New Technologies for Disinfection of Environmental Surfaces John M. Boyce, MD J.M. Boyce Consulting, LLC Middletown, CT Disclosures: JMB is a consultant to, and has received travel support from, Diversey and GOJO Industries, and has received an honorarium from Sodexo www.jmboyceconsulting.com
Burden of Healthcare-Associated Infections Due to Antimicrobial-Resistant Organisms • 10% to 15% of all hospital patients and 65% of all nursing home residents are colonized with one or more multidrug- resistant organisms (MDROs) • Antibiotic-resistant organisms are responsible for: • More than 2 million healthcare-associated infections (HAIs), and 23,000 deaths per year in the United States • At a direct cost of $20 billion • More than 220,000 HAIs occur in Canada annually and result in 8,500 - 12,000 deaths Manning ML et al. Am J Infect Control 2018;46:364
Role of Environment in Transmission of Healthcare-Associated Pathogens • Increasing evidence that contaminated environmental surfaces contribute to transmission of healthcare-associated pathogens • Contaminated surfaces serve as a source of: • Contamination of the hands of healthcare personnel (HCP) • Transmission to patients via direct contact • There is substantial evidence that improving environmental disinfection reduces transmission of pathogens • Novel strategies for improving daily and terminal disinfection of environmental surfaces warrant further evaluation Hayden MK et al. Infect Control Hosp Epidemiol 2008;29:149 Otter JA et al. Infect Control Hosp Epidemiol 2011;32:687 Weber DJ et al. Curr Opin Infect Dis 2013;26:338 Donskey CJ Am J Infect Control 2013;41:S12 Boyce JM Antimicrob Resist Infect Control 2016; doi 10.1186/s13756-016-0111-x PIDAC Best Practices for Environmental Cleaning, 2018
Daily Cleaning/Disinfection Practices Are Often Suboptimal • Patients colonized or infected with pathogens shed the organisms onto environmental surfaces • Daily cleaning of surfaces by Environmental Services (EVS) staff can vary considerably, and is sometimes suboptimal Overbed Table Overbed Table Before Cleaning After Cleaning • Poor daily disinfection practices or use of an ineffective agent results in persistent contamination of surfaces Hayden MK et al. Clin Infect Dis 2006;42:1552 Eckstein BC et al. BMC Infect Dis 2007;7:61 Faires MC et al. BMC Infect Dis 2012;12:290 VRE on call button Boyce JM et al. Infect Control Hosp Epidemiol 2010;31:99 after cleaning Gavalda L et al. Am J Infect Control 2015;43:776
Importance of Daily Room Cleaning and Disinfection • Appropriate daily cleaning reduces: • Level of environmental contamination by pathogens • Transfer of pathogens from surfaces to hands of healthcare personnel (HCP) • Acquisition of pathogens by patients • HAIs Hayden MK et al. Clin Infect Dis 2006;42:1552 Hardy KJ et al. J Hosp Infect 2007;66:360 Meakin NS et al. J Hosp Infect 2012;80:122 Eckstein BC et al. BMC Infect Dis 2007;7:61 Kundrapu S et al. Infect Control Hosp Epidemiol 2012;33:1039 Donskey CJ Am J Infect Control 2013;41:S12 Boyce JM et al. Am J Infect Control 2017;45:1006 5
Need for Innovative Approaches to Daily Disinfection of Surfaces • High-touch surfaces become re-contaminated with pathogens within hours after daily cleaning • Cleaning high-touch surfaces more than once/day can reduce both microbial burden on surfaces and HAIs • Novel approaches for disinfecting patient rooms more frequently than once/day are needed Hardy KJ et al. J Hosp Infect 2007;66:360 Aldeyab MA et al. Infect Control Hosp Epidemiol 2009;30:304 Wilson AP et al. Crit Care Med 2011; Attaway HH et al. Am J Infect Control 2012;40:907 Bogusz A et al. Healthcare Infect 2013;18:3 Schmidt MG et al. Infect Control Hosp Epidemiol 2013;34:530 Dancer SJ et al. BMC Med 2009;7:28
Importance of Terminal Room Cleaning/Disinfection • Multiple studies have assessed terminal room disinfection by obtaining cultures Before and After terminal room cleaning/disinfection • Quality of both daily and terminal cleaning is highly variable, and is often suboptimal • Residual contamination of surfaces occurs if terminal disinfection is not performed correctly Otter JA et al. J Hosp Infect 2007;67:182 Hota B et al. J Hosp Infect 2009;71:123 Otter JA et al. Am J Infect Control 2010;38:754 Carling PC et al. Infect Control Hosp Epidemiol 2008;29:1035 Boyce JM et al. Infect Control Hosp Epidemiol 2011;32:1187 Manian FA Am J Infect Control 2013;41:384 Sitzlar B et al. Infect Control Hosp Epidemiol 2013;34:459 Rupp ME et al. Infect Control Hosp Epidemiol 2014;35:721 Ali S et al. J Hosp Infect 2016;93:70 7
Level of MDRO Surfaces Contamination After Manual Terminal Cleaning, BETR study • Prospective study of surface contamination and MDRO transmission events • Rooms vacated by patients on Contact Precautions cultured when new patients were admitted • > 1 MDRO was recovered from 55% of rooms after manual terminal cleaning Baseline Contamination of Hospital Surfaces at Enrollment by Pathogen N = 80 CFU (~ 3 CFU/cm 2 ) Chen LF et al. Infect Control Hosp Epidemiol 2019;40:47
Risk Associated with Prior Room Occupancy • Patients admitted to a Risk of Acquisition of pathogens room previously from Prior Room Occupants occupied by a patient with a resistant pathogen are at increased risk of acquiring the organism • On average, they are twice as likely to acquire the pathogen as patients admitted to a room not occupied by a patient with a resistant pathogen Mitchell DB et al. J Hosp Infect 2015;91:211
Rationale for Adopting New Technologies to Supplement Manual Disinfection Practices • Continuing challenges affecting effectiveness of environmental disinfection programs: • Frequent personnel turnover in EVS departments • Low salaries available for EVS personnel • Inadequate training of EVS and nursing personnel • Confusion among EVS and nursing personnel regarding “who is supposed to clean what?” • New strategies for cleaning/disinfecting environmental surfaces are needed • “No - touch” methods designed to supplement manual disinfection are gaining popularity, but choosing the most appropriate technology can be difficult Zuberi DM et al. Soc Sci Med 2011;72:907 Dumigan DG et al. Am J Infect Control 2010;38:387 Anderson RE et al. J Hosp Infect 2011;78:178
No-Touch Disinfection Technologies - Hydrogen peroxide vapor (HPV) - Self-disinfecting surfaces - Copper alloys - Aerosolized hydrogen peroxide - Silver - HPV + peracetic acid - Organosilane surface applications - Ozone gas - High- intensity, narrow spectrum light (405 nm) - Quaternary ammonium fogging - Alcohol mist - UV-based air disinfection systems - Steam vapor - Aerosolized peracetic acid/H 2 O 2 - Ultraviolet light - Mobile devices - Fixed installations Doll M et al. Curr Infect Dis Rep 2015;17:44 Weber DJ et al. Am J Infect Control 2016;44(5 Suppl):e77 Weber DJ et al. Curr Opin Infect Dis 2016;29:424 Marra AR et al. Infect Control Hosp Epidemiol 2018;39:20 PIDAC Best Practices for Environmental Cleaning, 3 rd ed., 2018
Hydrogen Peroxide Vapor Micro-Condensation Process • Hydrogen peroxide vapor (HPV) micro-condensation process • Uses 30% - 35% H 2 O 2 • Produces vapor [gas] (particle size < 1 u) • H 2 O 2 is distributed throughout room being treated • H 2 O 2 converted to water and oxygen (no residue) • Effective against a broad range of healthcare- Generator associated pathogens including C. difficile spores • Yields 10 5 to 10 6 log 10 reduction of most pathogens • Air ducts and doors must be closed during process, which takes 2-3 hours Otter JA et al. J Hosp Infect 2011;83:1 Weber DJ et al. Am J Infect Control 2016;44(5 Suppl):e77 Marra AR et al. Infect Control Hosp Epidemiol 2018;39:20 Aeration unit PIDAC Best Practices for Environmental Cleaning, 2018
Hydrogen Peroxide Vapor • Multiple studies have shown that HPV reduces bacterial contamination of surfaces in outbreak and non-outbreak settings • Impact of HPV on MDRO acquisition or infection • 5 studies in outbreak settings • 4 studies in non-outbreak settings • All studies showed reduction of HAIs due to target pathogens • Regression to the mean may have explained some reductions • Due to room turn-around times, HPV is not practical for routine terminal room disinfection • Most likely to be helpful for: • Terminating outbreaks or transmission in hyperendemic settings • Reducing difficult-to-eradicate or highly dangerous pathogens Weber DJ et al. Am J Infect Control 2016;44(5 Suppl):e77 Marra AR et al. Infect Control Hosp Epidemiol 2018;39:20 PIDAC Best Practices for Environmental Cleaning, 2018
Hydrogen Peroxide “Dry” Mist Systems • One system uses 5% H 2 O 2 , <50 ppm silver and <50 ppm orthophosporic acid • Inactivated < 10% of pouched 10 6 G. stearothermophilus spores (BIs) • ~33% of 10 4 G. stearothermophilus spores • Uneven distribution within room • Has shown reduction in bacterial contamination in experimental and actual hospital rooms • Eliminated growth of bacteria and mold from surfaces in 5 rooms of a burn unit • Clinical isolates and reference strains inoculated on glass carriers 3 – 4.6 log 10 reductions of various pathogens were achieved • Less effective than HPV vs C. difficile spores Andersen BM et al. J Hosp Infect 2006;62:149 Bartels MD et al. J Hosp Infect 2008;70:35 Shapey S et al. J Hosp Infect 2008;70:136 Fu TY et al. J Hosp Infect 2012:80:199 Cobrado L et al. Surg Infect 2018;19: doi 10.1089/sur.2017.311 Herruzo R J Hosp Infect 2014;87:175
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