New technologies in environmental cleaning

Dr. Moustapha Ahmed Ramadan
Head of Infection Control Department
Al-Adan Hospital
March 2016
1

Environmental Contamination
 There is excellent evidence in the scientific
literature that environmental contamination plays
an important role in the transmission of several
key healthcare-associated pathogens.
 Including methicillin-resistant Staphylococcus
aureus [MRSA] , vancomycin-resistant
Enterococcus [VRE], Acinetobacter, norovirus, and
Clostridium difficile.
2

 Admission to a room previously occupied by a
patient colonized or infected with certain
nosocomial pathogens increases the risk of
acquisition by subsequent occupants.
 Studies showed that inadequate terminal cleaning
of rooms, patients acquire the organism
• directly from contaminated surfaces
• from HCWs who contaminate their hands in
the room
3

 While routine cleaning can reduce the microbiological
burden in a patient room it does not always eliminate
the presence of bacteria and hence risk of infection.
 Traditional cleaning strategies do not remove all
environmental MDROs.
 The complications of room topology, and the presence
of dust, grime or biofilm significantly increase the
resistance of bacteria to decontamination methods.
4

• Housekeepers and nursing staff often do not agree on
who should clean what
• Housekeepers do not always understand
– Which detergent/disinfectant to use
– What concentration should be used
• Other contributing factors
– Staff shortages and frequent turnover of personnel
with demands for fast room.
5

0 0.5 1 1.5 2 2.5 3 3.5 4
MDR Acinetobacter (Nseir S, 2011)
C. diff (Shaughnessy M, 2011)
VRE^ (Drees M, 2008)
MDR Pseudomonas (Nseir S, 2011)
VRE (Huang S, 2006)
VRE* (Dress M, 2008)
MRSA (Huang S, 2006)
* Prior room occupant infected; ^Any room occupant in prior 2 weeks infected.
Relative Risk of pathogen acquisition if prior room occupant infected

Pathogen Survival Time
S. aureus (including MRSA) 7 days to >12 months
Enterococcus spp. (including VRE) 5 days to >46 months
Acinetobacter spp. 3 days to 11 months
Clostridium difficile (spores) >5 months
Norovirus (and feline calicivirus) 8 hours to >2 weeks
Pseudomonas aeruginosa 6 hours to 16 months
Klebsiella spp. 2 hours to >30 months
Environmental survival of key pathogens on hospital surfaces

• Items frequently
contaminated near patients
include:
• Bed rails
• Bed linen
• Overbed tables
• Blood pressure cuffs
• Intravenous pumps
• Nurse call buttons
• Urinary collection bags
8

 It has long been recommended that environmental
surfaces in patient rooms should be cleaned/ disinfected
on a regular basis, when surfaces are visibly soiled, and
following patient discharge (terminal cleaning).
 Studies have demonstrated that adequate environment
cleaning is frequently lacking.
9

Carling et al. found that only
49% of surfaces targeted for
terminal cleaning had been
cleaned.
Overbed Table Overbed Table
Before Cleaning After Cleaning
VRE on call button after cleaning
10

A number of studies have shown that improved cleaning
and disinfection of environmental surfaces can reduce
transmission of pathogens such as C. difficile,
vancomycin-resistant enterococci (VRE), and methicillin-
resistant S. aureus (MRSA)
11

• Environmental cleaning
rate increased significantly
• VRE environmental
contamination decreased
significantly
• VRE acquisitions by
patients decreased
significantly
Cleaning Rate vs VRE Acquisitions
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
1 2 3 4
Period
0
5
10
15
20
25
30
35
40
Cleaning rate VRE acquisitions
12

Level of Disinfection/Cleaning for Patient
Care Equipment
Spaulding
Classification
of Objects
Application Level of
Germicidal
Action Required
Critical Entry or penetration
into sterile tissue,
cavity or
bloodstream
Sterilization
Semi-critical Contact with
mucous membranes,
or non-intact skin
High-level
Disinfection
Non-critical Contact with intact
skin
Low-level
Disinfection 13

Common Agents Used for Disinfection
of Environmental Surfaces
 Chlorine and Chlorine compounds
 Ethyl or isopropyl alcohol (70-90%)
 Quaternary ammonium germicidal solutions
 Phenolic germicidal detergent solutions
 Iodophor germicidal solutions
 Peracetic and hydrogen peroxide
14

Advantages and Disadvantages
of Common Disinfectants
Disinfectant Advantages Disadvantages
Sodium hypochlorite
(household bleach)
Inexpensive
Fast-acting
Widely available
Active against
bacteria, spores, Mtb,
viruses
Odor can be irritating
Corrosive to metals
Inactivated by
organic material
May discolor fabrics
Ethyl or isopropyl
alcohol (70-90%)
Inexpensive
Widely available
Rapidly effective
Active against
bacteria, Mtb, viruses
Not effective against
bacterial spores
Not for large surfaces

Advantages and Disadvantages
of Common Disinfectants
Disinfectant Advantages Disadvantages
Quaternary
ammonium
compounds
Not too expensive
Widely available
Good cleaning agents
Not effective against
bacterial spores, Mtb,
non-enveloped viruses
May become
contaminated
Phenolics Widely available May be toxic to infants
Poor activity against
bacterial spores and
non-enveloped viruses
16

Sodium hypochlorite (5.25 – 6.15% solutions)
“household bleach”
Preparation Parts per million
(ppm) available
chlorine
Comments
1:10 dilution of
household bleach
5,250 - 6,150 Active against C. difficile
spores
1:50 dilution of
household bleach
1,050 - 1,230 Active against Mtb,
Norovirus
1:500 dilution of
household bleach
105 - 123 Active against vegetative
bacteria

Improving Cleaning/Disinfection
Practices
• Develop policies regarding which patient-care
equipment and environmental surfaces are to be
cleaned by housekeepers and by nursing staff
• Educate and train housekeepers regarding
recommended cleaning practices and the importance
of following hospital cleaning policies
18

Improving Cleaning/Disinfection
Practices
• Ensure and audit compliance of cleaning and
disinfection procedures
• Develop and apply new technologies/ devices for
environmental cleaning and equipment disinfection.
19

Methods for Assessing Cleaning
Practices
• Visual inspection
– Check list to assure surfaces have been wiped
• Marking surfaces with fluorescent dye, and
checking to see if marker was removed during
cleaning
20

Methods for Assessing Cleaning
Practices
• Culturing surfaces (aerobic colony counts)
– Contact agar plates or moistened swab cultures
• ATP bioluminescence assays to measure cleanliness
21

Advantages and Disadvantages of
Methods for Assessing Cleaning Practices
Method Advantages Disadvantages
Visual inspection Simple Does not provide
reliable assessment of
cleanliness
Fluorescent marker
system
Inexpensive
Minimal equipment
needed
Must mark surfaces
before cleaning, and
check them after
cleaning
Aerobic colony counts Relatively simple
Detects presence of
pathogens
More expensive
Results not available for
48 hrs later
ATP bioluminescence
assay systems
Provides quantitative
measure of cleanliness
Quick results
More expensive
Requires special
equipment
22

NEW TECHNOLOGIES TO
IMPROVE DISINFECTION OF
ENVIRONMENTAL SURFACES
23

• “No touch” terminal disinfection
 UV light: UV-C or pulsed xenon
 Hydrogen peroxide systems: Vapor or aerosol
 Portable devices: UV, steam
• “Self disinfecting” surfaces
 Heavy metal surface coatings: Silver, copper
 Sharklet pattern
 Germicide impregnated surfaces: Triclosan
24

NTD/ UV-C
 Mobile UV unit.
 Emits UVC (254nm), which damages DNA.
 Some systems control the dose of UV according to
room topology.
 Some have the option for multiple emitters.
26

NTD/ UV-C
 The efficacy of UV irradiation is a function of
many different parameters such as intensity,
exposure time, lamp placement, and air movement
patterns.
 Multiple room locations recommended.
 Single room cycle times range from ~30 mins to
>90 mins depending on setting
27

NTD/UV-C
Results/ Findings:
UV-C system is capable of reducing (MRSA, VRE,
Acinetobacter baumannii) by >3-4-log10 in 15-20 minutes,
and C. difficile by >1.7-4-log10 in 35-100 minutes.
Significantly less effective out of direct line of sight, e.g.
only 1 log reduction in C. difficile and Aspergillus sp.
28

NTD/ Pulsed Xenon UV
 Mobile UV unit.
 Produces flashes of UV light in the 200-320nm range
which causes cellular damage
 Cycles are fast: 15 minutes (process times 60 mins for
standard methods vs. 50 mins for PX-UV including
pre-cleaning)
 Limited published data
30

 Sites contaminated with MRSA
127
108
11
1
0
20
40
60
80
100
120
140
Manual PX-UV
Before
After
31

 Mean contaminated samples with C.difficile
2.39
22.97
0.71 1.19
0
5
10
15
20
25
Bleach PX-UV
Before
After
32

 C. difficile transmission
33

Pros and Cons of UV system
Advantages:
 Reliable biocidal activity against a wide range of
healthcare-associated pathogens as room surfaces and
equipment decontaminated (but not eliminated)
 Room decontamination is rapid (~15-25 minutes) for
vegetative bacteria
 Effective against Clostridium difficile, although
requires longer exposure (~50 minutes)
35

Advantages:
 HVAC (heating, ventilation and air conditioning)
system does not need to be disabled and the room
does not need to be sealed
 UV is residual free and does not give rise to health or
safety concerns
 No consumable products so costs include only capital
equipment and staff time
36

Disadvantages:
 All patients and staff must be removed from the room
prior to decontamination
 Decontamination can only be accomplished at
terminal disinfection (i.e., cannot be used for daily
disinfection) as room must be emptied of people
 Hence cleaning must precede UV decontamination
37

Disadvantages:
 Sensitive to use parameters (e.g., wavelength, UV dose
delivered)
 Requires that equipment and furniture be moved away
from the walls
 Less effective out of direct line of sight
38

UV-C Vs Pulsed Xenon UV
UV-C PX-UV
Efficacy 3-4 log reduction in
vegetative bacteria
2-3 log reduction in
C. difficile
4-5 log reduction in
Vegetative bacteria
Limited published
data for C. difficile
Reduce but do not eliminate pathogens
Distribution Less effective out of direct line of sight
Ease of use Single or multiple
locations
Multiple locations
Cycle time 15-50 mins 15 mins
39

NTD/ HPV
 Portable HPV generator + aeration unit for the
healthcare settings.
 Produces HPV from a 30%-35% H2O2 liquid solution.
 Distributed as a vapour (gas) then condenses on
surfaces.
40

NTD/ HPV
 The process also generate hydroxyl free radicals (OH-)
which kill microorganisms.
 At the end of the process HPV is catalytically broken
down to water vapor and O2.
 Compatible with hospital materials including sensitive
electronics.
41

NTD/ HPV
Results/finding:
Passaretti et al. demonstrated that environmental
decontamination with HPV reduced the risk of a
patient admitted to a room previously occupied by a
colonized or infected patient with a MDRO from
acquiring an MDRO by 64% compared to using
standard disinfection methods
42

NTD/ HPV
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
Before During
CDI cases/1000 patient days
CDI Rates
p= 0.047
43

NTD/ aPV
 Portable H2O2 aerosolizes.
 5-6% hydrogen peroxide and 50-60ppm silver plus
stabilisers.
 Aerosolized (droplets –not gas) particles
 Passive aeration, H2O2 left to degrade naturally.
 Cycle time >2 hour for a single room.
45

NTD/ aPV
Results/finding:
Exposure to 0.35 ml-aHP/ft3 achieved a 2.5-log
reduction in Norovirus, 4.3, and 3.4-log reduction
Feline Calcivirus and Tulane virus respectively.
46

NTD/ aPV
Log10 reduction under aPV of two C. difficile strains
(without organic soiling)
47

NTD/ aPV
Log10 reduction under aPV of two C. difficile strains
(with organic soiling)
48

0
1
2
3
4
5
6
7
8
9
Conventional Cleaning H2o2
Before
After
Effects of conventional cleaning method vs H2O2
system against MDRO surface contamination in ICU
p= 0.371 p= 0.004
49

0
5
10
15
20
25
30
HPV aHP aHP
Before
After
HPV vs aHP for C. difficile decontamination
%ofsitescontaminatedwithC.difficile
p <0.001 p< 0.005 p <0.001
50

Pros and Cons of Hydrogen peroxide system
Advantages:
 Reliable biocidal activity against a wide range of
healthcare-associated pathogens on room surfaces and
equipment
 Useful for disinfecting complex equipment and
furniture
 Does not require that furniture and equipment be
moved away from the walls
51

Advantages:
 Demonstrated to reduce healthcare-associated
infections (i.e., Clostridium difficile)
 HPV is residual free and does not give rise to health or
safety concerns (aeration unit converts HP into oxygen
and water)
 Uniform distribution in the room via an automated
dispersal system
52

Disadvantages:
 All patients and staff must be removed from the room
prior to decontamination
 Decontamination can only be accomplished at
terminal disinfection (i.e., cannot be used for daily
disinfection) as room must be emptied of people
 Hence cleaning must precede UV decontamination
53

Disadvantages:
 HVAC system must be disabled to prevent unwanted
dilution of HP during use and the doors must be
closed with gaps sealed by tape
 Decontamination requires ~2.5 to 5 hours
 Sensitive to use parameters (e.g. HP concentration)
54

HPV vs aPV
HPV aPV
Efficacy > 6 log reduction 4-6 log reduction
Distribution Homogenous
(vapor phase)
Non-Homogenous
(aerosol phase)
Ease of use 2 units plus cables 1 unit no cable
Need to seal doors and air vents
Cycle time 2 hours
Active aeration
>2 hours
Passive aeration 55

Hydrogen peroxide Vs Ultra Violet
 500 bed hospital (15 patient rooms at random from 8
wards)
 5 high touch surfaces cultured for Aerobic colony
counts
 Steel discs loaded with 6 log10 C. difficile spores
placed in 5 areas close to high touch surfaces
 Biological indicators with 4 log10 and 6 log10 G.
stearothermophilus
56

0
2
4
6
8
10
12
14
Bedside rail Overbed
table
TV remote Grab bar Toilet seat
HPV
UV-C
Direct line of sight
Numbersofsitespositive
Indirect line of sight
57

HPV UV-C
ACC 93% 52%
C. Difficile
reduction
6 log 10 < 2 log10
BI Killed 99-100% 0-22%
Hour cycle 2.5-3 hours 0.6-1.7 hour
58

Which to be used?
HPV aPV UV-C PX-UV
Efficacy 1 1-2 3 3-4
Distribution 1 2 4 3
Ease of use 4 3 1 2
Cycle time 3 4 2 1
Running
cost
3 2 1 1
59

Heavy metals coatings
Antimicrobial copper works on two steps
 First step is a direct interaction between the surface
and the bacterial outer membrane, causing the
membrane to rupture.
 Second is related to the holes in the outer membrane,
through which the cell loses vital nutrients and water,
causing a general weakening of the cell.
63

 Antimicrobial Copper is designed to cover high touch
surfaces.
 More studies are needed.
64

 The antimicrobial effects of silver are through protein
inactivation, DNA association and penetrating the cell.
 Mainly used for medical devices and equipment as in
silicone based medical devices.
65

Germicide impregnated surfaces
 Not designed to protect users from disease causing
microorganisms.
 Protects against stain and odors.
 Not recommended any more in several settings.
66

Sharklet pattern
 New technology aims to inhibit bacterial growth
through physical surface modification alone.
 The surface topography is made of millions of
microscopic diamonds that disrupt the ability for
bacteria to aggregate, colonize, and develop into
biofilms.
 High touch surfaces/ medical equipment
67

Conclusion
 The surface environment in rooms of colonized or
infected patients is frequently contaminated with
pathogens.
 These pathogens are capable of surviving on hospital
room surfaces and medical equipment for a prolonged
period of time.
 Contact with hospital room surfaces or medical
equipment by healthcare personnel frequently leads to
contamination of hands and/or gloves.
68

Conclusion
 Patient admitted to a room previously occupied by a
patient colonized or infected with a pathogen has an
increased likelihood of developing colonization or
infection with that pathogen
 The frequency with which room surfaces are
contaminated correlates with the frequency of hand
and/or glove contamination of healthcare personnel
69

Conclusion
 Clonal outbreaks of pathogens contaminating the
room surfaces of colonized or infected patients are
demonstrated to be due to person-to-person
transmission or shared medical equipment
 Improved terminal cleaning and disinfection of rooms
leads to a decreased rate of infections
70

Conclusion
 These technologies supplement, but do not replace,
standard cleaning and disinfection because surfaces
must be physically cleaned of dirt and debris.
 Additionally, these methods can only be used for
terminal or discharge room decontamination (i.e.,
cannot be used for daily room decontamination)
because the room must be emptied of people.
71

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