New Technologies in Environmental Cleaning. Jim Gauthier, MLT, CIC, Senior Clinical Advisor, Infection Prevention

Transcription

1 New Technologies in Environmental Cleaning Jim Gauthier, MLT, CIC, Senior Clinical Advisor, Infection Prevention

2 Objectives Look at some of the technologies out there Surfaces Ultraviolet Fogging Discuss Pros and Cons

3 Daily Cleaning... Evolution of Disinfectants Improved Hydrogen Peroxide Maximize Efficiency & Effectiveness Legacy Disinfection Phenolics Traditional Disinfection Bleach Quats Cost-effective Dilutable Fast, Effective Reliable Sustainable Broad Spectrum Sporicidal Optimal Patient Outcomes Specialty Tasks Help reduce the risk of infection with effective, safe and sustainable solutions.

4 Disinfectant Chemistries Balancing Tradeoffs 4

5 NIOSH Investigation: Peracetic Acid in Pennsylvania Symptom Reported Symptom No (%) Work Related No (%)* Watery Eyes 31 (40) 20 (29) Nasal Problems 28 (41) 15 (22) Asthma-Like Symptoms 19 (28) 10 (15) Shortness of Breath 11 (16) 5 (7) Skin Problems 10 (15) 7 (10) Wheeze 10 (15) 5 (7) Chest Tightness 9 (13) 2 (3) Cough 3 (4) 1 (1) Asthma Attack 2 (3) 1 (1)

6 How do disinfectants kill? Bacteria and Fungi Breaks cell wall, leaking out intracellular contents (oxidizers) Interrupts cell processes (quat/phenolics) Dehydrates the cell (alcohol) Viruses Chemically reacts with organism and breaks it down Think of it as chemically burning the organism, which causes it to die 6

7 Disinfectants vs. Antibiotics Antibiotics work through a specific lock and key process. Disinfectants are less elegant. They are the sledgehammer to the watermelon or the dragon breathing fire on the unsuspecting village There s minimal risk that bacteria will become immune to disinfectants the way they have antibiotics

8 Antibiotics Lock and Key

9 Antibiotic Resistance 9

10 Analogy for Disinfectants

11 The Family Tree Family Cucurbitaceae Genus Last Name Species First Name

12 Disinfectant Actions:

13 Genetic Mutations Watermelon yum Watermelon ESBL Watermelon CRE

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15 Self Disinfecting Options Altering the surface components to minimize the likelihood that bacteria will adhere or replicate; Coating the surface or fabric with an acknowledged antimicrobial compound whose activity persists; Using a material that has some inherent anti-biofilm or microbiocidal activity.

16 Surface Treatments (Residual Disinfection) There has been ongoing interest in using disinfectants that can leave a residual coating on surfaces. The two main chemistries are quat-siloxane polymers and silver citrate. The benefit (if any) from these products is very limited and the following concerns are raised 16

17 Issues with Residual Disinfection The residual treatments have no demonstrated ability to penetrate soil and kill bacteria. Using surface treatments does not remove the need to clean surfaces and treatments must be refreshed periodically.

18 Issues with Residual Disinfection Used in addition to surface disinfection, surface treatments may provide some limited benefit, but it s not a replacement for surface disinfection. Surface treatments can make surfaces slippery, or can build up over time, and may discolor some surfaces.

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20 Organo-Silanes Silicone and a quaternary ammonium moiety <1log reduction NOTE: mean Aerobic colony count in rooms was colonies before cleaning?possible quat binding, as product applied with microfiber

21 Used a isopropyl alcohol/organofunctional silane solution (IOS) surface treatment. Showed a significant drop in aerobic colony counts and RLU assessment with ATP (<45 is clean)

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23 Photo-Activated Surfaces (Humphries 2014) Titanium dioxide (TiO 2 ) When UV comes in contact, reactive oxygen species are released Some antimicrobial properties Methylene Blue / Gold Nanoparticles 99% (2 log) reduction in surface bacteria (Ismail 2011)

24 Surface Composition Making a surface out of a material that is naturally bacteriostatic or bactericidal Copper Copper alloys Silver Silver alloys

25 Copper Google Copper Surfaces and get 1.9 million hits Canadian Agency for Drugs and Technology in Health (CADTH) Provides some killing between routine environmental cleaning

26 Copper Metallic copper has intrinsic and continuous broad spectrum antimicrobial spectrum Alloys of up to 60% (including brass and bronzes) offer strength, durability, color selection and tarnish resistance Lab tests indicate 99.9% kill within 2 hours, an ongoing kill at 99% Kill effect should not stop through life of product Now Health Canada and EPA registered

27 Copper A study where high touch surfaces in an ICU were replaced with copper impregnated surfaces showed a statistically significant reduction in overall HAI and MRSA/VRE colonization (Salgado 2013) No adverse effects noted from copper in rooms

28 Copper Costs Cost estimates for UK ICU: Using a 20% reduction in HAI, even with a 30,600 increase in cost to install, there would be a 2,000,000 savings over 5 years. US: $ $15000 per room, 420 beds then $3-6 million to outfit, but annual savings of $7.2 mil per year or operating expense savings of $66 mil over 10 years.

29 Copper Alloy Coatings Still experimental Study done at Toronto General Hospital and showed a 65% reduction in surface colony counts (overall microbial burden).

30 Issues Not an instantaneous kill, varies in the 20 minutes to hours range Still needs to be cleaned, and seeing discoloring issues with some ongoing experiments

31 No Touch Disinfection Due to limitations of quality and consistency of discharge (terminal) patient room cleaning, there has been growing interest in using technology to eliminate the variability. The two primary technologies are fogging systems, using vaporized hydrogen peroxide, and irradiation, using UV light. With both technologies, the room must be cleaned before use to remove soils. 31

32 Fogging Uses hydrogen peroxide misted onto room surfaces to coat surfaces with fine droplets of peroxide Delivers excellent efficacy (6 log), but can take hours to turn around a room Room must be sealed and HVAC disabled during cycle Room air must be cleaned of peroxide before re-entry.

33 Used on 5 high CDI incidence wards Reduction in rate from 2.28 to 1.28 p=0.47

34 Ultraviolet Light

35 Ultraviolet C Light

36 How UVc Light Works

37 Common Questions Is it safe? Yes, there are sensors that shut machine off if door opened. Additional barriers are across door. UV light doesn t penetrate through glass The odor is skin/hair remnants Does it work? Yes, in the laboratory it has been demonstrated that it kills bacteria.

38 Types of UVC technology available Steady state low pressure mercury bulbs versus xenon bulbs (pulsed UV-C) UV-C dose based on either by measuring direct and/or reflected light OR using a preset dose. Measurement of UV-C either with remote wireless sensors placed in different room areas or via sensors on the emitter to measure light reflected back to the device

39 UV Energy Inverse Square Law: Energy decreases by the square of the distance Energy at bulb or up to 1 foot = 100 arbitrary units Energy at two feet = 25 units (100/4 [the square of 2]), not 50 Energy at three feet = 11 units (100/9 [the square of 3]), not 33 Energy at four feet = 6.25 units (100/16 [the square of 4]), not 25

40 The Angle of Incidence Affects Energy Applied

41 Effective Dosing Horizontal and Vertical Surfaces 1. Bed Rails / Controls 2. Tray Table 3. IV Pole 4. Call Box / Button 5. Telephone 6. Bedside Table Handle 7. Chair 8. Room Sink 9. Room Light Switch 10.Room Inner Door Knob 11.Bathroom Light Switch 12.Bathroom Hand Rails 13.Bathroom Sink 14.Toilet Seat 15.Toilet Flush Handle 16.Toilet Bedpan Cleaner CDC List of high touch surfaces Horizontal Surfaces

42 Additional High Risk Surfaces: 1. Television Remote 2. Computer Keyboards 3. IV Pump Control 4. Multi-Module Monitor Controls Effective Dosing Horizontal and Vertical Surfaces 5. Multi-Module Monitor Touch Screen 6. Multi-Module Monitor Cables 7. Ventilator Control Panel 8. Bedside Commodes

43 UVC and Sunbathing

44 Combination of distance and angle can radically impact the amount of time it takes to effectively disinfect with UV Distance & Angle Matter

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46 Issues with Standardization Exposure time Exposure intensity Angle of exposure Perpendicular, vertical, 45 o Organisms tested or measured Aerobic Colony Counts Outcomes

47 Does UVC work clinically? Many studies to show decrease in bioburden Limited studies on impact on HAI reduction Vianna PG AJIC 2016:44: : historical comparison Napolitano NA AJIC 2015;43:1342-6: historical comparison Anderson DJ et al. Lancet 2017; 389:

48 UV vs Fogging Havill 2012 Compared both systems head to head Fogging wins in all categories Measure H 2 O 2 UV Some ACC After Treatment O 52% CD log reduction >6 ~2 Cycle Time Min

49 UV vs Fogging Both technologies can deliver some efficacy. Fogging delivers better efficacy, but with longer cycle times. UV delivers short cycle times, but less efficacy. Fogging units cost significantly less than UV units on average

50 Summary If you have to clean first, clean and disinfect well! Train staff well In outbreaks or hyper-endemic situations, need to consider as an adjunct Copper is still in its infancy, more research on durability and cleanability needed.

51 References Anderson JL, et al. Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study. Lancet 2017;389: Boyce JM, et al. Impact of hydrogen peroxide vapor room decontamination on Clostridium difficile environmental contamination and transmission in a healthcare setting. ICHE 2008;29(8):723-9 Boyce JM, et al. Evaluation of two organosilane products for sustained antimicrobial activity on high-touch surfaces in patient rooms. ICHE 2014;(40):326-8

52 References Havill NL, et al. Comparison of the microbiological efficacy of hydrogen peroxide vapor and ultraviolet light processes for room decontamination. ICHE 2012;33(5): Hinsa-Leasure S, et al. Copper alloy surfaces sustain terminal cleaning levels in a rural hospital. AJIC 2016;44:e Humphries H. Self-disinfecting and microbiocide-impregnated surfaces and fabrics: what potential in interrupting the spread of healthcare-associated infection? Clinical Infectious Diseases 2014;58(6): Ismail S, et al. Efficacy of a novel light-activated antimicrobial coating for disinfecting hospital surfaces. ICHE 2011;32(11):1130-2

53 References Ndegwa S. Antimicrobial Copper Surfaces for the Reduction of Health Care Associated Infections in Intensive Care Settings [Issues in emerging health technologies, Issue 133]. Ottawa: Canadian Agency for Drugs and Technologies in Health; Salgado CD, et al. Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit. ICHE 2013;34(5):