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Metanalysis: Cleaning Hospital Room Surfaces to Prevent Health Care—Associated Infections

I recently came across this detailed review “Metanalysis: Cleaning Hospital Room Surfaces to Prevent Health Care—Associated Infections” from the Annals of Internal Medicine.  I think this is a fascinating topic because hospitals have to walk such a fine line with regards to microbes.  On the one hand they want to avoid the probably counter-productive “kill them all” mentality… yet on the other hand need to reduce the (rising) incidence of hospital-acquired (nosocomial) infection.   This review seems to do a good job of covering the topic with resorting to over simplified solutions like “cover everything in copper and call it good”.  Abstract below:

The cleaning of hard surfaces in hospital rooms is critical for reducing health care—associated infections. This review describes the evidence examining current methods of cleaning, disinfecting, and monitoring cleanliness of patient rooms, as well as contextual factors that may affect implementation and effectiveness. Key informants were interviewed, and a systematic search for publications since 1990 was done with the use of several bibliographic and gray literature resources. Studies examining surface contamination, colonization, or infection with Clostridium difficile, methicillin-resistant Staphylococcus aureus, or vancomycin-resistant enterococci were included. Eighty studies were identified–76 primary studies and 4 systematic reviews. Forty-nine studies examined cleaning methods, 14 evaluated monitoring strategies, and 17 addressed challenges or facilitators to implementation. Only 5 studies were randomized, controlled trials, and surface contamination was the most commonly assessed outcome. Comparative effectiveness studies of disinfecting methods and monitoring strategies were uncommon. Future research should evaluate and compare newly emerging strategies, such as self-disinfecting coatings for disinfecting and adenosine triphosphate and ultraviolet/fluorescent surface markers for monitoring. Studies should also assess patient-centered outcomes, such as infection, when possible. Other challenges include identifying high-touch surfaces that confer the greatest risk for pathogen transmission; developing standard thresholds for defining cleanliness; and using methods to adjust for confounders, such as hand hygiene, when examining the effect of disinfecting methods.

Key Summary Points

Environmental cleaning is an important component of a multifaceted infection control strategy to prevent health care—associated infections.

Emerging technologies have led to increased interest in evaluating environmental cleaning, disinfecting, and monitoring in the acute care hospital setting.

A major limitation of the evidence base is the relative lack of comparative studies addressing the relative effectiveness of various cleaning, disinfecting, and monitoring strategies.

Few studies assess clinical, patient-centered outcomes, including patient colonization and health care—associated infection rates.

Future studies are needed that directly compare newer disinfecting and monitoring methods, assess the effect of contextual factors on implementation, and evaluate patient-centered outcomes.

Health care—associated infections (HAIs) are a leading cause of illness and death in the United States and worldwide. In 2011, an estimated 721 800 HAIs occurred in the United States, leading to 75 000 deaths (1). A multifaceted approach to preventing infection is critical to reducing the risk for HAIs, including hand hygiene practices, antimicrobial stewardship, and environmental cleaning and disinfecting.

Several studies demonstrate that health care—associated pathogens frequently contaminate the patient environment, including both porous surfaces (such as curtains) and hard, nonporous surfaces (such as bed rails and medical equipment) (24). Contaminated surfaces are a reservoir for transmission of pathogens directly through patient contact with the environment or indirectly through contamination of health care workers’ hands and gloves.

Environmental cleaning is important for reducing microbial contamination of surfaces and subsequent risk for HAIs. Environmental cleaning is a complex, multifaceted process and involves the physical action of cleaning surfaces to remove organic and inorganic material, followed by application of a disinfectant, as well as monitoring strategies to ensure the appropriateness of these practices. In addition, contextual factors, such as management tools and organizational structure, and culture can affect the implementation and effectiveness of cleaning, disinfecting, and monitoring strategies. The goal of this review is to provide a systematic overview on environmental cleaning of hospital room surfaces to prevent HAIs. We focus on environmental cleaning of the hard surfaces most frequently touched by patients and health care workers, which are often called high-touch surfaces or objects. We also discuss key health care—associated pathogens for which there is the most evidence for environmental transmission, specifically methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Clostridium difficile (58). Finally, we enumerate the evidence gaps in the literature and propose future research directions.

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David Coil

David Coil is a Project Scientist in the lab of Jonathan Eisen at UC Davis. David works at the intersection between research, education, and outreach in the areas of the microbiology of the built environment, microbial ecology, and bacterial genomics. Twitter

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