disinfectants can enhance the efficacy of reducing bacterial contamination on hard surfaces in the clinical setting. We found that specific phages are active in chemical disinfectants and that the combined use of phages and chemical disinfectants was highly effective in reducing bacterial presence on hard surfaces. As a proof-of-concept, we demonstrated that adding specific phages directly to chemical disinfectants is an effective and cost-efficient strategy for clinical environment disinfection.

Hygiene requirements for cleaning and disinfection of surfaces: recommendation of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute

This recommendation of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) addresses not only hospitals, but also outpatient health care facilities and compiles current evidence. The following criteria are the basis for the indications for cleaning and disinfection: Infectious bioburden and tenacity of potential pathogens on surfaces and their transmission routes, influence of disinfecting surface cleaning on the rate of nosocomial infections, interruption of cross infections due to multidrug-resistant organisms, and outbreak control by disinfecting cleaning within bundles. The criteria for the selection of disinfectants are determined by the requirements for effectiveness, the efficacy spectrum, the compatibility for humans and the environment, as well as the risk potential for the development of tolerance and resistance. Detailed instructions on the organization and implementation of cleaning and disinfection measures, including structural and equipment requirements, serve as the basis for their implementation. Since the agents for surface disinfection and disinfecting surface cleaning have been classified as biocides in Europe since 2013, the regulatory consequences are explained. As possible addition to surface disinfection, probiotic cleaning, is pointed out. In an informative appendix (only in German), the pathogen characteristics for their acquisition of surfaces, such as tenacity, infectious dose and biofilm formation, and the toxicological and ecotoxicological characteristics of microbicidal agents as the basis for their selection are explained, and methods for the evaluation of the resulting quality of cleaning or disinfecting surface cleaning are presented.

Can the adenosine triphosphate (ATP) bioluminescence assay be used as an indicator for hospital cleaning? - A pilot study

Background

In hospital cleaning, there is currently no standard for uniform monitoring of surface cleaning, either in Germany or internationally. One possibility for monitoring is the use of so-called objective methods for checking cleaning performance (e.g. fluorescence or adenosine triphosphate (ATP) method).

Aim

The aim of the study was to monitor and evaluate the implementation of the adenosine triphosphate (ATP) bioluminescence assay as a cleaning indicator in everyday hospital cleaning, in order to verify its utility and effectiveness.

Methods

In three phases, five frequently touched surfaces were examined with the ATP bioluminescence assay at different time points. 846 measurements were performed on the dermatology ward of a university hospital (phase 1), 1,350 measurements were performed on five different wards of the university hospital (phase 2), and 1,044 measurements were performed on five wards of another large hospital (phase 3). For this purpose, one structurally old and one structurally new ward as well as an intensive care unit (ICU), an outpatient clinic and a radiology department were selected for phases 2 and 3.

Results

With the ATP bioluminescence method, we were able to demonstrate a reduction in values after cleaning: before cleaning mean of ATP, 907 relative light units (RLU) (95% confidence interval [CI] 777; 1,038); after cleaning mean=286 RLU (CI=233; 495) (phase 1) and by intervention (five hours after daily cleaning mean=360 RLU (CI=303; 428); five hours after daily cleaning and two additional cleanings mean=128 RLU (CI=107; 152) (phase 3). The ATP values increased five hours after cleaning in phases 1 and 2, and eight hours after cleaning in phase 3. The structurally old wards had the highest ATP content, the ICU and the radiology department, among others, the lowest. In all phases, door handles showed both a reduction after cleaning or intervention and a subsequent increase in ATP values. Chair armrests, examination tables and door handles had high ATP values overall.

Conclusion

The study shows ward differences both for cleaning effects and for the soiling characteristics of surfaces during the course of the day. In addition, it demonstrates the benefit of intermediate cleaning twice a day. It is noteworthy that structurally old stations and older inventory were more heavily soiled and, in some cases, more difficult to clean. The results show that the ATP bioluminescence method is suitable for detecting cleaning effects and can be used in everyday clinical practice for simple cleaning monitoring. Furthermore, it enables the detection of risk surfaces and easy-to-clean surfaces with significant re-soiling.

Is the combination of UV-C light and bleach less effective than bleach alone for intensive care unit surface disinfection?

Background

Chlorine-based disinfectants, such as bleach, are commonly used for cleaning in healthcare settings to prevent the transmission of nosocomial pathogens. To enhance the efficacy of disinfection, ultraviolet-C (UV-C) light systems have been proposed to supplement standard cleaning procedures. As bleach decomposes in UV light, we hypothesised that the use of UV-C light as an adjunct to manual cleaning with bleach, may decrease the efficacy of disinfection instead.

Methods

In the laboratory, stainless steel sheets and plastic keyboards were inoculated with Pseudomonas aeruginosa (∼106 CFU/ml) and subjected to treatment with either UV-C light only, bleach only or a combination of UV-C light and bleach. The residual bioburden (CFU/ml) was quantified through conventional microbiological techniques. Results were compared to non-exposed control surfaces and against each treatment strategy.

Results

On tested surfaces, there were statistically significant reductions in P. aeruginosa when surfaces were treated with UV-C light only (>2.5 log10 reduction), bleach only (>5.6 log10 reduction) and a combination of UV-C light and bleach (>6.3 log10 reduction) compared to positive control (P < 0.001, all treatment strategies). No significant differences were observed when surfaces were treated with the addition of UV-C light to bleach compared to treatment with bleach alone.

Conclusion

There was no difference in the efficacy of disinfection against P. aeruginosa with the combined treatment strategy of UV-C light and bleach compared to bleach alone under laboratory conditions. Further studies are warranted to elucidate the effectiveness of this technology on other healthcare-associated pathogens.

Efficacy of a continuously active disinfectant wipe on the environmental bioburden in the intensive care unit: A randomized controlled study

OBJECTIVE

To evaluate the efficacy of a new continuously active disinfectant (CAD) to decrease bioburden on high-touch environmental surfaces compared to a standard disinfectant in the intensive care unit.

DESIGN

A single-blind randomized controlled trial with 1:1 allocation.

SETTING

Medical intensive care unit (MICU) at an urban tertiary-care hospital.

PARTICIPANTS

Adult patients admitted to the MICU and on contact precautions.

INTERVENTION

A new CAD wipe used for daily cleaning.

METHODS

Samples were collected from 5 high-touch environmental surfaces before cleaning and at 1, 4, and 24 hours after cleaning. The primary outcome was the mean bioburden 24 hours after cleaning. The secondary outcome was the detection of any epidemiologically important pathogen (EIP) 24 hours after cleaning.

RESULTS

In total, 843 environmental samples were collected from 43 unique patient rooms. At 24 hours, the mean bioburden recovered from the patient rooms cleaned with the new CAD wipe (intervention) was 52 CFU/mL, and the mean bioburden was 92 CFU/mL in the rooms cleaned the standard disinfectant (control). After log transformation for multivariable analysis, the mean difference in bioburden between the intervention and control arm was -0.59 (95% CI, -1.45 to 0.27). The odds of EIP detection were 14% lower in the rooms cleaned with the CAD wipe (OR, 0.86; 95% CI, 0.31-2.32).

CONCLUSIONS

The bacterial bioburden and odds of detection of EIPs were not statistically different in rooms cleaned with the CAD compared to the standard disinfectant after 24 hours. Although CAD technology appears promising in vitro, larger studies may be warranted to evaluate efficacy in clinical settings.

The effectiveness of simulation-based training on KAU hospital housekeeping staff performance

BACKGROUND

Hospital Housekeeping staff play a key role in maintaining safe and clean environments to prevent infection and its spread in hospital. Innovative training approaches are necessary for this category; especially since their educational level is below average. Simulation based training can be a valuable tool for them in health care sector. However, no studies have explored the impact of simulation-based training on housekeeping staff performance, which is the focus of this study.

OBJECTIVE

This research focuses on exploring the effectiveness of simulation-based training for Hospital Housekeeping Staff.

METHODS

The study used pre-post training data from 124 housekeeping staff in different work areas at KAUH to measure the effectiveness of the program on their performance. The training includes five segments: General Knowledge training, Personal Protective Equipment, Hand Hygiene, Cleaning Biological Materials, and Terminal Cleaning. The study incorporated a two-sample paired T-test, One-Way ANOVA to detect differences in mean performance pre-and post-training and between groups in terms of gender and work area.

RESULTS

Study results show a significant improvement in housekeeping staff performance after the training, where the performance measure of GK was improved by 33%, PPE 42%, HH 53%, Biological Spill Kit is 64%, and terminal cleaning 11% However, there is no significant difference in performance improvements in all stations in regards of gender and work area except for the Biological Spill Kit in terms of the work area.

CONCLUSION

Results show the effectiveness of training as there are statistically significant differences in housekeeping staff mean performance pre-and post-training. The simulation-based training changed the behavior of the cleaners, as they became more confident and understanding in performing their work. Expanding the use of simulation as a basis for training this important group and further study is recommended.

Worldwide emergence of fluconazole-resistant Candida parapsilosis: current framework and future research roadmap

Candida parapsilosis is one of the most commen causes of life-threatening candidaemia, particularly in premature neonates, individuals with cancer of the haematopoietic system, and recipients of organ transplants. Historically, drug-susceptible strains have been linked to clonal outbreaks. However, worldwide studies started since 2018 have reported severe outbreaks among adults caused by fluconazole-resistant strains. Outbreaks caused by fluconazole-resistant strains are associated with high mortality rates and can persist despite strict infection control strategies. The emergence of resistance threatens the efficacy of azoles, which is the most widely used class of antifungals and the only available oral treatment option for candidaemia. The fact that most patients infected with fluconazole-resistant strains are azole-naive underscores the high potential adaptability of fluconazole-resistant strains to diverse hosts, environmental niches, and reservoirs. Another concern is the multidrug-resistant and echinocandin-tolerant C parapsilosis isolates, which emerged in 2020. Raising awareness, establishing effective clinical interventions, and understanding the biology and pathogenesis of fluconazole-resistant C parapsilosis are urgently needed to improve treatment strategies and outcomes.

[Quality of healthcare in oncological patients from health personnel's perspective]

INTRODUCTION

The quality of care in health institutions is a constant challenge, mainly in oncology. The literature shows it has partially evaluated in contrast to it proposed by Donabedian; in addition, health personnel's perspective, who has direct contact with the patient, knows and executes the care process, has not been considered. The objective of the present study was to establish a framework to evaluate the quality of healthcare provided to patients with colorectal or ovarian cancer from health personnel's perspective.

MATERIAL AND METHODS

Cross-sectional study that included health personnel belonging to nine services of a cancer hospital. A questionnaire was applied to evaluate the quality of healthcare through amenities, the interpersonal and scientific-technical dimension (Donabedian's model). The variables were standardized, compliance with them among services was compared using non-parametric tests (Kruskal-Wallis test and Mann-Whitney U test), and 40 indicators were evaluated.

RESULTS

Health personnel's 181 members participated, the evaluated oncology hospital presented regular compliance to the quality of healthcare (bad ≤82, regular 83-109, good ≥110). When comparing this in the nine services, differences were detected between surgery and radiotherapy (higher compliance scores, 132 and 126 respectively) versus the other services P<.05. Both services had more than 25 indicators with compliance ≥80%.

CONCLUSIONS

It is shown that the established framework is useful for evaluating the quality of healthcare from health personnel's perspective (an approach not used so far for this type of evaluation), by detecting differences in its compliance, specific problems and its causes by service.

Contact time and disinfectant formulation significantly impact the efficacies of disinfectant towelettes against Candida auris on hard, non-porous surfaces

There has been an increase in Candida auris healthcare-associated infections, which result from cross-contamination from surfaces and equipment. In this study, we tested the efficacies of EPA-registered disinfectant towelettes products that are increasingly used for infection control against C. auris at a range of contact times following modifications to standard EPA protocol MB-33-00. Hydrogen peroxide (HP)-based disinfectant towelettes were more efficacious against C. auris than the quaternary ammonium chloride (QAC)-alcohol-based disinfectant towelettes irrespective of tested contact times. Thirty s contact time was significantly less effective in reducing C. auris compared to 1-, 2-, 3-, and 10-min contact times. However, there were no statistically significant differences in the level of disinfection among 1-min and longer contact times regardless of product chemistry. None of the products achieved a standard six-log₁₀ reduction at any tested contact times. Overall, the HP-based disinfectant towelette was significantly more fungicidal than the QAC-alcohol-based disinfectant towelette. For all product types, 30 s contact time did not achieve the same level of disinfection as 1-min or longer contact times. Overall, disinfectant towelette efficacy is dependent upon product formulation and contact time.

The impact of bedside wipes in multi-patient rooms: a prospective, crossover trial evaluating infections and survival

BACKGROUND

Multidrug-resistant organisms (MDROs) are prevalent on high-touch surfaces in multi-patient rooms.

AIM

To quantify the impact of hanging single-use cleaning/disinfecting wipes next to each bed. Pre-specified outcomes were: (1) hospital-acquired infections (HAIs), (2) cleaning frequency, (3) MDRO room contamination, (4) new MDRO acquisitions, and (5) mortality.

METHODS

Clustered randomized crossover trial at Shamir Medical Center, Israel (October 2016 to January 2018). Clusters were randomly assigned to use for cleaning either single-use quaternary ammonium wipes (Clinell) or standard practices (reusable cloths and buckets with bleach). Six-month intervention periods were implemented in alternating sequence, separated by a washout period. Five high-touch surfaces were monitored by fluorescent markers. Study outcomes were compared between periods using generalized estimating equations, Poisson regression, and Cox proportional hazards models.

FINDINGS

Overall, 7725 patients were included (47,670 person-days), 3793 patients in rooms with intervention cleaning and 3932 patients in rooms with standard practices. During the intervention, there was no significant difference in HAI rates (incidence rate ratio: 1.6; 95% confidence interval (CI): 0.7-3.5; P = 0.3). However, in intervention rooms, the frequency of environmental cleaning was higher (odds ratio: 3.73; 95% CI: 2.0-7.1; P < 0.0001), MDRO environmental contamination rate was insignificantly lower (odds ratio: 0.7; 95% CI: 0.5-1.0; P = 0.06), new MDRO acquisition rate was lower (hazard ratio: 0.4; 95% CI: 0.2-1.0; P = 0.04), and in-hospital mortality rate was lower (incidence rate ratio: 0.8; 95% CI: 0.7-1.0; P = 0.03).

CONCLUSION

Hanging single-use cleaning/disinfecting wipes next to each bed did not affect the HAI rates but did improve the frequency of cleaning, reduce MDRO environmental contamination, and was associated with reduced incidence of new MDRO acquisitions and reduced mortality. This is a feasible, recommended practice to improve patient outcomes in multi-patient rooms.

Hospital resource endowments and nosocomial infections: longitudinal evidence from the English National Health Service on Clostridioides difficile between 2011 and 2019

OBJECTIVES

To identify key factors associated with Clostridioides difficile infections (CDIs) in healthcare at the hospital organization level.

DESIGN

Longitudinal study covering the period 2011-2019. Hospital reports were analysed to determine the number of CDIs and several hospital-related environmental factors: financial resources (i.e., cleaning expenditure), spatial resources (i.e., number of single rooms with a private bathroom), human resources (i.e., number of physicians and nursing staff) and cultural resources (i.e., error reporting climate). The relationships between the environmental factors and CDIs were analysed in a hybrid within- and between-hospital random-effect model.

SETTING

A total of 129 general hospital Trusts operating in the English National Health Service (NHS).

PARTICIPANTS

All inpatients in 129 general hospital trusts of the NHS in the years 2011-2019, covering 120,629 cases of CDI.

MAIN OUTCOME MEASURE

Annual number of CDIs per hospital trust.

RESULTS

Single rooms were associated with fewer CDIs at the within-hospital level, but not at the between-hospital level. Similarly, more nursing staff was associated with fewer CDIs at the within-hospital level, but not at the between-hospital level. This effect was not observed for physician staffing. A different picture emerged for the protective effect of cultural resources, with a weakly significant effect of between-hospital differences, but no within-hospital effect. Financial resources were not associated with CDIs either between hospitals or within them over time.

CONCLUSIONS

The present study identified hospital resources with a beneficial influence on CDI rates. Healthcare organizations can use this knowledge for active CDI prevention.

Evaluation of daily environmental cleaning and disinfection practices in veterans affairs acute and long-term care facilities: A mixed methods study

OBJECTIVES

To describe daily environmental cleaning and disinfection practices and their associations with cleaning rates while exploring contextual factors experienced by healthcare workers involved in the cleaning process.

METHODS

A convergent mixed methods approach using quantitative observations (ie, direct observation of environmental service staff performing environmental cleaning using a standardized observation form) and qualitative interviews (ie, semistructured interviews of key healthcare workers) across 3 Veterans Affairs acute and long-term care facilities.

RESULTS

Between December 2018 and May 2019 a total of sixty-two room observations (N = 3602 surfaces) were conducted. The average observed surface cleaning rate during daily cleaning in patient rooms was 33.6% for all environmental surfaces and 60.0% for high-touch surfaces (HTS). Higher cleaning rates were observed with bathroom surfaces (Odds Ratio OR = 3.23), HTSs (OR = 1.57), and reusable medical equipment (RME) (OR = 1.40). Lower cleaning rates were observed when cleaning semiprivate rooms (OR = 0.71) and rooms in AC (OR = 0.56). In analysis stratified by patient presence (ie, present, or absent) in the room during cleaning, patient absence was associated with higher cleaning rates for HTSs (OR = 1.71). In addition, the odds that bathroom surfaces being cleaned more frequently than bedroom surfaces decreased (OR = 1.97) as well as the odds that private rooms being cleaned more frequently than semi-private rooms also decreased (OR = 0.26; 0.07-0.93). Between January and June 2019 eighteen qualitative interviews were conducted and found key themes (ie, patient presence and semiprivate rooms) as potential barriers to cleaning; this supports findings from the quantitative analysis.

CONCLUSION

Overall observed rates of daily cleaning of environmental surfaces in both acute and long-term care was low. Standardized environmental cleaning practices to address known barriers, specifically cleaning practices when patients are present in rooms and semi-private rooms are needed to achieve improvements in cleaning rates.

Co-Design in Electrical Medical Beds with Caregivers

Among the plethora of instruments present in healthcare environments, the hospital bed is undoubtedly one of the most important for patients and caregivers. However, their design usually follows a top-down approach without considering end-users opinions and desires. Exploiting Human-centered design (HCD) permits these users to have a substantial role in the final product outcome. This study aims to empower caregivers to express their opinion about the hospital bed using a qualitative approach. For a holistic vision, we conducted six focus groups and six semi-structured interviews with nurses, nursing students, social-health operators and physiotherapists belonging to many healthcare situations. We then used thematic analysis to extract the themes that participants faced during the procedures, providing a comprehensive guide to designing the future electrical medical bed. These work results could also help overcome many issues that caregivers face during their everyday working life. Moreover, we identified the User Experience features that could represent the essential elements to consider.

Effect of a "feedback prompt" from a disinfection tracking system on portable medical equipment disinfection

BACKGROUND

Portable medical equipment (PME) may contribute to transmission of multidrug-resistant organisms without proper disinfection. We studied whether a Disinfection Tracking System (DTS) with feedback prompt, attached to PME, can increase the frequency of PME disinfection.

METHODS

DTS devices were placed on 10 workstations-on-wheels (WOWs) and 5 vitals machine (VM). After a 25 day "screen-off" period, the DTS device screens were turned on to display the number of hours since the last recorded disinfection event for a 42 day period. We used a Bayesian multilevel zero-inflated negative binomial model to compare the number of events in the display "screen-off" to the "screen-on" period.

RESULTS

During the "screen-off" period, there were 1.26 and 0.49 mean disinfection events and during the "screen-on" period, there were 1.76 and 0.50 mean disinfection events for WOWs and VM, respectively, per day. The model estimated mean events per device per day in the the "screen-on" period for WOW's were 1.32 (1.10 - 1.57) times greater than those in the "screen-off" period and the "screen-on" period for VM devices was 1.37 (0.89 - 2.01) times greater than those in the "screen-off" period.

CONCLUSIONS

The rate of disinfection events for WOWs increased following the implementation of the DTS feedback prompt.

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.

A Computational Approach to Estimating Healthcare Contact Surface Material Resilience

There is growing evidence that contact surfaces within healthcare settings can serve as reservoirs for pathogen colonization and spread infectious bacteria to humans. This article aims to demonstrate the use of a Prevention through Design Environment Material Integrative Control (PtD-EMIC) instrument to predict the infection prevention resilience potential of materials commonly used for healthcare contact surfaces. PtD-EMIC is based on fuzzy logic and Adaptive Neural Fuzzy Inference System architecture. Its objective is to serve as a computational design tool that guides the selection and specification of interior materials that may moderate the spread of pathogens in healthcare environments. This objective is accomplished through an applied systems requirement simulation framework that can help guide interior material choice and design for healthcare spaces. The motivation for developing this instrument is to provide a vehicle that can expand healthcare design industry capabilities and interior environment analysis research by using computational approaches to inform interior material selection and design decisions that support healthcare environments’ infection control strategies. The selection and sourcing of embedded data related to relevant and high-use acute care treatment area finishes, the premise of instrument use, precedent research basis, and system architecture, as well as tool validation and demonstration of use, are all discussed. The text explains how using this instrument can facilitate categorization and leveraging interior material performance outcome data for informing safety-critical healthcare design.

An Enhanced Strategy for Daily Disinfection in Acute Care Hospital Rooms: A Randomized Clinical Trial

IMPORTANCE

Environmental contamination is a source of transmission between patients, health care practitioners, and other stakeholders in the acute care setting.

OBJECTIVE

To compare the efficacy of an enhanced daily disinfection strategy vs standard disinfection in acute care hospital rooms.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial (RCT) was conducted in acute care hospital rooms at Duke University Hospital in Durham, North Carolina, from November 2021 to March 2022. Rooms were occupied by patients with contact precautions. Room surfaces (bed rails, overbed table, and in-room sink) were divided into 2 sides (right vs left), allowing each room to serve as its own control. Each side was randomized 1:1 to the intervention group or control group.

INTERVENTIONS

The intervention was a quaternary ammonium, salt-based, 24-hour continuously active germicidal wipe. It was applied in addition to routine disinfection for the intervention group. The control group received no intervention beyond routine disinfection.

MAIN OUTCOMES AND MEASURES

The primary outcome was the total contamination, measured in colony-forming units (CFUs) on the bed rails, overbed table, and sink on study day 1. The secondary outcomes were the proportion of sample areas with positive test results for clinically important pathogens, including methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and carbapenem-resistant Enterobacteriaceae; the similarity in baseline contamination between sample area sides on study day 0 before application of the intervention, and the proportion of sample areas with removed UV luminescent gel on study day 1.

RESULTS

A total of 50 study rooms occupied by 50 unique patients (median [IQR] age, 61 [45-69] years; 26 men [52%]) with contact precautions were enrolled. Of these patients, 41 (82%) were actively receiving antibiotics, 39 (78%) were bedridden, and 28 (56%) had active infections with study-defined clinically important pathogens. On study day 1, the median (IQR) total CFUs for the intervention group was lower than that for the control group (3561 [1292-7602] CFUs vs 5219 [1540-12 364] CFUs; P = .002). On study day 1, the intervention side was less frequently contaminated with patient-associated clinically important pathogens compared with the control side of the room (4 [14%] vs 11 [39%]; P = .04).

CONCLUSIONS AND RELEVANCE

Results of this RCT demonstrated that a quaternary ammonium, salt-based, 24-hour continuously active germicidal wipe decreased the environmental bioburden in acute care hospital rooms compared with routine disinfection. The findings warrant large-scale RCTs to determine whether enhanced daily disinfection strategies can decrease patient acquisition and adverse patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05560321.

Comparative Assessment of Pulsed and Continuous LED UV-A Lighting for Disinfection of Contaminated Surfaces

The germicidal efficacy of LED UV-A lighting has scarcely been compared in continuous and pulsed modes for contaminated surfaces. Herein, we compare the disinfection properties of pulsed versus continuous lighting at equal irradiances using a 365 nm LED device that replicates the doses of occupied-space continuous disinfection UV-A products. Representative organisms evaluated in this study included human-infectious enveloped and non-enveloped viruses (lentivirus and adeno-associated virus, respectively), a bacterial endospore (Bacillus atrophaeus), and a resilient gram-positive bacterium (Enterococcus faecalis). Nominal UV-A irradiances were tested at or below the UL standard limit for continuous human exposure (maximum irradiance of 10 W/m2). We observed photoinactivation properties that varied by organism type, with bacteria and enveloped virus being more susceptible to UV-A than non-enveloped virus and spores. Overall, we conclude that continuous-mode UV-A lighting is better suited for occupied-space disinfection than pulsing UV-A at equivalent low irradiances, and we draw comparisons to other studies in the literature.

Surveillance of bacterial load and multi-drug resistant bacteria on bedsheets in a primary health care unit

A patient is in close proximity to different types of textiles in hospital environment, which contribute to the transfer of drug-resistant bacteria in healthcare settings. This study was undertaken to estimate the temporal variations in bacterial load on bedsheets in a primary healthcare unit in Delhi. Data were collected for a period of 7 months. Antibiotic susceptibility testing of isolates was performed. The mean count of Acinetobacter spp. was highest (2.10 × 10² CFU/cm²), and Klebsiella spp. showed the least mean count (7.5 × 10¹ CFU/cm²). The mean bacterial count over the period showed maximum bacterial load for most microbial groups in June, and minimum in November. Enterococcus faecalis and Streptococcus spp. were highly resistant to different antibiotics, while Acinetobacter spp. and Group A Streptococcus showed the least resistance toward the antibiotics tested. Bacterial counts on bedsheets were found to vary with the time of the year, indicating that environmental factors affect bacterial load.

The Evaluation of Electrolyzed Water, Sodium Dichloroisocyanurate and Peracetic Acid with Hydrogen Peroxide for the Disinfection of Patient Room Surfaces

BACKGROUND

Sporicidal disinfectants are necessary to control Clostridioides difficile and Candida auris. Novel application methods such as electrostatic sprayers may increase disinfection effectiveness. We employed a standardized protocol to assess three sporicidal disinfectants: electrolyzed water (EW), sodium dichloroisocyanurate (NaDCC) and peracetic acid/hydrogen peroxide (PAA/H₂O₂).

METHODS

The study was conducted at two New York City hospitals (1,082 total beds) over an 18-month period. The three chemicals were applied by housekeeping personnel following the hospital protocol; the use of electrostatic sprayers was incorporated into EW and NaDCC. In randomly selected rooms, five surfaces were sampled for microbial colony counts after cleaning. Data analyses were performed using negative binomial logistic regression.

RESULTS

We collected 774 samples. NaDCC-disinfected surfaces had a lower mean colony count (14 CFU) compared to PAA/H₂O₂ (18 CFU, p=0.36) and EW (37 CFU, p<.001). PAA/H₂O₂ and EW had more samples with any growth (both p<.05) compared to NaDCC. NaDCC applied with wipes and an electrostatic sprayer had the lowest number of samples with no growth and <2.5 CFU/cm² (difference not significant).

CONCLUSIONS

The use of NaDCC for surface disinfection resulted in the lowest bacterial colony counts on patient room high touch surfaces in our study.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Preventing healthcare-associated infections by decontaminating the clinical environment

Healthcare-associated infections (HAIs) continue to cause patient harm and at increasing rates. Factors contributing to this increase include suboptimal hand hygiene, antimicrobial resistance, and inadequate decontamination of the patient environment and shared patient equipment. To reduce the risk of HAIs and enhance patient safety, it is important that nurses and other healthcare professionals adhere to infection prevention and control guidance, including decontamination procedures. It is also important to identify and address the barriers that can affect adherence to this guidance. This article discusses effective decontamination of the patient environment and non-critical shared patient equipment, the barriers to adhering to guidance and strategies for improving decontamination procedures.

Infection prevention requirements for the medical care of immunosuppressed patients: recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute

In Germany, guidelines for hygiene in hospitals are given in form of recommendations by the Commission for Hospital Hygiene and Infection Prevention (Kommission für Krankenhaushygiene und Infektionsprävention, "KRINKO"). The KRINKO and its voluntary work are legitimized by the mandate according to § 23 of the Infection Protection Act (Infektionsschutzgesetz, "IfSG"). The original German version of this document was published in February 2021 and has now been made available to the international professional public in English. The guideline provides recommendations on infection prevention and control for immunocompromised individuals in health care facilities. This recommendation addresses not only measures related to direct medical care of immunocompromised patients, but also management aspects such as surveillance, screening, antibiotic stewardship, and technical/structural aspects such as patient rooms, air quality, and special measures during renovations.

Stopping Hospital Infections With Environmental Services (SHINE): A Cluster-randomized Trial of Intensive Monitoring Methods for Terminal Room Cleaning on Rates of Multidrug-resistant Organisms in the Intensive Care Unit

BACKGROUND

Multidrug-resistant organisms (MDROs) frequently contaminate hospital environments. We performed a multicenter, cluster-randomized, crossover trial of 2 methods for monitoring of terminal cleaning effectiveness.

METHODS

Six intensive care units (ICUs) at 3 medical centers received both interventions sequentially, in randomized order. Ten surfaces were surveyed each in 5 rooms weekly, after terminal cleaning, with adenosine triphosphate (ATP) monitoring or an ultraviolet fluorescent marker (UV/F). Results were delivered to environmental services staff in real time with failing surfaces recleaned. We measured monthly rates of MDRO infection or colonization, including methicillin-resistant Staphylococcus aureus, Clostridioides difficile, vancomycin-resistant Enterococcus, and MDR gram-negative bacilli (MDR-GNB) during a 12-month baseline period and sequential 6-month intervention periods, separated by a 2-month washout. Primary analysis compared only the randomized intervention periods, whereas secondary analysis included the baseline.

RESULTS

The ATP method was associated with a reduction in incidence rate of MDRO infection or colonization compared with the UV/F period (incidence rate ratio [IRR] 0.876; 95% confidence interval [CI], 0.807-0.951; P = .002). Including the baseline period, the ATP method was associated with reduced infection with MDROs (IRR 0.924; 95% CI, 0.855-0.998; P = .04), and MDR-GNB infection or colonization (IRR 0.856; 95% CI, 0.825-0.887; P < .001). The UV/F intervention was not associated with a statistically significant impact on these outcomes. Room turnaround time increased by a median of 1 minute with the ATP intervention and 4.5 minutes with UV/F compared with baseline.

CONCLUSIONS

Intensive monitoring of ICU terminal room cleaning with an ATP modality is associated with a reduction of MDRO infection and colonization.

Detrimental Effect of Ozone on Pathogenic Bacteria

(1) Background: Disinfection of medical devices designed for clinical use associated or not with the growing area of tissue engineering is an urgent need. However, traditional disinfection methods are not always suitable for some biomaterials, especially those sensitive to chemical, thermal, or radiation. Therefore, the objective of this study was to evaluate the minimal concentration of ozone gas (O₃) necessary to control and kill a set of sensitive or multi-resistant Gram-positive and Gram-negative bacteria. The cell viability, membrane permeability, and the levels of reactive intracellular oxygen (ROS) species were also investigated; (2) Material and Methods: Four standard strains and a clinical MDR strain were exposed to low doses of ozone at different concentrations and times. Bacterial inactivation (cultivability, membrane damage) was investigated using colony counts, resazurin as a metabolic indicator, and propidium iodide (PI). A fluorescent probe (H₂DCFDA) was used for the ROS analyses; (3) Results: No reduction in the count colony was detected after O₃ exposure compared to the control group. However, the cell viability of E. coli (30%), P. aeruginosa (25%), and A. baumannii (15%) was reduced considerably. The bacterial membrane of all strains was not affected by O₃ but presented a significant increase of ROS in E. coli (90 ± 14%), P. aeruginosa (62.5 ± 19%), and A. baumanni (52.6 ± 5%); (4) Conclusion: Low doses of ozone were able to interfere in the cell viability of most strains studied, and although it does not cause damage to the bacterial membrane, increased levels of reactive ROS are responsible for causing a detrimental effect in the lipids, proteins, and DNA metabolism.

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

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

Methicillin-Resistant Staphylococcus aureus: An Update on Prevention and Control in Acute Care Settings

Methicillin-resistant Staphylococcus aureus (MRSA) is a leading cause of health-care-associated infections. Controversies regarding the effectiveness of various control strategies have contributed to varying approaches to MRSA control. However, new evidence from large-scale studies has emerged, particularly concerning screening and decolonization. Importantly, implementation and outcomes of control measures in practice are not only influenced by scientific evidence, but also economic, administrative, and political factors, as demonstrated by decreasing MRSA rates in a number of countries after concerted and coordinated efforts at a national level. Flexibility to adapt measures based on local epidemiology and resources is essential for successful MRSA control.

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.

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.

Bacteriophage treatment before chemical disinfection can enhance removal of plastic surface-associated Pseudomonas aeruginosa

Opportunistic pathogens can linger on surfaces in hospital and building plumbing environments, leading to infections in at-risk populations. Further, biofilm-associated bacteria are protected from removal and inactivation protocols, such as disinfection. Bacteriophages show promise as tools to treat antibiotic resistant infections. As such, phages may also be useful in environmental applications to prevent newly acquired infections. In the current study, the potential of synergies between bacteriophage and chemical disinfection of the opportunistic pathogen Pseudomonas aeruginosa was assessed under various conditions. Specifically, surface-associated P. aeruginosa was treated with various concentrations of phages (P1 or JG004), chemical disinfectant (sodium hypochlorite or benzalkonium chloride), or combined sequential treatments under three distinct attachment models (spot inoculations, dry biofilms, and wet biofilms). Phages were very effective at removing bacteria in spot inoculation (>3.2 log₁₀ removal) and wet biofilms (up to 2.6 log₁₀ removal), while phages prevented regrowth of dry biofilms in the application time. In addition, phage treatment followed by chemical disinfection inactivated more P. aeruginosa under wet biofilm conditions better than either treatment alone. This effect was hindered when chemical disinfection was applied first, followed by phage treatment, suggesting additive benefits of combination treatments are lost when phage is applied last. Further, we confirm prior evidence of greater phage tolerance to benzalkonium chloride relative to sodium hypochlorite, informing choices for combination phage-disinfectant approaches. Overall, this paper further supports the potential of using combination phage and chemical disinfectant treatments to improve inactivation of surface-associated P. aeruginosa. Importance Phages are already utilized in the healthcare industry to treat antibiotic resistant infections, such as on implant-associated biofilms and in compassionate care cases. Phage treatment could also be a promising new tool to control pathogens in the built environment, preventing infections from occurring. This study shows that phage can be combined effectively with chemical disinfectants to improve removal of wet biofilms and bacteria spotted onto surfaces while preventing regrowth in dry biofilms. This has the potential to improve pathogen containment within the built environment and drinking water infrastructure to prevent infections of opportunistic pathogens.

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 Tn-seq Screen of Streptococcus pneumoniae Uncovers DNA Repair as the Major Pathway for Desiccation Tolerance and Transmission

Streptococcus pneumoniae is an opportunistic pathogen that is a common cause of serious invasive diseases such as pneumonia, bacteremia, meningitis, and otitis media. Transmission of this bacterium has classically been thought to occur through inhalation of respiratory droplets and direct contact with nasal secretions. However, the demonstration that S. pneumoniae is desiccation tolerant and, therefore, environmentally stable for extended periods of time opens up the possibility that this pathogen is also transmitted via contaminated surfaces (fomites). To better understand the molecular mechanisms that enable S. pneumoniae to survive periods of desiccation, we performed a high-throughput transposon sequencing (Tn-seq) screen in search of genetic determinants of desiccation tolerance. We identified 42 genes whose disruption reduced desiccation tolerance and 45 genes that enhanced desiccation tolerance. The nucleotide excision repair pathway was the most enriched category in our Tn-seq results, and we found that additional DNA repair pathways are required for desiccation tolerance, demonstrating the importance of maintaining genome integrity after desiccation. Deletion of the nucleotide excision repair gene uvrA resulted in a delay in transmission between infant mice, indicating a correlation between desiccation tolerance and pneumococcal transmssion. Understanding the molecular mechanisms that enable pneumococcal persistence in the environment may enable targeting of these pathways to prevent fomite transmission, thereby preventing the establishment of new colonization and any resulting invasive disease.

Evaluation of different monitoring methods of surface cleanliness in operating rooms

OBJECTIVES

to evaluate different monitoring methods for detecting the presence of organic or biological matter before and after the cleaning and disinfection processes of the operating room.

METHODS

this is a cross-sectional study based on visual inspection, adenosine triphosphate levels and microbiological culture for the assessment of cleaning and disinfection.

RESULTS

93.3% of the surfaces inspected visually for this study purpose were considered clean, even when high levels of adenosine triphosphate and microbiological analysis detected presence of microorganisms relevant to biofilm formation.

CONCLUSIONS

the cleaning and disinfection processes reduced the microbial load and organic matter of the inspected surfaces, demonstrated by the values obtained by the adenosine triphosphate bioluminescence assay and microbiological analysis, but the visual inspection as a unique tool to assess the surfaces' cleanliness may give a false impression of clean environment.

Does enhanced environmental cleaning reduce carbapenem-resistant Acinetobacter baumannii colonization in the intensive care unit?

OBJECTIVE

To evaluate the impact of enhanced environmental cleaning (two times per day) compared with conventional cleaning on the acquisition of carbapenem-resistant Acinetobacter baumannii (CRAB) in a highly endemic intensive care unit (ICU).

METHODS

The intervention consisted of alternating environmental cleaning and conventional cleaning every 3 months during the study period from July 2018 to June 2019. CRAB acquisition was assessed using incidence and prevalence rates, and colonization pressure.

RESULTS

The incidence rates of CRAB with and without enhanced cleaning were 16.3 and 13.9 cases per 1000 population, respectively; and the prevalence rates were 66.9 and 61.7 cases per 1000 population, respectively. Colonization pressure was 53.3% with enhanced cleaning and 51.3% without enhanced cleaning. No association was found between enhanced environmental cleaning and the incidence (P=0.156), prevalence (P=0.888) and colonization pressure (P=0.825) of CRAB acquisition. The ventilator utilization ratio increased the colonization pressure of CRAB acquisition (P=0.010, β coefficient=0.37). The proportion of new nurses with <3 years of clinical practice experience was positively correlated with the incidence and prevalence of CRAB acquisition.

CONCLUSION

Enhanced environmental cleaning alone failed to reduce CRAB acquisition in a highly endemic ICU. The ventilator utilization ratio may be of more importance than environmental cleaning. Inexperienced nurses may need to be monitored regarding infection control activities in addition to hand hygiene adherence.

Antibacterial Treatment of Selected High-Touch Objects and Surfaces within Provision of Nursing Care in Terms of Prevention of Healthcare-Associated Infections

Prevention of healthcare-associated infections is an important part of providing nursing care. High-touch objects and surfaces that can be contaminated with various bacteria are matters of concern. The possibility of reducing contamination is the use of antibacterial and hydrophobic nanolayers. The aim of this study was to determine, by means of an experimental method, the microbial efficacy of applied antibacterial and hydrophobic nanolayers on high-touch objects and surfaces used in nursing practice in a regional hospital in the Czech Republic. The results show that the antibacterial efficacy of the applied nanolayer was not demonstrated. Furthermore, the results show that selected objects and surfaces can always be contaminated by bacterial agents in about 1/3 of cases. It is mainly contamination with nonpathogenic bacteria; however, the presence of pathogenic bacteria, such as Staphylococcus aureus, has also been detected. The results of this study pinpoint the importance of following the basic rules for the use of decontaminated objects and surfaces used to provide healthcare.

Fast-cycle hydrogen peroxide nebulization against frequent healthcare-associated micro-organisms: efficacy assessment

BACKGROUND

Hydrogen peroxide (H₂O₂)-based technology is currently used with the aim of controlling microbial contamination in hospital settings. However, the long cycles required result in prolonged room turnover time, thus precluding a wider implementation of the technology.

AIM

To assess the efficacy of a shorter cycle of nebulized H₂O₂ against healthcare-associated micro-organisms, further comparing among multidrug-resistant and multidrug-susceptible strains.

METHODS

The efficacy of a standard cycle (1 h) and of a faster cycle (15 min) of a 7% H₂O₂ nebulized solution was compared against bacteria and yeasts. MDR and MDS strains were inoculated on polyvinyl chloride, stainless steel, linoleum, napa leather, and formica coupons, and their growth ability was compared.

FINDINGS

Globally, the mean efficacy of the standard cycle ranged between 82.5% (±17.0) and 95.9% (±8.3), while the efficacy of the fast cycle ranged between 84.4% (±17.0) and 95.7% (±10.5). No statistically significant differences were found for the majority of the tested cycles and materials. For all the tested strains, no differences were found regarding the efficacy of cycles.

CONCLUSION

The very high disinfection efficacy of the fast cycle was found to be similar to that of the standard cycle. Moreover, a similar efficacy was also demonstrated when comparing between multidrug-resistant and multidrug-susceptible strains. This study supports a wider implementation of the technology, with the expected advantages of reducing room turnover time, costs, and indirect infection transmission. Further assessment of the efficacy of this faster cycle against other emergent microbial global threats would be highly recommended.

Healthcare professionals' experiences of being observed regarding hygiene routines: the Hawthorne effect in vascular surgery

Background

The Hawthorne Effect is the change in behaviour by subjects due to their awareness of being observed and is evident in both research and clinical settings as a result of various forms of observation. When the Hawthorne effect exists, it is short-lived, and likely leads to increased productivity, compliance, or adherence to standard protocols. This study is a qualitative component of an ongoing multicentre study, examining the role of Incisional Negative Pressure Wound Therapy after vascular surgery (INVIPS Trial). Here we examine the factors that influence hygiene and the role of the Hawthorne effect on the adherence of healthcare professionals to standard hygiene precautions.

Methods

This is a qualitative interview study, investigating how healthcare professionals perceive the observation regarding hygiene routines and their compliance with them. Seven semi-structured focus group interviews were conducted, each interview included a different staff category and one individual interview with a nurse from the Department for Communicable Disease Control. Additionally, a structured questionnaire interview was performed with environmental services staff. The results were analysed based on the inductive qualitative content analysis approach.

Results

The analysis revealed four themes and 12 subthemes. Communication and hindering hierarchy were found to be crucial. Healthcare professionals sought more personal and direct feedback. All participants believed that there were routines that should be adhered to but did not know where to find information on them. Staff in the operating theatre were most meticulous in adhering to standard hygiene precautions. The need to give observers a clear mandate and support their work was identified. The staff had different opinions concerning the patient’s awareness of the importance of hygiene following surgery. The INVIPS Trial had mediated the Hawthorne effect.

Conclusion

The results of this study indicate that the themes identified, encompassing communication, behaviour, rules and routines, and work environment, influence the adherence of healthcare professionals to standard precautions to a considerable extent of which many factors could be mediated by a Hawthorne effect. It is important that managers within the healthcare system put into place an improved and sustainable hygiene care to reduce the rate of surgical site infections after vascular surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06097-5.

Effectiveness of dry hydrogen peroxide on reducing environmental microbial bioburden risk in a pediatric oncology intensive care unit

BACKGROUND

Routine manual cleaning and disinfection of the health care environment is often suboptimal. Residual contamination poses an infection risk, particularly for immunocompromised patients. This study evaluates the efficacy of dry hydrogen peroxide (DHP) on microbial surface contamination in a pediatric oncology intensive care unit.

METHODS

Surface samples from 5 high-touch and 2 low-touch surfaces were obtained for culture and adenosine triphosphate readings after manual cleaning on multiple days in 4 intensive care unit rooms, before and after DHP was deployed. Air samples were collected as well at the study site. Data outcomes were measured in terms of total colony-forming units for the cultures and relative light units for adenosine triphosphate.

RESULTS

The overall mean surface microbial burden was significantly reduced in the intervention group compared to the control group (mean 5.50 vs 11.77, P<.001). These reductions in colony-forming units were seen across all sampling sites in the intervention group. A reduction in the mean relative light units levels was also noted in the intervention group when compared to the control group (172.08 vs 225.83, P <.006). Reductions with the air samples were also noted (P = .139).

CONCLUSIONS

Study demonstrates that DHP was effective in reducing microbial surface contamination and improves quality of environmental cleaning.

Bacterial disinfection and cell assessment post ultraviolet-C LED exposure for wound treatment

Ultraviolet-C sourced LED (UVC-LED) has been widely used for disinfection purposes due to its germicidal spectrum. In this study, the efficiencies of UVC-LED for Pseudomonas aeruginosa (P. aeruginosa) and Staphylococcus aureus (S. aureus) disinfections were investigated at three exposure distances (1, 1.5, and 2 cm) and two exposure times (30 and 60 s). The respective bacterial inhibition zones were measured, followed by a morphological analysis under SEM. The viabilities of human skin fibroblast cells were further evaluated under the treatment of UVC-LED with the adoption of aforesaid exposure parameters. The inhibition zones were increased with the increment of exposure distances and times. The highest records of 5.40 ± 0.10 cm P. aeruginosa inhibition and 5.43 ± 0.11 cm S. aureus inhibition were observed at the UVC-LED distance of 2 cm and 60-s exposure. Bacterial physical damage with debris formation and reduction in size were visualized following the UVC-LED exposures. The cell viability percentages were in a range of 75.20-99.00% and 82-100.00% for the 30- and 60-s exposures, respectively. Thus, UVC-LED with 275-nm wavelength is capable in providing bacterial disinfection while maintaining accountable cell viability which is suitable to be adopted in wound treatment. Bacterial disinfection and human skin fibroblast cell assessment using UVC-LED.

Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review

Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolong hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach whereby different strategies may be implemented together, next to targeted, risk-based approaches, in order to reduce the risk of HAIs for patients. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. This review focuses on routine environmental cleaning and disinfection including areas with a moderate risk of contamination, such as general wards. As scientific evidence has not yet resulted in universally accepted guidelines nor led to universally accepted practical recommendations pertaining to surface cleaning and disinfection, this review provides expert guidance for healthcare workers in their daily practice. It also covers outbreak situations and suggests practical guidance for clinically relevant pathogens. Key elements of environmental cleaning and disinfection, including a fundamental clinical risk assessment, choice of appropriate disinfectants and cleaning equipment, definitions for standardized cleaning processes and the relevance of structured training, are reviewed in detail with a focus on practical topics and implementation.

In vitro inhibitory effects of commercial antiseptics and disinfectants on foodborne and environmental bacterial strains

Background: Antibacterial agents, including disinfectants and antiseptics are commonly used to reduce bacterial loads. As they have a broad-spectrum of activity against bacteria, function either as bactericidal or bacteriostatic agents. While bacterial antimicrobial resistance is increasing, disinfectants and antiseptics are still relevant antibacterial agents.   Methods:  This study investigated the in vitro inhibitory effects of commonly used antiseptics and disinfectants. Using standard disc diffusion methods, selected common household antibacterial agents were tested on resistant Staphylococcus aureus isolated from hospital environment and foodborne Escherichia coli and Bacillus species. Results: The study showed that the selected antibacterial agents were effective against the antibiotic resistant bacteria with appreciable zone of inhibition relative to the standard controls used. Conclusions: Though bacteria are consistently developing resistance to available antibiotics, disinfectants still inhibit bacterial growth and survival with considerable public health importance.

Is a reduction in viability enough to determine biofilm susceptibility to a biocide?

OBJECTIVE

The abundance and prevalence of dry-surface biofilms (DSBs) in hospitals constitute an emerging problem, yet studies rarely report the cleaning and disinfection efficacy against DSBs. Here, the combined impact of treatments on viability, transferability, and recovery of bacteria from DSBs has been investigated for the first time.

METHODS

Staphylococcus aureus DSBs were produced in alternating 48-hour wet-dry cycles for 12 days on AISI 430 stainless steel discs. The efficacy of 11 commercially available disinfectants, 4 detergents, and 2 contactless interventions were tested using a modified standardized product test. Reduction in viability, direct transferability, cross transmission (via glove intermediate), and DSB recovery after treatment were measured.

RESULTS

Of 11 disinfectants, 9 were effective in killing and removing bacteria from S. aureus DSBs with >4 log10 reduction. Only 2 disinfectants, sodium dichloroisocyanurate 1,000 ppm and peracetic acid 3,500 ppm, were able to lower both direct and cross transmission of bacteria (<2 compression contacts positive for bacterial growth). Of 11 disinfectants, 8 could not prevent DSB recovery for >2 days. Treatments not involving mechanical action (vaporized hydrogen peroxide and cold atmospheric plasma) were ineffective, producing <1 log10 reduction in viability, DSB regrowth within 1 day, and 100% transferability of DSB after treatment.

CONCLUSIONS

Reduction in bacterial viability alone does not determine product performance against biofilm and might give a false sense of security to consumers, manufacturers and regulators. The ability to prevent bacterial transfer and biofilm recovery after treatment requires a better understanding of the effectiveness of biocidal products.

Emerging carbapenem-resistant Klebsiella pneumoniae sequence type 16 causing multiple outbreaks in a tertiary hospital in southern Vietnam

The emergence of carbapenem resistance in Klebsiella pneumoniae represents a major global public health concern. Nosocomial outbreaks caused by multidrug-resistant K. pneumoniae are commonly reported to result in high morbidity and mortality due to limited treatment options. Between October 2019 and January 2020, two concurrent high-mortality nosocomial outbreaks occurred in a referral hospital in Ho Chi Minh City, Vietnam. We performed genome sequencing and phylogenetic analysis of eight K. pneumoniae isolates from infected patients and two environmental isolates for outbreak investigation. We identified two outbreaks caused by two distinct lineages of the international sequence type (ST) 16 clone, which displayed extensive drug resistance, including resistance to carbapenem and colistin. Carbapenem-resistant ST16 outbreak strains clustered tightly with previously described ST16 K. pneumoniae from other hospitals in Vietnam, suggesting local persistence and transmission of this particular clone in this setting. We found environmental isolates from a hospital bed and blood pressure cuff that were genetically linked to an outbreak case cluster, confirming the potential of high-touch surfaces as sources for nosocomial spread of K. pneumoniae. Further, we found colistin resistance caused by disruption of the mgrB gene by an ISL3-like element, and carbapenem resistance mediated by a transferable IncF/blaOXA-181 plasmid carrying the ISL3-like element. Our study highlights the importance of coordinated efforts between clinical and molecular microbiologists and infection control teams to rapidly identify, investigate and contain nosocomial outbreaks. Routine surveillance with advanced sequencing technology should be implemented to strengthen hospital infection control and prevention measures.

Clostridium difficile Infection Reservoirs Within an Acute Rehabilitation Environment

OBJECTIVE

Clostridium difficile infection is a common hospital-associated infection spread via patient contact or contaminated environments. The risk for spread of C difficile may be greater in inpatient rehabilitation units than in some hospital units as patients are not confined to their rooms and often share equipment. Environmental disinfection is challenging in shared medical equipment, especially in equipment with complex designs. The study aimed to examine the presence of C difficile spores within an acute rehabilitation environment and to evaluate disinfection effectiveness.

DESIGN

Cultures were performed on 28 rehabilitation rooms, 28 rehabilitation floor surfaces, and 80 shared devices and equipment. Two disinfection interventions were implemented, and environmental cultures then were repeated postintervention.

RESULTS

Environmental cultures positive for CD spores were rehabilitation rooms (1/28), rehabilitation floors (13/28), and wheelchairs (3/20). After the implementation of new disinfection methods, repeat cultures were obtained and produced negative results.

CONCLUSIONS

Nonsporicidal disinfectant was not effective on hospital floors. Sporicidal disinfection of the floor is important when rates of C difficile infection are increased. Wheelchairs are complex devices and difficult to properly clean. The hospital purchased an ultraviolent device for wheelchair cleaning with a subsequent reduction in spores on repeat cultures.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

CME OBJECTIVES

Upon completion of this article, the reader should be able to: (1) Recognize the impact of Clostridium difficile infections on the healthcare system; (2) Describe potential reservoirs of Clostridium difficile in the inpatient rehabilitation environment; and (3) Discuss interventions that may be implemented to reduce the reservoirs of Clostridium difficile on the rehabilitation unit.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

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.

Antimicrobial coating is associated with significantly lower aerobic colony counts in high-touch areas in an orthopedic ward environment

BACKGROUND

Hospital acquired infections (HAI) are the most common complication found in the hospital environment. The aim of the study was to examine whether the use of an antimicrobial coating in high-touch areas in an orthopedic ward could reduce bacterial growth and HAI.

METHODS

From December 2017 to February 2018, HAI were registered on two orthopedic wards. A second registration was performed from December 2018 to February 2019. On the second occasion, an antimicrobial organosilane coating was applied just before the study period and thereafter weekly on one ward, while the other ward served as a control. Twenty defined high-touch areas on each ward were cultured before treatment and after 1, 2, 4, 8, 12, 14 and 16 weeks. Samples were cultured for aerobic colony counts, Staphylococcus aureus and E. coli.

RESULTS

The total aerobic colony counts were 47% lower on the treated ward compared with the non-treated ward over the study period (p = 0.02). The colony counts for Staphylococcus aureus and E. coli were low on both wards. During the first registration period, the incidence of HAI was 22.7% and 20.0% on the non-treated and subsequently treated ward respectively. On the second occasion, after treatment, the incidence was 25.0% and 12.5% (treated ward) respectively (p = 0.0001).

CONCLUSIONS

The use of a long-lasting antimicrobial organosilane coating appears to reduce the bioburden and reduce HAI. Since the incidence of HAI varies substantially over time, longer observation times are needed.