9/6/2013 How to remove Bacteria from common hospital surfaces Evidence based cleaning and disinfecting Greg S Whiteley Gram Negative Bacteria: common characteristics • Frequently feacal – oral association • Ubiquitous (they’re everywhere) • Can swap genes and so transfer antibiotic resistance • Live in biofilms – with other dissimilar bacteria • Can colonise without causing disease • MDRO varieties can kill © Copyright Whiteley Corporation 2013 1 9/6/2013 Some GNB examples • E. coli : common in gut and mouths • Acinetobacter baumannii: common on skin and skin folds • Enterobacteriaceae : all species in this genus • ESBL’s (e.g. Klebsiella pnuemoniae) • Pseudomonas aeruginosa : skin and oral, liquids including some soaps/detergents GNB ‐ vulnerability and strengths Strengths Vulnerability • Strong association with healthy humans • Rapid growth in biofilms • Biofilms can be heterogenous • Resistance to some mild disinfectants • Can grow in detergent solutions (especially Ps. aeruginosa) • Quickly killed by most stronger disinfectants • Hospital Grade Disinfectants are all tested routinely against common GNB • Killed quickly by heat & autoclaving • Surface binding undone using strong detergent solutions (e.g. Matrix) 1: Vickery et al., AJIC:2009 © Copyright Whiteley Corporation 2013 2 9/6/2013 Surfaces associated with GNB • • • • • • • Toilets/bathrooms – everywhere1 Patient surrounds – everywhere2 Patient related devices (e.g. remote control)1 Critical Care surfaces in biofilms3 Patient bathrooms4 Bedpan cleaners 4 Clinical workspaces5 1. Friedman et al, 2013; 2. Fitzgerald et al., 2013; 3. Vickery et al., 2012; 4. Carling et al., 2008; 5. Anderson & Dancer et al., 2012 NHMRC Recommendations for standard and additional precautions • Standard Precautions – Clean and wipe with neutral detergent – NOTE: New Research suggests this may contribute to biofilm viability in some instances • Additional Precautions – 3 stage process: 1. clean and wipe with neutral detergent 2. Apply HGD disinfectant – TGA approved 3. Rinse away and leave to dry © Copyright Whiteley Corporation 2013 3 9/6/2013 New Learning on Disinfection • Wiping is THE critical process to remove and kill bacteria and other pathogens on surfaces1,2,3 • Non wiping will NOT WORK to remove bacteria (whether alive or dead) • Latest study – out of Geelong – published in the American Journal of Infection Control in June 2013 (author: Dr Deborah Friedman) 1. Rutala et al., 2012; Sattar et al., 2013; Friedman et al., AJIC: 2013 The key and killer combination • A moistened wipe – HGD wipe (TGA registered) • A HGD Disinfectant – TGA registered • Compatible formulations and allows interchange‐ability and interoperability © Copyright Whiteley Corporation 2013 4 9/6/2013 3 Stage Chlorine Process Clean with hot water & detergent Disinfect with Chlorine at 1000ppm: Leave for 10 minutes Initial VRE Count 25% of surfaces Rinse with warm water and detergent VRE Count (after) 11.1% of surfaces (n = 251) Single Stage Effective Clean/Disinfect Clean with Viraclean or Finish V‐Wipes Initial Count: VRE - 33% then down to 4.5% surfaces © Copyright Whiteley Corporation 2013 VRE count (after) <1.1% (n=282) 5 9/6/2013 Chlorine 3 stage vs. Viraclean VRE Count Before VRE Count After Rx Rx 3 Stage Chlorine Disinfect Single Stage Viraclean Initial Readings Only Single Stage Viraclean: Full Data set 63/251 = 25.1% 28/251 = 11.1% 7/21 = 33% 2/25 = 8% 11/241 = 4.5% 3/282 = < 1.1% 3 Stage Chlorine (Clean, Disinfect, Rinse) vs., Viraclean/ V‐Wipes (single pass) 30.00% 25.00% 20.00% VRE Initial Counts 15.00% VRE Count After Rx 10.00% 5.00% 0.00% 3 Stage Chlorine © Copyright Whiteley Corporation 2013 Viraclean/ V‐Wipes 6 9/6/2013 Observations from Friedman 2013 article • Viraclean/ V‐Wipes not only killed and removed VRE but the contamination rates were reduced • Viraclean/ V‐Wipes were preferred by environmental staff for ease of use and efficacy • Viraclean/ V‐Wipes are “more user friendly” to staff Patient Infection Rates (VRE) ‐ overall © Copyright Whiteley Corporation 2013 7 9/6/2013 Haematology Ward VRE Infection Rates: 2010 (3 stage Chlorine); 2011 (Viraclean) 30 25 20 Haem 2010 15 Haem 2011 10 5 0 Q1 Q2 Q3 Q4 ICU Ward VRE Infection Rates: 2010 (3 stage Chlorine); 2011 (Viraclean) 10 9 8 7 6 5 ICU 2010 4 ICU 2011 3 2 1 0 Q1 © Copyright Whiteley Corporation 2013 Q2 Q3 Q4 8 9/6/2013 References • • • • • Friedman ND, Walton AL et al., “The effectiveness of a single‐stage versus traditional three‐ staged protocol of hospital disinfection at eradicating vancomycin‐resistant enterococci from frequently touched surfaces”: Am. J Infection Control:2013:41:227‐231 Vickery K, Deva A, … Gosbell I; “Presence of biofilm containing viable multiresistant organisms despite terminal cleaning on clinical surfaces in an intensive care unit”: J Hospital Infection: 2012:80:52‐55 Rutala WA, Gergen MF, Weber DJ; “Efficacy of different cleaning and disinfection methods against Clostridium difficile spores: Importance of physical removal versus sporicidal inactivation”: Infection Control Hospital Epidemiology: 2012:33:1255‐1258 Sattar SA, Maillard J‐Y; “The crucial role of wiping in decontamination of high‐touch environmental surfaces: Review of the current status and directions for the future”: Am J Infection Control: 2013:41:S97‐S104 Moore G, Muzlay M, Wilson PR; “The type, level and distribution of microorganisms within the ward environment: A zonal analysis of an intensive care unit and a gastrointestinal surgical ward”: Infection Control Hospital Epidemiology: 2013:34:500‐506 References (continued) • • • • Fitzgerald G, Moore G, Wilson APR; “Hand hygiene after touching a patient’s surroundings: the opportunities most commonly missed”: J Hospital Infection: 2013:84:27‐31 Anderson RE, Young V,…Dancer SJ; “Cleanliness audit of clinical surfaces and equipment: who cleans what?”: J Hospital Infection: 2011:78:178‐181 Carling PC, Parry MM, Rupp ME, et al., “Improving cleaning of the environment surrounding patients in 36 acute care hospitals”: Infection Control Hospital Epidemiology: 2008:29:1035‐ 1041 Vickery K, Ngo Q‐D, Zou J, Cossart YE; “The effect of multiple cycles of contamination, detergent washing, and disinfection on the development of biofilm in endoscope tubing”: Am J Infection Control: 2009:37:470‐475 © Copyright Whiteley Corporation 2013 9