The Best Defense Against Hospital-Acquired Infections

Michelle Doll, MD, MPH,Virginia Commonwealth University Health Infection Prevention Program

Michelle Doll, MD, MPH

A narrative review of literature by Michelle Doll, MD, MPH, along with colleagues from the Virginia Commonwealth University's Health Infection Prevention Program, in Richmond, VA, has determined that when preventing hospital-acquired infections (HAIs) such as Clostridium difficile infection (CDI), manual cleaning supplemented with continuous assessment and feedback provides the most practical approach to environmental cleaning for healthcare facilities, particularly those with limited resources.

In a survey of published research articles concentrating on environmental cleaning options and processes to curb HAIs, the study determined that "human factors" are the best defense against HAIs.

Doll and colleagues write that "the extent to which the hospital environment contributes to hospital-acquired infections (HAIs) continues to be controversial," because "the extent to which environmental contamination contributes to healthcare-associated infections in unclear." Most of the research on environmental cleaning to avoid infection in healthcare settings, Doll and colleagues report, has focused on countries and healthcare systems with abundant resources to deal with environmental cleaning. This, Doll reports, ignores the challenges that resource-limited healthcare settings may face when it comes to environmental health.

The good news, is that according to data gleaned from the literature review, manual cleaning of "frequently touched hospital services," careful maintenance and cleaning of water sources (sinks, ice machines and bath areas), proper hand hygiene and meaningful monitoring/assessment of cleaning performance, seem to provide the most practical defense against HAIs and carry a relatively low cost in comparison to other environmental cleaning processes.

According to their review of qualitative and quantitative collected from more than 7,000 articles, Doll and colleagues have determined the human factor associated with manual cleaning that utilizes dedicated, trained and monitored cleaning teams for high-risk areas, such as patient rooms of CDI-positive patients, allows for a more targeted enhanced cleaning through the use of methods specific to those organisms and problem areas.

Costs for manual cleaning and training in specialized "enhanced cleaning" for high-risk areas are relatively low, considering the time-consuming nature of monitoring cleaning and the possible need for additional staff, according to Doll.

The study also compares the efficacy of manual cleaning to other interventions to improve manual cleaning like the use of antimicrobial surfaces (such as copper-containing surfaces), "touchless" technologies (UV-light emitting robots and hydrogen peroxide aerosols), and finds that although current studies have revealed the moderate effectiveness of these systems, the results of those studies have not shown significant impact on specific acquisition rates for MRSA and CDI among patients.

In addition to having concerns about effectiveness of alternative or adjunct cleaning interventions, Doll and colleagues state there are additional downsides to focusing on these environmental cleaning devices as opposed to manual cleaning in terms of cost of equipment, cost of training and time spent in disinfection process which can "require anywhere from 15 minutes to a few hours in an empty patient room."

Doll states that although "current cleaning methods are only partially successful in mediating [infection] risk" and there has been "substantial interest in improving the cleaning process" resulting in a range of proposed strategies from researchers, manual cleaning efforts, if properly monitored, and tailored to the needs of specific healthcare facilities, remains the most effective and cost-efficient means of deterring HAIs.

Doll concludes that human factors will ultimately determine the quality of environmental cleaning and remain the best defense against invisible threats in a hospital environment.

"Environmental cleaning and disinfection of patient areas" appears in the February 2018 issue of the International Journal of Infectious Diseases.