Environmental Cleaning: MRSA

1. Environmental Cleaning: MRSA Dr. Michelle J. Alfa, FCCM Medical Director Clinical Microbiology Discipline, Diagnostic Services of Manitoba

2. Overview • Evidence that environment plays a role in transmission of AROs in healthcare • Cross-transmission in healthcare: How does it occur? • Environmental cleaning- visibly clean- compliance of housekeeping- micro-fibre cloths- agent used • Summary: What can be done??

3. Infection Transmission: Environmental role • AROs such as VRE, MRSA, ESBLs, C.difficile, Acinetobacter spp, • Improvements; reduce all AROs • “A culture report should not dictate the practice of Standard Precautions” (Bartley et al 2008)

4. Microbial survival on surfaces Survives Years ** ** **Prolonged survival when suspended in dust/organic debris of up to six months to a year has been reported (Dancer 2007, Hardy 2007)

5. Distribution of S.aureus in General population and Nasal Carriers General Population: S.aureus nasal (+): Dancer S. Importance of the environment in MRSA acquisition: the case for hospital cleaning. http://infection.thelancetlcom 2007 DOI:10.1016/S1473-3099(07)70241-4

6. Environmental detection: MRSA in Stool of patient with diarrhea • Bedside rails: 100% • Blood pressure cuff: 88% • Television remote: 75% • Bedside Table: 63% • Toilets: 63% “High-touch sites” If MRSA (+) but not in stool; ~ 30% environmental contamination Boyce J Hosp Infect 2007;65:50-54, Dancer Infection.thelancet 2007

7. Do caregivers acquire MRSA from environment? 42% of 12 nurses contaminated gloves with MRSA by touching objects in room of patients with MRSA in wound or urine WITHOUT ANY PATIENT CONTACT! Boyce J Environmental contamination makes an important contribution to hospital infection J Hosp Infect 2007;65:50-54.

8. Chain of Cross-Transmission Patient shedding ARO- Bedrails, blood pressure cuff, etc Caregiver: transient acquisition- from patient- from environment Second patient: acquires ARO- environment contact (in same room as patient with ARO)- caregiver; transient carrier

9. How to Eliminate Chain of Transmission? ENSURE: - Environmental cleaning/disinfection - Hand hygiene Sounds Easy!! Why isn’t it working???

10. Hand-hygiene vs Environmental Cleaning* • Compliance with Hand-hygiene critical but hard to achieve • Reducing environmental sources of MRSA, VRE and C.difficile does reduce healthcare associated infection (& colonization) * Boyce J Environmental contamination makes an important contribution to hospital infection J Hosp Infect 2007;65:50-54.

11. Environmental Cleaning: • Visibly Clean: NOT ADEQUATE • Housekeeping compliance- how to know if cleaning done?- ?adequate staffing/time UVM Score: (3) (0) Alfa et al BMC-Infectious Diseases 2008

12. Audit of Cleaning Compliance • UV Marker:- Carling et al 2008: 49% of surfaces clean after “terminal cleaning”- Alfa et al 2008: 20 – 50% of toilets clean after routine cleaning - Carling 2008: 57.1% of ICU surfaces clean after patient discharge • ATP:- Cooper: < 500 RLU /cm2- Griffith et al 2007: 0 – 14% of surfaces “clean” after routine cleaning • Viable count:- Dancer 2004: < 5 cfu/cm2- Griffith 2007: 50 – 90% of surfaces “clean” after routine cleaning

13. New Audit Tools • Visibly clean: INADEQUATE • UV marker  useful; indicates if surface wiped or not • ATP  useful; detects presence of organic and microbial residues Need to provide positive feedback and ensure Housekeeping are part of the Infection Control TEAM!!

14. Microfibre cloths for cleaning? • Rutala et al 2007:- String mops not as effective as microfibre mops for microbial removal- Microfibre effective without disinfectant • Moore et al 2006: - Microfibre cloths vary in efficiency- Some microfibre cloths transfer organisms and re-contaminate surface during cleaning

15. Agent used for cleaning & disinfection • Two-step? • One-step with agent that cleans and disinfects? • Detergents (most) at their use-dilution and usual contact times have little to no microbial killing ability • Transfer/recontamination of surfaces during cleaning reduced if agent has killing ability

16. Room Fogging: VHP vapour Works  but rapidly re-contaminated (both MRSA and other bacteria) Hardy K et al Rapid recontamination with MRSA of the environment of an intensive care unit after decontamation with hydrogen peroxide vapour. J Hosp Infect 2007;66:360-368

17. Environmental cleaning • Cleaning: remove organic material as well as microorganisms • Re-contamination from patient etc occurs rapidly; need to have ongoing consistent cleaning process • Disinfection as well as cleaning is needed • Focus added cleaning efforts on “High-touch” areas for greatest impact for MRSA

18. SUMMARY: • Environment does play a role in infection transmission of many AROs • “visibly clean” is NOT adequate as a measure of proper cleaning • Audit tools for housekeeping compliance valuable • Microfibre good – but not all of equal efficiency • Cleaning agent with microbial kill • Housekeeping is CRITICAL PART OF THE INFECTION CONTROL TEAM!!!

19. References • Rutala et al Microbiologic evaluation of microfiber mops for surface disinfection AJIC 2007:35:569-73. • Moore G et al A laboratory evaluation of the decontamination properties of microfibre cloths J Hosp Infect 2006;64:379-385 • Bartley et al Reservoirs of pathogens causing health care associated infections in the 21st centurey: is renewed attention to inanimate surfaces warranted? Clin Micro Newletter 2—8;30:113-117 • Dancer et al MRSA acquisition in an intensive care unit. AJIC 2006;34:10-17 • Boyce Environmental contamination makes an important contribution to hospital infection J Hosp Infect 2007;65:50-54 • Carling et al Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals ICHE 2008:29:1-7 • Carling et al Intensive care unit environmental cleaning: an evaluation of sicteen hospitals using a novel assessment tool J Hosp Infect 2008;68:39-44 • Cooper et al Monitoring the effectiveness of cleaning in four British hospitals AJIC 2007;35:338-41 • Dancer Importance of the environment in MRSA acquisition: the case for hospital cleaning • Hardy et al Rapid recontamination with MRSA of environment of an ICU after decontamination with hydrogen peroxide vapour. J Hosp Infect 2007;66:360-68 • Griffith et al The effectiveness of existing and modified cleaning regimens in a Welsh hospital J Hosp Infect 2007;66:352-359