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Changing Landscape of Environmental Disinfection · The SHEA Podcast

• 0:06
  SPEAKER_00: Welcome to our podcast series, Digital and Electronic Innovations in Hospital Epic and Antimicrobial Stewardship, brought to you by the Society for Healthcare Epidemiology of America, Shea, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:25
  SPEAKER_00: This series will identify new or emerging technologies that can be leveraged to improve patient safety, data quality, and efficiency, describe the advantages and disadvantages of recent innovations, and recognize strategies to demonstrate success or lack thereof and substantiate implementation of new technology.
• 0:43
  SPEAKER_00: I'm Dr.
• 0:43
  SPEAKER_00: Chrissy Woods and I will be your podcast moderator today.
• 0:46
  SPEAKER_00: Shea is excited to launch this episode of the podcast series, which is entitled The Changing Landscape of Environmental Disinfection.
• 0:53
  SPEAKER_00: I'm happy to introduce our two speakers for today.
• 0:55
  SPEAKER_00: First, we have Dr.
• 0:56
  SPEAKER_00: Curtis Donsky, Professor of Medicine at Case Western Reserve University, as well as the hospital epidemiologist and chair of the infection control committee at the Lewis Stokes Cleveland VA Medical Center, and Dr.
• 1:08
  SPEAKER_00: William A.
• 1:09
  SPEAKER_00: Rutella, who is a professor in the Division of Infectious Diseases at the University of North Carolina School of Medicine, and the director of the North Carolina Statewide Program for Infection Control and Epidemiology.
• 1:20
  SPEAKER_00: Thank you very much for joining us today.
• 1:23
  SPEAKER_01: I'm happy to participate.
• 1:24
  SPEAKER_01: Thank you for the invitation.
• 1:26
  SPEAKER_02: Thank you all for joining us today.
• 1:27
  SPEAKER_02: I'm looking forward to our conversation.
• 1:29
  SPEAKER_00: Okay, so let's dive into our questions.
• 1:31
  SPEAKER_00: Everyone has a lot of questions on where this is going and very much looking forward to your perspective.
• 1:37
  SPEAKER_00: The physical environment represents an important source of pathogens that can cause infections or carry antibiotic resistance.
• 1:44
  SPEAKER_00: How has this changed over the past two years with COVID?
• 1:46
  SPEAKER_00: Dr.
• 1:47
  SPEAKER_00: Donsky?
• 1:48
  SPEAKER_01: You know, the pandemic has forced infection control programs to divert a lot of attention away from our usual efforts to control HAIs.
• 1:57
  SPEAKER_01: And that includes attention to environmental cleaning.
• 2:00
  SPEAKER_01: So, for example, in our facility, our program for monitoring, cleaning, and disinfection was suspended entirely for a long period during the pandemic and greatly reduced overall.
• 2:11
  SPEAKER_01: And that is probably the case for many healthcare facilities.
• 2:14
  SPEAKER_01: There is some evidence that lapses in standard infection control have had an impact.
• 2:19
  SPEAKER_01: Rates of several HAIs have increased during the pandemic.
• 2:23
  SPEAKER_01: Multiple outbreaks of MDROs have been reported on COVID units, including multi-drug-resistant GREM negatives in Canadaurus.
• 2:29
  SPEAKER_01: It isn't clear how much lapses in cleaning have contributed to these outbreaks, but infection control programs, I think, are hopeful that we can get back to re-emphasizing our standard practices, and that will include cleaning.
• 2:41
  SPEAKER_01: One other comment I would make is that a substantial change during the pandemic has been an increased appreciation for airborne transmission of pathogens.
• 2:50
  SPEAKER_01: And there's an opportunity to determine if interventions to improve ventilation or clean air might have an impact on other pathogens, particularly respiratory viruses.
• 2:59
  SPEAKER_01: One thing that has not changed, however, whether we're considering surface or air disinfection technologies, is the need for validation of manufacturers' claims by independent research groups.
• 3:12
  SPEAKER_01: There's a real concern that many of the technologies that are purported to clean the air may be unnecessary in settings of good ventilation or potentially hazardous.
• 3:21
  SPEAKER_01: They create things like ozone and other chemicals that can be harmful.
• 3:25
  SPEAKER_01: So if air cleaning technologies are used, there is evidence that inexpensive technologies can be just as effective as more expensive alternatives.
• 3:33
  SPEAKER_01: The CDC recommends that you need a HEPA.
• 3:35
  SPEAKER_01: You should use a HEPA filter if you want to have a portable air cleaner.
• 3:39
  SPEAKER_01: A lot of the extra kind of bells and whistles that are added to those are really not necessary.
• 3:44
  SPEAKER_01: And this has certainly been of an interest of both Dr.
• 3:46
  SPEAKER_01: Ratal and I for many years, making sure that the technologies that environmental services and infection prevention people are looking at are working as the claims are made by the companies.
• 3:59
  SPEAKER_00: And Dr.
• 3:59
  SPEAKER_00: Donsky, you pointed out that there have been many changes during this time of COVID in terms of how we're looking at our environment and maybe changes in surveillance.
• 4:08
  SPEAKER_00: So as we start to refocus the lens of infection prevention beyond COVID, are there particular pathogens where it'll be important for infection prevention programs to consider environmental disinfection?
• 4:18
  SPEAKER_01: I think Canada Auris is an example that is a particular concern.
• 4:22
  SPEAKER_01: It survives for long periods on surfaces, frequently contaminates portable equipment and surfaces in patient rooms.
• 4:29
  SPEAKER_01: Canadaurus has continued to spread during the pandemic.
• 4:32
  SPEAKER_01: Clinical cases were reported in 25 states during the past year.
• 4:36
  SPEAKER_01: Nine states have had 50 or more cases, including here in Ohio.
• 4:40
  SPEAKER_01: And several recent outbreaks have been reported.
• 4:43
  SPEAKER_01: There was one large outbreak on a COVID unit where lapses in cleaning and disinfection of shared portable equipment was suspected to be a potential contributor to transmission.
• 4:53
  SPEAKER_01: Improved protocols for cleaning portable equipment is needed in most healthcare settings, but particularly if you are dealing with an organism like Canada Auris.
• 5:02
  SPEAKER_01: A couple of other points about Canada Auris, infection prevention and environmental services personnel need to be aware that Canada Ourus has reduced susceptibility to quaternary ammonium disinfectants, so they should not be used.
• 5:13
  SPEAKER_01: The CDC also emphasizes daily or multiple times daily disinfection of surfaces in Canada Ourus rooms.
• 5:20
  SPEAKER_01: The rationale for that is that daily disinfection of surfaces provides source control.
• 5:26
  SPEAKER_01: By reducing the burden of pathogens on surfaces, you can reduce the risk that healthcare coming in and out of those rooms will become contaminated with those organisms.
• 5:34
  SPEAKER_01: And that's something we've previously shown.
• 5:36
  SPEAKER_01: Daily disinfection of surfaces in C.
• 5:38
  SPEAKER_01: difficile infection rooms can reduce the risk for contamination of personnel caring for those patients.
• 5:44
  SPEAKER_00: Dr.
• 5:44
  SPEAKER_00: Rotello, could you share with us what new technologies will create a changing landscape for environmental disinfection?
• 5:50
  SPEAKER_02: Yes, thank you for the opportunity to discuss change of landing technologies and processes to minimize contribution of the environment de transmission.
• 5:59
  SPEAKER_02: There are three, four, or five that I could quickly discuss.
• 6:02
  SPEAKER_02: One is electrostatic spraying.
• 6:05
  SPEAKER_02: Most disinfection in healthcare facilities is done using a moistened disposable wipe or via the application of a disinfectant with a cloth, such as a cotton cloth or a microfiber cloth.
• 6:17
  SPEAKER_02: One no-touch strategy that may improve through application to surfaces is the use of a disinfectant as a spray.
• 6:25
  SPEAKER_02: Dr.
• 6:26
  SPEAKER_02: Donsky and his colleagues have evaluated an electrostatic sprayer device, which delivers electrostatically charged droplets with an average size of 40 to 80 microns that are attracted to the surface to improve thoroughness of surface coverage.
• 6:44
  SPEAKER_02: The disinfectant used was 0.25 sodium hypochlorite, which is 2,500 parts per million of chlorine.
• 6:53
  SPEAKER_02: This concentration of chlorine reduced C.
• 6:56
  SPEAKER_02: defacyl scores by greater than six colony forming logs of colony forming units with a five-minute contact time, and a bacteriophage MS2 by six logs with a two-minute contact time.
• 7:11
  SPEAKER_02: In another recent study, Dr.
• 7:13
  SPEAKER_02: Donsky's group compared this new technology, electrostatic spray, or I should say technology that has only recently been evaluated by various researchers, to essentially UVC.
• 7:28
  SPEAKER_02: And the investigators found that the technologies were similarly effective.
• 7:33
  SPEAKER_02: That is, the UVC and the electrostatic sprayer were similarly effective in significantly reducing residual healthcare pathogen contamination on floors and high-touch surfaces after a manual disinfection.
• 7:48
  SPEAKER_02: So this technology has been found to be effective for several healthcare pathogens and used to decontaminate surfaces in various settings to include schools and airplanes and hospitals.
• 7:59
  SPEAKER_02: There is another new technology.
• 8:01
  SPEAKER_02: It's a new sporoside.
• 8:03
  SPEAKER_02: This is a novel hydrogen peroxide-based disinfectant that has been launched that has sporosidal claim.
• 8:11
  SPEAKER_02: The sporosidyl claim is due in part to a generation of parasitic acid with the 4% hydrogen peroxide and the less than 10% acidic acid.
• 8:22
  SPEAKER_02: Dr.
• 8:23
  SPEAKER_02: Donsky's laboratory with Jennifer Catnum again investigated this new sporocidal product and found that this sporosidal product was effective in killing C.
• 8:34
  SPEAKER_02: deficiel spores by approximately five logs in just one minute.
• 8:40
  SPEAKER_02: Another technology or maybe process that Dr.
• 8:43
  SPEAKER_02: Donsky and his laboratory investigate was the use of a sporide in all discharge patient rooms.
• 8:51
  SPEAKER_02: As everyone knows, environmental contamination has been demonstrated to be an important component of patient-to-patient transmission of C.
• 9:00
  SPEAKER_02: diffacil.
• 9:01
  SPEAKER_02: And infection control measures to prevent C.
• 9:04
  SPEAKER_02: diffacil include surfaces infection using a spore cidal disinfectant.
• 9:09
  SPEAKER_02: But there's also been several studies that suggest that an asymptomatic carrier might shed spores, contaminate environmental surfaces, and might play a role in transmission of C.
• 9:20
  SPEAKER_02: diffacil.
• 9:21
  SPEAKER_02: So Dr.
• 9:22
  SPEAKER_02: Wong and his colleagues in Dr.
• 9:24
  SPEAKER_02: Donsky's laboratory evaluated this issue of environmental shedding and contamination by asymptomatic carriers by use of a sporocidal disinfectant for all post-discharge disinfection.
• 9:39
  SPEAKER_02: They examined the frequency of C.
• 9:41
  SPEAKER_02: diffacyl contamination in non-C-facil infected rooms after disinfection with a quaternary ammonium disinfectant compared to a spray formulation of bleach.
• 9:54
  SPEAKER_02: And they found that the frequency of recovery of C.
• 9:57
  SPEAKER_02: diffacil spores from surfaces after post-discharge disinfection of non-C defacil infection rooms was significantly reduced from 24% to 5% after a spray formulation of bleach was substituted for quaternary ammonium compound.
• 10:17
  SPEAKER_02: Lastly, let me mention a colorized disinfectant.
• 10:21
  SPEAKER_02: Effective surface disinfection plays an important role in preventing transmission of several healthcare-associated pathogens, such as MRSA, VRE, acinidabacter, norovirus, and C.
• 10:33
  SPEAKER_02: dipacyl.
• 10:35
  SPEAKER_02: Unfortunately, suboptimal disinfection is a common problem with several studies demonstrating less than 50% of high-touch surfaces are disinfected during post-discharge cleaning.
• 10:46
  SPEAKER_02: While thoroughness monitoring is sometimes done and can improve disinfection, it's difficult to sustain and it is not continuous.
• 10:54
  SPEAKER_02: There is a novel colorized disinfectant for improving the thoroughness of disinfection that's been introduced and involves a color additive to the disinfectant.
• 11:06
  SPEAKER_02: Currently, it can be added to bleach and it can be added to a quad.
• 11:11
  SPEAKER_02: And this improves visualization of surface coverage and contact time so you can visualize the application of the disinfectant to the surface, which improves the thoroughness of disinfection.
• 11:25
  SPEAKER_02: In one study, the color additive reduced the failure rates of the disinfection based on a fluorescent marker removal.
• 11:35
  SPEAKER_02: And in another study, it quantitatively improved the thoroughness of disinfection, again, using a fluorescent marker.
• 11:43
  SPEAKER_02: Those are several of the new technologies or processes that I think may minimize transmission of infection from contaminated environmental surfaces.
• 11:54
  SPEAKER_01: You know, I would just add one comment related to using a sporoside in all discharge patient rooms.
• 12:00
  SPEAKER_01: There very recently, Phil Carling and his colleagues published an article in infection control and hospital epidemiology where they combined the fluorescent marker monitoring method that Phil Carling kind of has championed with a disinfectant switch to a sporosidal product.
• 12:17
  SPEAKER_01: And with that, they saw a significant reduction in C.
• 12:20
  SPEAKER_01: diff infection rate in the hospital in comparison to several control hospitals.
• 12:25
  SPEAKER_01: So there is, again, some evidence that use of a sporoside everywhere may not just reduce environmental contamination, but potentially could reduce infection rates.
• 12:35
  SPEAKER_01: And so I think there really is a need for a larger scale randomized trial looking at that, looking at the use of sporosides everywhere.
• 12:42
  SPEAKER_00: Thank you both for that.
• 12:43
  SPEAKER_00: I think it's exciting to hear about what is new out there.
• 12:46
  SPEAKER_00: And certainly there are some applications that kind of continuously look at and re-evaluate and try to find usefulness for it in the healthcare space.
• 12:54
  SPEAKER_00: And I think one of those is ultraviolet light technology.
• 12:57
  SPEAKER_00: Dr.
• 12:57
  SPEAKER_00: Donsky, I was wondering if you can comment a little bit about this.
• 13:00
  SPEAKER_00: Are there important recent developments related to UV that you can share with us?
• 13:04
  SPEAKER_00: And are there certain types of data that facilities should use in order to track and monitor the use of UV devices?
• 13:12
  SPEAKER_01: I think the central question about UV light is whether these devices should be routinely recommended as an adjunct to manual cleaning and disinfection.
• 13:21
  SPEAKER_01: So if you look up Canada Aurus on the CDC website, they will note that UV is effective against Canada AURIS, but state that there isn't enough evidence to make a recommendation.
• 13:32
  SPEAKER_01: In the SHA compendium guidelines for prevention of C.
• 13:34
  SPEAKER_01: difficile infections, use of touchless disinfection technologies like UV is listed as an unresolved issue.
• 13:42
  SPEAKER_01: I think there are good arguments in favor of UV, and I'm sure Dr.
• 13:45
  SPEAKER_01: Rotala would agree with that, that standard cleaning is suboptimal.
• 13:48
  SPEAKER_01: UV, we can show, is very effective at reducing contamination and surfaces.
• 13:53
  SPEAKER_01: There are quasi-experimental studies and one large randomized trial that have shown reductions in colonization or infection.
• 14:00
  SPEAKER_01: However, you know, there are also arguments against UV.
• 14:04
  SPEAKER_01: I mean, I think one can argue that the expense and time involved in use of UV could be used alternatively to improve manual cleaning and disinfection, which you could apply in all patient rooms rather than just in a small proportion of rooms that you typically are using a UV device in.
• 14:21
  SPEAKER_01: And there are some recent quasi-experimental studies that have not shown a reduction in HAIs when UV has been implemented.
• 14:27
  SPEAKER_01: And then finally, a high-quality randomized trial from Claire Rock and her colleagues at Johns Hopkins did show that UV did not reduce colonization or infection with C.
• 14:36
  SPEAKER_01: difficile or VRE in that study.
• 14:38
  SPEAKER_01: So there have not been any recent developments that would move the needle toward getting the CDC or guideline committees to routinely recommend use of UV.
• 14:48
  SPEAKER_01: Nevertheless, a lot of people are using UV.
• 14:51
  SPEAKER_01: And for facilities that do use UV or are planning to use UV, there are some notable developments.
• 14:57
  SPEAKER_01: First, the FDA does not regulate UV room decontamination devices.
• 15:02
  SPEAKER_01: And there are no standard test protocols to assess how effective these devices are.
• 15:06
  SPEAKER_01: So this is an important issue because we found that these devices can vary significantly in effectiveness.
• 15:12
  SPEAKER_01: One development, there are now commercial colorometric indicators that can be used to assess UV delivery to different areas and to make sure your device is working appropriately.
• 15:21
  SPEAKER_01: You can use these in different sites and patient rooms.
• 15:23
  SPEAKER_01: There's also a lot of momentum toward development of standard test protocols for UV devices.
• 15:28
  SPEAKER_01: So I would stay tuned.
• 15:29
  SPEAKER_01: Coming up potentially later this year will be some published recommendations for what we might use as a standard test protocol.
• 15:36
  SPEAKER_01: Second, there's a move to make UV a little bit easier.
• 15:38
  SPEAKER_01: So UV devices that are mounted on the wall are now commercially available.
• 15:42
  SPEAKER_01: If you're using UV in a site like an operating room or a procedure room, you can imagine that it might be much easier than wheeling a device in and out of the room to simply be able to push a button, activate the UV, and run a cycle after each patient, for example.
• 15:57
  SPEAKER_01: And then finally, a major limitation of UV is you can't use these UV technologies while people are present.
• 16:04
  SPEAKER_01: There is a move toward using, proposing at least, use of technologies like FARUV or low-intensity UV below the exposure limit that you could use while people are present to reduce both air and surface contamination.
• 16:18
  SPEAKER_01: So I think more data is needed on how safe and effective those technologies are, but they do look promising.
• 16:24
  SPEAKER_01: And then the final comment about monitoring.
• 16:26
  SPEAKER_01: Anybody who's using UV devices should monitor them to make sure they're not sitting in the closet somewhere and they're actually being used.
• 16:32
  SPEAKER_01: Gonzalo Beerman's group did a nice study where they looked at use of UV with a cloud-based approach and showed that initially the devices were there but were very infrequently being used.
• 16:42
  SPEAKER_01: And they provided monitoring and feedback to their environmental services team to make sure that expensive devices that we're purchasing are actually being used.
• 16:50
  SPEAKER_00: Thank you.
• 16:51
  SPEAKER_00: Dr.
• 16:51
  SPEAKER_00: Rotella, I was wondering if you can teach us what continuous room decontamination is and what is your argument for why we should need it.
• 16:59
  SPEAKER_02: Yes, uh let me first mention, as Dr.
• 17:02
  SPEAKER_02: Donsky did, the limitation of the no-touch room decontamination technologies is they can only be used for terminal room disinfection because they require removal of all persons from the room.
• 17:14
  SPEAKER_02: That's the difference between the no-touch room decontamination technology and continuous room decontamination technology, which I'll discuss briefly.
• 17:24
  SPEAKER_02: The continuous room decontamination technologies, all of these technologies could theoretically be used 24-7-365.
• 17:32
  SPEAKER_02: Persons can be in the room, whether it's of course a patient, the staff, or visitors.
• 17:38
  SPEAKER_02: But why do we need it?
• 17:39
  SPEAKER_02: Well, I think there's two reasons that we need that.
• 17:42
  SPEAKER_02: One reason is the issue of recontamination.
• 17:46
  SPEAKER_02: Micro contamination of environmental services and non-critical patient care items occurs continuously via patients, visitors, and staff.
• 17:56
  SPEAKER_02: So even after disinfection, surfaces can rapidly become recontaminated.
• 18:11
  SPEAKER_02: The first time to recontamination with this multiply drug resistant acid databacter was two to three hours.
• 18:18
  SPEAKER_02: So chairs and overbed tables and IV pumps and stop cabinets were recontaminated within two to three hours.
• 18:25
  SPEAKER_02: So that's the first reason.
• 18:27
  SPEAKER_02: The second reason is the issue of suboptimal disinfection.
• 18:33
  SPEAKER_02: Since routine disinfection of room services is frequently inadequate, continuous room decontamination methods are being evaluated.
• 18:44
  SPEAKER_02: And there are several of these continuous room decontamination methods.
• 18:48
  SPEAKER_02: The continuous room decontamination methods, the intent of these methods is to, of course, make surfaces hygienically clean, not sterile.
• 18:59
  SPEAKER_02: That is, they should be free of pathogens in sufficient numbers to prevent human disease.
• 19:06
  SPEAKER_02: So if the microbial load on surfaces is pathogen-free, or pathogens are substantially reduced, the treated surface will not act as a reservoir for pathogens and be linked to disease transmission.
• 19:20
  SPEAKER_02: Now, as mentioned, there's several of these continuous room decontamination technologies.
• 19:26
  SPEAKER_02: They include things like continuously active disinfectants, visible light disinfection, dry or dilute hydrogen peroxide, bipolar ionization.
• 19:38
  SPEAKER_02: There's a technology that's a multi-jet cold air plasma.
• 19:43
  SPEAKER_02: There is a far UVC that Dr.
• 19:45
  SPEAKER_02: Donsky mentioned at a 222-nanometer wavelength.
• 19:50
  SPEAKER_02: And then, of course, there are self-disinfecting surfaces.
• 19:54
  SPEAKER_02: I'm just going to say a couple words about a couple of these so it's better understood how they may work.
• 20:00
  SPEAKER_02: I'm going to say first a few words about a continuously active disinfectant.
• 20:06
  SPEAKER_02: As you know, disinfectants work at time zero, but they don't have a sustained or persistent antimicrobial activity.
• 20:14
  SPEAKER_02: There are some new products out there that essentially have a polymer that retains the antimicrobial, such as a quaternary ammonium compound, to the surface, and they have been registered with the Environmental Protection Agency to have a sustained antimicrobial activity, for example, to 24 hours.
• 20:36
  SPEAKER_02: Dr.
• 20:37
  SPEAKER_02: Donsky's laboratory and our laboratory at UNC evaluated some of these continuously active disinfectants and have found with these continuously active disinfectants that they kill microbes for minimally up to 24 hours and maybe longer.
• 20:54
  SPEAKER_02: There is, for example, a four to five log reduction after 24 hours using a standardized EPA method in five minutes for several healthcare associated pathogens, such as MRSA, CRE Enerobacter, VRE, Canada Ris, and SARS-CoV-2.
• 21:15
  SPEAKER_02: And Dr.
• 21:15
  SPEAKER_02: Donsky's laboratory has done a comparison of, for example, Staph Areas and Enercocci recovered from portable medical equipment at baseline one day, four days, and seven days.
• 21:28
  SPEAKER_02: And he's found that the percentage of positive sites when looking for staph aureus and intercoccus was significantly reduced on days one through seven in a continuously active group, only 3% positive, compared to 21% for the no treatment group and 11% for the quad group.
• 21:47
  SPEAKER_02: So again, these are continuously active disinfectants.
• 21:51
  SPEAKER_02: They are supposed to kill microbes when a surface is recontaminated.
• 21:56
  SPEAKER_02: And of course, they're supposed to minimize a problem.
• 22:00
  SPEAKER_02: Of suboptimal disinfection.
• 22:02
  SPEAKER_02: Now there are other technologies by visible light disinfection.
• 22:06
  SPEAKER_02: That is essentially a light in the wavelength of 400 to 450 nanometers.
• 22:14
  SPEAKER_02: It initiates a photoreaction with endogenous porphyrins that are found in microorganisms, which yield the production of reactive oxygen species inside microbes, leading to microbial death.
• 22:27
  SPEAKER_02: Now, the problem with nearly all of this technology is that we have some data for this technology, but we don't have all the data that we need to implement this technology.
• 22:37
  SPEAKER_02: We might have some microbial reduction data.
• 22:40
  SPEAKER_02: We may know that it's safe, but we don't know for many of these technologies whether they'll reduce health care associated infections and when implemented, of course, be cost effective.
• 22:51
  SPEAKER_02: Those are the additional things we have to do.
• 22:54
  SPEAKER_00: Thank you for that.
• 22:55
  SPEAKER_00: And on that note, I do want to say that you and your teams have done an incredible amount of work in this area and you've greatly contributed to pushing this area forward.
• 23:03
  SPEAKER_00: And as you reflect not only on your work, but of course on the work that remains, I'd like you to think about and tell us what you see as the most critical research gaps that require further investigation in this field.
• 23:14
  SPEAKER_00: Dr.
• 23:14
  SPEAKER_00: Donsky, we'll let you go first.
• 23:16
  SPEAKER_01: So I'll just mention one area that I'm particularly interested in.
• 23:20
  SPEAKER_01: And that is, you know, are there some practical modifications in design or in practices that we can use to reduce the risk of environmental transmission?
• 23:28
  SPEAKER_01: One example of this is sinks.
• 23:30
  SPEAKER_01: Every sink that you see is colonized with gram-negative bacteria.
• 23:35
  SPEAKER_01: There's typically Pseudomonas or Pseudomonas-like organisms in there.
• 23:38
  SPEAKER_01: There is evidence that organisms in the drain can disperse when you run water and they can contaminate surfaces or it can splutter onto the people who are washing their hands.
• 23:47
  SPEAKER_01: It does not seem like a good idea to address this problem by repeatedly pouring liquid or foam disinfectants down the drain to try to suppress colonization.
• 23:57
  SPEAKER_01: Ultimately, we need to change the design of sinks.
• 24:00
  SPEAKER_01: And it's quite feasible to do that to limit the potential for disposal, dispersal of organisms.
• 24:06
  SPEAKER_01: And there are other potential simple modifications.
• 24:08
  SPEAKER_01: In one study, found that drain used for waste disposal in an ICU was splattering organisms everywhere.
• 24:15
  SPEAKER_01: They place a cover over that drain and significantly reduce dispersal.
• 24:20
  SPEAKER_01: There are simple drain covers for sinks that can also be used.
• 24:23
  SPEAKER_01: The other example that I will use as one of my favorite topics is floors.
• 24:28
  SPEAKER_01: So floors like sinks are always heavily contaminated.
• 24:33
  SPEAKER_01: We're essentially making our patients walk with socks on through a lawn of C.
• 24:36
  SPEAKER_01: diff spores and MRSA and VRE.
• 24:39
  SPEAKER_01: And there's pretty compelling evidence that these organisms end up in the bedding and on surfaces in the room.
• 24:45
  SPEAKER_01: However, no one really wants to do anything about this because it's simply futile.
• 24:51
  SPEAKER_01: I mean, it is not feasible to disinfect all the floors in hospitals and nursing homes repeatedly.
• 24:56
  SPEAKER_01: One question is you know, can we develop some practical approaches to address this?
• 25:01
  SPEAKER_01: So we recently published a randomized trial where we placed a benign virus on the floor in patient rooms.
• 25:08
  SPEAKER_01: And we demonstrated that having patients wear slippers anytime they got out of bed significantly reduced transfer of that virus from the floor to the bedding and to surfaces in rooms.
• 25:20
  SPEAKER_01: This is, I think, a question for a lot of areas in infection prevention is can we develop these types of kind of practical approaches to address contamination of the environment?
• 25:31
  SPEAKER_02: Dr.
• 25:31
  SPEAKER_02: Rutella?
• 25:32
  SPEAKER_02: Yes, certainly I agree with Dr.
• 25:34
  SPEAKER_02: Donsky regarding those two issues, but I'm going to continue with the thought of continuous room decontamination.
• 25:41
  SPEAKER_02: And the reason I would like to pursue that, certainly with Dr.
• 25:45
  SPEAKER_02: Donsky, is for the reasons I've already mentioned.
• 25:48
  SPEAKER_02: And they are two, a constant problem of recontamination of non-critical environmental surfaces and non-critical medical devices.
• 25:57
  SPEAKER_02: And of course, the constant issue of subaltimal disinfection.
• 26:01
  SPEAKER_02: Even at discharge cleaning, we may clean less than 50% of the surfaces in a patient room, leaving those microbes for the next patient, which will increase their risk of a healthcare asota infection, which has been shown certainly for C.
• 26:19
  SPEAKER_02: depacyl and other pathogens.
• 26:21
  SPEAKER_02: So I would certainly like to continue efforts with continuous room decontamination technologies.
• 26:27
  SPEAKER_02: I think there's some promising technologies that are currently being investigated and need to be investigated thoroughly.
• 26:33
  SPEAKER_02: And I think there's four things that we have to do.
• 26:36
  SPEAKER_02: Certainly, when we evaluate new technology, we want it to be safe.
• 26:41
  SPEAKER_02: We want it to reduce microbial contamination.
• 26:44
  SPEAKER_02: And by reducing microbial contamination, if it's important from an infection prevention standpoint, it should reduce health care associated infections.
• 26:52
  SPEAKER_02: And if it reduces health care associated infections, it should be cost effective.
• 26:57
  SPEAKER_02: So I'd like to review and continue the evaluation of these continuous room decontamination technologies to see not only if they're safe and reduce microbial contamination, but importantly reduce healthcare associated infections, which would make them likely cost effective.
• 27:14
  SPEAKER_02: I think some of these technologies are promising to include continuously active disinfectants and possibly things like dry or diluted hydrogen peroxide, which, if they worked, could be relatively easily integrated into our healthcare practices so that they wouldn't involve a lot of continuous maintenance on the part of the healthcare workers.
• 27:36
  SPEAKER_02: Essentially, they would be invisible to most of us, but they would have the benefit of continuously reducing microbial contamination on non-critical environmental surfaces and non-critical medical devices, which, if present, could facilitate transmission of pathogens from those surfaces to patients if there was poor hand hygiene or inappropriate glove use.
• 28:29
  SPEAKER_01: There's evidence for both sides, once again, there was a recent cluster randomized trial where they compared ATP and fluorescent markers and found that the ATP method was more effective and was associated with a reduction in MDRO and multidrug-resistant gram-negative infection and colonization in comparison to fluorescent marker monitoring.
• 28:50
  SPEAKER_01: However, as I also mentioned previously, there recently has been a nice study from Phil Carling's group suggesting that fluorescent marker monitoring in combination with routine use of a sporosidal product can reduce C.
• 29:02
  SPEAKER_01: diff infection.
• 29:03
  SPEAKER_01: So there's some evidence for both of these technologies.
• 29:06
  SPEAKER_01: And I think there's still room for more work in sorting out what is the best way for us to monitor cleaning and make sure it's being done appropriately.
• 29:13
  SPEAKER_00: I think the takeaway with this and every other podcast that we've had is that there's still a whole lot of work to do.
• 29:19
  SPEAKER_00: But I want to thank you both, Dr.
• 29:20
  SPEAKER_00: Donsky and Dr.
• 29:21
  SPEAKER_00: Rutala, for such a fascinating conversation on such a really, really broad topic.
• 29:25
  SPEAKER_00: I'm sure we could talk for many, many months about all the different things that are on the horizon and uh what we know, what we don't know, and what we have yet to learn.
• 29:34
  SPEAKER_00: I really appreciate you joining us today.
• 29:37
  SPEAKER_02: Thank you very much for the opportunity.
• 29:38
  SPEAKER_01: Yes, thank you very much for having us.
• 29:40
  SPEAKER_01: We're happy to take questions from people who listen to the podcast.
• 29:43
  SPEAKER_00: And on that note, if we do have any questions that come in, we'll be happy to pass them on.
• 29:47
  SPEAKER_00: You can find more educational content like this podcast in Shay's online education center, Learning CE, at www.learningce.shay online.org.
• 29:59
  SPEAKER_00: This concludes today's episode of the Digital and Electronic Innovations and Hospital Epi and Antimicrobial Stewardship Series.
• 30:05
  SPEAKER_00: Thank you for tuning in.