key health infection control

Infection Control - Working together to fight infection

Trends in Fomite DisinfectionOctober 6th, 2010

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© All Rights Reserved 2010

ARS is a specialty chemical manufacturer of surfacedecontamination and antimicrobial technologies designed forthe health care and remediation marketplace.

ARS is entering our 11th year of operations with distribution insix countries including the United Kingdom.

We are an ISO 9001-2000 facility with a robust research anddevelopment staff.

Today, we hold 14 formulation patents along with numerousEPA and USDA registered antimicrobial products.

ARS Introduction

In addition to chemical manufacturing, ARS provides a widerange of investigation and consulting services for:

• Health Care Disinfection & Protection Strategies

• Mold Investigation & Mold Remediation Solutions

• Indoor Air Quality Investigations – SBS & BRI

• Architect & Building Contractor Mold Mitigation Education

• Green Building Standards Education

• Continuing Education For Industry Professionals

ARS Introduction

Today we will be discussing:

• Hospital Acquired Infection (HAI) Numbers

• Connection Between Fomites and HAIs

• Fomite Disinfection Challenges

• Disinfection Surveillance Technologies

• Sustainable Disinfection Technologies

Today’s Program

Nosocomial or hospital acquired infections (HAIs) are estimatedto occur in 5% of all acute care hospitalizations.

HAI accounts for more than 2 million cases per year.

The CDC estimates that HAIs result in over 99,000 deaths per

year. However, many industry experts believe the number of

HAI deaths exceed 120,000 per year.

Average treatment cost for HAIs is $15,275 costing the medical

industry over $30 billion per year not including litigation costs.

HAIs By The Numbers - US

According to the Department of Health, HAIs account for 5,000deaths per year at a cost of £1 billion.

Industry experts believe the number of HAI deaths is more likely10,000 per year.

It is estimated that 80% of hospitals underreport true HAI rates.

C. Diff cases have increased 17% in recent years.

MRSA infections are reported at 7,000 infections per year,however, experts believe the actual number is 25,000.

HAIs By The Numbers - UK

• Methicillin-resistant Staphylococcus aureus (MRSA)

• Clostridium difficile (C. diff)

• Ancinetobactor baumannii (MDRAB)

• Glycopeptide-resistant enterococci (GRE)

• Carbapenem-resistant Enterobacteriaceae (CRE)

• Vancomycin-resistant Enterococcus faecium (VRE)

• Pseudomonas aeruginosa

• Antifungal drug resistant Aspergillus

• Linezolid-resistant enterococcus

• Penicillin-resistant Streptococcus pneumoniae

• Multidrug-resistant tuberculosis

• Multidrug-resistant Salmonella paratyphi B

• Multidrug-resistant Escherichia coli

The Current Superbug List

On September 7th 2010, the CDC added NDM-1 (New Delhi

metallo-beta-lactamase-1) to the list.

NDM-1 is not a single superbug species, rather it is a gene that

deactivates beta-lactam antibiotics including the carbapenem

family.

NDM-1 carriers include C. diff, E. coli, CRE and Klebsiella.

Horizontal gene transfer is likely to increase carrier species.

First identified in a Swedish national in December 2009, it is

now being reported globally.

The Newest Addition

The number of HAI cases goes largely under reported therefore,the true numbers are difficult to ascertain.

1. There has been no formal mechanisms for tracking HAIs.

2. Many HAI pathogens are pervasive in the general public.

3. The clinical diagnosis is typically reported as the cause ofdeath, not the HAI - Cancer and not MRSA.

4. Facility administrators are reluctant to release numbers whenothers are not. Who wants the be the proud recipient of the“Dirty Hospital” award.

HAI Reporting

We’re the Dr. Phil of HAIs

You have them.

Get over it.

Disclaimer - Dr. Phil is not a medical doctor nor is he endorsing our infection control protocols.

HAI Reality

HAI Sources


With the increase in HAI incidences, more attention is beingfocused on common disease vectors.

• Patient Cross Contamination

• HCW Cross Contamination

• Intubation, Central Line & Surgical Infections

• Fomite Pathogen Vectors

The underlying cause is poor infection control and surfacedisinfection protocols.

Tracking HAI Sources

Pathogenic Pathways

Biologic aerosols or bioaerosols are pathogenic organisms thatare transmitted by air from one host to another.

The distance traveled and the quantity transmitted varies baseon the size of the bioaerosol droplet and environmental factors.

As humidity levels drop in buildings, droplet nuclei travel further.This is why we see a spike in colds and flu during cold weather.

HVAC systems play a critical role in bioaerosol density andtransportation.

Bioaerosols are an important factor in hospital infection control.

Bioaerosols

On average, 38% of HCW follow hand washing complianceguidelines. Compliance ranges from 14% to 48%. 1

Hand washing before patient contact was lower than afterpatient contact. 1

Hands are successful transmitting E. coli, Staph, Salmonella spp.(100%); Candida albicans (90%); rhino virus (61%); hepatitis A(33%); and rotavirus (16%). 2

Contaminated hands can transfer viruses to five more surfacesand 14 other patients. 2

1Mitka, M. (2008). Public, Private Insurers Refusing to Pay Hospitals for Costs of Avoidable Errors.2 Axel Kramer, Ingeborg Schwebke and Günter Kampf (2006) How long do nosocomial pathogens persist oninanimate surfaces?

Hand Contact

46% of HCW who touched bedrails and tables in rooms ofcolonized patients in turn contaminated their gloves with VRE.

VRE contaminated gloves or hands can transfer VRE touncontaminated surfaces that are subsequently touched by theHCW.

Environmental contamination in hospitals is roughlyproportional to the prevalence of hand contamination amongHCWs.

Up to 74% of the surfaces within a room occupied by a C. diffcolonized patient become contaminated.

Hand Contact

42% of HCW protective gloves were contaminated aftertouching fomite surfaces in patient rooms. 1

There is a 17.5% incidence of glove or gown contaminationduring contact with patients infected with MRSA or VRE. 2

In one study, more than 20% of nurses' uniforms had C. diff onthem at the end of a shift.

65% of HCW change lab coats less than once a week. 15% lessthan once a month.

Microbes can survive up to 90 days on hospital fabrics.

1 Association For Professionals In Infection Control and Epidemiology, Inc. 2008 Study2 Tamar F. Barlam, MD; Dennis L. Kasper, MD (2008) Common Contamination of Gloves and Gowns withMRSA and VRE during Routine Patient Care.

Gloves & Clothing

Bathroom SurfacesBed, Mattress, Rail, Frame & LinensBedpan/Bedpan cleanerBedside TableBlood Pressure CuffCall Button/Nurse BellChairs, Couch & FurnitureComputer Keyboard & MouseDoor HandlesElectronic ThermometerFaucet HandlesFloor Around BedHemodialysis Machine

Mechanical Vectors

Hydrotherapy EquipmentInfusion Equipment & StandsLight SwitchesOverbed TablePatient Hoist & Lift SlingPhlebotomy TourniquetStethoscopeSuctioning EquipmentResuscitation EquipmentTelephone, Mobile PhonesTelevision & RemoteVentilatorWork Table & Charting Area

Common patient room touch point surfaces harboring MRSA,VRE, C. Diff, RSV, Influenza, Rhino Virus, and A. baumannii.

Contact Points

Fomite Reservoirs


Fomites are defined as any inanimate object or substancecapable of carrying infectious organisms. But, how important isfomite sanitation in an overall infection control strategy?

Ten years ago it was argued that fomites could not supportsufficient colonies to act as a disease vector.

Today, study after study has shown that fomites are in factdisease vector reservoirs.

The tipping point in our understanding of fomite disease vectorswas the discovery of pathogen persistence and thepervasiveness of contamination throughout a facility.

Fomite Reservoirs

Argument - There must be a sufficient reservoir or dose ofpathogens to successfully infect through fomite contact. Untilyou get to 10,000 CFUs , fomites are not a disease vector.

Response:

1. The “dose” necessary to cause infection is different for everymicroorganism and every patient.

2. Dose is not a single event. A HCW can touch hundreds ofsurfaces before patient contact.

Fomite Vector Potential

Factors in Vectors

Pathogenic

Microorganism

Fomite

Reservoir

Mode of

Transmission

Means of

Host Entry

Host

Susceptibility

2008 Drees - Prior room contamination due to VRE was found to be highly predictive of VRE acquisition bysubsequent occupants of the room.

2007 Bracco - Infection control measures for preventing MRSA cross-transmission are more effective inintensive care units when single rooms are used.

2006 Hardy - It was shown that several patients who acquired MRSA while in the intensive care unit acquiredthe MRSA from the environment.

2006 Huang - An association between an ICU room previously occupied by an MRSA-positive patient or aVRE-positive patient and an elevated risk of acquiring MRSA or VRE, respectively.

2004 Denton - Authors found a significant correlation between environmental contamination with A.baumannii and recovery of the bacterium from patients.

2003 Martinez - A link was shown between the placement of patients in a particular room and acquisition ofVRE, supporting the role of environmental contamination on VRE transmission.

2001Rampling - An outbreak strain of MRSA recovered from surfaces near affected patients wasindistinguishable from patient strains.

1994 Orr - VRE was introduced into a facility via ‘clean’ therapeutic bed mattress covers.

1992 Livornese - An outbreak of VRE ended when health care providers ceased using contaminated electronicrectal thermometers.

Studies

The long held precept was microbes do not persist on dryfomite surfaces.

It was believed that natural die off would keep surface microbenumbers below an infection threshold.

However, studies have shown that die off rates are not linearand in fact microbial persistence on dry surfaces is much higherthan believed possible.

Fomite disinfection can only be achieved through concertedeffort - it will occur on its own.

Persistence of Pathogens

Acinetobacter spp. 5 monthsClostridium difficile (spores) 5 monthsEscherichia coli 16 monthsEnterococcus spp. (VRE & VSE) 4 monthsKlebsiella spp. 30 monthsListeria spp. 2 monthsPseudomonas aeruginosa 16 monthsStaphylococcus aureus, including MRSA 7 monthsStreptococcus pneumoniae 20 daysHerpes virus (Type 1 & 2) 2 monthsInfluenza virus 2 daysNorovirus 7 daysRhinovirus 7 daysRotavirus 3 months

Persistence of Pathogens

Fomite Reservoirs


These are the common chemistries used for fomite disinfection:

• Alcohols – Isoprolpyl & Ethanol

• Aldehydes – Glutaraldehyde & Ortho-phthalaldehyde

• Phenolics – Phenol & Thymol

• Quaternary Ammonium Compounds

• Oxidizing Agents – Peroxides, Ozone, Chlorine DioxideBleach (Sodium Hypochlorite) & Iodine.

• Iodine and Iodophors

Disinfection Arsenal

Terminal cleaning is effective at reducing 40% of pathogencapable colonies from fomite surfaces.

50% of toilets are properly disinfected after routine cleaning.

57.1% of ICU surfaces are clean after patient discharge.

Commonly used quaternary disinfectants detergents DO NOTeliminate C. diff spores. Such agents may actually promotesporulation of C. diff.

Disinfectants make poor surface cleaners. Biofilms are verydifficult to remove with traditional disinfectants. Extracellularpolymeric substance (EPS) persist after routine cleaning.

Disinfection Facts

Surfactants and emulsifiers found in effective surface cleanerswill breakdown and deactivate disinfectant ingredients.

Accordingly, cleaner-disinfectant combination products use aweak detergent as the cleaning additive.

Therefore, to effectively remove EPS biofilms from fomitesurfaces, the surfaces should first be cleaned with acombination surfactant-emulsifier cleaner followed by a properdisinfectant.

By following this two step protocol, effective surface disinfectioncan be achieved.

Biofilms & Disinfectants

Achieving Surface Disinfection

One mop, one sponge, one hospital floor and 5 hours to haveit disinfected.

Disinfection Breakdown

Being admitted to a room in which the prior occupant hadMRSA or VRE increases your chances of getting MRSA or VRE by40%. (S. S. Huang, Datta, & Platt, 2006)

31% of people coming into contact with C. diff patients testedpositive for C. diff. 58% of C. diff patient rooms were widelycontaminated. (Samore et al., 1996)

The incidence of C. diff in colonized patients correlatedsignificantly with the prevalence of environmental C. diff.(Fawley & Wilcox, 2001)

Disinfection Benefits

Facility Surveillance


Most hospitals we encounter do not perform routinedisinfection surveillance. They follow a recommendeddisinfection protocol and then respond to HAIs once they arediscovered in patients.

• No Environmental Monitoring

• No Evaluation of Chemistry Effectiveness

• No Supervision

• No Continuing Education

The reactive protocol to infection control is not working. Aproactive protocol is needed.

Reactive Protocols

What is Clean?

To determine if a surface is properlydecontaminated, a surface swab iscollected and sent to a lab for analysis.

At the lab, the swab material istransferred to a culture plate in order togrow colonies for analysis. Sufficientcolonies must be grown for microscopicidentification.

This process takes five days at a cost of$275 per swab!!!

Existing Surveillance Methods

From the time the swab was taken, there has been:

• 15 different HCWs interfacing with the patient

• 3 IV poles changed out

• 6 mobile COWs and diagnostic systems in and out.

• 6 stethoscopes used

• 1 catheter change

• 15 meals served

• 5 linen changes

• 0 bed disinfections

• 1 mop and rag used in a dozen other rooms

• No confidence that disinfection has been achieved

Cross Contamination

ATP meters are used throughout the foodprocessing industry to evaluate sanitationeffectiveness.

ATP meters identify both the presence anddensity of ATP on a surface. The only toolthat provides an instant analysis.

ATP (Adenosine triphosphate) is a highlyvolatile chemical. It can only exist throughactiveactiveactiveactive mitochondrial activity.

High ATP = High Biocontamination

New Surveillance Tool

The ATP meter is the only technology available to us thatprovides instant determination on surface cleanliness.

Swab the surface, mix with a reagent and insert into the meter,and within 15 seconds an evaluation of the density of ATP isgenerate.

The cost per reading is $2.00.

New Surveillance Tool

While ATP meters provide an immediate evaluation on thecleanliness of surface, they do not tell us everything we alwayswant to know.

ATP meters do not tell us what species of microorganism is onthe surface.

Many viruses and bacterial spores do not produce ATP.

One the other hand, if there is a presence of bacteria on asurface, then the surface is contaminated and needs to becleaned.

If the environmental staff just cleaned a room and the ATP meterreads high, the staff did not do a proper job.

Advantages & Disadvantages

Until someone develops the StarTrek Tricorder, ATP meters arethe best surveillance tool we have. So let’s start using it.

Best Tool We Have

Computer On Wheels Mobile X-RayKeyboard – 1107 RLU Handel – 265 RLUMouse – 2112 RLUMouse Pad – 3600 RLU Waiting Room

Chair Rail – 65 RLUBed - Post Terminal Cleaning Check In Desk – 221 RLU

Rail – 12 RLUControl Pad – 85 RLU ICU Disinfectant StandFrame – 519 RLU Button – 228 RLU

Infusion Pump - Post Terminal Cleaning ICU Auto Door PadControl Pad – 114 RLU Pad – 247 RLUPole – 381 RLU

ICU Blood Pressure CuffWorkstation - Post Terminal Cleaning Inside Cuff – 466 RLU

Countertop – 192 RLU

ATP Analysis

Traditional disinfectants have no residual effect. Once theyvolatilize from a surface, surfaces are open for recontamination.

Disinfectants are rated at a 99.999% kill rate in the lab. Viableorganisms can survive.

Considering the limitations of disinfectants in the field, viabilitysurvival rates are much higher.

Contamination Regeneration

In the mid 1990’s a new class of antimicrobial technology wasregistered at the EPA – Durable Antimicrobial.

This class of chemistry addressed the limitations of traditionaldisinfectants by providing residual (durable) antimicrobialperformance. This is known as a “biostatic antimicrobial”.

Biostats are designed to bond to surfaces and impart broadspectrum antimicrobial performance. This includes effectivenessagainst bacteria, virus and fungi.

Two classes of Biostats – Solvent Based & Water Based

Biostatic Antimicrobials

The antimicrobial agent in Biostat is a physical structure whichdestroys cellular membrane integrity upon contact.

As a microbe contacts a treated surface, a chemical reaction isinitiated that unzips the lipid bilayer of the cell.

Intercellular pressure causes the cell to rupture and themicroorganism dies.

Unlike disinfectants, microorganisms cannot build up resistanceto this process. Therefore, the killing effectiveness of biostaticantimicrobials is unaffected by time or exposure.


Biostat forms a permanent covalent bond to both porous andhard surfaces. Microbes are drawn onto the treated surfacethrough ionic attraction.

As the microbe contactsthe treated surface, thecell membrane bilayer iscompromised.

Biostat does not lose itseffectiveness over time orexposure to microbes.


Biostats are approved for all types of surfaces including solidand porous surfaces, textiles, equipment, and food preparationsurfaces.

• Uniforms, Scrubs, Foot Covers, Surgical Gowns, Lab Coats• Bathroom and Kitchen Surfaces• Privacy Curtains• Infusion, Diagnostic & Imaging Equipment• Railings, Door Handles, Buttons• Examination Tables, Surgical Tables• Emergency Vehicles, Gurneys• Light Switches, Buttons, Keyboards• Chairs, Desks, Upholstered Furniture• Telephones, TV Remote Controls, Computer Keyboards• Beds, Linens and Mattress Pads• Linen Carts, Mops, Cleaning Rags• Wallpaper, Wall Coverings, Carpets and Mats


Textiles are a pathogen reservoir. Studies have shown thatmicrobes can persist for up to 90 days on scrubs, lab coats andprivacy curtains.

65 percent of medical personnel say they change their lab coatsless than once a week and 15 percent change it less than oncea month.

MRSA transmission has been traced to contaminated lab coats,scrubs and neckties.

Tests have shown that medical garments treated with Biostatreduced the presence of microbes by 98% within a 24 hourperiod.1 (This included Staff, MRSA, VRE)

1. ASTM E 2149-01 fabric test method

Textile Treatment

While Biostats are durable, touch point surfaces are not andbecome abraded over time and use. Therefore, the productshould be reapplied on a routine basis.

• Continuous Touch Points - Every 30 daysBathroom Surfaces, Bed Rails, COWs, Portable Imaging Systems, Public Areas, Countertops, Door Handles, Light Switches, Railings, Telephones, TV Remotes, Keyboards, & Diagnostic Equipment.

• Frequent Touch Points - Every 90 daysRoom Furniture, Seat Cushions, Carpets, Mattress Pads, Blood Pressure Cuffs, Mops & Brooms.

• Low Impact Areas - Every 180+ daysPublic Areas, Waiting Rooms, Out Patient Facilities, Mass Transportation.


Biostats do not replace terminal disinfection.

They must be applied to a cleaned surface in order to achieveproper surface bonding.

Treated surfaces must remain free of biofilms, dirt and grime sothat microbes can contact the treated surface. Accordingly,biostats do not work well in showers where soap film rapidlyfouls the surface.

Surface durability is also an issue. Some surfaces abrade sorapidly that Biostat does not remain present.

Abrasive cleaning will scour surfaces and will remove the Biostatmolecule.

Biostat Limitations

Biostats can be applied to virtually any/every surface within thehospital.

Treated textiles provides protection for both staff and patients.

Biostat provide a safety net by increasing disinfectioneffectiveness.

Environmentally safe and will not leach or out gas.

By incorporating Biostat into general sanitation protocols, laborcan be redeployed and focused on addressing hot spots.

Biostat Benefits

Summation


• Public is Colonized with Drug Resistant Bugs

• HAI Numbers Are Increasing

• Traditional Disinfection Protocols Are Failing

• Hospitals Are Under Greater Financial Pressure

• Disinfection Services Are Being Outsourced

• Reactionary Response To Outbreak

• Few Surveillance Capabilities Or Tools

• Not Enough Outside Support

• No Continuing Education & Awareness Programs

Summation

Ineffectual DisinfectantsPoor Surveillance

Changing the Paradigm

New Antimicrobial

Tools

Education &

Supervision

Changing the Paradigm

Awareness without action is worthless.

HIA Reality

Questions

For more information on the ARS infection control program orto arrange a training presentation please contact:

Darren MageeKey Health Solutions Ltd.08700 420 73507717 [email protected]

Mark MisnerARS, Inc.001 770 [email protected]

For More Information

© All Rights Reserved 2010

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