Re: Environmental hygiene and disinfection as part of Standard Precautions model

[Michael Wishart]

[Moderator note: this message has been discussed with the original
poster of this thread, and agreed that the content is not product
specific and is worth consideration as part of this discussion.]

John

I read your post with great interest and think its a fantastic topic
(and badly needed) for discussion.

I was going to reply to the list but to be honest I am coming from a
slightly biased perspective and really do not want to the list to
degenerate into another marketing tool (or for that matter to get into
trouble with the people who manage the list.) so here is my (for what
its worth) feelings on the topic. Any feedback appreciated and if you
feel its not going to be taken or seen incorrectly then I am happy to
reply to everyone.

Unfortunately while opinion is changing (and changing rather quickly)
there is still debate in some circles as to the role of the environment
in the spread of HCAIs. History tells us that the medical profession
takes a while to change its mind (look at Semmelweis or John Snow)!

The historical belief that pathogens dont survive long in the hospital
environment has been proven to be completely wrong with evidence that
the many bacteria can survive weeks, months or even years in the
environment. The feeling that the patient contaminated the environment
but that the a contaminated environment was not a risk to a patient has
been reassessed and found to be incorrect in some circumstances. The
question is not now whether a contaminated environment makes an
important contribution to transmission but how much of a contribution
does it make. Related to this, what level of cleaning and disinfection
is required? Is cleaning enough? Do we need disinfection? To what level?

What is exacerbating the problem is the lack of data on the actual level
of contamination that exists in hospitals pre and post cleaning. Taking
two or three swabs, even on a routine basis just isnt sensitive enough
to give us that kind of data. How can sampling 2cm2 out of the entire
surface area (even out of the high hand touch surfaces) even give us an
indicative result on the level of contamination in a room? There is even
some doubt as to the sensitivity of standard swabbing. If you look at a
letter in AJIC in 2009, (Otter JA et al. Am J Infect Control
2009;37:517-8) standard swabbing found 2% of surfaces contaminated with
C.diff but moving to the newer pre moistened cellulose sponges swabbing
1m2 found that 28% of surfaces were contaminated. This goes to show how
inaccurate or lacking sensitivity our environmental testing, even when
it done routinely.

We all know that the environment contaminates healthcare workers hands,
particularly the near patient environment. There are multiple studies
that show this but the one that to me stands out is Hayden et al. Infect
Control Hosp Epidemiol 2008;29:149-154 which showed that VRE touching
that surface was posed the same risk of contaminating a HCW hands as
touching the patient !!!

The most convincing evidence that contaminated surfaces are important in
transmission comes from the fact that there is an increased risk to a
patient of acquiring a MDRO if the previous patient in that room had a MDRO:

Martinez et al. Arch Intern Med 2003; 163: 1905-12 showed if VRE was
cultured within the room the risk to the next patient increased by a
factor of 2.6, Huang et al. Arch Intern Med 2006; 166: 1945-51 showed
that if the prior room occupant had VRE the risk increased by a factor
of 1.6 and for MRSA it was 1.3 Drees et al. Clin Infect Dis 2008; 46:
678-85. demonstrated that if VRE was cultured within the room that the
risk increased by a factor of 1.9. prior room occupancy risk increased
by a factor of 2.2 and more worryingly even with all the cleaning that
if the previous room occupant at any tome in the previous 2 weeks had
VRE the risk still increased by a factor of 2.
Shaughnessy. Infect Control Hosp Epidemiol 2011;32:201-206 showed that
if the prior room occupant had C.diff that the risk to the next patient
admitted increased by a factor of 2.4.
Nseir et al. Clin Microbiol Infect 2010 looked at the MDR Gram Negatives
and showed that prior room occupancy was also a significant risk factor.
For Acinetobacter you risk increased by a factor of 3.8 and for
Pseudomonas the risk factor increased by 2.1.

So, having established that the environment contributes to transmission,
the question is, what is the best way to reduce the contamination to a
safe level?

We also know that cleaning and disinfection, even with the best
technique will not reliably eradicate this environmental contamination.
As far back as 2004 Garry French French et al. J Hosp Infect
2004;57:31-37 showed that manual cleaning failed to eradicate
environmental contamination from MRSA. Byers et al. Infect Control Hosp
Epidemiol 1998;19:261-264 showed that it took an average of 2.8
disinfections to eradicate VRE from a room, Boyce et al. Infect Control
Hosp 2008;29:723-729 showed that bleach leaning failed to eradicate
C.diff (using the more sensitive Sponge testing 25% of surfaces
remained contaminated after bleach cleaning).

Similarly, Farrin Manian demonstrated at SHEA in 2010 (and since part
published Manian et al. Infect Control Hosp Epidemiol
2011;32(7):667-672) that even with 2 daily bleach cleans and 4 repeat
bleach cleans on patient discharge that 26.6% of rooms remained
contaminated by MDR Acinetobacter or MRSA !!!!! 4 repeat bleach cleans
How many hospitals currently or will ever go to that standard ??

In the same study as above, Farrin Manian showed that Hydrogen Peroxide
Vapour (HPV) was more effective than the four rounds of cleaning and
bleach disinfection. Furthermore he demonstrated (again in SHEA 2010 but
not yet published) that by eradicating this contamination (using
Hydrogen Peroxide Vapour) that there was a 54% reduction of patient
acquisition rates for MDR Acinetobacter, 42% reduction on C.diff, 50%
reduction in VRE and a 24% reduction in MRSA !!

Two other studies also suggest that eradicating environmental
contamination reduces the acquisition of pathogens. John Boyce showed at
SHEA in 2006 and since published, Boyce et al. Infect Control Hosp
2008;29:723-729 that eradicating C.diff from the environment (again
using HPV) reduced patient acquisition rates for C. diff by 54%. In
another study of HPV decontamination in 2008, Passaretti presented data
at SHEA (still to be published and again using HPV) demonstrating that
by eradicating environmental contamination from a room where the
previous room occupant had a MDRO that the risk of acquisition to the
next patient dropped substantially. From VRE there was a 77% reduction,
for MRSA a 54% reduction for C.diff a 65% reduction and for Gram
negative rods a 38% reduction. Over all the eradication of environmental
contamination on patient discharge reduced the risk of acquiring a MDRO
by 66%…..

So, yes, routine cleaning and disinfection of the rooms of patients on
MRO precautions should be done but more may need to be done a patient
discharge to eradicate pathogens for the safety of the next patient.

Regarding terminology, I tend to use environmental decontamination to
encompass both cleaning and disinfection, but standardisation would be
helpful here.

I think we need to define a routine sampling technique and a minimum
standard for environmental contamination that must be achieved before a
patient can be admitted to a room or bed-space. (I suspect different
standards can be set for different areas depending on risk, for example
in Oncology, ICU and Organ transplant the standard may be <1 CFU per CM2
for general medical ward it could be <2CFU per cm2.) There are some
proposed guidelines (J Hosp Infect 2004; 56: 10-15 but these have not
been adopted widely). We need to find a reliable and repeatable method
of achieving this standard and it needs to be implemented and monitored.
And there needs to be a budget made available for this.

Regards

Kevin Griffin
Director Healthcare Solutions
Bioquell Asia Pacific Pte Ltd

T: +65 6592 5145
F: +65 6227 5878
M: +65 8511 3733
E: Kevin.Griffin@bioquell.com
W: http://www.bioquell.com

Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of AICA.

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Michael Wishart
Infection Control Coordinator
St Vincent's Private Hospital Northside & St Vincent's Private Hospital Brisbane
Brisbane, QLD
michael.wishart@svha.org.au

[Glenys Harrington]

Kevin,

Perhaps the answer is not to look for a “defined routine sampling technique to determine a minimum standard for environmental contamination” as there will always be problems with interpreting what the results mean given the environment is not meant to be “sterile”.

It would be more useful to determine what are the minimum, standardised, “reliable and repeatable” environmental decontamination procedure/s (i.e. cleaning and the use of florescent markers/cleaning and the use of microfiber/cleaning and chemical disinfection/cleaning and new technologies [HPV, UV, steam, other]) that can be shown to be linked to a sustainable reduction in infection and/or colonisation in patients in non-outbreak settings.

Regards

Glenys

Glenys Harrington
Consultant
Infection Control Consultancy (ICC)

PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426

—–Original Message—–

[Moderator note: this message has been discussed with the original poster of this thread, and agreed that the content is not product specific and is worth consideration as part of this discussion.]

John

I read your post with great interest and think its a fantastic topic (and badly needed) for discussion.

I was going to reply to the list but to be honest I am coming from a slightly biased perspective and really do not want to the list to degenerate into another marketing tool (or for that matter to get into trouble with the people who manage the list.) so here is my (for what its worth) feelings on the topic. Any feedback appreciated and if you feel its not going to be taken or seen incorrectly then I am happy to reply to everyone.

Unfortunately while opinion is changing (and changing rather quickly) there is still debate in some circles as to the role of the environment in the spread of HCAIs. History tells us that the medical profession takes a while to change its mind (look at Semmelweis or John Snow)!

The historical belief that pathogens dont survive long in the hospital environment has been proven to be completely wrong with evidence that the many bacteria can survive weeks, months or even years in the environment. The feeling that the patient contaminated the environment but that the a contaminated environment was not a risk to a patient has been reassessed and found to be incorrect in some circumstances. The question is not now whether a contaminated environment makes an important contribution to transmission but how much of a contribution does it make. Related to this, what level of cleaning and disinfection is required? Is cleaning enough? Do we need disinfection? To what level?

What is exacerbating the problem is the lack of data on the actual level of contamination that exists in hospitals pre and post cleaning. Taking two or three swabs, even on a routine basis just isnt sensitive enough to give us that kind of data. How can sampling 2cm2 out of the entire surface area (even out of the high hand touch surfaces) even give us an indicative result on the level of contamination in a room? There is even some doubt as to the sensitivity of standard swabbing. If you look at a letter in AJIC in 2009, (Otter JA et al. Am J Infect Control
2009;37:517-8) standard swabbing found 2% of surfaces contaminated with C.diff but moving to the newer pre moistened cellulose sponges swabbing
1m2 found that 28% of surfaces were contaminated. This goes to show how inaccurate or lacking sensitivity our environmental testing, even when it done routinely.

We all know that the environment contaminates healthcare workers hands, particularly the near patient environment. There are multiple studies that show this but the one that to me stands out is Hayden et al. Infect Control Hosp Epidemiol 2008;29:149-154 which showed that VRE touching that surface was posed the same risk of contaminating a HCW hands as touching the patient !!!

The most convincing evidence that contaminated surfaces are important in transmission comes from the fact that there is an increased risk to a patient of acquiring a MDRO if the previous patient in that room had a MDRO:

Martinez et al. Arch Intern Med 2003; 163: 1905-12 showed if VRE was cultured within the room the risk to the next patient increased by a factor of 2.6, Huang et al. Arch Intern Med 2006; 166: 1945-51 showed that if the prior room occupant had VRE the risk increased by a factor of 1.6 and for MRSA it was 1.3 Drees et al. Clin Infect Dis 2008; 46:
678-85. demonstrated that if VRE was cultured within the room that the risk increased by a factor of 1.9. prior room occupancy risk increased by a factor of 2.2 and more worryingly even with all the cleaning that if the previous room occupant at any tome in the previous 2 weeks had VRE the risk still increased by a factor of 2.
Shaughnessy. Infect Control Hosp Epidemiol 2011;32:201-206 showed that if the prior room occupant had C.diff that the risk to the next patient admitted increased by a factor of 2.4.
Nseir et al. Clin Microbiol Infect 2010 looked at the MDR Gram Negatives and showed that prior room occupancy was also a significant risk factor.
For Acinetobacter you risk increased by a factor of 3.8 and for Pseudomonas the risk factor increased by 2.1.

So, having established that the environment contributes to transmission, the question is, what is the best way to reduce the contamination to a safe level?

We also know that cleaning and disinfection, even with the best technique will not reliably eradicate this environmental contamination.
As far back as 2004 Garry French French et al. J Hosp Infect
2004;57:31-37 showed that manual cleaning failed to eradicate environmental contamination from MRSA. Byers et al. Infect Control Hosp Epidemiol 1998;19:261-264 showed that it took an average of 2.8 disinfections to eradicate VRE from a room, Boyce et al. Infect Control Hosp 2008;29:723-729 showed that bleach leaning failed to eradicate C.diff (using the more sensitive Sponge testing 25% of surfaces remained contaminated after bleach cleaning).

Similarly, Farrin Manian demonstrated at SHEA in 2010 (and since part published Manian et al. Infect Control Hosp Epidemiol
2011;32(7):667-672) that even with 2 daily bleach cleans and 4 repeat bleach cleans on patient discharge that 26.6% of rooms remained contaminated by MDR Acinetobacter or MRSA !!!!! 4 repeat bleach cleans
How many hospitals currently or will ever go to that standard ??

In the same study as above, Farrin Manian showed that Hydrogen Peroxide Vapour (HPV) was more effective than the four rounds of cleaning and bleach disinfection. Furthermore he demonstrated (again in SHEA 2010 but not yet published) that by eradicating this contamination (using Hydrogen Peroxide Vapour) that there was a 54% reduction of patient acquisition rates for MDR Acinetobacter, 42% reduction on C.diff, 50% reduction in VRE and a 24% reduction in MRSA !!

Two other studies also suggest that eradicating environmental contamination reduces the acquisition of pathogens. John Boyce showed at SHEA in 2006 and since published, Boyce et al. Infect Control Hosp
2008;29:723-729 that eradicating C.diff from the environment (again using HPV) reduced patient acquisition rates for C. diff by 54%. In another study of HPV decontamination in 2008, Passaretti presented data at SHEA (still to be published and again using HPV) demonstrating that by eradicating environmental contamination from a room where the previous room occupant had a MDRO that the risk of acquisition to the next patient dropped substantially. From VRE there was a 77% reduction, for MRSA a 54% reduction for C.diff a 65% reduction and for Gram negative rods a 38% reduction. Over all the eradication of environmental contamination on patient discharge reduced the risk of acquiring a MDRO by 66%…..

So, yes, routine cleaning and disinfection of the rooms of patients on MRO precautions should be done but more may need to be done a patient discharge to eradicate pathogens for the safety of the next patient.

Regarding terminology, I tend to use environmental decontamination to encompass both cleaning and disinfection, but standardisation would be helpful here.

I think we need to define a routine sampling technique and a minimum standard for environmental contamination that must be achieved before a patient can be admitted to a room or bed-space. (I suspect different standards can be set for different areas depending on risk, for example in Oncology, ICU and Organ transplant the standard may be <1 CFU per CM2 for general medical ward it could be <2CFU per cm2.) There are some proposed guidelines (J Hosp Infect 2004; 56: 10-15 but these have not been adopted widely). We need to find a reliable and repeatable method of achieving this standard and it needs to be implemented and monitored.
And there needs to be a budget made available for this.

Regards

Kevin Griffin
Director Healthcare Solutions
Bioquell Asia Pacific Pte Ltd

T: +65 6592 5145
F: +65 6227 5878
M: +65 8511 3733
E: Kevin.Griffin@bioquell.com
W: http://www.bioquell.com

Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of AICA.

Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.

Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au

To send a message to the list administrator send an email to aicalist-request@aicalist.org.au.

You can unsubscribe from this list be sending 'signoff aicalist' (without the quotes) to listserv@aicalist.org.au

Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of AICA.

Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.

Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au

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