Are hygiene standards useful in assessing infection risk?

We monitored the surface level cleanliness of a five-bedded surgical intensive care unit (SICU) over a ten-week period in order to evaluate proposed hygiene standards.Ten environmental sites within SICU were sampled twice weekly along with collection of clinical and patient activity data. The standards designate aerobic colony counts (ACCs) >2.5cfu/cm2 from hand-touch sites and the presence of Staphylococcus aureus as hygiene failures. Nearly a quarter of 200 samples failed the standards, mostly from hand-touch sites on curtains, beds and medical equipment. The total number of fails each week was associated with bed occupancy (p=0.04), trending towards association with SICU-acquired infections (p=0.11). Environmental S.aureus was associated with the proportion of beds occupied (p = 0.02). Indistinguishable genotypes were found between patient and environmental staphylococci, with timescales supporting staphylococcal transmission in both directions. Hygiene standards based on microbial growth levels and the presence of S.aureus reflect patient activity and provide a means to risk manage infection. They also exposed a staphylococcal reservoir that could represent a more tangible risk to patients. Standards for surface level cleanliness deserve further evaluation

Infection control: evidence-based common sense

When compared against classical sciences, infection control is very much the ‘new kid-on-the-block’. This means that activities directed by infection prevention and control are more likely to reflect ‘common sense’ rather than robust evidence. Indeed, hand hygiene, isolation, screening, decontamination and cleaning remain hotly debated, especially the current vogue for bathing patients in antiseptics. So, which of these provide measurable benefit, and which do not? And why is it important? Do we actually need irrefutable evidence for the advice that we dispel on a daily basis? This opinion piece examines the main components of a modern day infection control service and assesses their worth from a mainly UK perspective. The findings suggest that the framework for preventing infection is structurally sound, despite the lack of evidence. Biological sciences, by their very nature, do not easily fit into neat equations; they remain subject to measurement variables, tempered by patient status and microscopic pathogens. Despite this, numerous reports from healthcare facilities all over the world stand testimony to basic hygiene, particularly when confronted by outbreaks. Managers and others who seek to undermine traditional infection control practices should be challenged, particularly when imposing knee-jerk policies for which there is no evidence at all. Given the insidious creep of antimicrobial resistance, infection prevention and control will inevitably assume the status it has hitherto been denied. Common sense, however defined, eventually turns into scientific evidence at some stage but this progression relies upon continued accumulation, evaluation and integration of evidence by professionals and policy makers

Covid-19 exposes the gaps in infection prevention and control

• Covid-19 has highlighted how little we really know about controlling infection.• The SARS-CoV-2 pandemic has ignited a tsunami of interest in basic hygiene.• Despite a shaky evidence base, hygienic activities have propelled infection control onto the global stage.• Covid-19 has compelled us to re-examine the chain of transmission as never before

How Do Biofilms Affect Surface Cleaning in Hospitals?

The science of biofilms is progressing rapidly [...

How Much Impact Do Antimicrobial Surfaces Really Have on Healthcare-acquired Infection?

Abstract not available

Hospital cleaning: past, present, and future

Introduction: The importance of hospital cleaning for controlling healthcare-associated infection (HAI) has taken years to acknowledge. This is mainly because the removal of dirt is inextricably entwined with gender and social status, along with lack of evidence and confusion over HAI definitions. Reducing so-called endogenous infection due to human carriage entails patient screening, decolonisation and/or prophylaxis, whereas adequate ventilation, plumbing and cleaning are needed to reduce exogenous infection. These infection types remain difficult to separate and quantitate. Patients themselves demonstrate wide-ranging vulnerability to infection, which further complicates attempted ranking of control interventions, including cleaning. There has been disproportionate attention towards endogenous infection with less interest in managing environmental reservoirs. Quantifying cleaning and cleanliness: Finding evidence for cleaning is compromised by the fact that modelling HAI rates against arbitrary measurements of cleaning/cleanliness requires universal standards and these are not yet established. Furthermore, the distinction between cleaning (soil removal) and cleanliness (soil remaining) is usually overlooked. Tangible bench marking for both cleaning methods and all surface types within different units, with modification according to patient status, would be invaluable for domestic planning, monitoring and specification. Aims and objectives: This narrative review will focus on recent history and current status of cleaning in hospitals. While its importance is now generally accepted, cleaning practices still need attention in order to determine how, when and where to clean. Renewed interest in removal and monitoring of surface bioburden would help to embed risk-based practice in hospitals across the world

Airborne SARS-CoV-2

Debate over the exact mode of transmission of SARS-CoV-2 has been intense. This is entirely reasonable, given that the mechanism of spread determines preventive and potentially lifesaving policies. But the choice between respiratory aerosol or droplet settled on short range droplets, which neatly circumvented any risk outside the fabled 2m zone. This choice gave rise to social distancing, hand and surface hygiene, and masks, but not to improved indoor air quality

Four Steps to Clean Hospitals: Look; Plan; Clean; and Dry

BackgroundNow that cleaning and decontamination are recognised as integral to infection control, it is timely to examine the process in more detail. This is because cleaning practices vary widely within healthcare districts and it is likely that both time and energy are needlessly wasted with ill-defined duties. Furthermore, inadequate cleaning will not reduce the infection risk but may even enhance it. The process would benefit from a systematic appraisal, with each component placed within an evidence-based and ordered protocol.MethodsA literary search was performed on ‘hospital cleaning’, with focus on manual aspects of cleaning, pathogen reservoirs and transmission, hand-hygiene, staff responsibilities and patient comfort.ResultsThere were no articles providing an evidence-based practical approach to systematic cleaning in hospitals. This review therefore proposes a simple four-step guide for daily cleaning of the occupied bed space. STEP 1 (Look) describes a visual assessment of the area to be cleaned; STEP 2 (Plan) argues why the bed space needs preparation before cleaning; STEP 3 (Clean) covers surface cleaning/decontamination; and STEP 4 (Dry) is the final stage whereby surfaces are allowed to dry.ConclusionGiven the lack of articles providing practical cleaning guidance, this review proposes a four-step protocol based on evidence if available, or justified where not. Each step is presented, discussed and risk-assessed. It is likely that a systematic cleaning process would reduce the risk of healthcare-acquired infection for everyone, including outbreaks, in addition to heightened confidence in overall quality of care

Dynamic Transmission of Staphylococcus Aureus in the Intensive Care Unit

Staphylococcus aureus is an important bacterial pathogen. This study utilized known staphylococcal epidemiology to track S. aureus between patients, surfaces, staff hands and air in a ten-bed intensive care unit (ICU). Methods: Patients, air and surfaces were screened for total colony counts and S. aureus using dipslides, settle plates and an MAS-100 slit-sampler once a month for 10 months. Data were modelled against proposed standards for air and surfaces, and ICU-acquired staphylococcal infection. Whole-cell genomic typing (WGS) demonstrated possible transmission pathways between reservoirs. Results: Frequently touched sites were more likely to be contaminated (>12 cfu/cm2; p = 0.08). Overall, 235 of 500 (47%) sites failed the surface standard (≤2.5 cfu/cm2); 20 of 40 (50%) passive air samples failed the “Index of Microbial Air” standard (2 cfu/9 cm plate/h), and 15/40 (37.5%) air samples failed the air standard