Safer Healthcare Environments for Infection Prevention

1
Safer Healthcare Environments for Infection
Prevention

• William A. Rutala, PhD, MPH
• Director, Hospital Epidemiology, Occupational
  Health and Safety Professor of Medicine and
  Director, Statewide Program for Infection Control
  and Epidemiology
• University of North Carolina at Chapel Hill, USA

2
DISCLOSURES

• Consultation
• Advanced Sterilization Products, Clorox
• Honoraria (speaking)
• Advanced Sterilization Products, 3M
• Grants
• CDC

3
Safer Healthcare Environments for Infection
Prevention

• Describe how products, practices, principles and
  technology in the healthcare environment (air,
  water, surfaces and disinfection and
  sterilization) have been and continue to be
  integrated into practice to prevent patient
  exposure to pathogens
• Discuss new technologies for the healthcare
  environment as well as future opportunities and
  challenges

4
Safer Healthcare Environments for Infection
PreventionNew Technologies and Future Challenges

• Reprocessing reusable medical/surgical
  instruments
• Hospital surfaces
• Water
• Air

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disinfectionandsterilization.org
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Safer Healthcare Environments for Infection
PreventionNew Technologies and Future Challenges

• Reprocessing reusable medical/surgical
  instruments
• Hospital surfaces
• Water
• Air

7
DISINFECTION AND STERILIZATION

• EH Spaulding believed that how an object will be
  disinfected depended on the objects intended use
• CRITICAL - objects which enter normally sterile
  tissue or the vascular system or through which
  blood flows should be sterile
• SEMICRITICAL - objects that touch mucous
  membranes or skin that is not intact require a
  disinfection process (high-level
  disinfectionHLD) that kills all microorganisms
  but high numbers of bacterial spores
• NONCRITICAL - objects that touch only intact skin
  require low-level disinfection

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New Trends in Sterilization of Patient Equipment

• Alternatives to ETO-CFC
• ETO-CO2, ETO-HCFC, 100 ETO
• New Low Temperature Sterilization Technology
• Hydrogen Peroxide Gas Plasma-most common
• Vaporized hydrogen peroxide-limited clinical use
• Ozone-limited clinical use

10
Rapid Readout BIs for Steam Now Require a 1-3h
Readout Compared to 24-48h
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Attest Super Rapid Readout Biological
IndicatorsCommercially available in early 2013

• 1491 BI (blue cap)
• Monitors 270F and 275F gravity displacement
  steam sterilization cycles
• 30 minute result (from 1 hour)

• 1492V BI (brown cap)
• Monitors 270F and 275F dynamic-air-removal
  (pre-vacuum) steam sterilization cycles
• 1 hour result (from 3 hours)

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DISINFECTION AND STERILIZATION

• EH Spaulding believed that how an object will be
  disinfected depended on the objects intended use
• CRITICAL - objects which enter normally sterile
  tissue or the vascular system or through which
  blood flows should be sterile
• SEMICRITICAL - objects that touch mucous
  membranes or skin that is not intact require a
  disinfection process (high-level
  disinfectionHLD) that kills all microorganisms
  but high numbers of bacterial spores
• NONCRITICAL - objects that touch only intact skin
  require low-level disinfection

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High-Level Disinfection of Semicritical Objects

• Exposure Time gt 8m-45m (US), 20oC
• Germicide
  Concentration_____
• Glutaraldehyde
  gt 2.0
• Ortho-phthalaldehyde
  0.55
• Hydrogen peroxide
  7.5
• Hydrogen peroxide and peracetic acid
  1.0/0.08
• Hydrogen peroxide and peracetic acid
  7.5/0.23
• Hypochlorite (free chlorine)
  650-675 ppm
• Accelerated hydrogen peroxide 2.0
• Peracetic acid 0.2
• Glut and isopropanol 3.4/26
• Glut and phenol/phenate
  1.21/1.93___
• May cause cosmetic and functional damage
  efficacy not verified

14
Automated Endoscope Reprocessors with Cleaning
Claim

• Product Definition
• Integrated double-bay AER
• Eliminates manual cleaning
• Uses New High-Level Disinfectant (HLD) with IP
  protection
• Single-shot HLD
• Automated testing of endoscope channels and
  minimum effective concentration of HLD
• Incorporates additional features (LAN, LCD
  display)
• Eliminates soil and microbes equivalent to
  optimal manual cleaning. BMC ID 2010 10200

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DISINFECTION AND STERILIZATIONRutala, Weber,
HICPAC. 2008. www.cdc.gov

• EH Spaulding believed that how an object will be
  disinfected depended on the objects intended use
• CRITICAL - objects which enter normally sterile
  tissue or the vascular system or through which
  blood flows should be sterile
• SEMICRITICAL - objects that touch mucous
  membranes or skin that is not intact require a
  disinfection process (high-level
  disinfectionHLD) that kills all microorganisms
  but high numbers of bacterial spores
• NONCRITICAL - objects that touch only intact skin
  require low-level disinfection

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LOW-LEVEL DISINFECTION FOR NONCRITICAL EQUIPMENT
AND SURFACES

• Exposure time gt 1
  min
• Germicide Use Concentration
• Ethyl or isopropyl alcohol 70-90
• Chlorine 100ppm (1500 dilution)
• Phenolic UD
• Iodophor UD
• Quaternary ammonium UD
• Improved hydrogen peroxide (HP) 0.5, 1.4
• __________________________________________________
  __
• UDManufacturers recommended use dilution

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IMPROVED HYDROGEN PEROXIDE (HP) SURFACE
DISINFECTANT

• Advantages
• 30 sec -1 min bactericidal and virucidal claim
  (fastest non-bleach contact time)
• 5 min mycobactericidal claim
• Safe for workers (lowest EPA toxicity category,
  IV)
• Benign for the environment noncorrosive surface
  compatible
• One step cleaner-disinfectant
• No harsh chemical odor
• EPA registered (0.5 RTU, 1.4 RTU, wet wipe)
• Disadvantages
• More expensive than QUAT

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BACTERICIDAL ACTIVITY OF DISINFECTANTS (log10
reduction) WITH A CONTACT TIME OF 1m WITH/WITHOUT
FCS. Rutala et al. ICHE. In press
Improved hydrogen peroxide is significantly
superior to standard HP at same concentration and
superior or similar to the QUAT tested
Organism IHP-0.5 0.5 HP IHP Cleaner-Dis 1.4 1.4 HP 3.0 HP QUAT
MRSA gt6.6 lt4.0 gt6.5 lt4.0 lt4.0 5.5
VRE gt6.3 lt3.6 gt6.1 lt3.6 lt3.6 4.6
MDR-Ab gt6.8 lt4.3 gt6.7 lt4.3 lt4.3 gt6.8
MRSA, FCS gt6.7 NT gt6.7 NT lt4.2 lt4.2
VRE, FCS gt6.3 NT gt6.3 NT lt3.8 lt3.8
MDR-Ab, FCS gt6.6 NT gt6.6 NT lt4.1 gt6.6
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Hospital Privacy Curtains(sprayed grab area 3x
from 6-8 with 1.4 IHP and allowed 2 minute
contact sampled)
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Decontamination of Curtains with Activated HP
(1.4)Rutala, Gergen, Weber. 2012
CP for Before Disinfection CFU/5 Rodacs (Path) After Disinfection CFU/5 Rodacs (Path) Reduction
MRSA 330 (10 MRSA) 21(0 MRSA) 93.6
MRSA 186 (24 VRE) 4 (0 VRE) 97.9
MRSA 108 (10 VRE) 2 (0 VRE) 98.2
VRE 75 (4 VRE) 0 (0 VRE) 100
VRE 68 (2 MRSA) 2 (0 MRSA) 97.1
VRE 98 (40 VRE) 1 (0 VRE) 99.0
MRSA 618 (341 MRSA) 1 (0 MRSA) 99.8
MRSA 55 (1 VRE) 0 (0 MRSA) 100
MRSA, VRE 320 (0 MRSA, 0 VRE) 1 (0 MRSA, 0 VRE) 99.7
MRSA 288 (0 MRSA) 1 (0 MRSA) 99.7
Mean 2146/10215 (432/1044) 33/103 (0) 98.5
All isolates after disinfection were Bacillus sp
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Safer Healthcare Environments for Infection
PreventionNew Technologies and Future Challenges

• Reprocessing reusable medical/surgical
  instruments
• Hospital surfaces (increasing evidence to support
  the contribution of the environment to disease
  transmission)
• Water
• Air

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HAZARDS IN THE HOSPITAL
MRSA, VRE,C. difficile, Acinetobacter
spp., norovirus
Endogenous flora 40-60 Cross-infection (hands)
20-40 Antibiotic driven 20-25 Other
(environment) 20
Weinstein RA. Am J Med 199191(suppl 3B)179S
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THE ROLE OF THE ENVIRONMENT IN DISEASE
TRANSMISSION

• Over the past decade there has been a growing
  appreciation that environmental contamination
  makes a contribution to HAI with MRSA, VRE,
  Acinetobacter, norovirus and C. difficile
• Surface disinfection practices are currently not
  effective in eliminating environmental
  contamination
• Inadequate terminal cleaning of rooms occupied by
  patients with MDR pathogens places the next
  patients in these rooms at increased risk of
  acquiring these organisms

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TRANSMISSION MECHANISMS INVOLVING THE SURFACE
ENVIRONMENT
Rutala WA, Weber DJ. InSHEA Practical
Healthcare Epidemiology (Lautenbach E, Woeltje
KF, Malani PN, eds), 3rd ed, 2010.
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ACQUISITION OF MRSA ON HANDS AFTER CONTACT WITH
ENVIRONMENTAL SITES
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TRANSFER OF MRSA FROM PATIENT OR ENVIRONMENT TO
IV DEVICE AND TRANSMISSON OF PATHOGEN
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ENVIRONMENTAL CONTAMINATION LEADS TO HAIsWeber,
Rutala, Miller et al. AJIC 201038S25

• Microbial persistence in the environment
• In vitro studies and environmental samples
• MRSA, VRE, AB, CDI
• Frequent environmental contamination
• MRSA, VRE, AB, CDI
• HCW hand contamination
• MRSA, VRE, AB, CDI
• Relationship between level of environmental
  contamination and hand contamination
• CDI

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ENVIRONMENTAL CONTAMINATION LEADS TO HAIs Weber,
Rutala, Miller et al. AJIC 201038S25

• Person-to-person transmission
• Molecular link
• MRSA, VRE, AB, CDI
• Housing in a room previously occupied by a
  patient with the pathogen of interest is a risk
  factor for disease
• MRSA, VRE, CDI
• Improved surface cleaning/disinfection reduces
  disease incidence
• MRSA, VRE, CDI

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KEY PATHOGENS WHERE ENVIRONMENTIAL SURFACES PLAY
A ROLE IN TRANSMISSION

• MRSA
• VRE
• Acinetobacter spp.
• Clostridium difficile
• Norovirus
• Rotavirus
• SARS

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C. difficile Environmental ContaminationRutala,
Weber. SHEA. 3rd Edition. 2010

• Frequency of sites found contaminated10-gt50
  from 13 studies-stethoscopes, bed frames/rails,
  call buttons, sinks, hospital charts, toys,
  floors, windowsills, commodes, toilets,
  bedsheets, scales, blood pressure cuffs, phones,
  door handles, electronic thermometers,
  flow-control devices for IV catheter, feeding
  tube equipment, bedpan hoppers
• C. difficile spore load is low-7 studies assessed
  the spore load and most found lt10 colonies on
  surfaces found to be contaminated. Two studies
  reported gt100 one reported a range of 1-gt200
  and one study sampled several sites with a sponge
  and found 1,300 colonies C. difficile.

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FREQUENCY OF ACQUISITION OF MRSA ON GLOVED HANDS
AFTER CONTACT WITH SKIN AND ENVIRONMENTAL SITES
No significant difference on contamination rates
of gloved hands after contact with skin or
environmental surfaces (40 vs 45 p0.59)
Stiefel U, et al. ICHE 201132185-187
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Risk of Acquiring MRSA and VREfrom Prior Room
Occupants

• Admission to a room previously occupied by an
  MRSA-positive patient or VRE-positive patient
  significantly increased the odds of acquisition
  for MRSA and VRE (although this route is a minor
  contributor to overall transmission). Arch Intern
  Med 20061661945.
• Prior environmental contamination, whether
  measured via environmental cultures or prior room
  occupancy by VRE-colonized patients, increases
  the risk of acquisition of VRE. Clin Infect Dis
  200846678.
• Prior room occupant with CDAD is a significant
  risk for CDAD acquisition. Shaughnessy et al.
  ICHE 201132201

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A Targeted Strategy for C. difficile Orenstein
et al. 2011. ICHE321137
Daily cleaning with bleach wipes on high
incidence wards reduced CDI 85 (24.2 to 3.6
cases/10,000 patient days and prolonged median
time between HA CDI from 8 to 80 days
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Thoroughness of Environmental CleaningCarling et
al. ECCMID, Milan, Italy, May 2011
gt110,000 Objects
Mean 32
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WipesCotton, Disposable, Microfiber
Wipe should have sufficient wetness to achieve
the disinfectant contact time. Discontinue use
of a disposable wipe if it no longer leaves the
surface visibly wet for gt 1m
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SURFACE DISINFECTIONEffectiveness of Different
Methods, Rutala et al. 2012
Technique (with cotton) MRSA Log10 Reduction (QUAT)
Saturated cloth 4.41
Spray (10s) and wipe 4.41
Spray, wipe, spray (1m), wipe 4.41
Spray 4.41
Spray, wipe, spray (until dry) 4.41
Disposable wipe with QUAT 4.55
Control detergent 2.88
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EFFECTIVENESS OF DISINFECTANTS AGAINST MRSA AND
VRE
Rutala WA, et al. Infect Control Hosp Epidemiol
20002133-38.
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Mean proportion of surfaces disinfected at
terminal cleaning is 32

• Terminal cleaning methods ineffective (products
  effective practices deficient surfaces not
  wiped) in eliminating epidemiologically
  important pathogens

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ENVIRONMENTAL CONTAMINATION LEADS TO HAIs

• There is increasing evidence to support the
  contribution of the environment to disease
  transmission
• This supports comprehensive disinfecting regimens
  (goal is not sterilization) to reduce the risk of
  acquiring a pathogen from the healthcare
  environment

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MONITORING THE EFFECTIVENESS OF CLEANINGCooper
et al. AJIC 200735338

• Visual assessment-not a reliable indicator of
  surface cleanliness
• ATP bioluminescence-measures organic debris
  (each unit has own reading scale, lt250-500 RLU)
• Microbiological methods-lt2.5CFUs/cm2-pass can be
  costly and pathogen specific
• Fluorescent marker

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TERMINAL ROOM CLEANING DEMONSTRATION OF IMPROVED
CLEANING

• Evaluated cleaning before and after an
  intervention to improve cleaning
• 36 US acute care hospitals
• Assessed cleaning using a fluorescent dye
• Interventions
• Increased education of environmental service
  workers
• Feedback to environmental service workers
• Regularly change dotted items to prevent
  targeting objects

Carling PC, et al. ICHE 2008291035-41
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NEW APPROACHES TO ROOM DECONTAMINATION
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ROOM DECONTAMINATION UNITSRutala, Weber. ICHE.
201132743
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UV Room Decontamination

• Fully automated, self calibrates, activated by
  hand-held remote
• Room ventilation does not need to be modified
• Uses UV-C (254 nm range) to decontaminate
  surfaces
• Measures UV reflected from walls, ceilings,
  floors or other treated areas and calculates the
  operation time to deliver the programmed lethal
  dose for pathogens.
• UV sensors determines and targets highly-shadowed
  areas to deliver measured dose of UV energy
  (12,000µWs/cm2 bacteria)
• After UV dose delivered, will power-down and
  audibly notify the operator
• Reduces colony counts of pathogens by gt99.9
  within 20-25m

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EFFECTIVENESS OF UV ROOM DECONTAMINATION
Rutala WA, et al. Infect Control Hosp Epidemiol.
2010311025-1029.
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HP SYSTEMS FOR ROOM DECONTAMINATION
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HP SYSTEMS FOR DECONTAMINATION OF THE HOSPITAL
ENVIRONMENT Falagas, et al. J Hosp Infect.
201178171.
Reliable biocidal activity against a wide range
of pathogens
Author, Year HP System Pathogen Before HPV After HPV Reduction
French, 2004 VHP MRSA 61/85-72 1/85-1 98
Bates, 2005 VHP Serratia 2/42-5 0/24-0 100
Jeanes, 2005 VHP MRSA 10/28-36 0/50-0 100
Hardy, 2007 VHP MRSA 7/29-24 0/29-0 100
Dryden, 2007 VHP MRSA 8/29-28 1/29-3 88
Otter, 2007 VHP MRSA 18/30-60 1/30-3 95
Boyce, 2008 VHP C. difficile 11/43-26 0/37-0 100
Bartels, 2008 HP dry mist MRSA 4/14-29 0/14-0 100
Shapey, 2008 HP dry mist C. difficile 48/203-24 7 7/203-3 0.4 88
Barbut, 2009 HP dry mist C. difficile 34/180-19 4/180-2 88
Otter, 2010 VHP GNR 10/21-48 0/63-0 100
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ROOM DECONTAMINATION WITH HPV

• Study design
• Before and after study of HPV
• Outcome
• C. difficile incidence
• Results
• HPV decreased environmental contamination with C.
  difficile (plt0.001), rates on high incidence
  floors from 2.28 to 1.28 cases per 1,000 pt days
  (p0.047), and throughout the hospital from 1.36
  to 0.84 cases per 1,000 pt days (p0.26)

Boyce JM, et al. Infect Control Hosp Epidemiol.
200829723-729.
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UV ROOM DECONTAMINATION ADVANTAGES AND
DISADVANTAGES

• Advantages
• Reliable biocidal activity against a wide range
  of pathogens
• Surfaces and equipment decontaminated
• Room decontamination is rapid (15 min) for
  vegetative bacteria
• HVAC system does not need to be disabled and room
  does not need to be sealed
• UV is residual free and does not give rise to
  health and safety concerns
• No consumable products so operating costs are low
  (key cost acquisition)
• Disadvantages
• No studies evaluating whether use reduces HAIs
• Can only be done for terminal disinfection (i.e.,
  not daily cleaning)
• All patients and staff must be removed from room
• Substantial capital equipment costs
• Does not remove dust and stains which are
  important to patients/visitors
• Sensitive use parameters (e.g., UV dose delivered)

Rutala WA, Weber DJ. ICHE 201132743-747
51
HP ROOM DECONTAMINATION ADVANTAGES AND
DISADVANTAGES

• Advantages
• Reliable biocidal activity against a wide range
  of pathogens
• Surfaces and equipment decontaminated
• Demonstrated to decrease disease incidence (C.
  difficile)
• Residual free and does not give rise to health
  and safety concerns (aeration units convert HPV
  into oxygen and water)
• Useful for disinfecting complex equipment and
  furniture
• Disadvantages
• Can only be done for terminal disinfection (i.e.,
  not daily cleaning)
• All patients and staff must be removed from room
• Decontamination takes approximately 3-5 hours
• HVAC system must be disabled and the room sealed
  with tape
• Substantial capital equipment costs
• Does not remove dust and stains which are
  important to patients/visitors
• Sensitive use parameters (e.g., HP concentration)

Rutala WA, Weber DJ. ICHE (In press)
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Rapid Hospital Room Decontamination Using UV
Light With a Nanostructured Reflective Coating

• Assessed the time required to kill HAI pathogens
  in a room with standard white paint (3-7 UV
  reflective) versus walls coated with an agent
  formulated to be reflective to UV-C wavelengths
  (65 UV reflective)
• Coating uses nanoscale metal oxides whose crystal
  structures are reflective to UV-C
• Coating is white in appearance and can be applied
  with a brush or roller in the same way as any
  common interior latex paint
• Cost to coat walls used in this study was
  estimated to be lt300.

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UV Reflective CoatingRutala, Gergen, Tande,
Weber. 2012
With the nanoscale reflective coating, cycle
times were 5-10m (80 reduction) which would
substantially reduce the turnover time of the room
Line-of-Sight MRSA w/coating MRSA no coating C. difficile w/coating C. difficile no coating
Cycle Time 5m03s 25m13s 9m24s 43m42s
Direct 4.70 (n42) 4.72 (n33) 3.28 (n39) 3.42 (n33)
Indirect 4.45 (n28) 4.30 (n27) 2.42 (n31) 2.01 (n27)
Total 4.60 (n70) 4.53 (n60) 2.91 (n70) 2.78 (n60)
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METHODS TO IMPROVE DISINFECTIONOF ENVIRONMENTAL
SURFACES

• Enhanced environmental cleaning and disinfection
• Improved education of environmental service
  workers
• Use of checklists
• Monitoring of cleaning with fluorescent dye,
  ATPase, aerobic plate counts
• No touch terminal disinfection
• UV light
• Hydrogen peroxide Vapor or aerosol
• Portable steam dispensers
• Self disinfecting surfaces (or persistent
  antimicrobials)

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RATIONALE FOR DEVELOPMENTOF SELF DISINFECTING
SURFACES

• Unlike improved environmental cleaning does not
  require a ongoing behavior change or education of
  personnel
• Self-sustaining once in place
• Allows continued disinfection (may eliminate the
  problem of recontamination), unlike no touch
  methods which can only be used for terminal
  disinfection
• Most hospital surfaces have a low bioburden of
  pathogens (i.e., lt100 per cm2)
• Once purchased might not have a maintenance cost

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SELF DISINFECTING SURFACES

• Surface impregnated with a heavy metal
• Silver
• Copper
• Surface impregnated with a germicide
• Triclosan
• Antimicrobial surfactant/quaternary ammonium
  salt?
• Organosilane products?
• Altered topography
• Sharklet pattern
• Light-activated antimicrobial coating

Weber DJ, Rutala WA. ICHE 20123310-13
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SELF DISINFECTING SURFACES
Copper coated overbed table
Sharklet Pattern
Triclosan pen
Antimicrobial effects of silver
59
IN VITRO EFFECTIVENESS OF A SILVER COATING
AGAINST BACTERIAL CHALLENGE

• Study design In vitro study
• Study agent Surfacine (10 ?g/cm2 silver
  iodide)
• Methods Surface coated with Surfacine and then
  challenged with VRE
• Results
• Antimicrobial activity retained despite repeated
  dry wiping or wiping with a QUAT

Rutala WA, Weber DJ. Emerg Infect Dis 20017348
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Role of Copper in Reducing Hospital Environmental
ContaminationCasey et al. 2010 7472-77
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COPPER VERSUS STANDARD ITEMSA CROSS-OVER STUDY
OF CONTAMINATION

• Study To assess antimicrobial activity of
  copper coated objects
• Method Cross-over study on an acute medical ward
• Results Copper reduced aerobic counts by
  90-100
• Toilet seat 87 v 2/ cm2 push plate 2 v 0/cm2
  hot water tap handle 7.5 v 0/cm2

Casey AL, et al. J Hosp Infect 20107472-77
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Efficacy of Copper Alloy in Clinical Environment

• Copper surfaces demonstrated to be cidal to HA
  pathogen
• Limitations
• Cost of purchasing and installing copper items
• Reduction of microbial contamination is modest
  (i.e., 1 log10)
• How soiling, cleaning, etc affect properties not
  studied
• Impractical/impossible to coat all environmental
  surfaces and medical devices that could lead to
  hand contamination
• No studies whether use reduces HAI rates

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SURFACE DISINFECTANTS PERSISTENCE
Surface disinfectant Persistence
Phenolic No
Quaternary ammonium compound Yes (with caveats)
Alcohol No
Hypochlorite No
Hydrogen peroxide No
64
QUATS AS SURFACE DISINFECTANTSWITH PERSISTENT
ACTIVITY

• Study of computer keyboards Challenge with VRE
  or P. aeruginosa
• Keys wiped with alcohol or quats (CaviWipes,
  Clorox Disinfecting Wipes, or Sani-Cloth Plus)
• Persistent activity when undisturbed any contact
  will result in removal of the Quat and loss of
  persistent activity

Rutala WA, White MS, Gergen MF, Weber DJ. ICHE
200627372-77.
65
EFFICACY OF LIGHT-ACTIVATED ANTIMICROBIAL COATING

• Germicide Silicone polymers containing
  photosensitizer methylene blue (MB) and Au
  nanoparticles
• Results (exposure to 28W light)
• Panel A Mean number of MRSA recovered after
  24hr incubation
• Panel B Mean number of MRSA recovered after 6hr
  incubation

Reduction MB 99.33 AU 99.99
Reduction MB 56.51 AU 92.30
Ismail S, et al. ICHE 2011321130-32
66
ADVANTAGES AND DISADVANTAGESOF SELF DISINFECTING
SURFACES

• Advantages
• Passive (i.e., requires no additional maintenance
  once installed)
• Effective throughout patient occupancy (i.e., not
  just at terminal disinfection)
• Prevents recontamination
• Depending on method may be manufactured in or
  applied by dipping, brushing or spraying
• Disadvantages
• No studies evaluating whether use reduces HAIs
• Impossible to coat/cover all frequently touched
  surfaces with antimicrobial coating (e.g.,
  medical equipment, television remote, curtains)
• Reduces but does not eliminate pathogenic
  microorganisms
• Durability? Cost? (unknown)
• Development of resistant pathogens (i.e., copper,
  silver)

67
Safer Healthcare Environments for Infection
PreventionNew Technologies and Future Challenges

• Reprocessing reusable medical/surgical
  instruments
• Hospital surfaces (increasing evidence to support
  the contribution of the environment to disease
  transmission)
• Water
• Air

68
Water and HealthcareMultiple Uses
CDC
CDC
69
Water-Related Pathogens and Their Disease
Transmission PathwaysExner et al. AJIC
33S26-40 2005
70
WATER RESERVOIRSRutala, Weber. ICHE 199718609
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Water Wall Fountains and Electronic Faucets
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Water Walls Linked to Legionnaires

• Palmore et al. ICHE 200930764
• 2 immunocompromised patients exposed to
  decorative fountain in radiation oncology
  isolates from patients and fountain identical
  disinfection with ozone, filter and weekly
  cleaning
• Houpt et al. ICHE 201233185
• Lab-confirmed Legionnaires disease was dx in 8
  patients 6 had exposure to decorative fountain
  (near main entrance to hospital) high counts of
  Legionella pneumophila 1 despite disinfection and
  maintenance

73
Water Walls and Decorative Water Fountains

• Present unacceptable risk in hospitals serving
  immunocompromised patients (even with standard
  maintenance and sanitizing methods)

74
Electronic FaucetsA Possible Source of
Nosocomial Infection?
75
Electronic Faucets

• Conserve water
• Conserve energy
• Hygienic
• Hands free
• Barrier free

76
Electronic (E) vs Handle-Operated (HO) Faucets

• 100 E vs 30 HO Legionella (no cases). Halabi et
  al. JHI 200149117
• Significant difference HPC levels between brand A
  (32) and B (8) E compared to HO (11).
  Hargreaves et al. 2001 22202
• No difference in P. aeruginosa. Assadian et al.
  ICHE. 20022344.
• 73 E samples did not meet water std vs 0 HO
• 29 of water samples from E and 1 from HO
  yielded P. aeruginosa. Merrer et al. Intensive
  Care Med 2005311715
• 95 E grew Legionella compared to 45 HO
  (water-disruption events). Syndor et al. ICHE
  33235

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Issues Associated with Electronic Faucets

• A longer distance between the valve and the tap,
  resulting in a longer column of stagnant, warm
  water, which favors production of biofilms
• Reduced water flow reduced flushing effect
  (growth favored)
• Valves and pipes made of plastic (enhances
  adhesion P. aeruginosa)

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Prevention Measures

• Electronic faucets constructed so they do not
  promote the growth of microorganisms
• A potential source of nosocomial pathogens
• No guideline (but some have recommended) to
  remove electronic faucets from at-risk patient
  care areas (BMTU)
• Some have recommended periodic monitoring of
  water samples for growth of Legionella
• More data are needed to establish role in HAIs

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Safer Healthcare Environments for Infection
PreventionNew Technologies and Future Challenges

• Reprocessing reusable medical/surgical
  instruments
• Hospital surfaces (increasing evidence to support
  the contribution of the environment to disease
  transmission)
• Water
• Air

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MOST COMMON PATHOGENS ASSOCIATED WITH
CONSTRUCTION OR RENOVATION OUTBREAKS

• Aspergillus spp. (by far most important)
• Zygomycetes
• Other fungi
• Miscellaneous

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UNDERLYING CONDITIONS IN PATIENTS WITH NOSOCOMIAL
ASPERGILLOSIS
No. of Patients Mortality ()
Hematologic malignancy 299 57.6
Solid organ transplant Renal transplant Liver transplant 36 8 55.9
Other immunocompromised High-dose steroid therapy Neonates Other malignancy Chronic lung disease ICU patients (high-risk) No exact classification possible 15 5 4 2 2 49 52.3
Patients without severe immunodeficiency Thoracic surgery Cataract surgery ICU patients (low risk) Other surgery patients 25 5 5 3 39.4
TOTAL 458 55.0
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NOSOCOMIAL ASPERGILLOSISIN OUTBREAK SETTINGS
Vonberg R-P, Gastmeier P. J Hosp Infect
200663246-54
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RELEVANT GUIDELINES

• 2003 Guidelines for preventing
  health-care-associated pneumonia (HICPAC)
• 2003 Guidelines for environmental infection
  control in health-care facilities (CDC, HICPAC)
• 2000 Guidelines for preventing opportunistic
  infections among hematopoietic stem cell
  transplant recipients (CDC, IDSA, ASBMT)
• American Institute of Architects Academy of
  Architecture for Health. Guidelines for Design
  and Construction of Hospital and Health Care
  Facilities , 2006. (telephone [phone])
• Construction and Renovation, 3rd Edition ,and
  Infection Prevention for Construction DVD,
  Association for Professionals in Infection
  Control and Epidemiology, 2007 (173 member
  price ) APIC store www.apic.org/
• APIC Text of Infection Control and Epidemiology,
  3rd ed. Association for Professionals in
  Infection Control and Epidemiology, 2009.
  www.apic.org/
• ASHRAE - American Society of Heating,
  Refrigeration and Air Conditioning Engineers

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INFECTION CONTROL RISK ASSESSMENT (ICRA)

• ICRA is an multidisciplinary, organizational,
  documented process that after considering the
  facilitys patient population and type of
  construction project (non-invasive to major
  demolition)
• Focuses on reduction of risk from infection
• Acts through phases of facility planning, design,
  construction, renovation, facility maintenance
  and
• Coordinates and weights knowledge about
  infection, infectious agents, type of
  construction project and care environment
  permitting the organization to anticipate
  potential impact

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STEP 1IDENTIFY TYPE OF CONSTRUCTION PROJECT
http//www.premierinc.com/quality-safety/tools-ser
vices/safety/topics/construction/downloads/ICRA- M
atrixColorRevised-091109.pdf
88
STEP 1IDENTIFY TYPE OF CONSTRUCTION PROJECT
89
STEP 2IDENTIFY PATIENT RISK
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STEP 3MATCH RISK GROUP WITH CONSTRUCTION TYPE
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INFECTION CONTROL BY CLASS
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INFECTION CONTROL BY CLASS
During construction
After construction
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INFECTION CONTROL BY CLASS
During construction
After construction
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Portable HEPA UnitsRutala et al. ICHE 199516391
Can rapidly reduce levels of airborne particles
(0.3µ, for example, 90 in 5 m) used in
construction worksite and reduce risk to TB
exposure.
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Safer Healthcare Environments for Infection
PreventionNew Technologies and Future Challenges

• Reprocessing reusable medical/surgical
  instruments
• Hospital surfaces
• Water
• Air

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CONCLUSIONS

• New sterilization, high-level disinfection and
  low-level disinfection technologies/practices/prod
  ucts are effective
• The contaminated surface environment in hospital
  rooms is important in the transmission of
  healthcare-associated pathogens (MRSA, VRE, C.
  difficile)
• Effective surface disinfection essential to
  eliminate the environment as a source for
  transmission of HA pathogens.
• New methods of reducing transmission of these
  pathogens may include improved room
  cleaning/disinfection, no-touch methods (UV,
  HP), and self-disinfecting surfaces
• Water reservoirs of HA pathogens (e.g., water
  walls) may present unacceptable risk to high-risk
  patients
• Use of Infection Control Risk Assessment is a
  logical method to reduce risks associated with
  construction and renovation projects

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disinfectionandsterilization.org
99
THANK YOU!