Literature Review and Practice Recommendations: Existing and emerging technologies used for decontamination of the healthcare environment Microfibre

Transcription

1 Literature Review and Practice Recommendations: Existing and emerging technologies used for decontamination of the healthcare environment Microfibre Version: 1.1 Date: December 2016 Review: December 2019

2 DOCUMENT CONTROL SHEET Key Information: Title: Existing and emerging technologies used for decontamination of the healthcare environment: Microfibre Date Published/Issued: December 2016 Date Effective From: December 2016 Version/Issue Number: 1.1 Document Type: Literature Review Document status: Final Author: Name: D. Scott, F. Hansraj Role: Healthcare Scientists (Health Protection) Division: HPS Owner: Infection Control Approver: Annette Rankin Approved by and Date: December 2016 Contact Name: Infection Control Team Tel: Version History: This literature review will be updated in real time if any significant changes are found in the professional literature or from national guidance/policy. Version Date Summary of changes Changes marked 1.1 December 2016 Addition of categories for recommendations. No changes made to the content of the literature review. 1.0 May 2015 Final for publication Version 1.1. December 2016 Page 2 of 18

3 Contents Topic... 4 Background... 4 Aim... 5 Objectives... 5 Research Questions... 5 Methodology... 6 Search Strategy... 6 Exclusion Criteria... 6 Screening... 7 Critical Appraisal... 7 Results... 7 Research Questions... 8 Discussion Recommendations for Clinical Practice Implications for Research Conclusion Appendix 1: MEDLINE Search References Version 1.1. December 2016 Page 3 of 18

4 Topic The use of microfibre products for decontamination of the healthcare environment. Background Current microbiological and epidemiological evidence indicates that contaminated surfaces in hospital settings can contribute to the transmission of nosocomial pathogens. 1 In particular, there appears to be a risk of pathogen acquisition from prior room occupants for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Clostridium difficile and Acinetobacter baumannii. 2 Accordingly, existing research implies that improved surface cleaning and disinfection can reduce healthcare-associated infections. 3 Manual processes for routine and terminal cleaning are frequently sub-optimal, indicating that novel technologies might offer an opportunity to improve cleaning efficacy and consistency. 4 Recent evidence indicates that microfibre cleaning products may be more efficient at removing soil and associated microbes than traditional cotton cleaning products. 5 There are two major types of microfibre product currently in use: microfibre products that are composed of synthetic polyamide and polyester fibres, and ultramicrofibre products that are similarly composed but particularly fine. 6 The advantages of microfibre products include their increased cleaning efficacy over standard cotton cloths or mops, and a lower tendency to bind quaternary ammonium compound disinfectants 7 (although these disinfectants are not widely used in Scotland 8 ). Among their disadvantages, there are claims that they cannot be used with chlorine-releasing agents as these disinfectants potentially damage the microfibres, shortening the life-span of the product. 6 Equally, the high temperatures used during laundering and drying can decrease their performance. 7 There is the potential risk that microfibre products may in fact contribute to cross-transmission by binding bacteria and transferring them from surface to surface. 7 However, single-use disposable microfibre products are prohibitively expensive at the present moment in time. 6 It has been reported that microfibre products are able to remove surface micro-organisms linked to healthcare-associated infections. 9 For this reason, it would be pertinent to evaluate the potential use of microfibre as an acceptable alternative to the current standard of cotton products recommended for use within NHSScotland. 10 This review intends to assess the evidence base on the appropriateness of using microfibre products for both routine cleaning and terminal cleaning in the healthcare environment. Version 1.1. December 2016 Page 4 of 18

5 Aim To review the evidence base for using microfibre products for decontamination of the healthcare environment. Objectives To provide a generic description of microfibre, including the proposed or actual mechanism of action and the procedure for use. To assess the scientific evidence for effectiveness of microfibre. To explore practical and safety considerations related to the use of microfibre. To explore the costs associated with microfibre. To produce a concise evidence summary for microfibre to assist the Equipment and Environmental Decontamination Steering Expert Advisory Group in making practical recommendations on the use of microfibre for NHSScotland. Research Questions The following research questions will be addressed: 1. Is microfibre currently in use in UK healthcare settings? 2. What is the actual or proposed mechanism of action of microfibre? 3. What is the procedure for using microfibre? 4. What is the scientific evidence for effectiveness of microfibre for decontamination of the healthcare environment? 5. Are there any safety considerations associated with using microfibre in the healthcare setting? 6. Are there any practical or logistical considerations associated with using microfibre in the healthcare setting? 7. What costs are associated with using microfibre in the healthcare setting? 8. Has microfibre been assessed by the Rapid Review Panel? Version 1.1. December 2016 Page 5 of 18

6 Methodology Search Strategy The following databases and websites were searched to identify relevant academic and grey literature: MEDLINE CINAHL EMBASE NHS Evidence ( Health Technology Assessment (HTA) database ( Database of Abstracts of Reviews of Effects (DARE) ( National Patient Safety Agency (NPSA) ( National Institute for Health and Care Excellence (NICE) ( Medicines & Healthcare products Regulatory Agency (MHRA) ( Rapid Review Panel (RRP): product evaluation statements ( Search terms were developed and adapted to suit each database/website. Initial literature searches were run between 24/06/2014 and 01/07/2014. For the update, the literature search was performed on 30/08/2016. The same search strategy was applied in both years. See Appendix 1 for an example of the search run in the MEDLINE database. Exclusion Criteria Academic and grey literature was excluded from the review on the basis of the following exclusion criteria: Article was released before 2004 Article was not published in the English language Article does not concern decontamination using microfibre in the healthcare environment (off-topic) Article is an opinion piece, a non-systematic review or a conference abstract Version 1.1. December 2016 Page 6 of 18

7 Article does not present evidence compatible with the McDonald-Arduino evidentiary hierarchy 11 Article concerns a study that did not have an appropriate comparison in the form of Screening standard cleaning methods There was a two-stage process for screening the items returned from the literature searches. In the first stage, the title/abstract was screened against the exclusion criteria by the lead reviewer. Items that were not excluded at the screening stage progressed to the second screening stage. In the second stage of the screening process, the full text of remaining items was screened against the exclusion criteria by the lead reviewer. Items that were not excluded at the second screening stage were included in the review. Critical Appraisal Critical appraisal of the studies included in this review and considered judgement of the evidence was carried out by the lead reviewer using the Scottish Intercollegiate Guidelines Network (SIGN) methodology. 12 The McDonald-Arduino evidentiary hierarchy was used as a framework for assessing the evidence. 11 Results The original search found 149 articles. After the first stage of screening this was reduced to 30 articles, and after the second stage there were four articles to critically appraise The update search retrieved a further 16 articles, of which six passed the first stage of screening, and two were critically appraised. 17;18 The six included studies used two different types of microfibre product: four studies used traditional microfibre 13;16-18 and two studies used ultramicrofibre. 14;15 Three of the six studies were conducted in the United Kingdom (UK), one was based in the United States of America (USA), 16 another was located in Canada, 18 and the final study was undertaken in Australia. 17 Two studies demonstrated that microfibre products were marginally more effective than cotton products, 17;18 although one of these studies used microfibre in conjunction with steam cleaning. 17 One study showed that microfibre products were less effective than cotton products when used in combination with a disinfectant, but more effective when a detergent was used. 16 Another study found that microfibre showed poor efficacy against a chlorine-releasing agent. 13 The two studies investigating the use of ultramicrofibre products both observed that they were more effective than cotton products, but combined their use with a copper biocide disinfectant. 14;15 Version 1.1. December 2016 Page 7 of 18

8 Research Questions Is microfibre currently in use in UK healthcare settings? Microfibre products are mentioned in The NHSScotland National Cleaning Services Specification, 10 the National Patient Safety Agency (NPSA) Revised Healthcare Cleaning Manual 19 and the Association of Healthcare Cleaning Professionals (AHCP) Revised Healthcare Cleaning Manual 20. The NHSScotland National Cleaning Services Specification 10 recommends that microfibre products may be used for cleaning a wide variety of surfaces including hard flooring, walls and doors, curtains and bed screens, sanitary fixtures and fittings, and furniture. The NPSA and AHCP Revised Healthcare Cleaning Manuals 19;20 both include sections on microfibre cloths and mops in their guidance. They recommend that NHS Trusts in England should consider implementing the routine use of microfibre technology. In addition, they provide background information on microfibre technology, including its strengths and limitations, as well as referring to published reports on their implementation for routine use. These findings suggest that microfibre products are widely in use within UK healthcare settings. What is the actual or proposed mechanism of action of microfibre? Microfibres are composite synthetic fibres typically made from polyesters, polyamides or a conjugation of polyester and polyamide. These fibres measure less than one denier, which is approximately one hundredth of the size of a human hair. 21 These fibres are woven into a fabric that provides approximately 40 times more surface area than a fabric made of cotton. 21 Microfibres accumulate organic matter as a result of electrostatic attraction, capillary action or a combination of the two. As the fibres are very small, they are able to reach into crevices that might be inaccessible to conventional cleaning materials. 22 Ultramicrofibres are finer than traditional microfibres (< 0.3 decitex or < 30 km/g) but have a similar mechanism of action. 23 What is the procedure for using microfibre? Microfibre cloths and mops are typically designed to be used dry or dampened with low volumes of water that does not contain disinfectants. 23 As a result, they would not be recommended for use in situations where disinfectants are considered essential. 22 However, some manufacturers explicitly market their microfibre products as safe to use with bleach. 24 Laundry guidance states that microfibre products cannot be laundered with chlorine-releasing agents. Reusable microfibre cloths and mops that can be used with bleach also come with manufacturer guidelines on how many times they can be laundered this tends to approximate 100 times with bleach and 250 times without bleach. 24 Disposable single-use microfibre cloths are also available. 25 Two studies looked Version 1.1. December 2016 Page 8 of 18

9 at the use of ultramicrofibre products, typically inco mpatible with standard biocides, to apply a novel copper-based biocide that they found to be clinically effective. 14;15 What is the scientific evidence for effectiveness of microfibre for decontamination of the healthcare environment? One interrupted time series, 17 four non-randomised controlled clinical trials and one nonrandomised controlled laboratory trial 18 evaluated the efficacy of microfibre for decontamination of the healthcare environment. It was demonstrated that this intervention had a variable effect on pathogen transmission and microbial bioburden. As detailed in the methodology, the McDonald-Arduino evidentiary hierarchy 11 was used as a framework for assessing the evidence relevant to this research question. Level V Demonstration of reduced microbial pathogen acquisition (colonisation or infection) by patients via non-outbreak surveillance testing and clinical incidence: The interrupted time series by Gillespie et al. 17 compared the efficacy of steam cleaning and microfibre cloths against standard terminal cleaning using detergent, followed by 1,000 ppm sodium hypochlorite solution, on the transmission of VRE in the ICU of an acute medical-surgical and trauma facility in Monash (Australia). Following the four-month baseline period of standard cleaning, the VRE transmission rate initially fell but then transiently increased, coinciding with a reduction in cleaning staff hours as a consequence of the allocation of additional responsibilities to the staff. A further significant improvement was demonstrated 15 months after introduction of the intervention (p = 0.003). The study combined multiple intervention components hence, it was not possible to determine whether this impact was solely from the use of steam cleaning or microfibre technology. In addition, a number of potential confounding factors were identified: an educational programme for cleaning staff, training in the use of fluorescent markers for monitoring of environmental contamination, and alterations in cleaning staff working hours. Level IV Demonstration of reduced microbial pathogen acquisition (colonisation or infection) by patients via outbreak surveillance testing and clinical incidence: No evidence identified. Level III Demonstration of in-use bioburden reduction that may be clinically relevant: No evidence identified. Level II Demonstration of in-use bioburden reduction effectiveness: Four non-randomised controlled clinical trials compared the use of microfibre or ultramicrofibre cloths and mops with standard cleaning methods in terms of in-use bioburden reduction. Two studies 14;15 showed that these products were more effective at reducing microbial bioburden Version 1.1. December 2016 Page 9 of 18

10 relative to standard cleaning products. Both of these studies used detergent as their standard cleaning method and tested ultramicrofibre products with a copper biocide disinfectant. The third study 13 tested microfibre cloths with or without a combined detergent and disinfectant, and concluded that standard cleaning using a chlorine-releasing agent was more effective than cleaning using microfibre. The fourth study 16 tested the use of microfibre mops with either a detergent or a disinfectant and showed that microfibre mops were more effective than standard cotton mops when tested with detergent and less effective when tested with a disinfectant. Level I Laboratory demonstration of bioburden reduction efficacy: The non-randomised controlled laboratory trial by Trajtman et al. 18 evaluated the use of microfibre cloths in removing C. difficile spores from a ceramic surface, in comparison with traditional cotton cloths; in both cases using a non-sporicidal hydrogen peroxide cleaning agent. The reduction in microbial bioburden was measured using viable spore counts. Microfibre cloths were found to remove significantly more spores (log 10 reduction of 2.4) than cotton cloths (log 10 reduction of 1.7). In addition, microfibre cloths transferred fewer spores during cleaning (1.7 log 10 ) than cotton cloths (2.4 log 10 ), indicating that microfibre cloths were more effective at preventing cross-transmission of spores during cleaning. However, the study was laboratory-based, rather than clinically-based, and it may therefore not be appropriate to extrapolate the findings of this study to the clinical setting. To summarise the evidence, it can be concluded that there is insufficient and inconsistent evidence to support the use of microfibre products for routine and terminal cleaning procedures in the healthcare environment. In accordance with SIGN methodology, all of the studies were designated level 3 (low-quality) evidence. Are there any safety considerations associated with using microfibre in the healthcare setting? Microfibre cloths are intended for use in general purpose cleaning either with or without water. The use of disinfectants is not recommended as these may degrade the microfibres. As a consequence, microfibre materials are not suitable for cleaning up blood or body fluids, or for use in areas where the use of disinfectants is essential. 22 As mentioned previously, there are some manufacturers which explicitly state that their products are suitable for use with bleach, 24 but the studies included in this review did not evaluate any of these products. Due to their ability to store particles in their fibres, microfibre cloths and mops can become contaminated with viable micro-organisms after use, potentially making them capable of contaminating the healthcare environment with these micro-organisms. 23 For this reason, disposable microfibre cloths and mops are available for single-use purposes. 25 Version 1.1. December 2016 Page 10 of 18

11 Are there any practical or logistical considerations associated with using microfibre in the healthcare setting? A key issue with all the microfibre products included in this review is the incompatibility with chlorine-based products, i.e. disinfectants that are recommended for environmental decontamination in some circumstances and widely used in the hospital environment. 26;27 Reusable mops and cloths also need to be laundered in purpose-built and validated washing machines that clean the materials using heat and water to avoid degradation of the microfibres. 22;28 There is conflicting evidence on the issue of whether microfibre performs best when new or after repeated washing. One study found that the advantage of using new microfibre mops and cloths was lost after repeated washing. 21 However, another study showed that the performance of microfibre mops and cloths improved with repeated washing, implying that they could be re-used many times assuming that adequate decontamination could be assured. 9 These microfibre mops and cloths came with guidance on how many times they could be laundered before their cleaning efficacy deteriorated. Microfibre tends not to perform as well as old and damaged surfaces because the fibres are more likely to snag on surface defects, making it more difficult to wipe these surfaces. It is worth taking such factors into consideration when deciding what kind of cloth to use for cleaning. It is also important to keep in mind that the materials are designed to be part of a total cleaning system and must be used to see the desired effects. 22 What costs are associated with using microfibre in the healthcare setting? The introduction of a microfibre system requires a capital investment to purchase and stock cleaners trolleys, with possible costs if storage facilities and laundry equipment need modification. Other costs to consider include laundering the mops and cloths, and replacement of these on reaching the end of their life cycle. It is also worth considering that, although a microfibre system might require many additional items, as the cloths and mops weigh less than conventional ones, more of them can be accommodated in a wash-load if the mops and cloths are being reused. 22 The number of times the mops and cloths can be washed should also be taken into account when calculating overall costs. 9 There are a number of factors involved in using conventional and microfibre materials, with many types of mops and cloths, all with different laundry requirements and expected service life; therefore, it is difficult to directly compare the costs involved. 22 Version 1.1. December 2016 Page 11 of 18

12 Has microfibre been assessed by the Rapid Review Panel? The Rapid Review Panel 29 (RRP) is a panel of UK experts established by the Department of Health to review new technologies with the potential to aid in the prevention and control of healthcareassociated infections. No microfibre products have been reviewed by the RRP to date. Discussion This systematic review incorporated the results of six studies into its findings. The quality of included studies was solely of level 3 (low-quality) evidence, concerning reduction of pathogen acquisition in a non-outbreak setting (level V) and in-use or laboratory bioburden reduction (level II and I, respectively). The study design of choice was either an interrupted time series or a nonrandomised controlled trial. The findings identified by the review were used to develop the following recommendations for clinical practice. Recommendations for Clinical Practice This review makes the following recommendations based on an assessment of the extant professional literature on microfibre products for environmental decontamination: The compatibility of microfibre cloths and mops with hypochlorite products must be established with manufacturers, taking into account the product properties and laundry specific guidance for reusable mops and cloths. (Grade D recommendation) Manufacturers instructions must be followed, ensuring adherence to the maximum number of uses; therefore, a system for product re-use must be in place and monitored for compliance. (Grade D recommendation) A monitoring system must be in place to ensure that microfibre cloths and mops are not laundered beyond the recommendation of the manufacturer. (Good Practice Point) Reusable microfibre cloths and mops must be washed in purpose-built laundries with validated washing machines that clean the materials using heat and water to avoid degrading the microfibres, ensuring that products are laundered in line with the manufacturers recommendations. (Grade D recommendation) Version 1.1. December 2016 Page 12 of 18

13 Reusable microfibre cloths and mops should not be used for cleaning the rooms of patients who are experiencing loose stools or with a known alert organism (or ward closure) as in these instances chlorine-based disinfectants must be used. (Grade D recommendation) All staff involved in the use of microfibre cloths and mops must be trained in their use. (Good Practice Point) If NHS boards adopt disposable microfibre products for environmental decontamination, the following must be considered: The compatibility of microfibre cloths and mops with hypochlorite products must be established with manufacturers. (Grade D recommendation) Each item is used for a single task/patient area. (Grade D recommendation) All staff involved in the use of microfibre cloths and mops must be trained in their use. (Good Practice Point) Implications for Research The review identified several gaps in the literature in relation to microfibre. Many of the relevant studies identified could not be included in this review as they did not make a suitable comparison in the form of standard cleaning as recommended for NHSScotland in the National Infection Prevention and Control Manual. 8 Future studies assessing the clinical effectiveness of microfibre products for decontamination should include suitable comparison groups to enable the results to be transferable to clinical practice within NHSScotland. The extant research focussed predominantly upon the efficacy of microfibre products in reducing environmental bioburden, whether clinically-based or laboratory-based. Extrapolating the findings of such studies to the prevention of nosocomial infections may not be valid under normal clinical working conditions. It is therefore necessary to conduct further studies demonstrating the effect of microfibre products on the reduction of healthcare-associated infections before conclusions on the efficacy of microfibre can be reached. Finally, very few studies thus far have evaluated the cost-effectiveness of microfibre. Of the few that have, the majority have concentrated on the capital costs of the necessary equipment and the cost of purpose-built laundry facilities. It can therefore be seen that a comprehensive costeffectiveness evaluation for the use of microfibre in NHSScotland would be timely. Version 1.1. December 2016 Page 13 of 18

14 Conclusion The contribution of environmental contamination in healthcare settings to the cross-transmission of nosocomial infections has been thoroughly demonstrated: firstly, by interventional studies in which improved surface cleaning has reduced the incidence of HAIs; 1 and secondly, by observational studies which have evidenced the higher risk of pathogen acquisition in patients admitted to rooms where the prior occupant was known to be infected or colonised. 2 Microfibre provides an example of a novel technology that may supplement standard cleaning practices and potentially further reduce the transmission of nosocomial pathogens. This review aimed to provide a concise evidence summary outlining: the evidence of effectiveness for, the practical and safety considerations of, and the costs associated with, the use of microfibre. The review found that there was insufficient and inconsistent evidence to support the use of microfibre decontamination for routine and terminal cleaning procedures in the healthcare environment. Six studies compared the use of microfibre products against standard cleaning using cotton products, with or without the use of a detergent or disinfectant, in reducing pathogen transmission or microbial bioburden. Two of these studies demonstrated that microfibre products were marginally more effective than cotton products, although one of these studies used microfibre in conjunction with steam cleaning. One study showed that microfibre products were less effective than cotton products when used in combination with a disinfectant, but more effective when a detergent was used. Another study found that microfibre showed poor efficacy against a chlorinereleasing agent, while the two studies investigating the use of ultramicrofibre products both observed that they were more effective than cotton products, but combined their use with a copper biocide disinfectant. If microfibre products are to be used by NHS Boards, their compatibility with chlorine-releasing agents must be established, otherwise they will not be suitable for routine and terminal cleaning under transmission-based precautions. Microfibre cloths and mops must be laundered with validated equipment, ensuring that the inappropriate use of high temperatures and chemical disinfectants does not result in degradation of the product. Similarly, because microfibre products may only be laundered a limited number of times, a monitoring system must be implemented to ensure that to confirm that microfibre cloths and mops are not being reused excessively. The Rapid Review Panel (RRP) has not yet evaluated any microfibre products. If NHS Boards wish to adopt microfibre products, they must be aware that these products have not been reviewed or approved by the RRP. Version 1.1. December 2016 Page 14 of 18

15 Appendix 1: MEDLINE Search Ovid MEDLINE(R) 1946 to present with daily update AND Ovid MEDLINE(R) In-process & other non-indexed citations Search dates 24/06/2014 and 25/06/ /08/ (all OR ) 2 (all OR ) microfibre.mp. microfiber.mp. ultramicrofibre.mp. ultramicrofiber.mp. AND Sterilization/ Decontamination/ Disinfection/ Housekeeping, Hospital/ clean*.mp. Limits English Language Publication Year Results: 38 Publication Year 2014 Current Results: 4 Version 1.1. December 2016 Page 15 of 18

16 References (1) Otter JA, Yezli S, Salkeld JA, French GL. Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings. AM J INFECT CONTROL 2013;41:S6-S11. (2) Mitchell BG, Dancer SJ, Anderson M, Dehn E. Risk of organism acquistion from prior room occupants: a systematic review and meta-analysis. Journal of Hospital Infection 2015;91: (3) Donskey CJ. Does improving surface cleaning and disinfection reduce health careassociated infections? AM J INFECT CONTROL 2013;41:S12-S19. (4) Carling P. Methods for assessing the adequacy of practice and improving room disinfection. AM J INFECT CONTROL 2013;41:S20-S25. (5) Mafu AA, Massicotte R, Pichette G, Lafleur S, Lemay MJ, Ahmed D. Influence of surface and cloth characteristics on mechanical removal of meticillin-resistant Staphylococcus aureus (MRSA) attached to inanimate environmental surfaces in hospital and healthcare facilities. International Journal of Infection Control 2013;9:3. (6) Dancer SJ. Controlling hospital-acquired infection: focus on the role of the environment and new technologies for decontamination. Clinical Microbiology Reviews 2014;27(4): (7) Boyce JM. Modern technologies for improving cleaning and disinfection of environmental surfaces in hospitals. Antimicrobial Resistance and Infection Control 2016;5:10. (8) Health Protection Scotland. National Infection Prevention and Control Manual Accessed: (9) Smith DL, Gillanders S, Holah JT, Gush C. Assessing the efficacy of different microfibre cloths at removing surface micro-organisms associated with healthcare-associated infections. Journal of Hospital Infection 2011;78(3): (10) Health Facilities Scotland. The NHSScotland National Cleaning Services Specification The%20NHSScotland%20National%20Cleaning%20Services%20Specification%20%20- %20June% pdf Accessed: (11) McDonald LC, Arduino M. Climbing the evidentiary hierarchy for environmental infection control. Clinical Infectious Diseases 2013;56(1):36-9. (12) Scottish Intercollegiate Guidelines Network. SIGN 50 A guideline developer's handbook Accessed: (13) Doan L, Forrest H, Fakis A, Craig J, Claxton L, Khare M. Clinical and cost effectiveness of eight disinfection methods for terminal disinfection of hospital isolation rooms contaminated with Clostridium difficile 027. Journal of Hospital Infection 2012;82(2): (14) Hall T, Jeanes A, Coen P, Odunaike A, Hickok S, Gant V. A hospital cleaning study using microfibre and a novel copper biocide. I. Microbiological studies. Journal of Infection Prevention 2011;12(5): Version 1.1. December 2016 Page 16 of 18

17 (15) Hall T, Jeanes A, McKain L, Jepson M, Coen P, Hickok S, et al. A UK district general hospital cleaning study: a comparison of the performance of ultramicrofibre technology with or without addition of a novel copper-based biocide with standard hypochlorite-based cleaning. Journal of Infection Prevention 2011;12(6): (16) Rutala WA, Gergen MF, Weber DJ. Microbiologic evaluation of microfiber mops for surface disinfection. AM J INFECT CONTROL 2007;35(9): (17) Gillespie E, Williams N, Sloane T, Wright L, Kotsanas D, Stuart RL. Using microfiber and steam technology to improve cleaning outcomes in an intensive care unit. AM J INFECT CONTROL 2015;43(2): (18) Trajtman AN, Manickam K, Alfa MJ. Microfiber cloths reduce the transfer of Clostridium difficile spores to environmental surfaces compared with cotton cloths. AM J INFECT CONTROL 2015;43(7): (19) National Patient Safety Agency. The Revised Healthcare Cleaning Manual Accessed: (20) Association of Healthcare Cleaning Professionals. Revised Healthcare Cleaning Manual v2.pdf Accessed: (21) Diab-Elschahawi M, Assadian O, Blacky A, Stadler M, Pernicka E, Berger J, et al. Evaluation of the decontamination efficacy of new and reprocessed microfiber cleaning cloth compared with other commonly used cleaning cloths in the hospital. AM J INFECT CONTROL 2010;38(4): (22) Department of Health. An Integrated Approach to Hospital Cleaning: Microfibre Cloth and Steam Cleaning Technology ofibre_report Accessed: (23) Hamilton D, Foster A, Ballantyne L, Kingsmore P, Bedwell D, Hall TJ, et al. Performance of ultramicrofibre cleaning technology with or without addition of a novel copper-based biocide. Journal of Hospital Infection 2010;74(1): (24) Rubbermaid Commercial Products. Rubbermaid Professional Microfibre Cloths Accessed: (25) Gillespie E, Lovegrove A, Kotsanas D. Health care workers use disposable microfiber cloths for cleaning clinical equipment. AM J INFECT CONTROL 2015;43(3): (26) Lehman D. Microfibers, macro benefits. Health care facilities discover microfiber mops and cloths. Health Facilities Management 2004;17(1):42-4. (27) Wren MWD, Rollins MSM, Jeanes A, Hall TJ, Coen PG, Gant VA. Removing bacteria from hospital surfaces: a laboratory comparison of ultramicrofibre and standard cloths. Journal of Hospital Infection 2008;70(3): (28) Moore G, Griffith C. A laboratory evaluation of the decontamination properties of microfibre cloths. Journal of Hospital Infection 2006;64(4): Version 1.1. December 2016 Page 17 of 18

18 (29) Public Health England. Rapid Review Panel Accessed: Version 1.1. December 2016 Page 18 of 18