Environmental approaches to controlling Clostridioides difficile infection in healthcare settings.

As today's most prevalent and costly healthcare-associated infection, hospital-onset Clostridioides difficile infection (HO-CDI) represents a major threat to patient safety world-wide. This review will discuss how new insights into the epidemiology of CDI have quantified the prevalence of C. difficile (CD) spore contamination of the patient-zone as well as the role of asymptomatically colonized patients who unavoidable contaminate their near and distant environments with resilient spores. Clarification of the epidemiology of CD in parallel with the development of a new generation of sporicidal agents which can be used on a daily basis without damaging surfaces, equipment, or the environment, led to the research discussed in this review. These advances underscore the potential for significantly mitigating HO-CDI when combined with ongoing programs for optimizing the thoroughness of cleaning as well as disinfection. The consequence of this paradigm-shift in environmental hygiene practice, particularly when combined with advances in hand hygiene practice, has the potential for significantly improving patient safety in hospitals globally by mitigating the acquisition of CD spores and, quite plausibly, other environmentally transmitted healthcare-associated pathogens.

Mitigating hospital-onset Clostridioides difficile: The impact of an optimized environmental hygiene program in eight hospitals.

OBJECTIVE: To evaluate the impact of a standardized, process-validated intervention utilizing daily hospital-wide patient-zone sporicidal disinfectant cleaning on incidence density of healthcare-onset Clostridioides difficile infection (HO-CDI) standardized infection ratios (SIRs). DESIGN: Multi-site, quasi-experimental study, with control hospitals and a nonequivalent dependent variable. SETTING: The study was conducted across 8 acute-care hospitals in 6 states with stable endemic HO-CDI SIRs. METHODS: Following an 18-month preintervention control period, each site implemented a program of daily hospital-wide sporicidal disinfectant patient zone cleaning. After a wash-in period, thoroughness of disinfection cleaning (TDC) was monitored prospectively and optimized with performance feedback utilizing a previously validated process improvement program. Mean HO-CDI SIRs were calculated by quarter for the pre- and postintervention periods for both the intervention and control hospitals. We used a difference-in-differences analysis to estimate the change in the average HO-CDI SIR and HO-CAUTI SIR for the pre- and postintervention periods. RESULTS: Following the wash-in period, the TDC improved steadily for all sites and by 18 months was 93.6% for the group. The mean HO-CDI SIRs decreased from 1.03 to 0.6 (95% CI, 0.13-0.75; P = .009). In the adjusted difference-in-differences analysis in comparison to controls, there was a 0.55 reduction (95% CI, -0.77 to -0.32) in HO-CDI (P < .001) or a 50% relative decrease from baseline. CONCLUSIONS: This study represents the first multiple-site, quasi-experimental study with control hospitals and a nonequivalent dependent variable to evaluate a 4-component intervention on HO-CDI. Following ongoing improvement in cleaning thoroughness, there was a sustained 50% decrease in HO-CDI SIRs compared to controls.

Health Care Environmental Hygiene: New Insights and Centers for Disease Control and Prevention Guidance.

Recent research has significantly clarified the impact of optimizing patient-zone environmental hygiene. New insights into the environmental microbial epidemiology of many hospital-associated pathogens, especially Clostridioides difficile, have clarified and quantified the role of ongoing occult pathogen transmission from the near-patient environment. The recent development of safe, broadly effective surface chemical disinfectants has led to new opportunities to broadly enhance environmental hygiene in all health care settings. The Centers for Disease Control and Prevention has recently developed a detailed guidance to assist all health care settings in implementing optimized programs to mitigate health care-associated pathogen transmission from the near-patient surfaces.

Wastewater drains: epidemiology and interventions in 23 carbapenem-resistant organism outbreaks.

For many years, patient-area wastewater drains (ie, sink and shower drains) have been considered a potential source of bacterial pathogens that can be transmitted to patients. Recently, evolving genomic epidemiology tools combined with new insights into the ecology of wastewater drain (WWD) biofilm have provided new perspectives on the clinical relevance and hospital-associated infection (HAI) transmission risks related to these fixtures. To further clarify the clinical relevance of WWD-associated pathogen transmission, reports of outbreaks attributed to WWDs were selected for review that (1) investigated the outbreak epidemiology of WWD-associated transmission of bacterial pathogens, (2) utilized advanced microbiologic methods to establish clonality of outbreak pathogens and/or resistance genes, or (3) described interventions implemented to mitigate transmission of the outbreak pathogens from WWDs. These reports were collated, compared, and analyzed, and the results are presented here.

A unified framework for developing effective hygiene procedures for hands, environmental surfaces and laundry in healthcare, domestic, food handling and other settings.

Hygiene procedures for hands, surfaces and fabrics are central to preventing spread of infection in settings including healthcare, food production, catering, agriculture, public settings, and home and everyday life. They are used in situations including hand hygiene, clinical procedures, decontamination of environmental surfaces, respiratory hygiene, food handling, laundry hygiene, toilet hygiene and so on. Although the principles are common to all, approaches currently used in different settings are inconsistent. A concern is the use of inconsistent terminology which is misleading, especially to people we need to communicate with such as the public or cleaning professionals. This paper reviews the data on current approaches, alongside new insights to developing hygiene procedures. Using this data, we propose a more scientifically-grounded framework for developing procedures that maximize protection against infection, based on consistent principles and terminology, and applicable across all settings. A key feature is use of test models which assess the state of surfaces after treatment rather than product performance alone. This allows procedures that rely on removal of microbes to be compared with those employing chemical or thermal inactivation. This makes it possible to ensure that a consistent "safety target level" is achieved regardless of the type of procedure used, and allows us deliver maximum health benefit whilst ensuring prudent usage of antimicrobial agents, detergents, water and energy.

A Multicenter Randomized Trial to Determine the Effect of an Environmental Disinfection Intervention on the Incidence of Healthcare-Associated Clostridium difficile Infection.

OBJECTIVE To determine the impact of an environmental disinfection intervention on the incidence of healthcare-associated Clostridium difficile infection (CDI). DESIGN A multicenter randomized trial. SETTING In total,16 acute-care hospitals in northeastern Ohio participated in the study. INTERVENTION We conducted a 12-month randomized trial to compare standard cleaning to enhanced cleaning that included monitoring of environmental services (EVS) personnel performance with feedback to EVS and infection control staff. We assessed the thoroughness of cleaning based on fluorescent marker removal from high-touch surfaces and the effectiveness of disinfection based on environmental cultures for C. difficile. A linear mixed model was used to compare CDI rates in the intervention and postintervention periods for control and intervention hospitals. The primary outcome was the incidence of healthcare-associated CDI. RESULTS Overall, 7 intervention hospitals and 8 control hospitals completed the study. The intervention resulted in significantly increased fluorescent marker removal in CDI and non-CDI rooms and decreased recovery of C. difficile from high-touch surfaces in CDI rooms. However, no reduction was observed in the incidence of healthcare-associated CDI in the intervention hospitals during the intervention and postintervention periods. Moreover, there was no correlation between the percentage of positive cultures after cleaning of CDI or non-CDI rooms and the incidence of healthcare-associated CDI. CONCLUSIONS An environmental disinfection intervention improved the thoroughness and effectiveness of cleaning but did not reduce the incidence of healthcare-associated CDI. Thus, interventions that focus only on improving cleaning may not be sufficient to control healthcare-associated CDI. Infect Control Hosp Epidemiol 2017;38:777-783.

Optimizing Health Care Environmental Hygiene.

This article presents a review and perspectives on aspects of optimizing health care environmental hygiene. The topics covered include the epidemiology of environmental surface contamination, a discussion of cleaning health care patient area surfaces, an overview of disinfecting health care surfaces, an overview of challenges in monitoring cleaning versus cleanliness, a description of an integrated approach to environmental hygiene and hand hygiene as interrelated disciplines, and an overview of the research opportunities and challenges related to health care environmental hygiene.

Evaluating a new paradigm for comparing surface disinfection in clinical practice.

BACKGROUND: Despite an increasing understanding of the importance of near-patient surfaces in the transmission of healthcare-associated pathogens, there remains a need to define the relative clinical effectiveness of disinfection interventions. DESIGN: A serial 2-phase evaluation of the clinical effectiveness of 2 surface disinfectants. SETTING: A general acute care hospital. METHODS: A unique system for quantifying bioburden reduction while monitoring the possible impact of differences in cleaning thoroughness was used to compare the clinical effectiveness of a traditional quaternary ammonium compound (QAC) and a novel peracetic acid/hydrogen peroxide disinfectant (ND) as part of terminal room cleaning. RESULTS: As a result of QAC cleaning, 93 (40%) of 237 cleaned surfaces confirmed by fluorescent marker (DAZO) removal were found to have complete removal of aerobic bioburden. During the ND phase of the study, bioburden was removed from 211 (77%) of 274 cleaned surfaces. Because there was no difference in the thoroughness of cleaning with either disinfectant (65.3% and 66.4%), the significant ([Formula: see text]) difference in bioburden reduction can be attributed to better cleaning efficacy with the ND. CONCLUSIONS: In the context of the study design, the ND was 1.93 times more effective in removing bacterial burden than the QAC ([Formula: see text]). Furthermore, the study design represents a new research paradigm in which 2 interventions can be compared by concomitantly and objectively analyzing both the product and process variables in a manner that can be used to define the relative effectiveness of all disinfection cleaning interventions.

Beyond the Hawthorne effect: reduction of Clostridium difficile environmental contamination through active intervention to improve cleaning practices.

Education and passive observation resulted in a significant improvement in housekeeper disinfection of nontoxigenic Clostridium difficile spores artificially inoculated onto surfaces in C. difficile infection rooms. A further significant reduction occurred with direct supervision and real-time feedback, suggesting that optimal disinfection is achieved by working closely with housekeepers.

Evaluating hygienic cleaning in health care settings: what you do not know can harm your patients.

Recent studies using direct covert observation or a fluorescent targeting method have consistently confirmed that most near patient surfaces are not being cleaned in accordance with existing hospital policies while other studies have confirmed that patients admitted to rooms previously occupied by patients with hospital pathogens have a substantially greater risk of acquiring the same pathogen than patients not occupying such rooms. These findings, in the context recent studies that have shown disinfection cleaning can be improved on average more than 100% over baseline, and that such improvement has been associated with a decrease in environmental contamination of high touch surfaces, support the benefit of decreasing environmental contamination of such surfaces. This review clarifies the differences between measuring cleanliness versus cleaning practices; describes and analyzes conventional and enhanced monitoring programs; addresses the critical aspects of evaluating disinfection hygiene in light of guidelines and standards; analyzes current hygienic practice monitoring tools; and recommends elements that should be included in an enhanced monitoring program.

Improving environmental hygiene in 27 intensive care units to decrease multidrug-resistant bacterial transmission.

OBJECTIVE: To determine the thoroughness of terminal disinfection and cleaning of patient rooms in hospital intensive care units and to assess the value of a structured intervention program to improve the quality of cleaning as a means of reducing environmental transmission of multidrug-resistant organisms within the intensive care unit. DESIGN: Prospective, multicenter, and pre- and postinterventional study. SETTING: Intensive care unit rooms in 27 acute care hospitals. Hospitals ranged in size from 25 beds to 709 beds (mean, 206 beds). INTERVENTIONS: A fluorescent targeting method was used to objectively evaluate the thoroughness of terminal room cleaning before and after structured educational, procedural, and administrative interventions. Systematic covert monitoring was performed by infection control personnel to assure accuracy and lack of bias. MEASUREMENTS AND MAIN RESULTS: In total, 3532 environmental surfaces (14 standardized objects) were assessed after terminal cleaning in 260 intensive care unit rooms. Only 49.5% (1748) of surfaces were cleaned at baseline (95% confidence interval, 42% to 57%). Thoroughness of cleaning at baseline did not correlate with hospital size, patient volume, case mix index, geographic location, or teaching status. After intervention and multiple cycles of objective performance feedback to environmental services staff, thoroughness of cleaning improved to 82% (95% confidence interval, 78% to 86%). CONCLUSIONS: Significant improvements in intensive care unit room cleaning can be achieved in most hospitals by using a structured approach that incorporates a simple, highly objective surface targeting method and repeated performance feedback to environmental services personnel. Given the documented environmental transmission of a wide range of multidrug-resistant pathogens, our findings identify a substantial opportunity to enhance patient safety by improving the thoroughness of intensive care unit environmental hygiene.

Cruise ship environmental hygiene and the risk of norovirus infection outbreaks: an objective assessment of 56 vessels over 3 years.

BACKGROUND: Norovirus infection outbreaks (NoVOs) occur frequently in closed populations, such as cruise ship passengers. Environmental contamination is believed to play an important role in NoVO propagation. METHODS: Trained health care professionals covertly evaluated the thoroughness of disinfection cleaning (TDC) of 6 standardized objects (toilet seat, flush handle or button, toilet stall inner handhold, stall inner door handle, restroom inner door handle, and baby changing table surfaces) with high potential for fecal contamination in cruise ship public restrooms, by means of a previously validated novel targeting method. RESULTS: Fifty-six cruise ships (approximately 30% of 180 vessels operated by 9 large cruise lines) were evaluated from July 2005 through August 2008. Overall, 37% (range, 4%-100%; 95% confidence interval, 29.2%-45.4%) of 8344 objects in 273 randomly selected public restrooms were cleaned daily. The TDC did not differ by cruise line and did not correlate with the Centers for Disease Control and Prevention (CDC) Vessel Sanitation Program inspection scores (r(2), .002; P = .75). More than half the vessels had overall TDC scores <30%, although several of these low-scoring ships had near-perfect CDC sanitation scores. The mean TDC of the 3 ships evaluated within 4 months before a NoVO (10.3%) was substantially less than the mean TDC of the 40 ships that did not experience NoVOs (40.4%) (P < .004). CONCLUSIONS: An objective evaluation of public restroom environmental hygiene on 56 cruise ships found that only 37% of selected toilet area objects were cleaned on a daily basis. Low TDC scores may predict subsequent NoVO-prone vessels. Enhanced public restroom cleaning may prevent or moderate NoVOs on cruise ships.

Dangerous cows: an analysis of disinfection cleaning of computer keyboards on wheels.

Keyboards in intensive care units have been shown to serve as reservoirs for multidrug-resistant microorganisms. The thoroughness of disinfection cleaning of keyboards on computers on wheels (COWs) in an intensive care units of an academic medical center were evaluated using an invisible florescent marker, and the movements of the COWs were tracked using their serial numbers. Following a series of educational and programmatic interventions, we were able to improve the thoroughness of cleaning to 100%.

Improving cleaning of the environment surrounding patients in 36 acute care hospitals.

OBJECTIVE: The prevalence of serious infections caused by multidrug-resistant pathogens transmitted in the hospital setting has reached alarming levels, despite intensified interventions. In the context of mandates that hospitals ensure compliance with disinfection procedures of surfaces in the environment surrounding the patient, we implemented a multihospital project to both evaluate and improve current cleaning practices. DESIGN: Prospective quasi-experimental, before-after, study. SETTING: Thirty-six acute care hospitals in the United States ranging in size from 25 to 721 beds. METHODS: We used a fluorescent targeting method to objectively evaluate the thoroughness of terminal room disinfection cleaning before and after structured educational and procedural interventions. RESULTS: Of 20,646 standardized environmental surfaces (14 types of objects), only 9,910 (48%) were cleaned at baseline (95% confidence interval, 43.4-51.8). Thoroughness of cleaning at baseline correlated only with hospital expenditures for environmental services personnel (P = .02). After implementation of interventions and provision of objective performance feedback to the environmental services staff, it was determined that 7,287 (77%) of 9,464 standardized environmental surfaces were cleaned (P < .001). Improvement was unrelated to any demographic, fiscal, or staffing parameter but was related to the degree to which cleaning was suboptimal at baseline (P < .001). CONCLUSIONS: Significant improvements in disinfection cleaning can be achieved in most hospitals, without a substantial added fiscal commitment, by the use of a structured approach that incorporates a simple, highly objective surface targeting method, repeated performance feedback to environmental services personnel, and administrative interventions. However, administrative leadership and institutional flexibility are necessary to achieve success, and sustainability requires an ongoing programmatic commitment from each institution.

An evaluation of patient area cleaning in 3 hospitals using a novel targeting methodology.

BACKGROUND: Although environmental cleaning and disinfecting practices have become a cornerstone of patient care, assessment of actual compliance with such procedures has not been reported. Using a novel methodology, we developed a means to monitor directly such activities. METHODS: A nontoxic target solution, which intensely fluoresces with a black light, was formulated to be inconspicuous yet readily removed by housekeeping products. Small volumes of material were confidentially applied to 12 target sites in patient rooms in 3 hospitals following terminal cleaning. The targets were reevaluated following terminal cleaning after several patients had occupied the room. RESULTS: One hundred fifty-seven rooms and 1404 targets were evaluated. In the 3 hospitals studied, only 45%, 42%, and 56% of targets were removed by routine terminal cleaning/disinfecting activities. The frequency with which various individual sites were cleaned varied widely but was similar in all hospitals. CONCLUSION: The use of a novel target compound to evaluate housekeeping practices confirmed high rates of cleaning of traditional sites but poor cleaning of many sites that have significant potential for harboring and transmitting microbial pathogens. This methodology has the potential for being used to evaluate objectively the cleaning/disinfecting activities in various health care settings.