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To describe the use of wall painting as part of an intervention to control an outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB).An interrupted time-series analysis was performed analyzing an intervention in a neurosurgical intensive care unit (NSICU) and an inpatient hematology department in a tertiary level medical center in Israel. The intervention involved wall painting using a water based acrylic paint following patient discharge and terminal cleaning with sodium troclosene as part of an infection control bundle for an outbreak of CRAB in a NSICU and concurrent outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) colonization/infection in the same NSICU and the hematology department.Between January 2013 and December 2018, 122 patients hospitalized in the NSICU were identified with new CRAB colonization/infection. The median incidence in the periods prior to/post intervention were 2.24/1000 HD (interquartile range [IQR] 0.84-2.90/1000) vs. 0/1000 HD (IQR 0-0.49/1000), respectively. Poisson regression indicated a decrease of 92% in the CRAB incidence following the intervention onset (relative risk [RR] 0.080, 95% confidence interval [CI] 0.037-0.174, p 0.001). Forty-seven patients in the NSICU and 110 in the hematology department were colonized/infected with CRE in the same time period; a significant change was not observed following the start of the intervention in either department (for NSICU RR 1.236, 95% CI 0.370-4.125, p = 0.731; for hematology RR 0.658, 95% CI 0.314-1.378, p = 0.267).A. baumannii is able to survive on environmental surfaces despite decontamination efforts; wall-painting as part of a bundle may be a successful infection control measure.

Background The clinical effectiveness of ultraviolet light (UV) disinfection remains unclear. This study aimed to investigate the effect of adding pulsed xenon UV (PX-UV) disinfection to the terminal cleaning protocol on the rate of methicillin-resistant Staphylococcus aureus (MRSA) acquisition at a Japanese hospital. Methods The use of a PX-UV disinfection device was added to the manual terminal cleaning protocol applied after the discharge or transfer of patients treated in the intensive and high care units. We used a Poisson regression model to examine the incidence of MRSA acquisition, based on the study period, PX-UV intervention status, unit type, and the rate of consumption of alcohol-based hand rub (ABHR). Results Approximately 86% of the rooms in the intervention units were terminally disinfected with the PX-UV device. In the intervention units, the incidence of MRSA acquisition decreased from 3.56 per 1,000 patient-days in the nonintervention period to 2.21 per 1,000 patient-days in the intervention period. Moreover, the use of PX-UV disinfection decreased the risk of MRSA acquisition (incident rate ratio: 0.556; 95% confidence interval, 0.309-0.999; P = .0497). ABHR consumption did not affect the risk of MRSA acquisition. Conclusions Adding PX-UV disinfection to terminal manual cleaning reduced the rate of MRSA acquisition.

Background Contaminated environmental surfaces are important sources of transmission for healthcare-associated pathogens, including Clostridioides (Clostridium) difficile. The effectiveness of manual bleach cleaning and pulsed xenon ultraviolet (PX-UV) disinfection on C. difficile contamination of hospital room high-touch surfaces in Japan was evaluated. Methods The environmental surfaces of 20 C. difficile infection (CDI) isolation rooms were sampled immediately after CDI patients were discharged or transferred. High-touch surfaces were sampled before and after either bleach cleaning or PX-UV disinfection in addition to nonbleach cleaning. Changes in the number of C. difficile-positive samples and bacterial counts for each cleaning method were assessed. Results Overall, 286 samples were collected (bleach cleaning, 144 samples; PX-UV disinfection, 142 samples). Before cleaning, the positive rates of C. difficile were 27.8% and 31.0% in bleach cleaning and PX-UV disinfection, respectively. Both bleach cleaning and PX-UV disinfection significantly reduced overall C. difficile-positive samples (P = .018 and P = .002, respectively) and C. difficile colony-forming unit counts (P = .002 and P = .001, respectively). Conclusions PX-UV disinfection in addition to manual nonbleach cleaning effectively reduces C. difficile contamination from high-touch surfaces. Further studies are warranted to evaluate the effect of PX-UV disinfection on CDI rates in Japanese hospitals.

Introduction-Hospital laundry are potential reservoirs of bacteria in hospitals. Preventing contamination and providing clean linen and laundry should help to prevent hospital acquired infections. Being an important component in the management of patients and the role in causing hospital acquired infections, the study about hospital laundry has been undertaken in our hospital. Methods- Quality control practiced in the Linen and Laundry Service was studied by conducting a prospective study. Samples were taken from the surface of these materials by sweep plate method prior to washing procedure. The second set of samples were collected from the same materials after the washing procedure. The organisms were identified by colony morphology, culture characteristics & biochemical reactions according to standard techniques. Results- Out of the 30 samples studied, 24 (80%) of them were contaminated with bacteria before washing. Organisms yielded were Staphylococcus aureus, coagulase negative Staphylococcus (CONS), Aerobic spore bearing bacilli (ASB), Escherichia coli and Pseudomonas aeruginosa. After washing, 25 (83%) of the clothes were sterile. Conclusion- Though terminal cleaning fails to completely eliminate bacteria from the laundered fabrics, it is effective in considerable reduction in bacterial growth.

Objective:To assess the impact of major interventions targeting infection control and diagnostic stewardship in efforts to decrease Clostridioides difficile hospital onset rates over a 6-year period.Design:Interrupted time series.Setting:The study was conducted in an 865-bed academic medical center.Methods:Monthly hospital-onset C. difficile infection (HO-CDI) rates from January 2013 through January 2019 were analyzed around 5 major interventions: (1) a 2-step cleaning process in which an initial quaternary ammonium product was followed with 10% bleach for daily and terminal cleaning of rooms of patients who have tested positive for C. difficile (February 2014), (2) UV-C device for all terminal cleaning of rooms of C. difficile patients (August 2015), (3) “contact plus” isolation precautions (June 2016), (4) sporicidal peroxyacetic acid and hydrogen peroxide cleaning in all patient areas (June 2017), (5) electronic medical record (EMR) decision support tool to facilitate appropriate C. difficile test ordering (March 2018).Results:Environmental cleaning interventions and enhanced “contact plus” isolation did not impact HO-CDI rates. Diagnostic stewardship via EMR decision support decreased the HO-CDI rate by 6.7 per 10,000 patient days (P = .0079). When adjusting rates for test volume, the EMR decision support significance was reduced to a difference of 5.1 case reductions per 10,000 patient days (P = .0470).Conclusion:Multiple aggressively implemented infection control interventions targeting CDI demonstrated a disappointing impact on endemic CDI rates over 6 years. This study adds to existing data that outside of an outbreak situation, traditional infection control guidance for CDI prevention has little impact on endemic rates.

This non-randomized comparative observational study evaluated the performance of a standard manual-chemical disinfection process with an automated process employing focused multivector ultraviolet (FMUV) light technology during operating room (OR) terminal cleaning.An Association of periOperative Registered Nurses terminal cleaning protocol was modified to incorporate the use of automated FMUV technology that allows workers to occupy the room during operation. This modified protocol was compared with a standard manual-chemical cleaning and disinfection protocol. Equipment surfaces were pre-sampled before and after terminal cleaning. A total of 165 objects were sampled in each process using a 5-point multisided sampling method.The parallel process employing FMUV reduced the active microbial burden by 96.5% from baseline (P.0001), which was over 2.5 times better than the standard process. The standard terminal manual-chemical disinfection process reduced the active microbial burden on sampled objects by 38.4% from baseline (P.0001).The data demonstrates that the performance of standard manual-chemical disinfection alone is variable in a live clinical setting even under the most ideal conditions. By comparison, automated FMUV treatment incorporated in a parallel process consistently produced thorough and significant reductions of microbial contamination levels on all visibly clean patient care equipment.

Background Inadequate hospital cleaning may contribute to cross-transmission of pathogens. It is important to implement effective cleaning for the safe hospital environment. We conducted a three-phase study using human factors engineering (HFE) approach to enhance environmental cleanliness. Methods This study was conducted using a prospective interventional trial, and 28 (33.3%) of 84 wards in a medical center were sampled. The three-phases included pre-intervention analysis (Phase 1), implementing interventions by HFE principles (Phase 2), and programmatic analysis (Phase 3). The evaluations of terminal cleaning and disinfection were performed using the fluorescent marker, the adenosine triphosphate bioluminescence assay, and the aerobic colony count method simultaneously in all phases. Effective terminal cleaning and disinfection was qualified with the aggregate outcome of the same 10 high-touch surfaces per room. A score for each high-touch surface was recorded, with 0 denoting a fail and 10 denoting a pass by the benchmark of the evaluation method, and the total terminal cleaning and disinfection score (TCD score) was a score out of 100. Results In each phase, 840 high-touch surfaces were collected from 84 rooms after terminal cleaning and disinfection. After the interventions, the TCD score by the three evaluation methods all showed significant improved. The carriage incidence of multidrug-resistant organism (MDRO) decreased significantly from 4.1 per 1000 patient-days to 3.6 per 1000 patient-days (P = .03). Conclusion The HFE approach can improve the thoroughness and the effectiveness of terminal cleaning and disinfection, and resulted in a reduction of patient carriage of MDRO at hospitals. Larger studies are necessary to establish whether such efforts of cleanliness can reduce the incidence of healthcare-associated infection.

Background and objective The number of ultraviolet light disinfection robot systems that are needed for a facility’s surgical suite(s) and/or procedure suite(s) depends in part on how many rooms need to be disinfected overnight by each robot and how long this will take. The answer needs to be determined separately for each surgical and procedure suite because those variables vary both among facilities and among operating rooms or procedure rooms within facilities. In this study, we consider statistical designs to assess how many rooms a facility can reliably (≥90% chance) disinfect overnight using an ultraviolet light disinfection robot system. Methods We used 133,927 observed disinfection times from 700 rooms as a population from which repeated samples were drawn with replacement in Monte-Carlo simulations. We used eight-hour and 10-hour shift lengths being multiples of 40 hours for full-time hourly employees. Results One possible strategy that we examined was to estimate total disinfection times by estimating the mean for each room and then summing up the means. However, that did not correctly answer the question of how many rooms can reliably be available for the next day’s first case. Summing up a percentile (e.g., 90%) instead also was inaccurate, because the proper percentile depended on the number of rooms. A suitable strategy is a brief trial (e.g., nine nights or 19 nights) with the endpoint being the daily number of rooms disinfected. Empirically, the smallest count of rooms disinfected among nine nights or the second smallest count among 19 nights are 10th percentiles (i.e., ≈90% probability that at least that number of rooms can be disinfected in the future). The drawback is that while this approach gives the probability of a night with fewer rooms disinfected, it does not give information as to how many fewer rooms may either skip ultraviolet decontamination or start late the next workday because disinfection was not completed. Our simulations showed that there is a substantial probability (≥95%) of at most two rooms fewer or one room greater than the 10th percentile with a nine-night trial and one room fewer or greater with a 19-night trial. Conclusions Because probability distributions of disinfection times are heterogeneous both among rooms and among treatments for the same room, each facility should plan to perform its own trial of nine nights or 19 nights. This will provide results that are within two rooms or one room of the correct answer in the long term. This information can be used when planning purchasing decisions, leasing, and technician staffing decisions.

Background:Clostridioides difficile infection (CDI) accounts for >500,000 community-, nursing-, and hospital-acquired infections (HAIs), as well as 15,000–30,000 deaths, and =$4.8 billion in the United States annually. C. difficile toxin B gene nucleic acid amplification testing (NAAT) cannot distinguish between active CDI and colonization, particularly in the setting of laxative use or enteral feeding. Lack of judicious testing can result in the incorrect diagnosis of CDI, unnecessary CDI treatment, increased costs, and falsely augmented HAI rates. Like many healthcare facilities, the VA San Diego Healthcare System (VASDHS) solely utilizes C. difficile NAAT for CDI diagnosis. The aim of this study was to implement and evaluate a facility-wide initiative at the VASDHS to reduce healthcare onset, healthcare facility associated CDI (HO-HCFA CDI), including the use of a test ordering algorithm. Methods: From fiscal year (FY) 2015–2018, various measures were implemented including a hand hygiene initiative, reduction in fluoroquinolone usage, prompt isolation of patients with CDI, thorough terminal cleaning of rooms, and, lastly, a test-ordering algorithm starting FY2018. A retrospective study was performed to assess VASDHS HO-HCFA CDI case incidence, risk factors for infection, laxative or enteral feeding use at the time of testing, and CDI treatment. Results: Patient demographic data, medical history, CDI history, laxative use, treatment, and cost of CDI treatment were reviewed. From 2015 to 2018, 127 cases of HO-HCFA CDI were identified. The total number of HO-HCFA CDI cases and medication cost for CDI treatment were dramatically reduced from 2017 to 2018 following implementation of the test-ordering algorithm (Table 1, Fig. 1). This trend corresponded to a significant reduction in median HO-HCFA CDI cases per month (P = .02), medication cost of CDI treatment (P = .02), and proton pump inhibitor (PPI) use at the time of testing (P = .01). The number of positive HO-HCFA CDI cases associated with laxative use or escalation at the time of CDI testing (accounting for those on chronic laxatives) also decreased across the study period—most dramatically from 2015 vs 2016 (20 vs 14) and 2017 vs 2018 (11 vs 4) (Table 1). Conclusions: At the VASDHS, diagnostic stewardship of C. difficile NAAT with the use of a test-ordering algorithm significantly reduced HO-HCFA CDI incidence and treatment cost. This trend also corresponded with significantly less PPI use at the time of testing and reduced detection of colonization among patients with laxative-induced diarrhea. Diagnostic stewardship may serve as an effective tool to correctly diagnose and treat HO-HCFA CDI, while significantly reducing treatment costs.Funding: NoneDisclosures: None

Perioperative nurses use aseptic and sterile technique along with standard cleaning and disinfection practices to prevent surgical site infections. At our hospital, OR team members identified a clinical problem: the lack of a systematic approach to determine the type of postprocedure cleaning required between procedures involving patients with multi-drug resistant organisms or Clostridium difficile. Facility leaders developed a project to design and implement an evidence-based decision-making algorithm to help perioperative nurses rapidly identify the appropriate environmental cleaning procedures for these ORs. After the perioperative nurses were taught how to use the algorithm, it was put into use. Nineteen months later, the nurses completed a postimplementation survey. The results of the survey were generally positive, and the cleaning process was more standardized. We found that a decision-making algorithm was an effective tool to determine the proper postprocedure environmental cleaning between surgical procedures for patients with multi-drug resistant organisms or C difficile.

Background In 2017, our hospital was identified as a high outlier for postoperative Clostridium difficile infections (CDIs) in the American College of Surgeons NSQIP semi-annual report. The Department of Surgery initiated a CDI task force with representation from Surgery, Infectious Disease, Pharmacy, and Performance Services to analyze available data, identify opportunities for improvement, and implement strategies to reduce CDIs. Study Design Strategies to reduce CDIs were reviewed from the literature and the following multidisciplinary strategies were initiated: antimicrobial stewardship optimization of perioperative order sets to avoid cefoxitin and fluoroquinolone use was completed; penicillin allergy assessment and skin testing were implemented concomitantly; increased use of ultraviolet disinfectant strategies for terminal cleaning of CDI patient rooms; increased hand hygiene and personal protection equipment signage, as well as monitoring in high-risk CDI areas; improved diagnostic stewardship by an electronic best practice advisory to reduce inappropriate CDI testing; education through surgical grand rounds; and routine data feedback via NSQIP and National Healthcare Safety Network CDI reports. Results The observed rate of CDIs decreased from 1.27% in 2016 to 0.91% in 2017. Cefoxitin and fluoroquinolone use decreased. Clostridium difficile infection testing for patients on laxatives decreased. Terminal cleaning with ultraviolet light increased. Handwashing compliance increased. Data feedback to stakeholders was established. Conclusions Our multidisciplinary CDI reduction program has demonstrated significant reductions in CDIs. It is effective, straightforward to implement and monitor, and can be generalized to high-outlier institutions.

Objective: The detailed epidemiological and molecular characterization of an outbreak of Burkholderia cepacia at a neurotrauma intensive care unit of a level 1 trauma centre is described. The stringent infection control interventions taken to successfully curb this outbreak are emphasized. Methods: The clinical and microbiological data for those patients who had more than one blood culture that grew B. cepacia were reviewed. Bacterial identification and antimicrobial susceptibility testing was done using automated Vitek 2 systems. Prospective surveillance, environmental sampling, and multilocus sequence typing (MLST) were performed for extensive source tracking. Intensive infection control measures were taken to further control the hospital spread. Results: Out of a total 48 patients with B. cepacia bacteraemia, 15 (31%) had central line-associated blood stream infections. Two hundred and thirty-one environmental samples were collected and screened, and only two water samples grew B. cepacia with similar phenotypic characteristics. The clinical strains characterized by MLST typing were clonal. However, isolates from the water represented a novel strain type (ST-1289). Intensive terminal cleaning, disinfection of the water supply, and the augmentation of infection control activities were done to curb the outbreak. A subsequent reduction in bacteraemia cases was observed. Conclusion: Early diagnosis and appropriate therapy, along with the rigorous implementation of essential hospital infection control practices is required for successful containment of this pathogen and to curb such an outbreak. Keywords: Burkholderia cepacia, Outbreak, Neurotrauma unit, MLST typing, Novel ST type

Introduction Recently, a worldwide outbreak of vancomycin-resistant Enterococci (VRE) was reported. However, due to the low incidence of VRE infection and colonization, VRE contamination of hospital environments has not been fully investigated in Japan. Methods Surfaces were swabbed, before and after manual cleaning and after pulsed xenon ultraviolet (PX-UV) disinfection, in five patient rooms that had been occupied by patients colonized with VRE. Difference in the number of VRE-positive samples and VRE colony forming units (CFUs), before and after disinfection, for each cleaning method was estimated. Results We detected VRE contamination in 22/60 (37%) and 14/60 (23%) samples collected before and after manual cleaning, respectively. In contrast, VRE contamination was not detected in the samples collected after PX-UV disinfection. In addition, 3/5 (60%) spray nozzles of electric warm-water bidet toilet seats were found to be contaminated with VRE before terminal cleaning. Manual cleaning caused a significant decrease in the number of VRE CFUs compared with that before cleaning (P = 0.031). PX-UV disinfection also caused a significant decrease in the number of VRE CFUs compared to that of manual cleaning (P Conclusion We identified hot spots of severe contamination, such as private bathrooms in patient rooms and areas around the bed of patients using diapers and required assistance. VRE contamination persisted even after terminal disinfection; PX-UV disinfection in addition to terminal disinfection was effective at eliminating VRE contamination. These results can be useful in controlling the spread of VRE infections in Japanese hospitals.

BACKGROUND Environmental cleaning is an effective measure to prevent infections. However, performance observation has been rarely delineated. This study aimed to compare correlations among visual inspection, performance observation, and effectiveness by using adenosine triphosphate bioluminescence (ATP bioluminescence) as a comparator to find out which method is better to assess hospital cleanliness. METHODS This prospective study was conducted at a medical center from April 2019 to October 2020. Seven high-touch surfaces were evaluated during and after terminal cleaning by performance observation, visual inspection, and ATP bioluminescence. RESULTS The scores by performance observation, visual inspection, and ATP were 55.4%, 87.5%, and 26.6% after cleaning. The correlations between performance observation and visual inspection and between performance observation and ATP interpretation were weak positive (φ = 0.300, 0.324, P < .001). No correlation was between the visual inspection and ATP interpretation (φ=0.137). The median of ATP readings was lower in "compliant" group by performance observation and "clean" group by visual inspection than "not compliant" group and "not clean" group (P < .001). CONCLUSIONS Performance observation combined with ATP would be preferred to include to audit cleanliness on high-risk surfaces. Visual inspection would be a rapid and time-saving assessment tool on low-risk surfaces.

BackgroundCleanliness of hospital surfaces helps prevent healthcare-associated infections, but larger evaluations of the effectiveness of various cleaning strategies during SARS-CoV-2 surges and worker shortages are scarce.MethodsIn an acute care hospital (ACH) and a long-term care facility (LTCF), 417 surfaces were tested for SARS-CoV-2 and adenosine triphosphate before and after various cleaning strategies, including ultraviolet light (UV-C), electrostatic spraying, and room fogging.ResultsACH surface contamination differed among outbreak and non-outbreak wards (p = 0.001). RNA was detected on 66% of surfaces before cleaning and on 23% of those surfaces immediately after terminal cleaning, for a 65% post-cleaning reduction (p = 0.001). UV-C resulted in an 87% reduction (p = 0.023), while spraying with electrostatic bleach resulted in a 47% reduction (p = 0.010). LTCF contamination rates differed between the dementia, rehabilitation, and the residential units (p = 0.005). 67% of surfaces had RNA after room fogging without terminal-style wiping. Fogging with wiping led to an 11% reduction in the proportion of positive surfaces.DiscussionBaseline contamination varied by type of unit and outbreak conditions, but not facility type. Removal of viral RNA varied according to strategy. Unlike previous reports, time spent cleaning was associated with cleaning thoroughness.

Background In intensive care units (ICUs) treating patients with Coronavirus disease 2019 (COVID-19) invasive ventilation poses a high risk for aerosol and droplet formation. Surface contamination of severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) or bacteria can result in nosocomial transmission. Methods Two tertiary care COVID-19 intensive care units treating 53 patients for 870 patient days were sampled after terminal cleaning and preparation for regular use to treat non-COVID-19 patients. Results A total of 176 swabs were sampled of defined locations covering both ICUs. No SARS-CoV-2 ribonucleic acid (RNA) was detected. Gram-negative bacterial contamination was mainly linked to sinks and siphons. Skin flora was isolated from most swabbed areas and Enterococcus faecium was detected on two keyboards. Conclusions After basic cleaning with standard disinfection measures no remaining SARS-CoV-2 RNA was detected. Bacterial contamination was low and mainly localised in sinks and siphons.

Summary We describe an outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) in a COVID-19 dedicated hospital. The suspected mechanism of transfer was an environmental source that persisted despite evacuation and terminal cleaning of the entire hospital, and transmitted through healthcare workers' hands or equipment. This outbreak demonstrates that practices to prevent the spread of multidrug-resistant organisms must not be neglected during the COVID-19 pandemic.

Background Environmental contamination is an important source of hospital multidrug-resistant organism (MDRO) transmission. Factors such as patient MDRO contact precautions (CP) status, patient proximity to surfaces, and unit type likely influence MDRO contamination and bacterial bioburden levels on patient room surfaces. Identifying factors associated with environmental contamination in patient rooms and on shared unit surfaces could help identify important environmental MDRO transmission routes. Methods Surfaces were sampled from MDRO CP and non-CP rooms, nursing stations, and mobile equipment in acute care, intensive care, and transplant units within 6 acute care hospitals using a convenience sampling approach blinded to cleaning events. Precaution rooms had patients with clinical or surveillance tests positive for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, carbapenem-resistant Enterobacteriaceae or Acinetobacter within the previous 6 months, or Clostridioides difficile toxin within the past 30 days. Rooms not meeting this definition were considered non-CP rooms. Samples were cultured for the above MDROs and total bioburden. Results Overall, an estimated 13% of rooms were contaminated with at least 1 MDRO. MDROs were detected more frequently in CP rooms (32% of 209 room-sample events) than non-CP rooms (12% of 234 room-sample events). Surface bioburden did not differ significantly between CP and non-CP rooms or MDRO-positive and MDRO-negative rooms. Conclusions CP room surfaces are contaminated more frequently than non-CP room surfaces; however, contamination of non-CP room surfaces is not uncommon and may be an important reservoir for ongoing MDRO transmission. MDRO contamination of non-CP rooms may indicate asymptomatic patient MDRO carriage, inadequate terminal cleaning, or cross-contamination of room surfaces via healthcare personnel hands.

Ultraviolet light (UVL) room disinfection has emerged as an adjunct to manual cleaning of patient rooms. Two different no-touch UVL devices were implemented in 3 health system hospitals to reduce Clostridioides difficile infections (CDI). CDI rates at all 3 facilities remained unchanged following implementation of UVL disinfection. Preintervention CDI rates were generally low, and data from one hospital showed high compliance with manual cleaning, which may have limited the impact of UVL disinfection.

The persistence of microorganisms as biofilms on dry surfaces resistant to the usual terminal cleaning methods may pose an additional risk of transmission of infections. In this study, the Centre for Disease Control (CDC) dry biofilm model (DBM) was adapted into a microtiter plate format (Model 1) and replicated to create a novel in vitro model that replicates conditions commonly encountered in the healthcare environment (Model 2). Biofilms of Staphylococcus aureus grown in the two models were comparable to the biofilms of the CDC DBM in terms of recovered log10 CFU well−1. Assessment of the antimicrobial tolerance of biofilms grown in the two models showed Model 2 a better model for biofilm formation. Confirmation of the biofilms’ phenotype with an extracellular matrix deficient S. aureus suggested stress tolerance through a non-matrix defined mechanism in microorganisms. This study highlights the importance of conditions maintained in bacterial growth as they affect biofilm phenotype and behaviour.

We describe an evidence-based approach for optimization of infection control and operating room management during the coronavirus disease 2019 (COVID-19) pandemic. Confirmed modes of viral transmission are primarily, but not exclusively, contact with contaminated environmental surfaces and aerosolization. Evidence-based improvement strategies for attenuation of residual environmental contamination involve a combination of deep cleaning with surface disinfectants and ultraviolet light (UV-C). (1) Place alcohol-based hand rubs on the intravenous (IV) pole to the left of the provider. Double glove during induction. (2) Place a wire basket lined with a zip closure plastic bag on the IV pole to the right of the provider. Place all contaminated instruments in the bag (eg, laryngoscope blades and handles) and close. Designate and maintain clean and dirty areas. After induction of anesthesia, wipe down all equipment and surfaces with disinfection wipes that contain a quaternary ammonium compound and alcohol. Use a top-down cleaning sequence adequate to reduce bioburden. Treat operating rooms using UV-C. (3) Decolonize patients using preprocedural chlorhexidine wipes, 2 doses of nasal povidone-iodine within 1 hour of incision, and chlorhexidine mouth rinse. (4) Create a closed lumen IV system and use hub disinfection. (5) Provide data feedback by surveillance of Enterococcus, Staphylococcus aureus, Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter spp. (ESKAPE) transmission. (6) To reduce the use of surgical masks and to reduce potential COVID-19 exposure, use relatively long (eg, 12 hours) staff shifts. If there are 8 essential cases to be done (each lasting 1-2 hours), the ideal solution is to have 2 teams complete the 8 cases, not 8 first case starts. (7) Do 1 case in each operating room daily, with terminal cleaning after each case including UV-C or equivalent. (8) Do not have patients go into a large, pooled phase I postanesthesia care unit because of the risk of contaminating facility at large along with many staff. Instead, have most patients recover in the room where they had surgery as is done routinely in Japan. These 8 programmatic recommendations stand on a substantial body of empirical evidence characterizing the epidemiology of perioperative transmission and infection development made possible by support from the Anesthesia Patient Safety Foundation (APSF).

ObjectiveThis article describes a CDI outbreak in a long-term care (LTC) facility that used molecular typing techniques and whole-genome sequencing to identify widespread dissemination of the clonal strain in the environment which was successfully removed after terminal cleaning.SettingThis study was conducted in a long-term care facility in Texas.MethodsA recently hospitalized LTC patient was diagnosed with CDI followed shortly thereafter by 7 subsequent CDI cases. A stool specimen was obtained from each patient for culturing and typing. An environmental point-prevalence study of the facility was conducted before and after terminal cleaning of the facility to assess environmental contamination. Cultured isolates were typed using ribotyping, multilocus variant analysis, and whole-genome sequencing.ResultsStool samples were available for 5 of 8 patients; of these specimens, 4 grew toxigenic C. difficile ribotype 027. Of 50 environmental swab samples collected throughout the facility prior to the facility-wide terminal cleaning, 19 (38%) grew toxigenic C. difficile (most commonly ribotype 027, 79%). The terminal cleaning was effective at reducing C. difficile spores in the environment and at eradicating the ribotype 027 strain (PConclusionUsing molecular typing techniques, we demonstrated reduced environmental contamination with toxigenic C. difficile and the eradication of a ribotype 027 clone. These techniques may help direct infection control efforts and decrease the burden of CDI in the healthcare system.

Background Manual cleaning and disinfection of the operating room (OR) environment may be inadequate due to human error. No-touch technologies, such as pulsed-xenon ultraviolet light (PX-UV), can be used as an adjunct to manual cleaning processes to reduce surface contamination in the OR. This article reports the cumulative results from 23 hospitals across the United States that performed microbiologic validation of PX-UV disinfection after manual cleaning. Methods We obtained samples from 732 high-touch surfaces in 136 ORs at 23 hospitals, after manual terminal cleaning, and again after PX-UV disinfection (n = 1464 surface samples). Samples were enumerated after incubation, and the results are reported as total colony-forming units (CFU). Results The average CFU after manual cleaning ranged from 5.8 to 34.37, and after PX-UV, from 0.69 to 6.43. With manual cleaning alone, 67% of surfaces were still positive for CFUs; after PX-UV disinfection, that number decreased to 38% of all sampled surfaces—a 44% reduction. When comparing manual cleaning to PX-UV, the reduction in CFU count was statistically significant. Conclusion When used after the manual cleaning process, the PX-UV device significantly reduced contamination on high-touch surfaces in the OR.

Candida auris is an emerging pathogen characterized for its difficult identification, rapid nosocomial spread, and limited treatment options. Data is currently limited; however, this will change as the pathogen’s prevalence increases. The goal of this review is to provide a concise summary of the available data to manage a possible C. auris infection. Candida auris has been rapidly spreading globally and has been evading popular identification methods with MALDI-TOF being the only successful modality as long as the “research use only” database is used. Echinocandins are the treatment of choice; however, all isolates should have susceptibilities performed as there have been reports of resistance to all antifungal classes. Several hospital outbreaks have occurred; thus, all patients should be isolated with appropriate terminal cleaning. Atypical or suspicious Candida isolates should be identified by MALDI-TOF. Most Candida auris strains are resistant to azoles; therefore, the suggested empirical treatment is an echinocandin. Echinocandin-resistant strains have been reported, and in those cases, a polyene is preferred. Strict contact precautions are recommended while in the hospital due to high levels of nosocomial transmission.

Background: Disinfection procedures are an essential aspect of preventing cross contamination, especially in situations where the risk of infection is higher, such as in operating rooms (ORs). Disinfection procedures in ORs at the end of each surgery session are not the same as final cleaning procedures. We assessed the difference in microbial contamination between different levels of disinfection, before T(0) and after T(1) the use of an ultraviolet C device (UVC-D). Methods: A cross-sectional study was conducted between December 2019 and August 2020 in a private clinic. Three sanitation levels (SL1–SL3) were compared for the reduction in colony-forming units (CFU) between T(0) and T(1): (1) no disinfection after surgery (SL1);, (2) after in-between cleaning (SL2), and (3) after terminal cleaning (SL3). UVC-D was used for 6 minutes, 3 minutes per bed side. Overall, 260 Petri dishes were used in 3 ORs, incubated at 36°C, and CFU were counted after 48 hours. Descriptive statistics, Wilcoxon test, and MANOVA for repeated measures were performed to verify the 95% statistical difference between T(0) and T(1), both on the whole sample and combined with the different SLs. Results: The unstratified analysis showed statistically significant differences (Wilcoxon test, p < 0.05) between T(0) and T(1), with means and standard deviations of 11.42 ± SD 41.19 CFU/PD and 5.91 ± SD 30.89, respectively. The Manova test for repeated measures, applied to 54 pairs of measurements, showed no significant difference between SLs in T(0)-T(1) CFU reduction. Overall, the mean percent reduction in CFU was 93.48% (CI95% = 86.97-99.99%). Conclusions: The results showed significant improvements in disinfection under any condition tested with UVC-D. Using the device immediately after surgery (SL1), before standard cleaning procedures, reduced CFUs by 97.3%. In some situations, UVC light was sufficient to reduce CFU to zero, even without chemical and mechanical cleaning. However, we do not recommend this approach; UVC light disinfection should be applied only after sanitization procedures because it does not remove dirt.Funding: UltraViolet Device, IncDisclosures: None

Background Periprosthetic joint infection (PJI) after total joint arthroplasty (TJA) is a serious complication with multiple etiologies. Prior spine literature has shown that later cases in the day were more likely to develop surgical site infection. However, the effect of case order on PJI after TJA is unknown. This study aims to determine the influence of case order, prior infected case, and terminal cleaning on the risk for a subsequent PJI. Methods A retrospective, single-institution study was conducted on 31,499 TJAs performed from 2000 to 2014. Case order was determined by case start times per date within the same operating room. PJI was defined by the Musculoskeletal Infection Society criteria. Logistic regression was used to determine risk factors for a subsequent PJI. Results Noninfected cases followed an infected case in 92 of 31,499 cases (0.29%) and were more likely to develop PJI (adjusted odds ratio [OR], 2.43; P = .029). However, terminal cleaning after infected cases did not affect the risk for PJI in cases the following morning (OR, 1.42; P = .066). Case order had an OR of 0.98 ( P = .655), implying that later cases did not have a higher likelihood of infection. Conclusion Although surgical case order is not an independent risk factor for subsequent PJI, TJA cases following an infected case in the same room on the same day have a higher infection risk. Despite improved sterile technique and clean air operating rooms, the risk of contaminating a TJA with pathogens from a prior infected case appears to be high. Terminal cleaning appears to be effective in reducing the bioburden in the operating room.

OBJECTIVEPrevention ofClostridium difficileinfection (CDI) in acute-care hospitals is a priority for hospitals and clinicians. We performed a qualitative systematic review to update the evidence on interventions to prevent CDI published since 2009.DESIGNWe searched Ovid, MEDLINE, EMBASE, The Cochrane Library, CINAHL, the ISI Web of Knowledge, and grey literature databases from January 1, 2009 to August 1, 2015.SETTINGWe included studies performed in acute-care hospitals.PATIENTS OR PARTICIPANTSWe included studies conducted on hospitalized patients that investigated the impact of specific interventions on CDI rates.INTERVENTIONSWe used the QI-Minimum Quality Criteria Set (QI-MQCS) to assess the quality of included studies. Interventions were grouped thematically: environmental disinfection, antimicrobial stewardship, hand hygiene, chlorhexidine bathing, probiotics, bundled approaches, and others. A meta-analysis was performed when possible.RESULTSOf 3,236 articles screened, 261 met the criteria for full-text review and 46 studies were ultimately included. The average quality rating was 82% according to the QI-MQCS. The most effective interventions, resulting in a 45% to 85% reduction in CDI, included daily to twice daily disinfection of high-touch surfaces (including bed rails) and terminal cleaning of patient rooms with chlorine-based products. Bundled interventions and antimicrobial stewardship showed promise for reducing CDI rates. Chlorhexidine bathing and intensified hand-hygiene practices were not effective for reducing CDI rates.CONCLUSIONSDaily and terminal cleaning of patient rooms using chlorine-based products were most effective in reducing CDI rates in hospitals. Further studies are needed to identify the components of bundled interventions that reduce CDI rates.Infect Control Hosp Epidemiol2017;38:476–482

Intensive care unit- (ICU-) acquired infections are a major health problem worldwide. Inanimate surfaces and equipment contamination may play a role in cross-transmission of pathogens and subsequent patient colonization or infection. Bacteria contaminate inanimate surfaces and equipment of the patient zone and healthcare area, generating a reservoir of potential pathogens, including multidrug resistant species. Traditional terminal cleaning methods have limitations. Indeed patients who receive a bed from prior patient carrying bacteria are exposed to an increased risk (odds ratio 2.13, 95% confidence intervals 1.62–2.81) of being colonized and potentially infected by the same bacterial species of the previous patient. Biofilm formation, even on dry surfaces, may play a role in reducing the efficacy of terminal cleaning procedures since it enables bacteria to survive in the environment for a long period and provides increased resistance to commonly used disinfectants. No-touch methods (e.g., UV-light, hydrogen peroxide vapour) are under investigation and further studies with patient-centred outcomes are needed, before considering them the standard of terminal cleaning in ICUs. Healthcare workers should be aware of the role of environmental contamination in the ICU and consider it in the broader perspective of infection control measures and stewardship initiatives.