The Role of Environmental Cleaning & Disinfection in a Different Pandemic 

There is a silent public health threat more deadly than COVID-19 killing an estimated 6.2 million people each year across the globe.¹ For perspective, COVID-19 killed 6.9 million people globally…but over a 3-year period!² The threat: antimicrobial resistance (AMR). The challenge with AMR pathogens is that they are not killed by the antimicrobial drugs typically used to treat them.³ AMR is now the third leading cause of death worldwide and is poised to rival the annual all-cancer death toll by the year 2050 with an estimated 10 million deaths.^1,4

AMR is often referred to as the “Silent Pandemic” because it represents a slow and hidden threat that has the potential to cause widespread health consequences.⁵ With AMR  continuously increasing and fewer new treatments in development, many experts believe that we are not entering, but rather we are living in the post-antimicrobial era.⁶ Surprisingly, only 6 pathogens are responsible for most of these infections.¹

AMR Is Not a U.S. Problem — or Is It?

More than 3 million Americans acquire an AMR infection each year.⁷ While not in the top 6, Clostridioides difficile (C. diff) is also considered to be an AMR pathogen because it is associated with taking antibiotics. C. diff causes close to 50,000 U.S. deaths annually.⁸

AMR was an issue before the pandemic, but pandemic-related factors have only intensified the problem including increased use of antibiotics as well as a healthcare system that was stressed to its limits. This made compliance with infection prevention and control measures more challenging⁸. There were also severe staffing shortages during this time which could have resulted in cutting corners. Replacement staff may not have been adequately trained in proper procedures. The result has been a significant increase in AMR with deaths increasing by 15% in just the first year of the pandemic.⁸

With the COVID-19 public health emergency declared over, our attention has been turned to other emerging and re-emerging microbial threats like Candida auris, Mpox, seasonal respiratory viruses, and even vaccine-preventable diseases. But if the future effectiveness of antimicrobial agents is to be preserved, it is imperative that AMR is given the same focused attention as the afore-mentioned pathogens. Recognized each year in November, World Antimicrobial Resistance Awareness Week (WAAW), is a campaign intended to do just that.⁹ This blog hopes to help WAAW in raising awareness of AMR and to promote the importance of a sanitary healthcare environment.

Slowing the Rate of AMR

WAAW’s theme this year is “Preventing antimicrobial resistance together.”⁸ The causes of AMR are complex due to the interconnectivity between people, animals, and the environment (learn more at CDC’s One Health). A multimodal approach, in which everyone plays a role, is crucial to slowing the rate of AMR and preserving antibiotics for future generations.

Key actions that the healthcare community can take to reduce AMR include:

• Perform pathogen surveillance for resistance patterns.
• Establish robust antimicrobial stewardship programs.
• Encourage immunizations of patients and staff.
• Perform frequent hand hygiene.
• Educate and train all healthcare staff on IPC measures to stop AMR spread.
• Ensure effective environmental cleaning and disinfection.
• Ensure cleaning and disinfection of medical equipment between patients.

The Relationship Between AMR and Environmental Cleaning & Disinfection

According to hygiene expert Dr. Nico Mutters, there are 3 reasons that AMR is increasing¹⁰:

1. Selection due to improper antimicrobial use.
2. Transmission resulting from inadequate IPC and hygiene (hands and environmental cleaning).
3. Host factors.

Studies show that more than 74% of healthcare surfaces are contaminated with AMR pathogens and that more than 50% of these surfaces that should be cleaned are missed.^11,12,13 There is considerable evidence that environmental surface contamination plays a key role in the transmission of many pathogens, particularly those that are AMR. There is sufficient evidence to show that the next patient to be admitted to a room where the prior occupant harbored an AMR pathogen has up to a 3-fold increased risk for acquiring that pathogen.¹⁴ This is almost certainly due to inadequate cleaning and disinfection. Environmental cleaning and disinfection breaks the chain of infection by preventing transmission from contaminated environmental surfaces. By preventing infections, the need for antibiotics is reduced, thereby decreasing the risk resistance. A clean and sanitary environment also reduces the direct transmission of AMR pathogens between patients.

To combat AMR, I recommend selecting products that target pathogens of concern for the facility and  that meet the users desired properties of the ideal disinfectant. Sporicidal disinfectants (e.g., bleach), with its broad antimicrobial activity, are ideal for combatting AMR. I also recommend using a sporicidal disinfectant for all discharge and terminal room cleans. This helps to ensure the highest level of cleanliness for the next patient admitted to that room.

Conclusion

The rates of AMR have only worsened in recent years and treatment options are becoming more limited. AMR infections come with high consequences including increased lengths of stay, increased cost, and can even result in loss of life. The time for action to reverse this trend is NOW. Learn more here.

References

<sup>1. Antimicrobial Resistance Collaborators. Global burden of antimicrobial resistance in 2019: a systematic analysis. Open Access Lancet [Internet]. 2022; DOI: https://doi.org/10.1016/S0140-6736(21)02724-0.
2. Johns Hopkins University. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) [Internet]. [cited 2023 Oct 28]. Available from: https://gisanddata.maps.arcgis.com/apps/dashboards/bda7594740fd40299423467b48e9ecf6
3. Centers for Disease Control and Prevention. National Antimicrobial Resistance Monitoring System for Enteric Bacteria (NARMS) [Internet]. [cited 2023 Nov 02]. Available from: https://www.cdc.gov/narms/resources/glossary.html
4. United Nations. UN News: Reduce Pollution to combat ‘superbugs’ and other antimicrobial resistance [Internet]. [cited 2023 Nov 02]. Available from https://news.un.org/en/story/2023/02/1133227#:~:text=Overall%2C%20nearly%20five%20million%20deaths,globally%20by%20cancer%20in%202020.
5. Google Scholar. Search term “Silent Pandemic” [Internet]. [cited 2023 Oct 29]. Available from: https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=silent+pandemic&btnG=
6. European Congress of Clinical Microbiology & Infectious Diseases. Press Release ECCMID 2023, Copenhagen, 15-18 April [Internet]. [cited 2023 Oct 29]. Available from: https://www.eurekalert.org/news-releases/982758
7. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States [Internet]. [cited 2023 Oct 30]. Available from: https://www.cdc.gov/drugresistance/biggest-threats.html
8. Centers for Disease Control and Prevention. 2022 Special Report: COVID-19 U.S. Impact on Antimicrobial Resistance [Internet]. [cited 2023 Oct 30]. Available from: CDC.
9. World Health Organization. World AMR Awareness Week 2023 [Internet]. [cited 2023 Oct 28]. Available from: WHO.
10. Mutters, N. Proceedings from International Conference on Prevention & Control (ICPIC) 2023. Session: Are we prepared for future challenges in infection prevention and control?
11. Carling PC, Bartley JM. Evaluating hygienic cleaning in health care settings: what you do not know can harm your patients. AM J Infect Control. 2010;38:S41-50
12. McKinnell J, Miller L, Singh R,  Walters D, Peterson E, Huang S. High Prevalence of MDRO Colonization in 28 NHs: An Iceberg Effect. JAMDA. 2020;21(12):1937-1943
13. Cassone M, Wang J, Lansing B, Mantey J, Gibson K, Gontjes K, et al. Proceedings from SHEA 2022. Poster: Diversity and persistence of MRSA and VRE in NHs: Environmental screening and whole-genome sequencing. ASHE. 2022;2:s80.
14. Chemaly R, Simmons S, Dale C, Ghantoji S, Rodriguez M, Gubb J, et al. The role of the healthcare environment in the spread of MDROs: update on current best practices. Ther Adv Infect Dis. 2014;2(3-4), 79-90.</sup>