A Fresh and Appropriate Approach to Hygienic Cleaning of Environmental Surfaces

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A Fresh and Appropriate Approach to Hygienic
Cleaning of EnvironmentalSurfaces
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Public attitudes towards bacterial resistance a
qualitative study

• Although members of the public can contribute to
  containing bacterial resistance, most do not feel
  that they have a personal role in either the
  problem or its solution. Campaigns should
  identify bacterial resistance as both a hospital
  and a community problem that individuals have the
  power to influence through specific actions
• April 21, 2007 Journal of Antimicrobial
  Chemotherapy,

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Current Practices

• Surfactant based cleaning and disinfecting
  contribution to microbial resistance to biocides
  and antibiotics.

This discussion presents a fresh approach to
address these problems
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Current Practices

• There is growing evidence today that leaving
  toxic surfactant detergent disinfectant residues
  on environmental surfaces and in our waste water
  contributes to development of bacterial
  resistance to biocides and antibiotics.

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Antimicrobial Agents Chemother. 2006 November
50(11) 35883596.
Adaptive Resistance of Salmonella enterica
Serovar Enteritidis Biofilms Exposed to
Benzalkonium Chloride

• Resistance of biofilm pathogens following
  exposure to either continuous (1 µg ml-1) or
  intermittent (10 µg ml-1 for 10 min daily)
  benzalkonium chloride (BC) was examined.
• Biofilm pathogens that adapted to BC exposure
  over 144-hours could survive a normally lethal BC
  challenge (500 µg ml-1 for 10 min) and then
  regrow

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• There are concerns that the inappropriate use
  (inadequate concentrations, insufficient cleaning
  before the application, or the presence of sub
  lethal residual disinfectants following cleaning)
  of these biocidal compounds may contribute to the
  spread of bacterial resistance to these
  compounds, as well as cross-resistance to certain
  therapeutic antibiotics.

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Susceptibility of multiresistant Pseudomonas
aeruginosa isolates to a hospital disinfectant
and molecular typing

• We found isolates with reduced susceptibility to
  the QAC disinfectant.
• Resistance to quaternary ammonium may co-select
  for antibiotic resistance via class 1 integrons
  and vice-versa.

Mem. Inst. Oswaldo Cruz vol.100 no.5 Rio de
Janeiro Aug. 2005
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Journal of Antimicrobial Chemotherapy (2007) 60,
947955Advance Access publication 13 September
2007
Prolonged treatment of Salmonella enterica
serovar Typhimurium with commercial disinfectants
selects for multiple antibiotic resistance

• Our work demonstrates that subinhibitory
  concentrations of disinfectants, which might
  occur during poor disinfection and cleaning
  procedures, can lead to selection of strains with
  reduced susceptibility, or even resistance to
  antibiotics.
• These effects were more pronounced with a
  quaternary ammonium based biocide and with the
  use of high concentrations of triclosan.

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Genomics of IncP-1 plasmids isolated from
wastewater treatment plants

• Based on genomic analysis of IncP-1 resistance
  plasmids
• These plasmids encode resistance to clinically
  relevant antimicrobial drug classes including
  tetracyclines, aminoglycosides, macrolides,
  ß-lactams, chloramphenicol, sulphonamides and
  trimethoprim.
• Additional genes were identified that encode
  resistance to heavy metals (mercury and chromate)
  or quaternary ammonium compounds (used in
  detergents).
• Integrons were frequently found on IncP-1
  plasmids
• Since these elements play an important role in
  the acquisition and exchange of genes encoding
  resistance to antibiotics and QACs, their
  presence on conjugative, broad-host-range
  plasmids is worrying. Indeed, linkage of genes
  encoding both antibiotic and QAC resistance
  allows for selection of drug resistance
  determinants by disinfectants

Microbiology reviews July 2007
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Disinfectant-resistant bacteria in Buenos Aires
city hospital wastewater

• Disinfectants present in the hospital wastewater
  may act as selective pressure for the retention
  of the plasmids that often contain the genes for
  resistance to numerous antibiotics (14,22,23,26).
  It is generally agreed that the selection and
  dissemination of resistant bacteria in nature
  should be avoided in order to ensure effective
  treatment against infectious diseases in humans
  and maintain an ecological balance that favors
  the predominance of a susceptible bacterial flora
  in nature. The indiscriminate use of
  antimicrobial agents may disrupt the microbial
  balance in favor of resistance bacteria. In
  particular, wastewater from hospital plants could
  play a role in the selection of resistance
  bacteria in sewage (6,16).

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JAC Advance Access published online on January
28, 2008 Journal of Antimicrobial Chemotherapy,
doi10.1093/jac/dkm520

• Objectives To detect genes conferring resistance
  to biguanides, quaternary ammonium compounds,
  ß-lactams and fluoroquinolones in clinical
  methicillin-resistant Staphylococcus aureus
  (MRSA) and to demonstrate whether reduced
  susceptibility is spread clonally and if the
  presence of any of the detected genes links to a
  specific epidemic MRSA. Finally, to identify if
  exposure to chlorhexidine may cause reduced
  susceptibility to antibiotics and chlorhexidine.
• Conclusions In our study, isolates resembling
  PFGE type EMRSA-16 harboured more biocide
  resistance genes than other types. The observed
  reduction in susceptibility of clinical isolates
  to chlorhexidine may mean that a selective
  pressure is being exerted by residues in the
  clinical environment, and highlights the
  importance of efficacy testing on clinical
  strains and good infection control practices. The
  development of reduced microbial susceptibility
  to biocides represents a serious cause for
  concern in the clinical environment

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Mem. Inst. Oswaldo Cruz vol.102 no.4 Rio de
Janeiro June 2007

• A total of 74 methicillin-resistant
  Staphylococcus aureus (MRSA) strains isolated
  from three government hospitals in 2002 and 2003
  were examined concerning the distribution of
  qacA/B gene, which is the determinant of
  resistance to quaternary ammonium compounds
  largely employed in hospital disinfection. By
  polymerase chain reaction the qacA/B gene was
  found in 80 of the isolates, which is a
  significant result considering it is the first
  time that qacA/B gene is being reported for
  Brazilian MRSA strains and it is presented at a
  high rate.

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The association between biocide tolerance and
the presence or absence of qac genes among
hospital-acquired and community-acquired MRSA
isolates

• In this study, Hospital Acquired MRSA
  isolates displayed significantly higher MBC to a
  quat than MSSA isolates. This would suggest
  that there is a correlation between
  antibiotic resistance and biocide tolerance.
• Although a definitive link between antibiotic
  and biocide resistance has not been established,
  it has been observed that the MBC of QACs was
  significantly higher for clinical isolates of
  MRSA than MSSA.
• Our study reinforces this link in S. aureus
  and the issue of biocideantibiotic co-resistance
  should no longer be ignored.

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The association between biocide tolerance and
the presence or absence of qac genes among
hospital-acquired and community-acquired MRSA
isolates

• The continued exposure of bacteria to residual
  levels of biocides in the hospital environment is
  causing concern.
• The presence of qac genes in the clinical S.
  aureus population and their ability to develop
  increased tolerance highlights the importance of
  effective and rigorous infection cleaning and
  infection control strategies.

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Importance of environmental decontamination a
critical view

• The level of evidence supporting different
  disinfection and cleaning procedures performed in
  healthcare settings worldwide is low.
• It must be kept in mind that the effect of
  surface disinfection is only transient, microbial
  contamination will have reached its former level
  within a few hours.
• With respect to environmental surfaces, the
  final assessment of whether use of disinfectants,
  rather than detergents alone, to reduce
  nosocomial infection rates in different clinical
  settings still awaits conclusive study.

Journal of Hospital Infection (2007) 65(S2) 5557
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Importance of environmental decontamination a
critical view

• As with proper cleaning procedures, targeted
  surface disinfection is indispensable in modern
  hospitals. However, disinfectants may be
  hazardous to personnel and patients, as well as
  the environment, and require special safety
  precautions. An uncritical use of biocides,
  especially in low concentrations, may lead to
  the development of resistance.

Journal of Hospital Infection (2007) 65(S2) 5557
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MRSA

• Cleaning surfaces with detergent-based cleaners
  or Environmental Protection Agency
  (EPA)-registered disinfectants is effective at
  removing MRSA from the environment.
• CDC MRSA in Schools

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Current Practices

• The current practice of leaving toxic residues on
  environmental surfaces after cleaning has not
  reduced the potential spread of pathogens from
  environmental surfaces.
• Antimicrobial surfactants residues after drying
  on surfaces are quickly reduced to sub-inhibitory
  concentrations.

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Induction of multiple antibiotic resistance by
benzene and benzene- derived active compounds

• Objectives To determine the potential of active
  compounds (ACs) present in commonly used
  analgesics/antiseptics and cleaning agents
  (detergents and disinfectants) to induce multiple
  antibiotic resistance (MAR) in Bacteroides
  fragilis.

Journal of Antimicrobial Chemotherapy Advance
Access published September 20, 2007
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Tested inorganic compounds(sodium hypochlorite,
ammonium hydroxide and hydrogen peroxide) were
essentially non-inducing.
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Toxicity of anionic detergents determined by
Saccharomycescerevisiae microarray
analysisSophon Sirisattha, Yuko Momose, Emiko
Kitagawa, Hitoshi Iwahashi

• The mRNA expression profiles suggest that LAS
  and SDS cause damage to membranes and alterations
  in carbon metabolism, and induce the oxidative
  stress response. We also found that LAS and SDS
  induce the pleiotropic drug-resistance network,

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Some studies have demonstrated that these
residues can increase the persistence of C.
Difficile
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In vitro effects of environmental disinfectants
on spore formation (ii)
Fawley WN, et al. Infect Control Hosp Epidemiol
200728920-5.
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Antimicrobial Products In The HomeCanadian
Pediatric Society, 2006

• Where appropriate, alcohol, bleach or
  peroxidase-based agents are preferred because
  they dissipate readily and are less likely to
  exert prolonged antimicrobial pressure. Agents
  such as triclosan, chlorhexidine and quaternary
  ammonium compounds exert more prolonged
  antimicrobial pressure.

Pediatric and Child Health 200611169-173
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Surfactants are Toxic

• Surfactants used in cleaning and disinfecting of
  environmental surfaces are all rated as toxic to
  aquatic life.
• Surfactants used in cleaning of environmental
  surfaces all have toxic effects on microbial
  populations bactericidal and/or bacteriostatic.
• Surfactant toxic effects on microbial populations
  contributes to bacterial adaptation and
  resistance development.

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Journal of Antimicrobial Agents Volume 28,
Issue 6, December 2006
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Toxicity of anionic detergents determined by
Saccharomycescerevisiae microarray
analysisSophon Sirisattha, Yuko Momose, Emiko
Kitagawa, Hitoshi Iwahashi

• The concentrations of LAS and SDS that cause
  growth inhibition were studied after screening of
  the various concentrations of LAS and SDS that
  affect cellular growth. The growth curves showed
  that, at 0.02 LAS and 0.01 SDS, there was a
  50 decrease in the specific growth (IC50) after
  a 2 h treatment.

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International Symposium on Environmental
Biotechnology 2006, Leipzig, Germany288Effects
of detergent shock loads on anaerobic granular
sludge morphologyand methanogenic activity

• After exposure to 0.30 g/L of detergent the COD
  removal efficiency decreased drastically.

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Effect of Surfactants on Soil Bacteriaby
LUDWIG HARTMANNHead, Laboratory o
Engineering-BiologyTechnische H ochschule
Karlsruhe, Germany
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Consumption of Surfactants

• In 1998 the estimated annual consumption of
  surfactants in Europe was 1,696,000 metric tons.
• In the same period the estimated total
  consumption of antibiotics from all sources was
  less than 1,000 metric tons .

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Current Practices

• Low Level disinfectant cleaners like quats are
  used for damp dusting environmental surfaces with
  a simple wipe and go technique.
• More potent disinfectant cleaners are used in
  isolation areas, for cases of Noroviruses or C.
  difficile and simply when a higher degree of
  confidence is required.
• Because it is not common practice to maintain
  anappropriate wet contact time, cleaning staff
  are using antimicrobial products as cleaners, not
  disinfectants.
• Legally concerns claiming when claiming to
  disinfect but not following manufacturers
  instructions for use?

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Separate Cleaning From Disinfecting.

• One Step Cleaning and Disinfecting is
  contradictory to the science of disinfection.

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Focus on Cleaning.

• Use best cleaning practices.
• Prevent spreading contaminants.

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If your institution insist on cleaning with low
level disinfectant cleaners consider using sodium
hypochlorite to replace existing cleaning
solutions.

• Mild odor in low concentrations.
• Oxidizes organic soils that harbor many
  problematic pathogens.
• Safe in low concentrations.
• Easily formulated into effective cleaning
  solutions without detergent surfactants.
• Reduced environmental pressure on microbial
  populations..

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If your institution insist on cleaning with low
level disinfectant cleaners consider using sodium
hypochlorite to replace existing cleaning
solutions.

• Packaged in closed looped containers with
  accurate dispensers.
• Dilute solutions can be made stable for months
  after dilution when stored in clean work place
  bottles.
• Use in conjunction with best cleaning practices .

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• All 9 rooms of patients with CDI positive
  cultures prior to cleaning vs. 7 (78) after
  housekeeping cleaning (p 0.5), vs. only 1 (11)
  after bleach disinfection by research staff (p
  0.031)
• After an educational intervention, rates of
  environmental contamination after housekeeping
  cleaning were significantly reduced

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Moore Griffith. J Hosp Infect 200664379-85.
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• All 9 rooms of patients with CDI positive
  cultures prior to cleaning vs. 7 (78) after
  housekeeping cleaning (p 0.5), vs. only 1 (11)
  after bleach disinfection by research staff (p
  0.031)
• After an educational intervention, rates of
  environmental contamination after housekeeping
  cleaning were significantly reduced

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Targeted disinfection after cleaning.

• Limit disinfectant use to disinfection.
• Replace residue depositing disinfectants.
• Use one disinfectant considered effective on all
  hospital pathogens.
• Use cleaning products compatable with hospital
  disinfectant.
• Use safe storage, handling and in use practices.
• Sodium hypochlorite is very effective in short
  contact times when applied to pre cleaned
  surfaces.

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Michael Rochon Cogent Environmental
Solutions michael_at_ecogent.ca 1-877-994-9908