October 2013 US$39.00 S P E C I A L R E P O R T Hand Hygiene and Environmental Hygiene: Experts Debate Their Importance Hand hygiene and environmental hygiene are two key components of an infection prevention and control program but there is some debate as to whether one strategy may be more effective than the other at curbing and/or eliminating healthcare-acquired infections (HAIs). A point/ counterpoint discussion on this topic was featured in May 2013 at the spring conference of the Society for Healthcare Epidemiology of America (SHEA). By Kelly M. Pyrek Infection Control Today Hand Hygiene and Environmental Hygiene 1 infectioncontroltoday.com
INFECTION CONTROL T O D A Y Table of Contents Point: Hand Hygiene is More Important Than Environmental Disinfection in Preventing HAIs...3 Counterpoint: Environmental Disinfection is More Important Than Hand Hygiene in Preventing HAIs...8 Conclusion...12 References...14 Copyright 2013 VIRGO Publishing, LLC. All rights reserved. The publisher reserves the right to accept or reject any advertising or editorial material. Advertisers, and/or their agents, assume the responsibility for all content of published advertisements and assume responsibility for any claims against the publisher based on the advertisement. Editorial contributors assume responsibility for their published works and assume responsibility for any claims against the publisher based on the published work. Editorial content may not necessarily reflect the views of the publisher. Materials contained on this site may not be reproduced, modified, distributed, republished or hosted (either directly or by linking) without our prior written permission. You may not alter or remove any trademark, copyright or other notice from copies of content. You may, however, download material from the site (one machine readable copy and one print copy per page) for your personal, noncommercial use only. We reserve all rights in and title to all material downloaded. All items submitted to Infection Control Today become the sole property of VIRGO Publishing, LLC. Infection Control Today Hand Hygiene and Environmental Hygiene 2 infectioncontroltoday.com
Hand Hygiene and Environmental Hygiene: Experts Debate Their Importance By Kelly M. Pyrek Hand hygiene and environmental hygiene are two key components of an infection prevention and control program but there is some debate as to whether one strategy may be more effective than the other at curbing and/or eliminating healthcareacquired infections (HAIs). A point/counterpoint discussion on this topic was featured in May 2013 at the spring conference of the Society for Healthcare Epidemiology of America (SHEA) as part of a special educational track addressing Advancing Healthcare Epidemiology and the Role of the Environment. Point: Hand Hygiene is More Important Than Environmental Disinfection in Preventing HAIs Assuming the argument that Hand Hygiene is More Important Than Environmental Disinfection in Preventing HAIs, Michael Edmond, MD, MPH, chair of the Division of Infectious Diseases in the Virginia Commonwealth University School of Medicine, acknowledged the difficulty of debating such a complex issue by noting, We have no direct evidence to answer this question before us today, but perhaps we could if we had the right study. That study would be a clustered, randomized study of hospital inpatient units; in half the units we would remove all of the sinks and all the alcohol-based handrubs, but we would have extremely high levels of environmental hygiene coupled with technological innovation. In the other half of the hospital units we have alcohol-based handrubs, hand hygiene monitoring technology, and drive hand hygiene levels to near perfect but all housekeepers would be banned from the units. After the laughter among audience members subsided, Edmond added, Obviously we are never going to have that study, so we have to use indirect evidence to come to some conclusions. I think any effective infection prevention program is going to include surveillance, isolation for I think any effective infection prevention program is going to include surveillance, isolation for infections, antimicrobial stewardship, hand hygiene, environmental hygiene, and the various interventions that we all do. Michael Edmond, MD, MPH Infection Control Today Hand Hygiene and Environmental Hygiene 3 infectioncontroltoday.com
infections, antimicrobial stewardship, hand hygiene, environmental hygiene, and the various interventions that we all do. Over the last decade in the U.S. a lot of people have been consumed with the concept of vertical strategies that is, you pick a pathogen, try to find other patients with that pathogen and isolate them. We have been arguing for some time that s not the approach we should be taking but we should be looking for interventions that work against all organisms transmitted in the hospital setting. So we advocate a horizontal approach. When we look at these various approaches, one is a pathogenbased approach and the other is a population-based approach. And the two strategies we are talking about today, hand hygiene and environmental hygiene, are both examples of horizontal strategies. The horizontal approaches generally are lower cost and they are a much more utilitarian way of looking at prevention as opposed to focusing on one pathogen and dedicating a lot of resources to eradicating it. I think the horizontal approach is much more aligned with the way the patient thinks, because the patient will never say, I don t want a MRSA infection but I ll take VRE. That s ridiculous. During his presentation at the SHEA spring conference, Edmond shared with attendees his rationale for asserting that hand hygiene is more important than environmental disinfection, including experiences at and anecdotal data from his own hospital. We have eight ICUs and over the past few years we have had a 90 percent reduction in infections. At the same time, our hand hygiene compliance doubled from 45 percent when we started, to 97 percent across 50,000 to 60,000 observations. Do I think hand hygiene brought the infection rate down? It s difficult to say but we haven t done anything to change our environmental disinfection policies and we use none of the high-tech technologies in our hospital. So I think hand hygiene, as well as CHG bathing, has been a big part of this Horizontal vs. Vertical Approaches to Infection Prevention Infection control programs may include both horizontal (non pathogen-directed interventions) and vertical (pathogen-directed interventions) strategies. Debate continues over whether infection control programs should use horizontal strategies exclusively, or whether a combination of horizontal and vertical strategies is needed to control HAIs. Some experts believe that while horizontal approaches are essential for infection control programs, they should be supplemented with vertical strategies. For example, while hand hygiene is a cornerstone of HAI-prevention efforts, there are no data suggesting it is 100 percent effective at preventing transmission of HAIs and there is no precise estimate of the effectiveness at preventing nosocomial transmission. Some experts, such as John Jernigan, MD, director of the Office of Health Associated Infections Prevention Research and Evaluation, Division of Healthcare Quality Promotion at the CDC, say that there are situations in which horizontal approaches have limitations and some pathogens require active surveillance and contact isolation measures. It is important to note that the majority of guidelines issues by the Society for Healthcare Epidemiology of America (SHEA) recommend a horizontal approach to addressing HAIs. A study presented at the 2012 IDWeek meeting by Virginia Commonwealth University physicians highlights the issue. They found that substantial compliance with hand hygiene and focusing on other simple infection control measures on medical, surgical and neuroscience intensive care units resulted in reduced rates of methicillin-resistant Staphylococcus aureus (MRSA) infection by 95 percent in a nine-year study, according to research findings. The researchers noted that most hospitals use vertical infection prevention strategies, which focus on culturing for Infection Control Today Hand Hygiene and Environmental Hygiene 4 infectioncontroltoday.com
reduction. There has been no active surveillance for MRSA conducted except for in our neonatal ICU, which does it against my recommendation. Edmond continued, So what about the data in the literature? This is where we start to run into some problems because when you look for data on how effective hand hygiene is against HAIs, you don t find a whole lot. I think you will find more and better data for environmental hygiene than for hand hygiene but I think in the end the environmental disinfection data will show you that it isn t environmental hygiene that is helping us. The best data are from the community setting, specifically a meta-analysis from Elaine Larson s group that has pretty good data to show that hand hygiene is effective. But what about inside the hospital? There are less data. There is a quasi-experimental study of a hand hygiene intervention in a hospital but there is no randomization, it does not have a control group, and it is a before-and-after study showing significant decrease on mortality rate but this is Ignaz Semelweiss data from the 1800s. So we have known for a long time that hand hygiene is effective. Edmond pointed to a study by Kirkland, et al. (2012) that was constructed as a three-year interrupted time series with multiple sequential interventions and a one-year post-intervention follow-up that examined interventions In five categories: leadership/accountability; measurement/ feedback; hand sanitizer availability; education/ training; and marketing/communication. The researchers measured monthly changes in observed hand hygiene compliance and rates of healthcareassociated infection (including Staphylococcus aureus infections, Clostridium difficile infections and bloodstream infections) per 1,000 inpatient days. The subset of S aureus infections attributable to the operating room served as a tracer condition, and statistical process control charts were used to identify significant changes. They found that hand hygiene compliance increased significantly from 41 percent to 87 percent during the initiapatients harboring organisms such as MRSA and isolating those patients. This can cost millions of dollars annually and puts patients at risk for problems that occur when the patient is isolated. The VCU team took a different approach and employed a horizontal infection prevention strategy of high compliance with handwashing that prevents not just MRSA, but all infections that are transmitted via contact. Our study showed that using a simple approach over a nine-year period resulted in low rates of MRSA infection, says lead investigator Michael B. Edmond, MD, MPH, chair of the Division of Infectious Diseases in the VCU School of Medicine. Patient safety is the key benefit to this approach. We found that it not only prevents MRSA, but other infections that are transmitted via contact. It can also safe hospitals a lot of money. And we know that isolating patients results in anxiety, depression, increased risks of falls and bed sores, and fewer visits by doctors and nurses. Our approach reduces the need for patient isolation. In the study, trained infection preventionists conducted surveillance for infections throughout the medical, surgical and neuroscience intensive care units for a period of nine years. These experts used Centers for Disease Control and Prevention (CDC) methodology to perform surveillance. According to Edmond, the results achieved to date validate the team s approach and will lead to further efforts to drive hand hygiene compliance even higher than the current compliance rate of 93 percent. It is important to note that the majority of guidelines issues by the Society for Healthcare Epidemiology of America (SHEA) recommend a horizontal approach to addressing HAIs. Infection Control Today Hand Hygiene and Environmental Hygiene 5 infectioncontroltoday.com
tive, and improved further to 91 percent the following year. There was a significant, sustained decline in the HAI rate from 4.8 to 3.3 per 1,000 inpatient days. The rate of S aureus infections attributable to the operating room rose, while the rate of other S aureus infections fell. As Kirkland, et al. (2012) concluded, Our initiative was associated with a large and significant hospital-wide improvement in hand hygiene which was sustained through the following year and a significant, sustained reduction in the incidence of healthcare-associated infection. The observed increased incidence of the tracer condition supports the assertion that hand hygiene improvement contributed to infection reduction. Persistent variation in hand hygiene performance among different groups requires further study. As Edmond noted, Kirkland and colleagues were able to show that as hand hygiene compliance increases, infections decrease. Edmond reminded attendees of where pathogens come from in the healthcare setting: They come from humans, staff who work at the hospital, patients themselves, visitors I think all of us would agree that the major source of pathogens in the healthcare setting are humans in one form or another. When you consider the typical interaction between a healthcare worker and a patient, you must notice the points of contact the hand of the healthcare worker on the patient, the stethoscope placed on the patient, the cuffs and hems of lab coats touching the patient bed all these things are points of transmission, in either direction, of pathogens. The healthcare worker contaminates the environment, the environment contaminates the healthcare worker, and the patients and healthcare workers contaminate each other. There are mitigating factors, however, Edmond said: Environmental cleaning should keep us from contaminating ourselves and the patient, while hand hygiene and a bare-below-the-elbows policy keeps the environment from being contaminated by us and transmitting organisms to the patient. Strategies like CHG bathing keep the patient from contaminating the environment and the healthcare worker. So when I start to think about this concept of providing a sterile environment, I have a hard time getting my hands around that. Because although we ve reached a point where we probably can try to sterilize the environment with the technology that we have, how long is that environment sterile? It s important to reduce the number of pathogens in the patient setting, but I am not sure how practical it is in the long run. Edmond referenced a number of studies on disinfection with vaporized hydrogen peroxide as an example of technologies being used to boost environmental hygiene, cautioning clinicians to look carefully at the outcomes: For example for VRE, in one study when standard cleaning was done, 80 percent of the patients acquired VRE versus about 2 percent with HPV. A few things that concern me is that the outcome was not infections the infection rate is always lower than colonization rates and the major effect demonstrated in the study did not involve molecular typing. One of my hospital s infection preventionists came to me and said We have had four consecutive patients in the same room in our ICU and all of them got VRE. I thought, We really are having housekeeping Infection Control Today Hand Hygiene and Environmental Hygiene 6 infectioncontroltoday.com
problems in the medical ICU. We had the isolates and all four were genetically distinct. We discovered it was not due to poor housekeeping or cross-contamination, it was a problem with antibiotic usage. Edmond continued, In some of these studies on environmental disinfection we see differences that are not that big or statistically significant for HAIs or colonization. So what this leads me to is looking at studies of prior occupants in patient rooms to see whether various interventions reduced transmission to subsequent patients as a good surrogate marker for how important the environment is for transmission. He pointed to a study by Huang, et al. (2006) which asserted that environmental contamination with MRSA and VRE occurs during the care of patients harboring these organisms and may increase the risk of transmission to subsequent room occupants. In a 20-month retrospective cohort study of patients admitted to eight intensive care units performing routine admission and weekly screening for MRSA and VRE, the researchers assessed the relative odds of acquisition among patients admitted to rooms in which the most recent occupants were MRSA positive or VRE positive, compared with patients admitted to other rooms. Of 11,528 ICU room stays, 10,151 occupants were eligible to acquire MRSA, and 10,349 were eligible to acquire VRE. Among patients whose prior room occupant was MRSA positive, 3.9 percent acquired MRSA, compared with 2.9 percent of patients whose prior room occupant was MRSA negative. VRE, Among patients whose prior room occupant was VRE positive, these values were 4.5 percent and 2.8 percent respectively. These excess risks accounted for 5.1 percent of all incident MRSA cases and 6.8 percent of all incident VRE cases, with a population attributable risk among exposed patients of less than 2 percent for either organism. Acquisition was significantly associated with longer post-intensive care unit length of stay. As Huang et al. (2006) concluded, Admission to a room previously occupied by an MRSApositive patient or a VRE-positive patient significantly increased the odds of acquisition for MRSA and VRE. However, this route of transmission was a minor contributor to overall transmission. The effect of current cleaning practices in reducing the risk to the observed levels and the potential for further reduction are unknown. Edmond said the differences reported in the Huang study were relatively small and also referenced a paper from the University of Maryland in which 270 patients acquired ESBLs; the researchers conducted molecular typing and there were six cases for which there was an identical or closely related strain. Only 2 percent could be attributed to the environment. Edmond said that having a prior occupant who was ESBL positive was not significant in terms of an independent risk factor but colonization pressure was, so the more ESBL patients you had on a unit the more likely it was patients would become colonized. To me that is a marker for hand hygiene, not the environment, Edmond said. I take away from this that The environment accounts for about 10 percent of the source of pathogens inthe patient setting we now have to figure out the other 90 percent. Michael Edmond, MD, MPH Infection Control Today Hand Hygiene and Environmental Hygiene 7 infectioncontroltoday.com
the environment accounts for about 10 percent of the source of pathogens in the patient setting we now have to figure out the other 90 percent. I estimate that half of that is endogenous and other half is hand hygiene. I believe hand hygiene is bigger than that but I am trying to be conservative. I think the role of hand transmission is much greater than the role of the environment in terms of transmitting pathogens to patients. Edmond continued, Decontamination of our hands can be done frequently, it s low cost and we can do it as a practical measure. At the other end of the spectrum the decontamination of the environment is a high labor input, it s not rapid to some degree, the cost is expensive and it s not practical. I would say that hand hygiene and environmental disinfection are both necessary components of an effective infection prevention program. But based on the available evidence I think the environment plays a relatively minor role in the transmission of pathogens to patients but given our goal to eliminate all preventable HAIs, I think hands are the most common pathway for most HAIs. Counterpoint: Environmental Disinfection is More Important Than Hand Hygiene in Preventing HAIs Arguing that Environmental Disinfection is More Important Than Hand Hygiene in Preventing HAIs was Deverick Anderson, MD, associate professor of medicine at Duke University Medical Center, who acknowledged that going into the debate, Hand hygiene has the upper hand and everyone in our field believes it s important. I can t tell you how many times I have begged and cajoled healthcare workers to improve their hand hygiene compliance. But I believe environmental disinfection is more important than hand hygiene. Anderson said that both hand hygiene and environmental disinfection have good theory behind them, but there is still room for significant improvement. He asserted that there are minimal data to support hand hygiene as an effective intervention to prevent HAIs, and that for environmental decontamination, the quality and breadth of published data are better. Anderson explained that while Rutala and Weber s overview of how bad bugs get to susceptible hosts specifically the hand and environment pathway has purpose for each intervention, exposure to a dirty environment is continuous while exposure to dirty hands is intermittent. When you speak about opportunities for improvement, that picture of the petri dish is a powerful icon to show that hands are very contaminated, Anderson said. To drive home the environmental disinfection message, you can show a picture of a patient room, visually highlighting all touch surfaces and you can easily show that almost everything is contaminated. Environmental surfaces are dirty and there is need for improvement an average of only 50 percent of surfaces have been cleaned. (Carling, et al 2008) To frame his argument that environmental disinfection is more important than hand hygiene, Anderson referenced the four steps to the translational research paradigm: T1 research seeks to move a basic discovery into a candidate health application T2 research assesses the value of T1 application for health practice leading to the development of evidence-based guidelines Infection Control Today Hand Hygiene and Environmental Hygiene 8 infectioncontroltoday.com
T3 research attempts to move evidence-based guidelines into health practice, through delivery, dissemination, and diffusion research T4 research seeks to evaluate the real world health outcomes of a T1 application in practice Anderson explained that the major difference between hand hygiene and environmental disinfection are the data quality: While there are minimal data to support hand hygiene as an effective intervention to prevent HAIs, the quality of published data are better for environmental disinfection, he said, pointing to some of the gold standard sources commonly cited by clinicians. In the CDC hand hygiene guidelines of 2002, Anderson noted that of 423 references, 26 discussed hand contamination; 15 looked at hand hygiene and the risk of HAIs and just five were quasi-experimental studies. In the World Health Organization (WHO) hand hygiene guidelines of 2009, of 1,168 references, 16 focused on hand hygiene and risk of HAIs. He noted that the best paper that hand hygiene proponents have is the Pittet, et al. (2000) study in The Lancet that focused on the implementation of a multi-modal hand hygiene campaign in a teaching hospital in Geneva, Switzerland, before and during implementation of a handhygiene campaign. Seven hospital-wide observational surveys were done twice yearly from December 1994 to December 1997. Secondary outcome measures were nosocomial infection rates, attack rates of methicillin-resistant Staphylococcus aureus (MRSA), and consumption of handrub disinfectant. The researchers observed more than 20,000 opportunities for hand hygiene. Compliance improved progressively from 48 percent in 1994, to 66 percent in 1997. Although recourse to handwashing with soap and water remained stable, frequency of hand disinfection substantially increased during the study period. This result was unchanged after adjustment for known risk factors of poor adherence. Hand hygiene improved significantly among nurses and nursing assistants, but remained poor among doctors. During the same period, overall nosocomial infection decreased (prevalence of 16 9 percent in 1994 to 9 9 percecent in 1998; p=0 04), MRSA transmission rates decreased (2.16 to 0.93 episodes per 10,000 patient-days; p<0 001), and the consumption of alcohol-based handrub solution increased from 3.5 to 15.4 L per 1,000 patient-days between 1993 and 1998 (p<0 001). Anderson asserted that there are very little data to demonstrate that hand hygiene reduces rates of HAIs and that the current data are limited to before-and-after studies, outbreak settings, show that hand hygiene is paired with other interventions; and are conducted in lowresource settings. On the other hand, he emphasized, there are data in support of environmental disinfection relating to the fact that transmission occurs from To drive home the environmental disinfection message, you can show a picture of a patient room, visually highlighting all touch surfaces and you can easily show that almost everything is contaminated. Deverick Anderson, MD Infection Control Today Hand Hygiene and Environmental Hygiene 9 infectioncontroltoday.com
the room surfaces and objects to the patient and healthcare worker; that transmission can be prevented through improved surface cleaning and disinfection; and that it can be equally effective in both outbreak and endemic settings. Anderson pointed to several studies focusing on the room-to-patient transmission of pathogens (Huang, et al. 2006; Drees, et al. 2008) as well as transmission to healthcare workers via hands and healthcare workers apparel (Boyce, et al. 1997; Morgan, et al. 2012; Duckro, et al. 2005). Specifically, Anderson noted that 13 percent to 46 percent of hands and gloves are contaminated with MRSA and VRE and that hands/gloves contaminated by the environment transmit to other surfaces 10 percent of the time. In addition, hand contamination correlated with the intensity of environmental contamination for Clostridium difficile. Another study found that the environment contaminates gown sleeves 4 percent to 12 percent after a single encounter with a patient. Anderson emphasized that positive environmental culture is the leading factor for contamination of healthcare workers hands and apparel. Anderson also referenced a study by Eckstein, et al. (2007) in which the researchers assessed the adequacy of cleaning practices in rooms of patients with Clostridium difficileassociated diarrhea (CDAD) and VRE colonization or infection and examined whether an intervention would result in improved decontamination of surfaces. During a six-week period, the researchers cultured commonly touched surfaces (i.e. bedrails, telephones, call buttons, door knobs, toilet seats, and bedside tables) in rooms of patients with CDAD and VRE colonization or infection before and after housekeeping cleaning, and again after disinfection with 10 percent bleach performed by the research staff. After the housekeeping staff received education and feedback, additional cultures were collected before and after housekeeping cleaning during a 10-week follow-up period. Of the 17 rooms of patients with VRE colonization or infection, 16 (94 percent) had one or more positive environmental cultures before cleaning versus 12 (71 percent) after housekeeping cleaning, whereas none had positive cultures after bleach disinfection by the research staff. Of the nine rooms of patients with CDAD, 100 percent had positive cultures prior to cleaning versus seven (78 percent) after housekeeping cleaning, whereas only one (11 percent) had positive cultures after bleach disinfection by research staff. After an educational intervention, rates of environmental contamination after housekeeping cleaning were significantly reduced. In a quasi-experimental study in 10 ICUs by Datta, et al. (2011), an enhanced cleaning intervention was employed (feedback using bioluminescent markers, pre-saturated cloths and education for environmental services personnel); the findings showed that a cleaning intervention lowered MRSA acquisition by 49 percent and VRE acquisition by 29 percent for patients admitted to rooms previously occupied by carriers of either organism, in any of 10 ICUs in a 750-bed academic medical center. The cleaning intervention consisted of frequently immersing cleaning cloths in buckets containing an ammonium agent. The adequacy of cleaning was measured by the presence of a tracking marker that was visible under UV light. Based on measures of the marker, staff were given targeted feedback de- Infection Control Today Hand Hygiene and Environmental Hygiene 10 infectioncontroltoday.com
signed to improve their cleaning technique. The researchers compared hospital occupancy data during the two years when the enhanced cleaning intervention was implemented (Sept. 1, 2006, through April 30, 2008) with baseline data from the two years prior to the implementation (Sept. 1, 2003, through April 30, 2005). For MRSA detection, there were 10,151 eligible room stays at baseline, and 11,849 at intervention. There were 10,349 eligible room stays for VRE detection at baseline, and 11,871 at intervention. The MRSA acquisition rate decreased from 3 percent (305 of 10,151) at baseline to 1.5 percent (182 of 11,849) at intervention. The VRE acquisition rate fell from 3 percent (314 of 10,349) at baseline to 2.2 percent (256 of 11,871) at intervention. Patients at baseline who were admitted to rooms previously occupied by MRSA carriers had a 3.9 percent risk of MRSA acquisition, compared with 2.9 percent for patients admitted to rooms previously occupied by MRSA-negative patients. After the cleaning intervention, the risk of MRSA acquisition was 1.5 percent for all patients, regardless of whether the previous room occupant had MRSA. Patients admitted at baseline to rooms previously occupied by VRE carriers had a 4.5 percent risk of VRE acquisition, compared with a 2.8 percent risk when the previous room occupant was not a VRE carrier. After the intervention, the risk of acquiring VRE was 3.5 percent when the previous room occupant was a VRE carrier and 2 percent when the previous room occupant wasn t a carrier. Anderson also pointed to a study by Hayden, et al. (2006) in which the researchers using VRE as a marker organism investigated the effects of improved environmental cleaning with and without promotion of hand hygiene adherence on the spread of VRE in a medical intensive care unit. The study comprised a baseline period (period 1), a period of educational intervention to improve environmental cleaning (period 2), a washout period without any specific intervention (period 3), and a period of multimodal hand hygiene intervention (period 4). The researchers performed cultures for VRE of rectal swab samples obtained from patients at admission to the intensive care unit and daily thereafter, and performed cultures of environmental samples and samples from the hands of healthcare workers twice weekly. The researchers measured patient clinical and demographic variables and monitored intervention adherence frequently. The study included 748 admissions to the intensive care unit over a nine-month period. VRE acquisition rates were 33.47 cases per 1,000 patient days at risk for period 1 and 16.84, 12.09, and 10.40 cases per 1,000 patient days at risk for periods 2, 3, and 4, respectively. The mean weekly rate of environmental sites cleaned increased from 0.480.08 at baseline to 0.87 ± 0.08 in period 2; similarly high cleaning rates persisted in periods 3 and 4. Mean weekly hand hygiene adherence rate was 0.40 ± 0.01 at baseline and increased to 0.57 ± 0.11 in period 2, without a specific intervention to improve adherence, but decreased to 0.29 ± 0.26 in period 3 and 0.43 ± 0.1 in period 4. Mean proportions of positive results of cultures of environmental and hand samples decreased in period 2 and remained low thereafter. A study by Dancer showed that enhanced cleaning was associated with a 32.5 percent reduction in levels of microbial contamination at handtouch sites when wards received robust cleaning. Infection Control Today Hand Hygiene and Environmental Hygiene 11 infectioncontroltoday.com
Another key study on environmental cleaning Anderson referenced was that by Dancer, et al. (2009) which aimed to evaluate the potential impact of one additional cleaner by using microbiological standards based on aerobic colony counts and the presence of Staphylococcus aureus including MRSA. The researchers introduced an additional cleaner into two matched wards from Monday to Friday, with each ward receiving enhanced cleaning for six months in a cross-over design. Ten hand-touch sites on both wards were screened weekly using standardized methods and patients were monitored for MRSA infection throughout the year-long study. Patient and environmental MRSA isolates were characterized using molecular methods in order to investigate temporal and clonal relationships. Enhanced cleaning was associated with a 32.5 percent reduction in levels of microbial contamination at hand-touch sites when wards received robust cleaning. Near-patient sites (lockers, overbed tables and beds) were more frequently contaminated with MRSA/S. aureus than sites further from the patient. Genotyping identified indistinguishable strains from both hand-touch sites and patients. There was a 26.6 percent reduction in new MRSA infections on the wards receiving extra cleaning, despite higher MRSA patient-days and bed occupancy rates during enhanced cleaning periods. Adjusting for MRSA patient-days and based upon nine new MRSA infections seen during routine cleaning, the researchers expected 13 new infections during enhanced cleaning periods rather than the four that actually occurred. Clusters of new MRSA infections were identified two to four weeks after the cleaner left both wards. As Anderson noted, there are many more studies indicating the effectiveness of environmental disinfection and that A great deal of work is occurring in this topic, using numerous techniques, which will improve our knowledge. He added, Hand hygiene is important but it is, at best, barely evidence-based. While hand hygiene and environmental disinfection are equal perhaps in terms of theory and the opportunities for improvement, I would argue that environmental disinfection is more important.. In the end the main difference is the data data can drive what you do in your hospital, so clinicians must decide what is evidence-based and what is worth your time. If you use pure data as your guide you cannot argue against the notion that environmental disinfection is less important than HH for reducing HAIs. A great deal of work is occurring in this topic (of environmental disinfection), using numerous techniques, which will improve our knowledge. Deverick Anderson, MD Infection Control Today Hand Hygiene and Environmental Hygiene 12 infectioncontroltoday.com
Conclusion The take-home message from this point/counterpoint debate held at the SHEA spring conference is to get practitioners thinking about the strategies they employ at their healthcare institutions and to be up to date on what the scientific literature offers that may better inform which interventions are appropriate. It is important to note that both interventions hand hygiene and environmental disinfection are symbiotic strategies that can work together to help hospitals address their HAI rates. David K. Henderson, MD, deputy director for clinical care at the Clinical Center of the National Institutes of Health, says this kind of lively debate over evidence-base research stirs valuable dialogue in the medical community: If you look at Semmelweis original data it s pretty clear that his one intervention had a dramatic effect. Clever epidemiologists will argue that it was in an outbreak setting and maybe that s not the same as an endemic setting these issues have been fodder for many discussions that have taken place over the years. Hand hygiene is a significant part of healthcare epidemiology, and for reasons I don t understand, it s evident that some of our colleagues don t take it as seriously as they ought to. It puzzles me that we have not been able to successfully integrate hand hygiene into every aspect of patient care. One of the reasons to have these point/counterpoint conversations is to come away with an appreciation that maybe both components hand hygiene and environmental hygiene are important. I think the inanimate environment in the healthcare setting has probably been given short shrift until the last three or four years. When healthcare epidemiology grew up as a discipline in the UK in the 1960s, it focused on the environment, not on healthcare providers as important in the transmission of healthcare-associated infections. Then the CDC got involved in the 1970s and 1980s and we learned a lot about the basic epidemiology of healthcare-associated infections (HAIs). Clinician investigators started focusing on healthcare personnel, almost to the total exclusion of the environment. And that probably wasn t smart either. But this recent interest in the environment has come about for a number of reasons. One is that people have again started becoming worried about it, especially in the hospitals such as mine where we have numerous patients who are immunosuppressed and are at risk for acquiring virtually all healthcare-associated pathogens. And now we have all of these new tools and technologies some of them are expensive, some of them are technically difficult to use, but many of them are effective in decreasing the bioburden. We are waiting for efficacy studies; one was just published by investigators at Johns Hopkins and I think another is being conducted by investigators at Duke, among others. These studies will tell us whether the juice is worth the squeeze. It s very hard, because of the complexity of our laboratory, to isolate one factor and say yes, this disinfection strategy decreased the rate of healthcare-associated infection. It s extremely hard to do that. But hard does not mean impossible, and I think some of these newer studies are going to get there. They will help us understand the extent to which these new strategies and novel interventions may actually make the environment safer for our patients. Infection Control Today Hand Hygiene and Environmental Hygiene 13 infectioncontroltoday.com
References Dancer SJ, White LF, Lamb J, Girvan EK and Robertson C. Measuring the effect of enhanced cleaning in a UK hospital: a prospective cross-over study. BMC Medicine 2009, 7:28 doi:10.1186/1741-7015-7-28 Datta, et al. Arch Intern Med 2011;171-491. Eckstein BC, Adams DA, Eckstein EC, Rao A, Sethi AK, Yadavalli GK and Donskey CJ. Reduction of Clostridium Difficile and vancomycin-resistant Enterococcus contamination of environmental surfaces after an intervention to improve cleaning methods. BMC Infectious Diseases 2007, 7:61 doi:10.1186/1471-2334-7-61. Hayden MK, Bonten MJM, Blom DW, Lyle EA, van de Vijver D and Weinstein RA. Reduction in Acquisition of Vancomycin-Resistant Enterococcus after Enforcement of Routine Environmental Cleaning Measures. Clin Infect Dis. 2006;42:1552. Huang SS, Datta R and Platt R. Risk of Acquiring Antibiotic-Resistant Bacteria From Prior Room Occupants. Arch Intern Med. 2006;166(18):1945-1951. Kirkland KB, Homa KA, Lasky RA, Ptak JA, Taylor EA and Splaine ME. Impact of a hospitalwide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series. BMJ Qual Saf 2012;21:1019-1026. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S and Perneger TV. Effectiveness of a hospital-wide program to improve compliance with hand hygiene. The Lancet. Vol. 356, No. 9238, Pages 1307-1312, October 2000 Recommended reading Wenzel RP, Edmond MB. Infection control: the case for horizontal rather than vertical interventional programs. Int J Infect Dis. 2010 Oct;14 Suppl 4:S3-5. doi: 10.1016/j. ijid.2010.05.002. Epub 2010 Sep 18. Infection Control Today Hand Hygiene and Environmental Hygiene 14 infectioncontroltoday.com