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									   Monitoring Cleaning and Disinfection Practices


                           John M. Boyce, MD
          Director, Hospital Epidemiology & Infection Control
                        Yale-New Haven Hospital
                                   and
                     Clinical Professor of Medicine
                  Yale University School of Medicine
                             New Haven, CT


Disclosures: Consultant to Clorox Corporation, 3M Corporation, BIOQUELL PLC.
 Honoraria from Clorox, 3M. Research support from 3M, Clorox, Crothall
Advances in Environmental Cleaning/Disinfection


• Approaches to monitoring cleaning practices




• Coating surfaces with antimicrobial metals

• Applying products with long-term antimicrobial
  activity to suppress contamination of surfaces
             Role of Environment in Transmission
             of Healthcare-Associated Pathogens


  •    Numerous investigators have provided evidence
      that contaminated environmental surfaces can
      contribute to transmission of healthcare-
      associated infections




Hota B Clin Infect Dis 2004;39:1182
Boyce JM J Hosp Infect 2007;65 (Suppl 2):50
Weber DJ et al. Am J Infect Control 2010;38 (5 Suppl 1):S25
Weber DJ and Rutala WA Infect Control Hosp Epidemiol 2011;32:207
Otter JA et al. Infect Control Hosp Epidemiol 2011;32:687
Weber DJ et al. Curr Opin Infect Dis 2013;26:338
     Improving Cleaning/Disinfection Practices


 • Pay close attention to cleaning and disinfection of
   high-touch surfaces in patient-care areas

 • Ensure compliance by housekeeping staff with
   cleaning and disinfection procedures

 • Disinfect (or clean) environmental surfaces on a
   regular basis, and when surfaces are visibly soiled

Sehulster L et al. MMWR Recomm Rep 2003;52(RR-10):1
Rutala WA, Weber DJ et al. HICPAC Guideline for
 Disinfection and Sterilization in Healthcare Facilities, 2008
     Methods for Assessing Cleaning Practices
   • Visual inspection of surfaces
       – Check lists sometimes used
   • Observation of housekeeper technique

   • Fluorescent marker system

   • Aerobic colony counts

   • ATP bioluminescence assays

Griffith CJ et al. J Hosp Infect 2000;45:19
Cooper RA et al. Am J Infect Control 2007;35:338
Dancer SJ J Hosp Infect 2009;73:378
Luick L et al. Am J Infect Control 2013;41:751
           Check lists to Improve Cleaning Practices




http://www.cdc.gov/hai/toolkits/evaluating-environmental-cleaning.html
                Visual Inspection of Surfaces

   • Simple, can be conducted in any facility

   • Usually performed by housekeeping managers

   • Assess surfaces to detect visible dirt/stains

   • Problem: Surfaces that appeared clean by visual
     inspection often failed to pass criteria for
     cleanliness when tested by objective measures:
     aerobic colony counts or ATP bioluminescence
Griffith CJ et al. J Hosp Infect 2000;45:19
Cooper RA et al. AJIC 2007;35:338
Luick L et al. AJIC 2013;41:751
      Observation of Housekeeper Technique


  • Covert or overt observation of housekeepers
    during routine cleaning/disinfection activities
      – Establish variations in amount of time spent cleaning or
        disinfecting high-touch objects
      – Determine number of disinfectant wipes used/room
      – Detect which surfaces are not wiped adequately
      – Establish if housekeepers are allowing disinfectant to
        remain on surfaces for appropriate contact time


Hayden MK et al. Clin Infect Dis 2006;42:1552
Boyce JM et al. ICHE 2010;31:99
Guerrero D et al. 2010 Decennial conference, Abstr 60
                        Observation and Supervision
                        of Housekeeper Performance
•     Investigators applied C. difficile spores
      (non-toxigenic) to 3 high-touch surfaces    Percent of inoculated surfaces positive
      in mulitple rooms before terminal             for C. difficile after cleaning, with
      cleaning                                            different interventions
•     Phase 1: housekeepers were not
      observed and were unaware
•     Phase 2: Housekeeper education and
      direct monitoring of practice
•     Phase 3: Direct supervision by
      investigator, reinforcement of education
      and real-time feedback
•     Results: Education and passive
      observation sigificantly improved
      disinfection
•     Further significant reduction in
      contamination occurred with direct
      supervision and real-time feedback
      significantly improved disinfection

    Guerrero DM et al. ICHE 2013;34:524
                   Aerobic Colony Counts

• Methods of culturing environmental surfaces
    – Moistened swab inoculated onto agar +/- broth enrichment
        • Most useful for irregularly shaped surfaces
    – Agar contact plates (Rodac)
        • Recommended for flat surfaces
        • Yield number of colonies per square inch or centimeter

• Currently, no standard methods for how to obtain &
  to process specimens for aerobic colony counts
    – Provide data on contamination by important pathogens
• No accepted criteria for defining a surface as “clean”
  by using aerobic colony counts

Sehulster L et al. MMWR Recomm Rep 2003;52(RR-10):1
Dancer SJ J Hosp Infect 2004;56:10
                Moistened Swab with Direct Plating

 • Use moistened swab to sample surfaces
     • If defined area not sampled; results are at
         best semi-quatitative
      • If a defined area is sampled using a template,
         results are quantitative (CFUs/cm2); preferable

 • Moistening (wetting) agents include normal saline,
   broth media (most common), or broth containing
   disinfectant neutralizer(s)
                                                           VRE on Bedside Rail
 • Swab is used to directly inoculate non-selective or
   selective media, followed by incubation x 48 hrs

 • Useful for sampling irregularly shaped objects,
   medical equipment, hard to reach areas, HCP hands




Lemmen SW et al. Int J Hyg Environ Health 2001;203:245
Duckro AN et al. Arch Intern Med 2005;165:302
                                                           Hand imprint culture
Donskey CJ et al. N Engl J Med 2009;360:e3
        Aerobic Colony Counts Using RODAC Plates
•   RODAC plates are small petri plates filled with agar in order to
    provide convex surface for sampling flat environmental surfaces

•   Agar surface is pressed against a flat surface, plate is incubated

•   Advantages:
    – Very easy to perform; more standardized approach than others
    – Results can be expressed as CFUs/cm2 (quantitative result)
    – May be preferable for detecting Gram-positive bacteria (e.g.,
      MRSA)
    – Neutralizer – containing media (Dey-Engley) are available

•   Disadvantages:
    – Greater cost; limited media available; sample small area per
      plate
Obee P et al. J Hosp Infect 2007;65:35
Rutala WA et al. ICHE 2010;31:1025
Galvin S et al. J Hosp Infect 2012;82:143
Havill NL       Am J Infect Control 2013;41:S26
Anderson DJ et al. ICHE 2013;34:466
               RODAC Plates

              Cultures of Overbed Table




     Before Cleaning                      After Cleaning

Boyce JM et al. SHEA 2011, Abstr 4711
           Fluorescent Marker System for
           Monitoring Cleaning Practices
•   Prospective study conducted in 3 hospitals

•   12 high-touch objects in patient rooms were marked with
    invisible fluorescent solution after terminal cleaning
    – Marks moistened by disinfectant spray could be removed by
      wiping surface for 5 seconds with light pressure

•   After at least 2 patients had occupied the rooms and rooms
    were terminally cleaned, target surfaces were evaluated using
    a portable UV light to see if the marker had been wiped off

•   Intervention: education and feedback given to cleaning staff

Carling PC et al. J Hosp Infect 2008;68:3
                 Improving Cleaning Practices
              by Using Fluorescent Marker System
•   1404 objects were evaluated
    before the intervention

•   744 objects were evaluated after
    the intervention

•   Proportion of objects cleaned
     – Before intervention: 47%
     – After interventions: 76 - 92%

•   Technique improved in all 3
    hospitals (p < 0.001)

•   This method has been used to
    improve cleaning practices in
    several larger studies

Carling PC et al. Clin Infect Dis 2006;42:385
Carling PC et al. Infect Control Hosp Epidemiol 2008;29:1
Carling PC et al. Crit Care Med 2010;38:1054
             Improving Cleaning Practices
          by Using Fluorescent Marker System

 •   Prospective study in 36 acute-
     care hospitals
      – Hospital size: 25 to 721 beds

 •   Fluorescent markers applied to
     14 types of objects before
     terminal room disinfection

 •   20,646 surfaces checked after
     terminal cleaning

 •   Intervention included providing
     housekeepers with
     performance feedback

Carling PC et al. ICHE 2008;29:1035
              Evaluating Cleaning Measures in an ICU
                Using Fluorescent Marker System
•   Prospective study of the impact of cleaning interventions on
    environmental contamination by MRSA and VRE

•   Intervention consisted of
    – Change from use of pour bottles to bucket immersion of cleaning cloths
    – Educational campaign for housekeepers
    – Feedback regarding adequacy of terminal room cleaning

•   15 surfaces in rooms were marked with a fluorescent dye, and               6
    surfaces in patient rooms were cultured for MRSA and VRE
•   Results:
    – Removal of fluorescent dye occurred on
       • 44% of surfaces during baseline period
       • 71% of surfaces during intervention period
    – Cultures (+) for MRSA or VRE decreased from 45% at baseline to 27%


Goodman ER et al. Infect Control Hosp Epidemiol 2008;29:593
           Evaluating Cleaning Measures in an ICU
             Using Fluorescent Marker System




Goodman ER et al. Infect Control Hosp Epidemiol 2008;29:593
         Monitoring Hospital Cleanliness
       Using ATP Bioluminescence Assays

 • ATP bioluminescence assays have been used to
   monitor cleanliness of surfaces in hospitals
     – Daily cleaning or terminal cleaning
     – Assess variations in housekeeper performance


Griffith CL et al. J Hosp Infect 2000;45:19
Malik RE et al. AJIC 2003;31:181
Cooper RA et al. AJIC 2007;35:338
Lewis T et al. J Hosp Infect 2008;69:156
Boyce JM et al. Infect Control Hosp Epidemiol 2009;30:678
Boyce JM et al. Infect Control Hosp Epidemiol 2010;31:99
Moore G et al. AJIC 2010;38:617
Havill NL et al. AJIC 2011;39:602
Anderson RE et al. J Hosp Infect 2011;78:178
              ATP Bioluminescence Method




     Step 1              Step 2                 Step 3

Use special swab      Place swab in   Place tube in luminometer
to sample surface     reaction tube   Results: Relative Light Units
      Assessing Terminal Cleaning Practices
                Using 3 Methods

  • Prospective study to compare how many
    surfaces would be considered clean, based on
      – Aerobic colony counts obtained by agar contact plates
      – Fluorescent marker method
      – ATP bioluminescence assay system

  • 5 high-touch surfaces were sampled in a
    convenience sample of 100 hospital rooms

  • Adjacent surfaces on 5 high-touch surfaces were
    sampled before and after terminal cleaning

Boyce JM et al. ICHE 2011;32:1187
   Assessing Terminal Cleaning Practices
             Using 3 Methods

• Main outcome measures expressed as
  percent of surfaces sampled after cleaning with:
   – Aerobic colony count < 2.5 cfu/cm2
   – Most or all of fluorescent marker removed
   – ATP reading of < 250 Relative Light Units
Proportion of 500 High-Touch Surfaces Classified as Having
  Been Cleaned by Fluorescent Marker, or as “Clean” by
        ACC or ATP Criteria After Terminal Cleaning




                               P < 0.0001

                    P = 0.65
 Proportion of 382 High-Touch Surfaces Classified as
   Having Been Cleaned by Fluorescent Marker, or
        Clean by ATP After Terminal Cleaning




                                P < 0.0001
Rooms Classified as Clean BEFORE
terminal cleaning by ATP were excluded
   382 High-Touch Surfaces Classified as Not Clean
              Before Terminal Cleaning,
       Results for Fluorescent Marker and ATP




                (53.6%)         (34.7%)
                                                   (6.7%)




               N = 168         N = 124    N = 90

Boyce JM et al. ICHE 2011;32:1187
   Re-Evaluating Cutoffs for Defining Cleanliness,
  ATP Bioluminescence and Aerobic Colony Counts

• Cleaning by housekeepers, using Quat disinfectant




Note: Each graph represents 1000 data points

Boyce JM et al. APIC Annual meeting, 2013, Poster 1705
     Re-Evaluating Cutoffs for Defining Cleanliness,
    ATP Bioluminescence and Aerobic Colony Counts
 • Cleaning by infection preventionist, using peroxide-based disinfectant




Note: Each graph includes 720 data points (data are for after cleaning only)
         ATP Bioluminescence for Evaluating Disinfection
                  of C. difficile Isolation Rooms

•   140 high-touch sites in 50 rooms
    were cultured for C. difficile and
    sampled using an ATP assay after
    terminal or daily cleaning using
    bleach-based disinfectant
     –   Surfaces with ATP < 250 RLU were
         considered to be clean

•    3% of 71 sites with ATP readings
    of < 250 RLU had positive culture
    19% of 69 sites with ATP readings
    > 250 RLU had positive culture

•   Measuring ATP on surfaces could
    be a useful & rapid method to
    assess cleaning of C. difficile rooms
    Deshpande A et al. Infect Control Hosp Epidemiol 2013;34:865
    Comparison of Visual Inspection, Fluorescent Marker,
     Aerobic Colony Counts and ATP Bioluminescence
•    250 environmental surfaces in 50 rooms were sampled after
     terminal cleaning using three monitoring methods
      – Aerobic colony counts [ACC] (before & after cleaning)
      – Fluorescent markers (checked for complete removal after cleaning)
      – ATP bioluminescence assay system (before & after cleaning)
•    Results:
      – 93% of surfaces had no visible contamination after cleaning
      – 76% were considered clean by ATP method after cleaning
      – 87% were considered clean by ACC after cleaning
•    Sensitivity, specificity and NPV of methods, compared to ACC
      – Fluorescent marker: sensitivity = 75%, specificity = 40%, NPV = 28%
      – ATP: sensitivity = 76%, specificity = 35%, NPV = 26%

•    Conclusion: Fluorescent marker and ATP are better than visual
     assessment. Both may be useful for monitoring cleaning
Luick L et al. AJIC 2013;41:751
           Caveats on Using ATP Bioluminescence
             to Monitor Environmental Cleaning
• No standard, evidence-based criteria for defining surfaces as
  clean by ATP bioluminescence is currently available

• Cut-offs used to classify surfaces as clean by ATP assays
  depends on the brand of assay used
    – Some systems classify surfaces with < 250 RLU as clean
    – Other systems classify surfaces with < 100 RLU as clean
    – Sensitivity and specificity of different luminometers and assay
      systems differ
       • Consider manufacturer’s recommendations for cut-off
    – Further research is needed to refine criteria for cleanliness, both by
      ATP assays and by aerobic colony counts

 Mulvey D et al. J Hosp Infect 2011;77:25
 Aiken ZA et al. Infect Control Hosp Epidemiol 2011;32:507
 Shama G et al. Int J Hyg Environmental Health 2013;216:115
         Advantages and Disadvantages of Methods for
         Monitoring Cleaning and Disinfection Practices




                                              Housekeepers may “game” system




Havill NL Am J Infect Control 2013;41:S26
Sequential Interventions and Use of Two Monitoring Methods
    Improved Disinfection of C. difficile Isolation Rooms

• 21-month prospective intervention trial was conducted to
  evaluate methods for disinfection of C. difficile isolation rooms
   – Phase 1) Fluorescent markers + education and feedback to housekeepers
   – Phase 2) Addition of automated UV light units for adjunctive disinfection
   – Phase 3) Use of dedicated daily disinfection team, and requiring rooms to be
     “cleared” by housekeeper supervisor or infection preventionist using
       • visual assessment and
       • ATP bioluminescence assay of 3 sites in each room

• Surfaces were cultured for presence of C. difficile
• Results: Percent of rooms with positive C.difficile cultures:
   – Baseline: 67%
   – Phase 1: 57%
   – Phase 2: 35%
   – Phase 3: 7%
Sitzlar B et al. Infect Control Hosp Epidemiol 2013;34:459
Sequential Interventions and Use of Two Monitoring Methods
   to Improve Disinfection of C. difficile Isolation Rooms




Sitzlar B et al. Infect Control Hosp Epidemiol 2013;34:459
                         Conclusions
• Contaminated environmental surfaces can contribute to
  transmission of healthcare-associated pathogens

• Monitoring cleaning and disinfection of environmental
  surfaces is recommended in national guidelines

• Visual inspection correlates poorly with objective methods

• Fluorescent marker methods and ATP bioluminescence
  are being used increasingly to monitoring cleaning
   – Each method has advantages and limitations
   – Can be used in combination
• Aerobic colony counts are more expensive and require
  more time, but provide unique information
   – Have been used during outbreaks and for research purposes
   Coating Surfaces with Antimicrobial Metals

  • Coating medical equipment with metals which
    have antimicrobial activity is a new strategy for
    reducing environmental contamination

  • Examples include:
      – Copper alloys (studied most extensively)
      – Silver or nano-silver particles + titanium dioxide
      – Zinc



Dancer SJ Eur J Clin Microbiol Infect Dis 2011;30:1473
Weber DJ et al. ICHE 2012;33:10
     Copper Alloys as Antimicrobial Surfaces

  • Environmental surfaces or medical equipment
    coated with copper alloys have been shown to
      – Have sustained antimicrobial activity
      – Reduce levels of bacterial contamination of surfaces in
        clinical settings when compared with usual equipment
      – Effective against a variety of pathogens
         • Less effective against MRSA and C. difficile



Noyce JO et al. J Hosp Infect 2006;63:289
Wheeldon et al. J Antimicrob Chemother 2008;62:522
Casey AL et al. J Hosp Infect 2010;74:72
Grass G et al. Appl Environ Microbiol 2011;77:1541
Karpanen TJ et al. ICHE 2012;33:3
   Antimicrobial (Self-Disinfecting) Surfaces
   Are Promising, But Require Further Study

• Many of the proposed products yielded only
  modest killing of pathogens
• Not proven to be effective against some
  important pathogens (e.g. C. difficile)
• Cost of installing metal-coated equipment and of
  products applied to usual equipment not clear
• Durability of antimicrobial activity of such
  products has not been established
• No data on impact of such strategies on HAIs

Weber DJ et al. ICHE 2012;33:10
    Applying of Compounds with Long-Term
       Antimicrobial Activity to Surfaces

•   Silver iodide-based compound
•   Triclosan
•   Quaternary ammonium salt-based surfactant
•   Organosilane compounds
    – Quaternary ammonium + silicone-based compound
    – Effective in a few trials, but not in another
• Light-activated antimicrobial coatings
    – Toluidine blue O + rose Bengal



Weber DJ et al. ICHE 2012;33:10
Havill NL & Boyce JM (unpublished)

								
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