Monitoring Cleaning and Disinfection Practices

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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
2
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

3
Role of Environment in Transmissionof
Healthcare-Associated Pathogens

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

Hota B Clin Infect Dis 2004391182 Boyce JM J
Hosp Infect 200765 (Suppl 2)50 Weber DJ et al.
Am J Infect Control 201038 (5 Suppl 1)S25 Weber
DJ and Rutala WA Infect Control Hosp Epidemiol
201132207 Otter JA et al. Infect Control Hosp
Epidemiol 201132687 Weber DJ et al. Curr Opin
Infect Dis 201326338
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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
200352(RR-10)1 Rutala WA, Weber DJ et al.
HICPAC Guideline for Disinfection and
Sterilization in Healthcare Facilities, 2008
5
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
20004519 Cooper RA et al. Am J Infect Control
200735338 Dancer SJ J Hosp Infect
200973378 Luick L et al. Am J Infect Control
201341751
6
Check lists to Improve Cleaning Practices
http//www.cdc.gov/hai/toolkits/evaluating-environ
mental-cleaning.html
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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
20004519 Cooper RA et al. AJIC
200735338 Luick L et al. AJIC 201341751
8
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
2006421552 Boyce JM et al. ICHE
20103199 Guerrero D et al. 2010 Decennial
conference, Abstr 60
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Observation and Supervision of Housekeeper
Performance

• Investigators applied C. difficile spores
  (non-toxigenic) to 3 high-touch surfaces in
  mulitple rooms before terminal cleaning
• 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

Percent of inoculated surfaces positive for C.
difficile after cleaning, with different
interventions
Guerrero DM et al. ICHE 201334524
10
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
200352(RR-10)1 Dancer SJ J Hosp Infect
20045610
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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)
• 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

VRE on Bedside Rail
Lemmen SW et al. Int J Hyg Environ Health
2001203245 Duckro AN et al. Arch Intern Med
2005165302 Donskey CJ et al. N Engl J Med
2009360e3
Hand imprint culture
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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 20076535 Rutala
WA et al. ICHE 2010311025 Galvin S et al. J
Hosp Infect 201282143 Havill NL Am J
Infect Control 201341S26 Anderson DJ et al.
ICHE 201334466
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RODAC Plates
Cultures of Overbed Table
Before Cleaning After
Cleaning
Boyce JM et al. SHEA 2011, Abstr 4711
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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 2008683
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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 lt
  0.001)
• This method has been used to improve cleaning
  practices in several larger studies

Carling PC et al. Clin Infect Dis
200642385 Carling PC et al. Infect Control
Hosp Epidemiol 2008291 Carling PC et al. Crit
Care Med 2010381054
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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 2008291035
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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
200829593
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Evaluating Cleaning Measures in an ICU Using
Fluorescent Marker System
Goodman ER et al. Infect Control Hosp Epidemiol
200829593
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Monitoring Hospital CleanlinessUsing 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
20004519 Malik RE et al. AJIC
200331181 Cooper RA et al. AJIC
200735338 Lewis T et al. J Hosp Infect
200869156 Boyce JM et al. Infect Control Hosp
Epidemiol 200930678 Boyce JM et al. Infect
Control Hosp Epidemiol 20103199 Moore G et al.
AJIC 201038617 Havill NL et al. AJIC
201139602 Anderson RE et al. J Hosp Infect
201178178
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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
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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 2011321187
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Assessing Terminal Cleaning Practices Using 3
Methods

• Main outcome measures expressed as percent of
  surfaces sampled after cleaning with
• Aerobic colony count lt 2.5 cfu/cm2
• Most or all of fluorescent marker removed
• ATP reading of lt 250 Relative Light Units

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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 lt 0.0001
P 0.65
24
Proportion of 382 High-Touch Surfaces Classified
as Having Been Cleaned by Fluorescent Marker, or
Clean by ATP After Terminal Cleaning
P lt 0.0001
Rooms Classified as Clean BEFORE terminal
cleaning by ATP were excluded
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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 2011321187
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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
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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)
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ATP Bioluminescence for Evaluating
Disinfectionof 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 lt 250 RLU were considered to be
  clean
• 3 of 71 sites with ATP readings of lt 250 RLU
  had positive culture
• 19 of 69 sites with ATP readings gt 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
201334865
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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 201341751
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Caveats on Using ATP Bioluminescenceto 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 lt 250 RLU as
  clean
• Other systems classify surfaces with lt 100 RLU as
  clean
• Sensitivity and specificity of different
  luminometers and assay systems differ
• Consider manufacturers 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 20117725 Aiken
ZA et al. Infect Control Hosp Epidemiol
201132507 Shama G et al. Int J Hyg
Environmental Health 2013216115
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Advantages and Disadvantages of Methods for
Monitoring Cleaning and Disinfection Practices
Housekeepers may game system
Havill NL Am J Infect Control 201341S26
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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
201334459
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Sequential Interventions and Use of Two
Monitoring Methods to Improve Disinfection of C.
difficile Isolation Rooms
Sitzlar B et al. Infect Control Hosp Epidemiol
201334459
34
Conclusions

• Contaminated environmental surfaces can
  contribute to transmission of healthcare-associate
  d 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

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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
2011301473 Weber DJ et al. ICHE 20123310
37
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 200663289 Wheeldo
n et al. J Antimicrob Chemother
200862522 Casey AL et al. J Hosp Infect
20107472 Grass G et al. Appl Environ Microbiol
2011771541 Karpanen TJ et al. ICHE 2012333
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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 20123310
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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 20123310 Havill NL
Boyce JM (unpublished)