The presentation is solely meant for Academic purpose

AIFIC '13

Environmental Decontamination:

Paradigms Redefined

Disclosures- nil

800 B.C – Homer described the burning of Sulphur

in the house

4th century A.D. – Susruta used sulphur to clean

rooms for surgery

Mercury, copper, alkalis acids all were used for

‘Purifying’

429 B.C Hippocrates recommended fumigation by

burning odoriferous herbs to control an epidemic

History

Advocated pure air, pure water,

efficient drainage, cleanliness and

light as the cornerstones of good

health and prevention of mortality

1850’s- Crimean war

Hospital

Project

Engineering

Housekeepi

ng

Infection

control

AIFIC '13

It is important to maintain a healthy

environment

What best infection control practices

are available?

How to use it cost effectively to

protect patients and health care

workers from infectious hazards?

The hospital environment

Chain of infection

Reservoirs

AIR

WATER

SURFACE

ENVIRONMENT

HCW

Found in 7-37% environmental samples

More common if patients have diarrhoea

Nurses gowns contaminated

8% of cultures positive even after terminal

cleaning

Boyce 1994, Montecalvo 1995, Boyce 1995

VRE & environment

Burns unit – attack rate 75%

- 33 of 145 environmental swabs positive

Hydrotherapy facilities contaminated

Surgical units without MRSA problem

-1 of 36 samples positive

Crossley 1979

MRSA & environment

25 rooms of MRSA positive patients

53.6% surface samples positive

28% of air samples

Molecular typing PFGE

70% of patient and environmental swabs

indistinguishable

Sexton et al JHI 2006

MRSA & environment

50 ICU rooms occupied with patients

having MDR AB

9.8% (47 of 479) of the environmental

surfaces were contaminated with MDR-AB.

Supply cart handles were the most

frequently contaminated surface (20%),

room floors (16%), infusion pumps (14%),

ventilator touch pads (11.4%) and bed rails

(10.2%).

A. baumanii & environment

Am J Infect Control 2011;39:711-715

Vancomycin-resistant enterococci (VRE),

Clostridium difficile*, and multidrug-

resistant gram-negative bacteria (MDR-

GNB) are increasing

Hence increasing attention being paid to

the role of high-touch environmental

surfaces in transmission

MDRO’s in environment

*Am J Epidemiol. 1988 Jun;127(6):1289-

Am J Infect Control 2010;38:S25-33

Do environmental surfaces play a role in

initiating infection?

OR

Merely reflect the presence of a source

patient contaminating his surroundings?

Environmental surfaces

1

• Source patient (occupant of room or reusable eqpt)

2 • Environmental

surface

3 • Subsequent patient

1 • Source patient

2

• Environmental surface

3 • Hands of HCW

4 • Subsequent patient

Primary role Secondary role

Environmental surfaces

AIFIC '13

Outbreak of Klebsiella pneumoniae in

NICU- 3 cases

Investigations included- handwashing

compliance monitoring, disinfectant usage,

focussed cleaning

Swabs from incubators, ventilator tops,

mobile phone of doctors to look for specific

pathogen

Klebsiella in environment

Klebsiella pneumoniae with similar

antibiogram was isolated from the top of

ventilator.

Increased emphasis of focused cleaning in

and around the patients

Outbreak curtailed

Klebsiella in environment

Dry surface – Gram positive cocci, fungi

Wet surface – Gram negative bacilli

Cleaning with soap and water or detergent

or disinfectant

Cleaning and disinfection of surfaces

Manual cleaning and then application of

disinfectant or detergent/disinfectant

New disinfectants with greater potency and

shorter contact times

Standard environmental cleaning methods

Tertiary care 8 wards

Phenolic disinfection vs detergent

6 months, random selection of wards

Users blind to product used

No difference in HAI rates

Danfoth JHI 1987

Detergent or disinfectant? Study 1

ICU floors cleaned 3X daily

6 months detergent

6 months disinfectant

Bedside tables, bed frames etc cleaned with

disinfectant

No difference in HAI rates

Dashner 1980

Detergent or disinfectant? Study 2

1960’s Vesley and Micaelsen – detergents

can achieve microbial reduction equivalent

to disinfectants*

Maki et al- no change in infection rates in

new and old hospital and new environment

was contaminated to old rates in 6-12

months

Detergent or disinfectant?

*Appl Environ Microbiol 1987:53;1042-1045

Cleaning Agent Manufacturer

Sapona Inter national Hygiene Products

Teepol - 300 Reckett and Coleman

Spiral Hindustan Lever

Ajax Colgate Palmolive

Fesca Metropole

Wizard Quartz Home Care

Brisk Modi Industries

Spick and Span Etoshapan

Cleaning agents - detergents

JAHA Vol. 13, No. 1 (2001-01 - 2001-06

Detergent Disinfectants

Polysan - (Akyl phenoxy poly active ingredient ethoxy - ethanol, iodine)

Polyphan Pvt. Ltd

Germinol Etosha pan

Lamp phenyl Bengal chemicals

Trishul phenyl Ampey Lean

Phoenix Metro pole

Dettol-H - (Ben 2 alkonim chlorid sol. 1. P40 1v/v disodeim edeati)

Rickett and Colman

Bacilloid Special _ ( D. hydroxy - 2,5, Dioxyhexene glutaaldehydi,

Raman Pvt. Ltd de n 201 konuim chloride, caxosguanidiam ehlondi)

Detergent-disinfectant

JAHA Vol. 13, No. 1 (2001-01 - 2001-06

Properties Phenolic Quaternary Iodophor peroxides

Effectiveness

against S. aureus Fair to good Good Good good

M tuberculosis Fair to good Good Good good

Effect on organic

matter Good Good Fair good

Skin irritation

properites Harsh Mild Mild mild

Odour

Strong to

mild Mild Mild mild

pH of use

soulution

Alkaline(pH9.

10)

Neutral or

alkaline(pH7.10)

Acidic(pH3.

6)

Soil removal

property Poor to good Good Fair fair

Corrosion to floor

Surface

Safe at

correct

dilutions Safe Safe safe

Properties of disinfectants

JAHA Vol. 13, No. 1 (2001-01 - 2001-06

Cost

Area to be disinfected- steel OT –

lysoformin

Vinyl floors- QAC (benzalkonium chloride)

Room occupied with patient with

Clostridium difficile – Hypochlorite

solutions

Choice of disinfectant

Operation theatres , BMT units , ICU –

disinfectant after cleaning

Wards – disinfectant/ detergent

General areas- detergent

Choice of disinfectant / detergent

First clean with detergent and surfactant to

remove organic matter, salt and visible

soils.

The physical action of scrubbing and

rinsing removes large numbers of

microorganisms

Factors affecting Disinfection of surfaces

Potential for direct patient contact

Degree and frequency of hand contact

Potential contamination of surfaces with

body fluids and environmental

contamination

Choice of disinfectant – QAC, hypochlorites,

hydrogen peroxides, lysoformin etc

Strategies for Cleaning and disinfection of surfaces

Surfaces with minimal hand-contact –

ceiling, floor

Areas with frequent hand-contact – high

touch surfaces (door knobs, bed rails, wall

around toilet, light switches, edges of

curtains) require more cleaning/

disinfection

Housekeeping surfaces

Solutions to be replaced frequently

Two bucket system to be used

Mop heads to be changed at each shift

Mops to be dried before use

Detergent / disinfectant solutions can

support Gram negative bacteria

(pseudomonas) if stored for a long time

Cleaning solutions and tools – a source of pathogens

“Nontouch disinfection” (NTD) methods

Microcondensation hydrogen peroxide

vapor

hydrogen peroxide dry mist system

gaseous ozone

alcohol/quaternary ammonium power

sanitizing system

ultraviolet light room decontamination

Newer Strategies for Terminal Room Decontamination

Both methods appear highly efficacious in

inactivating the microbial bioburden

present on surfaces

Both remove much of the variance inherent

in human cleaning activity via a high degree

of automation and feedback loops for

verification that contact or irradiation times

are adequate

HP Vapour & UVGI

Patients admitted to rooms using HPV were

64% less likely to acquire any MDRO (esp

VRE).

The proportion of rooms environmentally

contaminated with MDROs was reduced

significantly on the HPV units (relative risk,

0.65, P = .03), but not on non-HPV units.

HPV efficacy v/s standard disinfectant

Passaretti et al .Clin Infect Dis. 2013:56:27-35.

An automated mobile UV light unit that

emits UV-C light was placed in 25 patient

rooms after patient discharge and operated

The mobile UV-C light unit significantly

reduced aerobic colony counts and C.

difficile spores on contaminated surfaces in

patient rooms

UV light disinfection

Infect Control Hosp Epidemiol2011 Aug;32(8):737-42.

Single room

Use of gloves and gown when in contact

with patient / patient environment

Donning PPE at room entry and discarding

before exiting room

Duration of precautions is not known

Contact precautions for MDRO, C. difficile

http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf

Previous room occupancy by patients with

VRE or MRSA increases risk for acquiring

these multidrug-resistant organisms in

patients subsequently admitted to the same

rooms.

The need for terminal cleaning and disinfection

Clin Infect Dis. 2008;46:678-685.

Arch Intern Med. 2003;163:1905-1912

Arch Intern Med. 2006;166:1945-1951

Hayden et al. Clinical Infectious Diseases 2006; 42:1552–60

Carpets to be avoided (especially in ICU, OR,

BMT units)

If flowers are present, the water should be

changed frequently and these should be

handled by staff not having patient contact

Flowers (fresh and dried ) can harbour

Aspergillus spores

Other factors

Have housekeeping managers conduct visual

inspection (not reliable)

Mark high touch surfaces with a fluorescent solution

and check later to determine whether the mark has

been removed by housekeepers during room

cleaning

Count aerobic colonies of specimens obtained from

high touch surfaces

Use adenosine triphosphate (ATP) bioluminescence

assay to assess the cleanliness of surfaces

Monitoring Cleaning and Disinfecting Practices

Terminal cleaning is often suboptimal.

Only about 50% of the surfaces in patient

rooms that should be cleaned are wiped by

housekeepers.

This phenomenon has been documented in

different types of hospitals and intensive

care units as well as on general medical or

surgical wards.

Monitoring cleaning practices

Clin Infect Dis. 2006;42:385-388, Infect Control Hosp Epidemiol. 2008;29:1-7

Infect Control Hosp Epidemiol. 2008;29:593-599

Providing housekeepers with feedback

about the results of such monitoring and

educating them about the importance of

their activities has led to significant

improvements in the proportion of surfaces

that are cleaned by housekeepers

Feedback & Education

Infect Control Hosp Epidemiol. 2009;30:678

Surgical site exposes sterile tissue to microorganisms from :

respiratory droplets and nuclei,

skin scales carried on air currents,

direct contact with the surgical team's skin,

and contaminated fomites.

The route with the most significant potential for

iatrogenic bacterial transfer is direct physical

contact.

Air

Dermatol Surg. 2011 Dec;37(12):1709-20

Talking – 3000 droplet nuclei

Sneezing – 40,000 droplet nuclei

Sweeping

Dry plants

Staphylococci, Streptococci, Fungal spores

Microbial contamination of air

Filtration

Air changes

Pressure differentials

Ultraviolet installations

Laminar air flow

Strategies to reduce air contamination

Isolation room BMT unit Operating room

Air pressure Negative Positive Positive

Room air changes

≥12 ≥ 12 ≥ 20

Sealed Yes Yes yes

Room leakage (0.1 cfm/ft2 ) (0.1 cfm/ft2 )

(0.1 cfm/ft2 )

Directed airflow Clean- to- dirty (HCW clean)

Clean- to- dirty (patient clean)

Displacement flow in surgical site critical

Filtration supply 90% 99.97% HEPA @0.3um

90%

Special ventilation areas

Pressurisation

Air changes

Filtration – non microbiologic method –

particle count

Verification of ventilation parameters

Non viable airborne particles detected by

particle counter, optical or laser.

Particle size >0.5 um used for assessing

clean room

Air – particle count

Classification based on HEPA filtered (99.7%

efficient at 0.3 um diameter particles)

operating room or BMT room with no

people should be capable of class 1000

clean room status

(there are <1000 particles per cubic foot

>0.5 um in diameter)

Clean room classification - ISO

Clean room classification - ISO

A comparison of air counts and

environmental contamination rates was

made with the Inov8 units on and off. The

Inov8 unit produced an overall reduction in

both air sample and settle plate counts in

each setting (P < 0.001)

? Effect on specific pathogens

? Safety issues for patients and HCW

Hydroxyl radical air disinfection system

J Hosp Infect. 2011:78;194-99

Ozone fumigation successfully controlled and

eradicated multidrug-resistant Acinetobacter

baumanii from an intensive care unit

Environmental samples positivity decreased

from 31% to 7 % following ozone fumigation

Ozone

R Stümpfle et al Critical Care 2010, 14(Suppl 1):P67

Respiratory therapy equipment

Fiberoptic endoscopes

Faucet shower heads with Pseudomonas

Shower heads and Legionellosis

Faucet aerators & Stenotrophomonas

maltophilia

Water and HAI

Hot water supplies

Hydrotherapy pools and tanks

Potable water

Sinks

Water baths

Dialysis water

Toilets

Dental unit water systems

Water reservoirs

Contamination by Gram negative bacteria

Monthly testing for bacterial counts and

endotoxin levels

Dialysis fluid

Hemodialysis fluid

Method Maximum heterotrophs (cfu/ml)

Max. endotoxin level (EU/ml)

Product water Plate count 500ul on TSA

200 2

Dialysate LAL gel clot assay

200 2

AAMI standards for dialysis fluid

ANSI/AAMI RD52:2004 Dialysate for hemodialysis

Environmental decontamination

Earlier thoughts

• Fumigation with formalin- the final solution to a clean environment

Current concepts

• Focused cleaning of high contact areas

• Isolation of patients with MDR

• Terminal cleaning

• Vapour methods

AIFIC '13

Before 1970’s in US, regular scheduled

culturing of air and environmental surfaces

was done

By 1970, CDC advised discontinuation of

routine environmental surveillance as not

association of HAI with levels of

environmental contamination was noted

Microbiologic sampling of environment

Used currently for:

Research (potential reservoirs on surface,

survival of pathogens, sources of

contamination)

As part of epidemiologic investigation

Specific QA purposes

Microbiologic sampling of environment – current concepts

Survival of agent (Clostridium spores persist

for years, Staphylococcus for months)

Interference from particulates- dust, heavy

metals

Adherence of microorganism

Methods of detection

Variables affecting sampling

Sampling devices:

Wipe

Swab

Agar Contact plate

Microvacuum sampling

HEPA vacuum collection sock

Microbiologic sampling of Environmental surfaces

Use of neutralisers for residual

disinfectants

Media

Microbiologic sampling of Environmental surfaces

Results:

Have we found what we were looking for –

the target organism?

No standard guidelines for validation of

surveillance cultures

Microbiologic sampling of Environmental surfaces

ATP technology for real time analysis of

surfaces suspected of being contaminated

Bioluminescent material attached to protein

or ATP from living cells.

Done as a quality audit

Environmental surfaces

2. For research purposes – for e.g to

compare HAI rates in old and new facility

before and after occupation

Can provide new information regarding

spread of HAI

Environmental sampling - indications

3. To monitor a potentially hazardous

environmental condition, confirm the

presence of hazardous chemical or

biological agent, to validate the

successful abatement of the hazard

e.g. to monitor bioaerosols released from

health care equipment

Environmental sampling - indications

4. For quality assurance purposes to evaluate

the effects of a change in infection control

practices

Or to ensure that equipment or systems

perform according to specifications and

expected outcomes

Environmental sampling - indications

Air sampling for qualitative measurement of

microbial contamination during prolonged

construction to look for breach in

environmental control measures

Sampling before commissioning special

care areas (OR’s, BMT units)

Air sampling

Impingement in liquids

Impaction on solid surfaces (slit samplers)

Sedimentation (settle plates)

Filtration

Centrifugation

Electrostatic precipitation

Air Sampling Methods

Active air samplers are used, which collect a

known volume of air, blown on to a nutrient

medium by different techniques.

Active Air sampling

Slit samplers Petri samplers (sieve impaction)

Lack of uniform air quality standards

The microbial air contamination can be

measured by counting the number of cfu

per cubic metre (cfu/m3) of air.

Active Air sampling

C. Pasquarella*, O. Pitzurra† and A. Savino . The index of microbial air

contamination. Journal of Hospital Infection (2000) 46: 241–256

The schedule 1/1/1 was devised as a

standard

The Petri dish must be left open to the air

for 1 h, 1m above the floor, 1m from the

wall.

After 48 h incubation at 36°C the cfu are

counted. The number of cfu is the Index of

microbial air contaminatopn (IMA).

Passive air sampling -Settle plates

Fisher G, Fodré S, Nehéz M. Z Ges Hyg 1971; 17: 576–579

British bacteriological standard for

ultraclean operating room air of 10 cfu/m3

Surface contamination rate of 350

cfu/m2/h measured by means of settle

plates

Standards for colony counts

Friberg B, Friberg S, Burman LG. J Hosp Infect 1999; 42:

287–293.

IMA value Cfu/m3/h Performance locations

0-5 0-9 Very good OR- ultra clean, BMT

6-25 10-39 Good Conventional OR, dialysis unit, ICU

26-50 40-84 Fair Wards, day care

51-75 85-124 Poor

>76 >125 Very poor

Maximum acceptable risks of IMA

C. Pasquarella*, O. Pitzurra† and A. Savino . The index of microbial air

contamination. Journal of Hospital Infection (2000) 46: 241–256

Routine water testing is not indicated

Done to detect water borne pathogens

To determine quality of finished water in

the distribution systems

To be done in outbreak situations to initiate

appropriate infection control measures

Dialysis water to be tested monthly

Water sampling

Plate count

Membrane filtration

Potable water – coliform count

Water sampling

Environment can serve as reservoirs for

pathogens

Hand hygiene is paramount

Cleaning and disinfecting environmental

surfaces is mandatory

Surveillance cultures neither cost-effective

nor warranted.

Summary

Thank you

AIFIC '13