ESCMID Online Lecture Library. by author

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1 What is the role of the healthcare environment in hospital-acquired infection? Dr Stephanie Dancer, NHS Scotland smuht.nwest.nhs.uk

2 Maidstone Hospital Cleaning Room Sink Sunday Times: UK (2008)

3 Why are we still debating the role of cleaning? Invisible Aesthetic bias Evidence-based science? No accepted measure Women's work Fabric deficits Costly Low paid; low status; and dirty

4 MRSA Acinetobacter C.difficile VRE Norovirus Properties of hospital pathogens Survival time Infectious dose 7 days to >7 months 4 cfu s 3 days to >5 months 250 cfu s >5 months 7 spores 5 days to >4 months <10 3 cfu s 8 hours to 7 days virions Kramer, BMC Infect Dis, 2006; Wagenvoort, JHI 2000; Chiang, Crit Care Med 2009; Wilcox M, 2010; Larson, Lancet 1978; Kjerulf et al, APMIS 1998

5 If we only had eyes to see...what would we see?

6 Where are the pathogens in a hospital? VisinVis project, 2012

7 C.difficile on skin; C.difficile in the environment: CID 2007 Percentages of C.difficile skin (A) and environmental (B) contamination among study groups. Samples from skin and environmental surfaces were collected for culture concurrently with stool samples from patients with C. difficile associated disease (CDAD), asymptomatic faecal carriers, and non-carriers (negative stools).

8 Percentage of positive environmental cultures for C.difficile before and after cleaning and after disinfection with 10% bleach Frequently touched surfaces in rooms of patients with CDAD remain contaminated even after terminal cleaning Eckstein et al, BMC Infect Dis, 2007

9 It s just as easy to pick up microbes from the environment as it is from the patient and the next patient in this room is also at risk Carling & Bartley AmJIC 2009

10 Date Specimen site Environment PFGE profile Foot 15e Nose 15b/15z/ Foot / Groin 15h Nose 15a Nose 15d Groin 15b/15z/ Computer Patient notes Overbed table Throat 15a Heel 15b/15z/ Patient notes 15b/15z/ Hoist / Door handle / Throat 15b/15z/ Leg 124b Central line tubing / Stoma Hoist 15a Bedside locker 15a Desk 15e Arm 15b/15z/ Catheter line 15b/15z/ Bed frame 15e Overbed table 15b/15z/ Throat 16-98/ Nose Bed frame 15a Bed frame 15e Hoist 15d Desk 15b/15z/ Throat 15b/15z/ BP stand 15b/15z/15-71 * Molecular relationships between patient & environmental MRSA Nose 15a Dancer et al, BMC Med 2009 * * * *

11 Dancer et al, BMC Med, 2009 *

12 Persistence of mixed staphylococci assemblages following disinfection of hospital room surfaces PCR products of staphylococci from surface swabs collected before and after daily cleaning Brackets above fingerprints indicate paired samples representing communities collected from the same surface before and after cleaning. Sigler & Hensley, J Hosp Infect 2013

13 Links between environmental, personnel and patient strains of MDR-Gram-negative bacilli from ICUs recovery of MDR-GNB from inanimate surfaces persisted even after colonized patients were discharged from ICU The environment should be considered as a source of MDR-GNB even when patients cannot be identified with these pathogens Env Staff Pt D Agata EM et al, J Clin Microbiol 1999 Betteridge T et al, Microb Drug Resist 2012

14 AIR Dynamic transmission cycle of hospital pathogens Patients Hands Environment

15 'Bioaerosol deposition in single and two-bed hospital rooms: a numerical and experimental study', King MF et al, Build & Environ 2012

16 Just hanging around.airborne Clostridium difficile! Spore Terminal velocity Fallout time (hours) from a height of: length (mm/s) 1 m 2 m 3 m 4 m 0.79 mm a mm b mm b mm b mm c a Shortest overall spore length b Average spore lengths for 3 tested strains c Longest overall spore length Snelling et al, ICHE 2010

17 Are patients hands the missing link? Banfield & Kerr, J Hosp Infect 2005 There are pathogens on patients hands as well Istenes et al, Am J Infect Control 2013 Cleaning patients hands reduces MRSA infection rates Gagne et al, J Hosp Infect 2010

18 How good is the cleaning in your hospital? Fluorescent gel placed on chosen sites After patient discharge, a site is considered cleaned if the fluorescent material is removed or disrupted Ecolab Carling et al, Am J Infect Control, 2006

19 What s the long term effect? Maintenance of Environmental Services Cleaning and Disinfection in the ICU After a Performance Improvement Project Fitzgerald et al, AmJIC 2012

20 How do we measure hospital cleanliness? What is clean? 82-91% Visually clean 10-24% ATP clean 30-45% Microbiologically clean what an individual thinks it is Griffith CJ et al, J Hosp Infect 2000

21 Surface evaluation using ATP bioluminescence Swab surface luciferase tagging of ATP Luminometer Used in the commercial food preparation industry to evaluate surface cleaning and as an educational tool for more than 30 years

22 ATP values (in RLU s) for sites on medical & surgical wards Site Before After Locker (M) Locker (S) L Bed (M) L Bed (S) O/B Table (M) O/B Table (S) R Bed (M) R Bed (S) Range Mean Range Mean Range Mean Range Mean Range Mean Range Mean Range Mean Range Mean Site Mean ATP Before Site Mean ATP After Mulvey et al, JHI 2011

23 Would microbiological standards help? 5 cfu/cm 2 45 cfu/cm 2 Slide from Chris Griffith

24 Microbiological standards for surface hygiene in hospitals Standard 1 There should be <1cfu/cm 2 pathogen (MRSA; C.difficile; VRE; etc) in the clinical environment Standard 2 Aerobic Colony Count (ACC) or total microbial growth level from a hand contact surface should be <5 cfu/cm 2 These standards are based upon food industry counts as applied to food preparation surfaces but could be utilised for frequent hand touch surfaces in hospitals Dancer S, J Hosp Infect 2004

25 Application of cleaning standards on ICU 25% of 200 samples failed the standards, mostly hand-touch sites Hygiene fails were associated with bed occupancy and incidence of ICU-acquired infection Hygiene standards reflect patient activity and provide a means to risk manage infection White et al, AmJIC, 2008

26 Lessons from the food industry Griffith CJ, Biomed Scientist, 2006

27 Environmental sampling is important One study suggests that if an organism is found in the food preparation environment, there is a 70% chance of it getting into the food. Environmental monitoring provides an early indication of loss of control and it s better than end-product testing Chris Griffith, IAFP Rome 2007

28 Does extra cleaning have an effect on MRSA? Two wards received targeted cleaning from Monday to Friday, with each ward receiving extra cleaning for six months in a prospective cross-over design Hand-touch sites on both wards were screened weekly and patients were monitored for MRSA infection Patient and environmental MRSA isolates were characterized using DNA finger- printing BBC website, 2008 Dancer et al, BMC Med 2009

29 Total ACC Total aerobic colony counts (ACC) from hand-touch sites Total aerobic colony count from ten hand-touch sites on two on two matched wards; the cleaner moved from Ward A matched to Ward surgical B at week wards T o tal aero bic co lo ny co unt fro m ten hand-to uch sites o n two matched surgical wards Weeks W a r d A Weeks W a r d B NB. Middle 6 months of study Ward A Ward B Dancer et al, BMC Med, 2009

30 Wiping Out Clostridium difficile Clostridium difficile infection incidence for units A and B combined, before and after the intervention HAI, hospital-acquired CDAD; INC, overall CDAD incidence; PD, patient days; PT, patient. Orenstein et al, ICHE 2011

31 Rates of pan-resistant Acinetobacter baumanii acquisition in 3 intensive care units Apisarnthanarak A et al, Clin Infect Dis 2008

32 Effect of cleaning surfaces & hands on VRE Baseline Intervention Washout HH Emphasis - decreased surface contamination with VRE; - less frequent VRE contaminated HCW hands - a significant reduction in VRE cross-transmission Hayden et al, CID 2006

33 Disinfectants vs Detergents Disinfectants do not degrade They are expensive & toxic Incite mutation and resistance Are there less toxic alternatives? Microfibre: recontamination; decontamination Moore & Griffith, JHI 2006; Wren et al, JHI 2008; Bergen et al, JHI 2009 Steam: operator dependent; electrical items; aerosol potential Meunier et al, Pathol Biol 2008; Griffith & Dancer, JHI 2009 Hydrogen peroxide: expensive; confined areas; not fabrics Shapey et al, JHI 2008; Davies et al, JHI 2011 UV (HINS) light: expensive; hidden corners; inadequate for C.difficile Havill et al, SHEA 2010; Maclean et al, JHI 2010

34 How long do hospital surfaces stay clean? Contact plates from patient locker surface Left to right: Pre clean, 1 hour, 2 hour, 3 hour assessment Mike Rollins, Osprey MRSA rapidly recontaminates high-touch sites after cleaning Hardy KJ et al, JHI 2007

35 Disinfectant cleaning reduces microbial soil on beds Attaway et al, AmJIC cfu/cm2.but not for long!

36 <5cfu/cm 2 Bogusz et al, Healthcare Infect, 2013

37 Time to get PHYSICAL! C.difficile and cleaning alternative options to using chlorine-releasing disinfectants..could C.difficile be removed by routine physical cleaning? Awadel-Kariem et al, J Hosp Infect 2011 A single clean can reduce contamination by around 90%... Speight et al, J Hosp Infect 2011 Physical removal of C.difficile spores is more important than sporicidal inactivation Rutala et al, ICHE 2012

38 How should we clean clinical equipment? Three methods: 1.Disposable barrier 2.Detergent 3.Disinfection with 1/10 dilution of 5% sodium hypochlorite All three protocols decreased MRSA surface load by >99% from cfu/cm 2 to 0.1 cfu/cm 2 (p<0.001) Petti et al, AmJIC 2012

39 Just a quick blast The efficacy of any cleaning/disinfectant agent tested is dependent on physical action... Alfa MJ et al, BMC Infect Dis 2010, 10: 268

40 Why did Mrs Robinson get C.difficile? Because her hospital was not cleaned properly! Detergent! Targeted! Frequently!

41 Thank you! NB. No disclosures, no shares, no shady deals

42 Bleach cleaning reduces CDAD acquisition in patients Mayfield et al, CID, 2000