Sehulster Lynne1

Whats New With CDC
Guidelines
Spotlight on Cleaning
Lynne Sehulster, PhD, M(ASCP)
Division of Healthcare Quality Promotion
September 21, 2009
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2009 ASHES Annual Conference

September 20-24, 2009
Reno, NV
Disclaimer
The findings and conclusions in this presentation are those of the author and her
information resources and do not necessarily represent any determination or
policy of the Centers for Disease Control and Prevention (CDC).
Unofficial Mascot of Environmental Services!

Reno, NV
Topics for Todays Presentation

Compare and contrast two guidelines from CDC and
HICPAC
Updates on cleaning from the medical literature:
Assessment methods
Observations about cleaning strategies and areas for
improvement
Updates on assorted sundry topics
Novel H1N1 influenza virus environmental control
Drug and antimicrobial resistance

Reno, NV
Goals for Todays Presentation

Attendees will gain a basic understanding of:
The new topics in the D/S guideline and some of its
unresolved issues
Transmission of microorganisms as it relates to
environmental surfaces
Current strategies to control MDROs
Environmental control for novel H1N1 influenza
Environmental assessment methods to monitor
cleaning
Green considerations for cleaning, including patient
and worker safety and a microfiber review
Bonus material: environmental sampling principles

Reno, NV
CDCs EIC
Guideline
2003
Environmental
Services
Laundry and
Bedding
Environmental
Sampling
Regulated Medical
Waste

Reno, NV
Where Can I Find the EIC

Guidelines?
y Part II Recommendations:
y MMWR 2003; 52 (RR-10): 1-44
y Errata: MMWR 2003; 52 (42): 1025-6
y Full text version:
y www.cdc.gov/ncidod/dhqp/gl_environinfection.html
y Print version (ASHE):

y www.hospitalconnect.com/ashe/resources/
importantresources.html

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HICPACs D/S
Guideline, 2008
Disinfection of healthcare equipment
Chemical disinfectants
Sterilization

Reno, NV
Where Can I Find the D/S

Guideline?
Online only:
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection
_Nov_2008.pdf
Scheduled to be published in the MMWR later in

2009

Reno, NV
Whats New from the D/S

Guideline
Extensive section on endoscope reprocessing
Extensive review of the chemical disinfectants
Chemical properties
Modes of action
Uses
Extensive review of sterilizer technologies

Expanded discussion of emerging pathogen
infection prevention issues
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Selected New Subtopics from the D/S

Guideline
Discussion of inactivation of bioterrorism agents
Occupational hazards associated with cleaners
and disinfectants
Review of current technologies for sterilization of
medical instruments
Discussion of inactivation strategies for
emerging infectious agents:
Norovirus
SARS
E. coli O157:H7

Reno, NV
D/S Guideline: Environmental

Management of Select Clinical Areas
Hemodialysis unit:
Use disinfectants with bloodborne pathogen label claims or
hypochlorite (1:100 v/v) dilution)
Reprocessing the hemodialyzers
Ambulatory care and Home care:

Bleach, alcohol, hydrogen peroxide to disinfect clinical
equipment and reusable medical devices
Avoid use of environmentally safe products (e.g., Borax,
vinegar) not EPA-registered
Dental clinics
Repeats info from CDCs dental infection control guideline

Reno, NV
D/S Guideline: Cleaning Topics

Cleaning topic focuses on the use of detergents
or enzymatic cleaners on medical devices
Surface disinfection: Should we do it?
Advantages/disadvantages
Transfer of microorganisms from one area to another
via cleaning methods
Equipment vs. housekeeping surfaces
Discussion of microfiber

Reno, NV
D/S Guideline: Cleaning Topics

Active ingredient review:
Alcohol
Chlorine and chlorine compounds
Formaldehyde and glutaraldehyde
Hydrogen peroxide and peracetic acid
Iodophors
Ortho-phthalaldehyde
Phenolics
Quaternary ammonium compounds
New chemicals as disinfectants:

Silver coatings, impregnated items
Copper-clad items
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Regulations vs. Evidence

Disinfectant contact time as per the EPAregistered product label
10 minutes (many products now have shorter CT)
D/S authors: Most healthcare facility ES staff apply
disinfectant and let it dry (~1 minute)
Lab evidence supports significant microbial

reduction with a variety of active ingredients for
contact times of 30 60 seconds
FIFRA advisory on the label: violation of federal
law to use a registered product inconsistent with
its label instructions
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An Example on Why
Instructions are so Important
EPA-registered products labeled as
cleaner/disinfectants:
Label clearly distinguishes between use
of the product as a cleaner OR as a
disinfectant
Level of soil, precleaned surface
Contact time
Surface is to remain WET for the full
contact time
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Chain of Infection
Virulent pathogen
Sufficient numbers of this pathogen
(infectious dose)
Portal of exit
Mode of transmission
Portal of entry
Susceptible host
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Environmentally Transmitted Infections

Healthcare workers and patients can be
infected directly or indirectly from
environmental sources
Sources can be air, fomites, instruments, or
aerosols
Environmental surfaces (e.g., walls, floors)

are not directly involved in infectious
disease transmission
Fomite: An inanimate object or substance capable of carrying infectious
organisms and hence transferring them from one individual to another
Reno, NV
From Point A to Point B

Medical/Dental Instruments
and Accessories
Patient A
Physicians,
Nurses, and
Assistants
Medical Equipment,
Environmental Surfaces,
Frequently Touched
Surfaces
Reno, NV
Patient B
The Inanimate Environment Can

Facilitate Transmission
X represents VRE culture positive sites
~ Contaminated surfaces increase cross-transmission ~

Abstract: The Risk of Hand and Glove Contamination after Contact with a
VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.
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So Why All the Fuss About

Hand Hygiene?
y Most common
mode of transferral
of pathogens is via
the hands!
y Infections acquired
in healthcare
y Spread of resistant
microorganisms
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Minimize Glove Misuse

Failure to remove or change contaminated gloves
18.3% (4/22) samples showed potential transferral of
microorganisms [a = from patient, b = from gloves]
Source: Girou E, Chai SHT, Oppein F, et al. J Hosp Infect 2004; 57: 162-9
Glove Cultures
Environmental Cultures
Bacterial
Counts
(CFU)
Pathogenic
Bacteria
Sampled
Surfaces
4,500
P. aeruginosa (a),
Serratia
marcescens (a)
10
>30,000
10
17
# of Contacts
Prior to
Sampling
Bacterial
Counts
(CFU)
Pathogenic
Bacteria
Bed barrier
(rail)
85
P. aeruginosa,
Serratia
marcescens (a, b)
P. aeruginosa
Bedside
table
P. aeruginosa
>30,000
P. aeruginosa
Bedside
table
>300
P. Aeruginosa (a)
>30,000
P. aeruginosa
Weighing
machine
169
P. aeruginosa (b)

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The most important step in

instrument reprocessing or
surface management is.

Reno, NV
Cleaning
A process that:
Renders a surface or device safe to
handle
Reduces the natural bioburden on
devices and environmental surfaces
Removes organic/inorganic contaminants
Reduces the challenge load posed to a
sterilizing or disinfecting process
Soaps and detergents, surfactants
Reno, NV
Cleaning vs. Disinfection

y Cleaning: removal of soil, bioburden; safe to
handle (decontamination)
y Disinfection: inactivation of micoorgranisms,
usually with the use of chemicals
y Non-critical medical equipment and
environmental surfaces: cleaning, low - to
intermediate level disinfection as appropriate
y In general, cleaners dont disinfect, and
disinfectants dont clean!
Reno, NV
Cleaning and Disinfecting of

the Housekeeping Surfaces
y Clean regularly to remove soil and dust
y Physical removal of microorganisms and soil is
as important as the antimicrobial effect of the
disinfecting agent
y Surfaces not touched frequently by hand (i.e.,
floors) in general care areas are cleaned and
disinfected
y Controversy routine disinfection of floors
is not supported by epidemiology; lack of
consensus among infection control staff and
hospital epidemiologists
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Cleaning and Disinfecting of the

Housekeeping Surfaces
y Follow manufacturers
instructions if using proprietary
cleaners or disinfectants
y Use conditions (e.g.,
concentration, contact time)
y Clean and disinfect surfaces
that are touched by hand on a
frequent and regular basis
y Door knobs, light switches,
bed rails
y Surfaces around the toilet
Reno, NV
Cleaning and Disinfecting of

Medical Equipment
FOLLOW THE MANUFACTURERS
INSTRUCTIONS!!!
In the absence of instructions, clean and
follow with low- to intermediate-level
disinfection depending on the degree of
contamination
Consider covering those surfaces that are
frequently touched during delivery of care
Reno, NV
Environmental Infection Control:

Bacterial Spores
Anthrax spore abatement; management of
Clostridium difficile outbreaks
The Big Dilemma!
HLDs are not routinely recommended for
use on environmental surfaces
Only one ILD has been EPA-registered as
a sporicide
Safe, yet effective decontamination of
affected areas
Reno, NV
VRE
MRSA
C.difficile
All electron micrographs courtesy J. Carr (DHQP) available at CDC Public
Health Image Library
Reno, NV
Staphylococcus aureus and MRSA:

Infection Control Issues
People are the source:
Carriage, infection
Shed into the general environment
Transmit to other people
Small numbers of staph can initiate infection
Staph contaminates the environment
Person to environment to person
Staph can survive for long periods of time
Cleaning can reduce staph and MRSA in the
environment
Cleaning can reduce staph / MRSA infection rates
Adapted from: Dancer SJ. The Lancet Infectious Disease; epub 10/31/07
Reno, NV
Environmental Sites Positive for MRSA in

Endemic and Outbreak Situations
Item or Surface
Mean %
Range %
Floor
34.5
9.0 60.0
Patient Gown
40.5
34.0 53.0
Bed Rails
27.0
1.0 60.0
Bed Linens
41.0
34.0 54.0
Overbed Table
40.0
18.0 67.0
Bathroom Door Knob
14.0
8.0 24.0
Room Door Knob
21.5
4.0 59.0
Furniture
27.0
11.0 59.0
Flat Surfaces
21.5
7.0 38.0
Sink Taps
23.5
14.0 33.0
Infusion Pump Button
19.0
7.0 30.0
Adapted from: Dancer SJ. The Lancet Infectious Diseases: epub 10/31/07
Reno, NV
MDROs and Environmental Infection

Control
y V.A.6. Environmental Measures
y a. Clean and disinfect surfaces and equipment that may be
contaminated, including those in close proximity to the patient and
frequently touched surfaces in the patient care environment on a
more frequent schedule compared to that for minimal touch
surfaces. Category IB
y b. Dedicate noncritical medical items when patients are known to
be infected or colonized with MDROs. Category IB
y c. Prioritize room cleaning of patients on Contact Precautions.
Focus on cleaning and disinfecting frequently touched surfaces and
equipment in the immediate vicinity of the patient. Category IB
Management of Multi-Drug Resistant Organisms in Healthcare Settings, 2006. HICPAC
guideline available at: www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf

Reno, NV
MDROs: When All Else Fails

y V.B.8 Enhanced Environmental Measures
y a. Use patient-dedicated or single-use noncritical equipment
and devices. Category IB
y b. Intensify training of environmental staff to achieve
consistency of proper environmental cleaning and
disinfection services. Category IB
y c. Monitor cleaning performance to ensure consistent
cleaning and disinfection of surfaces in close proximity to the
patient and those likely to be touched by the patient and HCP
Management of Multi-Drug Resistant Organisms in Healthcare Settings, 2006.
HICPAC guideline available at:
www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf

Reno, NV
MDROs: When All Else Fails

y V.B.8 Enhanced Environmental Measures
y d. Obtain environmental cultures when there is
epidemiologic evidence that an environmental source is
associated with ongoing transmission. Category IB
y e. Vacate units for environmental assessment and intensive
cleaning when previous efforts to eliminate environmental
reservoirs have failed. Category II
Management of Multi-Drug Resistant Organisms in Healthcare Settings, 2006.
HICPAC guideline available at:
www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf

Reno, NV
Environmental Cleaning Study:

VRE in RUMC MICU
y
4 periods of time over 9 months:

y Period 1: baseline, current procedures
y Period 2: enhanced environmental cleaning
y Virex (cleaner / quat disinfectant)
y 20 25 mins / room, 2X per day
y Bucket method for the floors, 8 12 cloths for touched surfaces
y Period 3: washout (no continued emphasis)

y Period 4: hand hygiene campaign
y
y
Rectal swabs for patients; environmental swabs; hand cultures for HCWs
VRE acquisition rates:
y
y
y
y
Period 1: 33.47 cases per 1000 patient-days at risk

Period 2: 16.84
Period 3: 12.09
Period 4: 10.40
Limitations to the study and unanswered questions:

y No reported use of neutralizer for the disinfectant
y Little or no details on the housekeeping procedures
Hayden MK, et al. Reduction in acquisition of vancomycin-resistant Enterococcus after enforcement of routine
environmental cleaning measures Clin Infect Dis 2006; 42: 1552-60
Reno, NV
Back to the Future!

Hard Surface Sampling for
Cleaning Assessment

Reno, NV
Visual Methods Currently Used to

Evaluate Cleaning
Visual inspection only
Application of clear chemicals that fluoresce under
UV light
Glo Germ
Gluten-derived glues + detergent + fluorescent dye
Qualitative: Yes / No
ATP
Proprietary swabs and solution
Luminometer reads presence of organic matter expressed in relative light units (RLU)
Can be quantitative
Reno, NV
Cleaning in the ICU:

The Most and the Least
Cleaning Effectiveness in the ICU
100
Percentageof ObjectsCle
90
80
70
60
50
40
30
20
10
0
A
A = Sink
B = Tray Table C = Toilet Seat D = Bedside Table
E = Room Door Knobs F = Bathroom Door Knobs G = Bedpan Cleaner
H = Bathroom Light Switch
Adapted From: Carling PC, et al. J Hosp Infect 2008; 68: 39-44
Reno, NV
ATP Method to Evaluate Cleaning

ATP Bioluminescence (RLU)
Medical Ward
Standard Cleaning Protocol

Mean
Range
Modified Cleaning Protocol

Mean
Range
Commode
590
(320 1200)
14
(6 29)
Drugs Trolley
460
(260 1100)
12
(5 60)
Bedside
Locker
140
(31 300)
34
(12 76)
Bedside Table
340
(130 550)
180
(27 280)
Tap Handle
450
(95 750)
130
(17 490)
Toilet Handle
340
(27 3100)
19
(11 80)
Adapted from: Lewis T, Griffith C, Gallo M, Weinbren M. J Hosp Infect 2008; 69: 156-63.
Reno, NV
Sherlock O, et al. Is it really clean? An evaluation of the efficacy of four methods for determining
hospital cleanliness. J Hosp Infect 2009; 72: 140-6.
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Cleaning Assessment:
Aerobic Colony Count Method
Al-Hamad A, Maxwell S. How clean is clean? Proposed methods for hospital cleaning
assessment. J Hosp Infect 2008; 70: 328-34.
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Tentative Standards for Cleaning

Assessment Methods
Visual inspection:
No obvious soil, organic matter, or moisture
Aerobic colony counts (ACC):

< 2.5 colony-forming units (CFUs)/cm2
MRSA or MSSA cultures:

No growth on selective media
UV fluorescence methods:
No fluorescence remaining on surfaces
ATP measurements:
< 250 RLU

Reno, NV
Failure of Personnel, Product, or Procedure?
Sequential trial for cleaning improvement in an MICU and respiratory

step-down unit
Education, observation of practices
Measured # of sites cleaned, # of site contaminated with VRE after
cleaning
Results:
# of sites cleaned improved from 49% to 85% (P < 0.001)
# of sites remaining contaminated dropped from 21% to 8% before
cleaning (P < 0.0001) and from 13% to 8% (P < 0.0001)
Multivariate model: cleaning thoroughness strongly influenced the
degree of environmental contamination, with 6% decline in VRE
prevalence for every 10% increase in the percentage of sites cleaned.
Failure to Clean (and Disinfect as Appropriate)

Source: Hota, B, et al. J Hosp Infect 2009; 71: 123-131

Reno, NV
Back to the Future! (Again!)

Fogging for Disinfection Purposes

Reno, NV
Hydrogen Peroxide Vapor (HPV)

Sporicidal at concentrations ranging from 0.5 <
10mg/L; optimal range of 2.4 mg/L
Break down products are non toxic (water and
oxygen)
Can adsorb to some plastics
Use requirements:
Vacated space by patients and staff
Cleaned of visible dirt and dust
Sealed room
Vapor cycle time varies: ~ 2 hours 4 hours

Reno, NV
Hydrogen Peroxide Vapor (HPV)
Two commercial companies slightly different technologies

One (STERIS) is EPA-registered
Effective in inactivating pathogens:

70% swabs (+) for MRSA before cleaning
66% swabs (+) for MRSA after cleaning
1.2% swabs (+) for MRSA after HPV treatment
Source: French GL, et al. J Hosp Infect 2004; 57: 31-37
However, treated rooms can become repopulated with MRSA, etc.,

within 24 hrs. of readmitting patients
17.2% of sampled sites became (+) for MRSA (5 of 29 sites)
Source: Hardy KJ, et al. J Hosp Infect 2007; 66: 360-368
Has been used for laboratories, building decontamination following

anthrax releases from intentionally contaminated mail, glove boxes,
aerosol chambers, patient wards and rooms in healthcare facilities

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On the Horizon
Steam Vapor Disinfection

Reno, NV
Good practical
information, a summary
of logical approaches
to cleaning practices
and strategies

Reno, NV
Antimicrobial Resistance And

Emerging Pathogens
Newly discovered pathogens or organisms
that acquire antimicrobial resistance are
usually erroneously assigned extraordinary
resistance to commonly used disinfection and
sterilization procedures
Examples: SARsCo-V, HIV, HCV, Ebola virus,
Hantavirus, MDR-Tb, VRE, MRSA, VRSA

Reno, NV
Antimicrobial Resistance
In general, antibiotic resistance is a
trait independent of an organisms
innate susceptibility or resistance to a
disinfectants properties.
Environmental infection control of
major antibiotic-resistant bacteria
(e.g., MRSA, VRSA, VRE) is similar to
that for antibiotic-sensitive organisms
Reno, NV
Drug Resistant Pathogens

No correlation to drug resistance and
resistance to disinfection
Some organisms may develop tolerance
at concentrations hundreds to thousand
folds below use dilution
Current protocols do not have to be
altered; use products per manufacturers
label
Reno, NV
Novel Influenza A (H1N1) 2009

Novel influenza A virus
infections: influenza A virus
subtypes that differ from the
currently circulating human
subtypes (A/H1 and A/H3)
Human infections with novel
influenza A viruses
transmissible person to
person may signal the
beginning of an influenza
pandemic
Current novel H1N1 virus
not efficiently spread from
person-to-person
Photo Source: CDC Public Health Image Library
Reno, NV
Photo Source: CDC Public

Health Image Library
Reno, NV
Fomites/Surfaces vs. Aerosol Transmission:

Influenza Virus
Boone & Gerba (2005): 23% - 59% of fomites in child care facilities and
homes were positive for influenza A RNA by PCR
Mubareka et al (2009): influenza A viruses studied in guinea pigs:
Influenza A/Panama/2007/1999 (H3N2):
infectious aerosol transmission more
efficient compared to spread via
contaminated fomites
3 of 4 (75%) and 5 of 6 (83%) animals
infected in aerosol studies, while
1 of 8 (12.5%) animals infected when
exposed to contaminated surface;
0 of 6 animals infected when
exposed to contaminated fomites

Reno, NV
Environmental Control of Novel

H1N1 Influenza Virus
Basic biophysical and biochemical properties of
the novel H1N1 (swine) influenza virus have not
changed compared to seasonal influenza virus
Sensitivity to disinfectants predicted to be
equivalent to that for human influenza viruses
Infection control strategy for environmental
surfaces will be similar to current protocols
(e.g., focus on clinical touch surfaces, LLD)
Reno, NV

Reno, NV
Impact on Staff and Patients

Staff:
Irritant and allergic
contact dermatitis on
hands and forearms
Occupational asthma
on the increase
20% are eye and skin
burns (chemical
exposures)
Muscular/skeletal
injuries (ergonomics)
Reno, NV
y Patients:
- Many exposed
to chemicals 24/7
- Chemical
sensitivities
Health Issues and Cleaning Chemicals

y Annually institutional cleaning products acutely
injure 6% of housekeeping workers.
y Respiratory system irritation and burns to eyes and
skin can be caused by cleaning and disinfecting
products in health care facilities.
y Patients and professional health care workers
frequently complain about odors and respiratory
problems associated with cleaning products and
processes.
y Annually $75 million are spent for medical expenses
and lost time wages due to these cleaning product
chemical injuries.
www.wrppn.org
Reno, NV
Chemicals in Environmental Services

HARD FLOOR CARE
y
y
y
y
y
Floor Cleaner
Floor Sealer and Finish
Wax Stripper
Baseboard Cleaner
Spray Buffing
Compound
DISINFECTING & SANITIZING

y
y
y
y
y
Disinfectant Cleaners
Chemical Sterilants
Bowl Cleaner-Disinfectants
Washroom Disinfectants
Chlorine Bleach Solutions
GENERAL CLEANING PRODUCTS

CARPET CARE
y
y
y
y
y
Carpet Cleaner Conc.

Carpet Prespray
Spotters
Betadine Remover
Defoamer

Reno, NV
y
y
y
y
y
y
y
General Purpose Cleaner

Glass Cleaner
Stainless Steel Cleaner/Polish
Furniture Polish
Graffiti Remover
Drain Maintainer
Odor Eliminator
Safety Assessment of Cleaning and

Disinfectant Products
y How is the product diluted and how frequently
is it being used?
y What is the products intended use?
y What is the likelihood it will be misused?
y What is the experience level of users?

Reno, NV
Safety Assessment of Cleaning and

Disinfectant Products
y What are the hazard ratings for the product?
y What does the MSDS say about the product
safety?
y Does the product present an acceptable level of
risk?
y What do others report about the product safety?

Reno, NV
Steps to Developing a Greener

Cleaning/Disinfecting Strategy
y Follow manufacturer / label instructions for
use of disinfectants and proper equipment or
surface management
y Review MSDS carefully and consider
chemical sensitivities of patients, workers
y Evaluate new products carefully: look for
EPA registrations, independent studies if
available
Reno, NV
Steps to Developing a Greener

Cleaning/Disinfecting Strategy II
y Choose chemical application methods that
minimize aerosol production
y Ensure sufficient potency appropriate for the
job and materials compatibility
y Evaluate whether or not a chemical residual
is necessary or desirable
y Incorporate barrier coverings whenever
practical for items that are difficult to clean

Reno, NV
Strategies to Enhance the Safety and

Efficacy of Cleaning and Disinfecting
Be familiar with the products MSDS
and instructions for proper and safe
application
Look for opportunities to prevent
surface contamination from
occurring
Look for opportunities to reduce the
amounts of chemicals used
Reno, NV
A Housekeeping Process in
Transition
y Mopping procedures:
y Frequency of replacing cleaning solutions during
use, rinse procedures, mop head switch-out,
disposable vs. reusable
y New! Microfiber cleaning materials

y UC Davis MC study: ergonomic, economical
www.epa.gov/Region9/waste/p2/projects/mops.pdf
y Resource savings: 95% less chemicals, 95% less
water, overall cost savings 5-10%, microfiber mop
heads lasted 5-10 times longer
y Not effective on grease or body substance spills
Reno, NV
Microfiber Pilot Test Results

Swedish Hospital Seattle Washington
y Water/chemical usage before microfiber: 36
gallons per day and 18 oz. of cleaning
chemical
y Water/chemical usage post microfiber: 9
gallons per day and 4.5 oz. cleaning chemical
y Staff satisfaction: cleaner floors, no mop
wringers, reduction of shoulder and arm
strain injuries
Source: Mike Smith, Swedish Hospital, Seattle Washington
Reno, NV
Reductions in Soil and

Microorganisms with Microfiber
2.5
L o g R ed u ctio n
1.5
1
0.5
0
MF 1
MF 2
MF 3
MF 4
MF 5
MF 6
GP Cloth
-0.5
Cloth Type
Organic Debris (RLU)
Microorganisms (CFU)
Paper
Towel
Dry surfaces
wiped with a wet
cloth
No use of
cleaners or
disinfectants
during the tests
Variable results in
cleaning
efficiency
Texture was
important
Damp cloth
worked best
Source: Moore G, Griffith C. A laboratory evaluation of the decontamination properties of microfibre

cloth. J Hosp Infection 2006; 64: 379-85.
Reno, NV
Microorganism Removal with Microfiber
Cleaning
Solution
Cleaning System
Dry Time
(mins)
Mean % Reduction CFU +

SD
QUAT
Cotton string mop/standard

bucket with wringer
2:48
94.84 + 4.8
QUAT
Microfiber mop/standard
bucket with wringer
2:13
87.94 + 17.2
QUAT
Microfiber mop/microfiber
bucket
7:04
95.31 + 5.7
Detergent
Cotton string mop/standard

bucket with wringer
2:48
67.75 + 31.6
Detergent
Microfiber mop/standard
bucket with wringer
2:23
79.74 + 24.8
Detergent
Microfiber mop/microfiber
bucket
8:03
94.50 + 4.6
QUAT = 1:128 dilution of product containing 5.15% didecyl dimethyl ammonium chloride,
3.43% dimethyl benzyl ammonium chloride. Detergent was a neutral cleaner with no
germicidal properties
RODAC plates with D/E Neutralizing agar; CFU compared before and after cleaning
Source: Rutala WA, Gergen MF, Weber DJ. Microbiologic evaluation of microfiber mops for surface
disinfection. Am J Infect Control 2007; 35: 569-73.
Reno, NV
Some Closing Thoughts on Cleaning

and Disinfection
In general, it should be kept in mind that the use
of disinfectants is only one part of an evidencebased, multimodal strategy to control
healthcare-related infections and to prevent the
spread of resistance. Well-designed studies
that systematically investigate the effects of
specific interventions in this area are urgently
required to support a rational approach to
hospital disinfection.
Dettenkofer M, Block C. Hospital disinfection: efficacy and safety issues.
Curr Opin Infect Dis 2005; 18: 320-325.

Reno, NV
So Howd We Do Today?
D/S guideline:
Highlighted the topics in the D/S guideline that were new or
addressed updated material
Discussed the problem between evidence-based guidance and
regulatory requirements
Transmission of microorganisms: surfaces

Reviewed the Chain of Infection
Discussed hand transfer of microorganisms
Strategies to control MDROs

Discussed current tiered strategies for environmental
management
Reviewed disinfectant issues related to emerging pathogens
Environmental control for novel H1N1 influenza

Discussed efficiency of transmission via droplets and surfaces

Reno, NV
So Howd We Do Today?
Environmental assessment methods for cleaning
Compared and contrasted different methods
Reviewed current medical literature information on
these methods
Green cleaning issues

Reviewed patient and worker safety concerns
Provided an update on microfiber from the literature
Bonus material
Summarized environmental sampling principles from
the EIC guideline
Reno, NV
Acknowledgements!
Stephen Ashkin
The Ashkin Group, LLC
For selected slides and insightful
conversations
Roger McFadden, MS
VP for Technical Services,
Coastwide Laboratories
For additional slides and more
insightful conversations
Reno, NV
Source: U.S. Dept. of the Interior, National Park Service: Grand Teton National Park
Reno, NV
Thank You!
Division of Healthcare Quality Promotion
Centers for Disease Control and Prevention
Protect patients, protect health-care
personnel, and promote safety, quality, and
value in the health-care delivery system

Reno, NV
Bonus Material
Environmental Sampling of
Hard Surfaces:
Principles and Practices

Reno, NV
Should Environmental
Sampling Be Done?
y NO, not routinely
y Environmental sampling may be useful:
y To verify the effectiveness of a new cleaning
and disinfecting process
y To identify environmental reservoirs during
outbreak situations
y Coordinate sampling with the laboratory

Reno, NV
Environmental Sampling
Environmental microbiology is not clinical
microbiology
Sampling is supported by epidemiologic
assessment
Random, undirected sampling is not
recommended
Sampling requires a protocol for sampling
and culturing, analysis of results, and
action based on the interpretation of
results
Reno, NV
Environmental Sampling
Expensive and time-consuming; subject to many
variables in protocol, analysis, and interpretation
Sampling is a public exercise and is always
subject to disclosure; therefore, the investigator
is required to minimize false negatives and,
more rarely, false positives.
Quotation source: Chapter 10, Sampling Design Strategy, in Recognition, Evaluation, and
Control of Indoor Mold, Prezant B, Weekes DM, Miller JD, eds. AIHA, Fairfax VA; 2008

Reno, NV
Environmental Surface Sampling

Decision to sample should be driven by
epidemiology, infection control
Disinfectant neutralizers may be needed
Major methods include:
Sample/rinse using sponges, wipes or swabs
Direct immersion
Containment (interior surfaces of a container)
RODAC plate (direct surface sampling)
Reno, NV
Things to Consider Prior to Surface

Sampling
Background literature and present activities
Preliminary results from epidemiological
investigation
Locations to sample
Collection method and equipment
Number of replicate samples needed
Are controls or comparisons needed?
Parameters for assay; qualitative, quantitative, or both?
Estimate of maximum allowable microbial numbers or
types on surface(s) sampled
Some anticipation of a plan of action based on results
Source: A. Streifel and J. Wideman, AIHAce 2004
Reno, NV
Surface Sampling Methods

Target
Uses
Biological
Agents
Wipe
Sterile 2 x 2 noncotton gauze,

moistened; wipe
area of known size
Nonporous
surfaces, usually
small in area
Screening small
nonporous surfaces
extent of contamination
decontamination
effectiveness
Bacteria,
viruses,
fungi,
biological
toxins
Swab
Sterile non-cotton
swab, individually
wrapped, then
moistened with
sterile solution;
wipe area of known
size
Nonporous
surfaces, usually
very small in area,
complex surfaces
with crevices,
corners
Screening small
nonporous surfaces
decontamination
effectiveness
Bacteria,
viruses,
fungi,
biological
toxins
RODAC
Convex agar
surface in culture
dish, press onto
surface, incubate
Nonporous
surfaces,
relatively small
area
Screening small
nonporous surfaces
decontamination
effectiveness
Bacteria,
fungi
Sample
Type
Description
Source: Busher A, Noble-Wang J, Rose L. Surface Sampling, in Sampling for Biological Agents in the Environment
Reno, NV
Things to Consider Before Conducting

Surface Sampling
Asepsis is critical
Sterilized sampling materials
Aseptic technique
Document the circumstances of sampling
State of the surface and its preparation, if
any, prior to sampling
Prepare a sampling strategy or plan that
ensures the validity of the results and is
appropriate for the organism(s) being sampled
Controls!
Reno, NV
Wipe Method
Materials used:
Sterile gloves, sterile sample containers, sterile
wrapped 2x2 gauze sponge pads, disposable sterile
sampling template, sterile water or other appropriate
fluid, plastic bags, identification tags
Affix the template
Aseptically wet the gauze with fluid and thoroughly wipe
the area within the template
Fold the gauze so the exposed side is inward and place in
sample container; label
Repeat with new template and new gauze if another
surface is to be sampled
Source: Busher A, Noble-Wang J, Rose L. Surface Sampling.
Reno, NV
Swab Sampling Procedure

Materials used:
Sterile items: gloves, sample containers (e.g., large
cfg tubes), wrapped non-cotton swabs, wetting
solution, scissors, disposable template
Sealable plastic bags, identifying markers, tags
Affix the template to the surface
Wet the swab and wipe using an S-shaped pattern
(vertically & horizontally), rolling the swab over the
surface
Place the swab aseptically in a sample tube; label
Change gloves and use a new template if sampling
another surface
Reno, NV
RODAC Plate Sampling Method

Materials used:
RODAC plate (agar medium is overfilled to
give a convex surface)
Used to sample cleaned surfaces; not suitable
for visibly dirty or irregular surfaces
Neutralizers can be incorporated into the
medium if surface disinfectant residuals are
present
Press the convex medium onto the surface; do
not twist or move the plate around

Reno, NV
Neutralizing Agents
Disinfectant
Neutralizer or Neutralizing Media
Sodium hypochlorite, chlorine

dioxide, iodine
Sodium thiosulfate, Dey Engley

(D/E) broth or agar
Formaldehyde, glutaraldehyde
Glycine, D/E broth or agar
Hydrogen peroxide
Catalase
Phenolics
Tween 80, D/E broth or agar
Quaternary ammonium
compounds
Lecithin + Lubrol W, Letheen broth

or agar, D/E broth or agar
Vaporized hydrogen peroxide
None needed end products are

H2O and O2
Adapted from Russell AD. Principles of antimicrobial activity and resistance, p. 31-56. in
Block SS (ed). Disinfection, Sterilization, and Preservation. 5th Ed., Philadelphia PA, LWW: 2001
Reno, NV
For More Details

CDCs EIC Guideline
Emanuel P, Roos JW, Niyogi K. Sampling for
Biological Agents in the Environment.
Washington DC, ASM Press: 2008.
Hung LL, Miller JD, Dillon HK. Field Guide for
the Determination of Biological Contaminants
in Environmental Samples. Fairfax VA, AIHA
Press: 2005
Bond WW, Sehulster LM. Microbiological
Assay of Environmental and Medical Device
Surfaces. Chap 13-10 in Clinical Microbiology
Procedures Handbook, 2nd Ed, Isenberg HD,
ed. Washington DC, ASM Press: 2004
Reno, NV

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Whats New With CDC

2009 ASHES Annual Conference

Unofficial Mascot of Environmental Services!

Topics for Todays Presentation

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Goals for Todays Presentation

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y Print version (ASHE):

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2009 ASHES Annual Conference

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The Inanimate Environment Can

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Bathroom Door Knob

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4 periods of time over 9 months:

y Period 3: washout (no continued emphasis)

Period 1: 33.47 cases per 1000 patient-days at risk

Limitations to the study and unanswered questions:

Back to the Future!

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