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The concept of universal disinfection as put forward
in this manuscript is important for the infection control community to
consider. We have entered a new age in infection control in which serious
pathogens are no longer limited to occasional patients who can be isolated.
Instead, we face a situation in which high percentages of patients are likely
colonized with one or more MDRO. Additionally, in some settings the isolation
capacity of facilities is overloaded. Meanwhile, the disinfection protocols are
complex and lead to low compliance. We need to be considering new approaches to
infection control and environmental hygiene.
INTRODUCTION
Pathogens
in the healthcare environment are increasingly resistant to antibiotics and
pose a significant threat to the safety of patients, visitors and healthcare
workers. Infections that could previously be treated with a dose of antibiotics
may now result in life-threatening infections. As pathogens have evolved to
become resistant to more antibiotics, the way we clean and disinfect hospitals,
by and large, has become more complex.
Currently,
the removal of pathogens from the healthcare environment is shared between
nursing and environmental services or housekeeping department. Nursing is
usually in charge of cleaning medical devices in close proximity to the
patient. The cleaning teams are faced with a daunting task – not only to make
the environment pleasant for patients, but also to make it safe and pathogen
free. The cleaning teams are given inadequate time and rudimentary tools such
as buckets, mops, rags, wipes and chemicals to disinfect the environment. They
receive limited training and there are often high amounts of turnover in
cleaning staff, leading to new hires that are not fully trained. Cleaning teams
often receive less support to do their job within the culture of the healthcare
facility, compared to other departments [1]. This results in two fundamental
problems: disinfection errors and inadequate disinfection.
Problem 1:
Disinfection errors
Current disinfection protocols are not
designed for compliance, ease of implementation or the reality of the
healthcare environment. Hospital cleaning and disinfection protocols are
complex and varied. The type and level of disinfectant varies by pathogen
identified, surface location, outbreak status, equipment type and other factors
[2,3]. For example, hypochlorite dilution can vary from 250 ppm for floors, 500
ppm for beds and walls, 1000 ppm if a C.
auris or a carbapenem-resistant Enterobacteriaceae has been identified up
to 2000 ppm in outbreak context [2,3]. Alcohol based disinfectants are used
routinely, however, they are inactive on spores and sporicidal agents will be
needed.
Room or bed status impacts protocols, with isolation rooms requiring different daily and terminal disinfection. Unit status could also impact the protocol, with clusters and outbreaks altering disinfection practice [2]. Special pathogen-specific protocols also exist, for example, if C. auris or C. difficile is present [4]. Each piece of medical equipment may also have its own protocol, with some being disinfected by nursing and others by environmental services. Certain medical equipment and healthcare areas may be specified as disinfected by nursing, technicians or environmental service personnel leading to confusion and disinfection failure [3,4]. Equipment manufacturers may specify certain disinfection methods and forbid others. Failure to comply may result in loss of warranty.
The complexity of these processes results in
errors, non-compliance and confusion.
Problem 2:
Inadequate disinfection
Most protocols specify disinfection for
spaces occupied by isolated or infected patients [2]. This practice assumes
that infection control measures have adequately contained the contamination of
surfaces, equipment and hands during that patient’s hospitalization. Cleaners
may not be informed of the diagnosis of the prior patient and may use chemical
disinfectants that do not have efficacy against the pathogen [3]. In settings
with multi-occupancy rooms and shared bathrooms, it is unlikely that infection
control measures are able to contain the contamination. Furthermore, undetected
colonized individuals can shed contaminate the environment. It is estimated
that 30% of C. auris contact become
colonized by C. auris and one out of
10 contacts will be contaminated [4]. The contamination will not be limited to
the patient bed space and may include all areas where the patient was,
including the nurse’s stations and the sluices.
Finally, dry biofilms, patinas and abraded
surfaces, reduce the effectiveness of disinfectants in the healthcare
environment. When a biofilm forms on a surface, bacteria attaches and creates a
protective layer of proteins and sugars that prevent chemicals from penetrating
into the film. This protective layer also helps the biofilm adhere to surfaces,
which makes removal by manual cleaning (“scrubbing”) almost impossible [5].
Further complications arise when pathogens become less sensitive to chemical
disinfectants.
The above results in inadequate disinfection
of the healthcare environment.
UNIVERSAL
PRECAUTIONS: AN ANALOGY
The fundamental problems outlined above, combined with the increasing prevalence of MDROs diagnosed and undiagnosed both in the healthcare environment and the community pose challenges to providing all patients with a safe environment of care. At the early stages of the HIV epidemic, precautions for medical procedures were applied to patients at AIDS stage only. As an HIV test became available, it became evident that anyone could be positive for HIV and, there was a shift to universal precautions – with healthcare workers using full infection control protocols for every procedure [6]. Something similar needs to happen in environment cleaning. We need a simple approach that is done for all patients to fulfill our obligation to provide a safe and healing healthcare environment. This approach should be easy to implement, have high compliance, and have the capability to be widely used throughout the healthcare environment. Disinfection technologies are emerging that meet the criteria outline in Table 1 [7].
CONCLUSION
Infection control practices need to be
elevated to meet the rising multi-drug resistance of pathogens. Disinfection
technology can provide assurance and consistency in disinfection protocols.
Making the healthcare environment clean and pathogen free is a necessary
component to achieve the goal of zero hospital-acquired infections.
1.
Bernstein DA, Salsgiver E,
Simon MS, Greendyke W, Eiras DP, et al. (2016) Understanding barriers to
optimal cleaning and disinfection in hospitals: Knowledge, attitudes and
practices survey of environmental services workers. Infect Control Hosp
Epidemiol 37: 1492-1495.
2.
Ling ML, Apisarnthanarak A,
Villanueva V, Pandjaitan C, Yusof MY (2015) APSIC Guidelines for environmental
cleaning and decontamination. Antimicrob Resistance Infect Control 4: 58.
3.
Smith R, Martinelli J, Derman S
(2017) AIHA Guidelines for selection and use of environmental surface
disinfectants in healthcare. Am J Infect Control 45: S2.
4.
Jeffery-Smith A, Taori SK,
Schelenz S, Jeffery K, Johnson EM, et al. (2018) Candida auris: A review of the literature. Clin Microbiol Rev 31:
e00029-17.
5.
Otter JA, Vickery K, Walker JD,
Pulcini ED, Stoodley P, et al. (2015) Surface-attached cells, biofilms and
biocide susceptibility: Implications for hospital cleaning and disinfection. J
Hosp Infect 89: 16-27.
6.
Sinha D (2016) Importance of
universal precautions in HIV, HBV, HCV positive patients. J Renal Nutr Metab 2:
5.
7.
Doll M, Stevens MP, Bearman G
(2018) New technologies for infection prevention. Infect Prev, pp: 55-66.
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