In Part 1 of this blog series, we highlighted the challenges that make cleaning and disinfection in the LTC setting different from acute care settings. This blog (part 2) will provide some solutions to tackling these challenges head-on with confidence.

Now that we understand the risks to LTC residents and the challenges, how should we approach cleaning and disinfection in this setting? A great starting point for establishing an effective and efficient program is the CDC’s Core Components of Environmental Cleaning and Disinfection as shown in Figure 3. This guidance takes into consideration that the healthcare environment is a reservoir to a diverse population of microbes, many of which are continuously shed into the environment.

Figure 3. Core Components of a Cleaning and Disinfection Program

Focusing on the product selection component, CMS requires that EPA-registered healthcare-grade disinfectants are used.1 The LTC IP has oversight for the environmental cleaning and disinfection program so he or she should be involved in product selection and approval. Other product considerations include:

Regarding where and when to clean in the LTC setting, CMS regulations require routine cleaning and disinfection of LTC environmental surfaces.1 Because CMS does not define “routine,” this is left to the facility to determine and define in their policies. However, the CDC does have a Cleaning Frequency Risk Assessment to help in determining the right frequency by space in a facility. Cleaning frequencies should be based on 3 factors:

  1. Probability of contamination (e.g., low, moderate or heavy contamination),
  2. Vulnerability of the population to infection (e.g., less vs more susceptible), and
  3. Potential for exposure (low-touch surface vs. high-touch surfaces).

While our focus should be on horizontal surfaces and high-touch surfaces (Figure 4), truly all touch surfaces should have a schedule for routine cleaning and disinfection. In general, the CDC recommends daily cleaning at a minimum but also recommends more frequent disinfection of high-touch surfaces as compared to those surfaces with minimal hand contact.23 Additionally, the CDC recommends that public and shared restrooms and isolation rooms are cleaned at least twice daily.22 Shared medical equipment should be cleaned and disinfected after each use.23 Disposable disinfecting wipes will greatly increase compliance and should be readily available at the point-of-use such as the entrance to resident rooms. At a minimum, these wipes should be available at the entrance to isolation or enhanced barrier precautions rooms. If there are resident safety concerns, a risk assessment can be conducted.

Figure 4. Common High-Touch Surfaces in LTC Settings


The LTC setting has its own unique challenges to cleaning and disinfection, but these can be overcome with a robust cleaning and disinfection program. Environmental cleaning and disinfection can stop transmission of many of the pathogens responsible for HAIs in this setting. Bottom line — it’s a low-cost, high-yield, “just-do-it,” evidence-based intervention that eliminates the environment as a source of infection.


1. CMS. State Operations Manual-Appendix PP – Guidance to Surveyors for Long-Term Care Facilities, 2017. [Internet]. [Cited 2022 July 16]. Available from
2. Richards M. Causes of infection in long-term care facilities: An overview [Internet]. [Cited 2022 May 1]. Available from
3. CDC. HAIs: Environmental Cleaning Procedures. [Internet]. [Cite 2022 May 25]. Available from

Americans are living longer, and the population is rapidly graying. Baby Boomers, who currently make up 21% of the US population, will be 65 or older by 2030. As a result, the number of persons living in nursing homes is expected to double. For the first time ever in this country, there will be more older adults than children. Most of these older adults will need long-term care (LTC) services at some point in their lives.1,2,3

Currently, about 8.3 million people live in the country’s nearly 66,000 regulated LTC facilities.4 These residents are at high risk for infection due to their frailty, waning immune systems, multiple chronic conditions, prolonged healthcare stays, and over-exposure to antibiotics.5 Compounding this risk is the congregate nature of LTC living with shared rooms and common spaces. Unfortunately, there is no requirement to report healthcare-associated infections (HAIs) in LTC settings — at least not yet. Without this data, it is unclear just how many HAIs occur in this setting, but it estimated to be somewhere between 1 to 3 million per year.6 The environment is an important reservoir for HAI-causing pathogens - many of which can survive for prolonged periods in the environment where they can be picked up on the hands of healthcare workers and then transmitted to residents. However, cleaning and disinfection can stop transmission as shown in Figure 1. Part 1 of this 2-part blog will highlight some of the challenges in regards to cleaning and disinfection that LTC facilities face. Part 2 will provide actionable solutions.

Figure 1. Cleaning and Disinfection Stops Transmission.

Adapted from CDC's Healthcare Environmental Infection Prevention: Reduce Risk from Surfaces

Challenges to Cleaning & Disinfection in LTC Settings

Long-term care is different as compared to acute care settings and here are some reasons why. First, hand hygiene alone, while important, is insufficient to control the spread of pathogens. Effective and consistent cleaning and disinfection is essential to reducing HAI incidence. While the same sanitation principles apply, simply adopting acute care environmental cleaning and disinfection protocols and practices does not address the challenges that LTC facilities face as shown in Table 1.

Table 1. Acute Care vs LTC Setting Differences that Impact Cleaning and Disinfection.

Some of the setting differences include:

In addition to setting differences, a recent study found that residents touch surfaces in shared areas on average 12 times per hour and staff contact these surfaces 26 times per hour.7 Consider this in light of another new study that found that 90% of surfaces across 11 LTC facilities tested positive for fecal pathogens.8 Not surprisingly, multidrug-resistant organisms (MDROS) are highly prevalent in LTC facilities. Studies show that over half of residents are colonized with an MDRO. The cases we see - the active infections - are only the tip of the iceberg. Asymptomatic carriage contributes to silent spread. Several studies have reported that 93%-100% of surfaces in LTC facilities are contaminated with MDROs.9-11 It’s vital to prevent MDRO transmission as treatment options are limited.

As if these challenges are not enough, there are staffing issues. The new CMS regulatory requirement calls for LTC facilities to have a designated and trained IP.12 This coupled with the Great Resignation, has resulted in many new IPs in this setting. On average, these IPs spend less than 9% of their time on cleaning and disinfection which makes becoming proficient in this area a challenge.13 IPs are not the only ones who are under-staffed. There are shortages in nursing and environmental care staff (EVS) as well. While turn-over has always been high in the LTC sector, the pandemic has dramatically exacerbated the issue. With so many new hires, it can be difficult to ensure that everyone is cleaning in a standardized way.

Another challenge that LTC facilities face are disparities in their environmental cleaning and disinfection programs. A recent CMS pilot project found that 80% of LTC facilities had the following gaps:14

Cleaning Failures: Improper cleaning contributes to pathogen transmission. Studies show that we miss more than half of surfaces that should be cleaned. Additionally, researchers have identified a significant increase in risk to the next patient to occupy a room previously occupied by an infected patient to acquiring that pathogen. Environmental surfaces, objects, and medical devices can serve as reservoirs for pathogens that can be transmitted by the hands of healthcare workers to patients. In fact, hands have been implicated in 20–40% of HAIs. This failure rate of both hand and environmental surfaces cleaning leaves much room for improvement. Figure 2 is a nice infographic that summarizes this section on cleaning failures.15-18

Figure 2. Improper Cleaning Contributes to Transmission of Pathogens.

In closing, the LTC setting has its own unique challenges to cleaning and disinfection but these can be overcome with a robust cleaning and disinfection program. This brings us to Part 2 of this blog: Solutions to Cleaning and Disinfection Challenges in LTC Settings.


1. The Checkup. Long-Term Care Statistics 2022. [Internet]. [Cited 2022 May 20]. Available from
2. US Census Bureau. Older People Projected to Outnumber Children for First Time in US History. [Internet]. [Cited 2022 May 20]. Available from,decade%20for%20the%20U.S.%20population.
3. NIH. Supporting Older Patients with Chronic Conditions. [Internet]. [Cited 2022 May 20]. Available from
4. Consumer Affairs. Long-term care statistics [Internet]. [Cited 2022 Mar 20]. Available from,people%20in%20assisted%20living%20facilities
5. Infection Prevention Guide to Long-Term Care. 2nd ed. Arlington, VA: APIC; 2019
6. CDC. HAI Data Portal, 2021. Available from
7. Pineles L, Perencevich E, Roghmann M, Gupta K, Cadena, J, Barocco G, et al. Frequency of Nursing Home Resident Contact with Staff, other Residents, and the Environment outside Resident Rooms. Infection Control & Hospital Epidemiology. 2019;1-3.
8. Cannon JL, Park GW, Anderson B, Leone C, Chao M, Vinje J, et al. Hygienic Monitoring in LTCFs using ATP, crAssphage, and Human Norovirus to Detect Environmental Surface Cleaning. AJIC. 2022; 50: 289-294.
9.     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
10.  Cassone M, Wang J, Lansing B, Mantey J, Gibson K, Gontjes K, et al. Proceeding from SHEA 2022. Poster: Diversity and persistence of MRSA and VRE in NHs: Environmental screening and whole-genome sequencing. ASHE. 2022;2:s80.
11. McKinnell J, Singh R, Miller L, Kleinman K, Gussin G, He J, et al. The SHIELD Orange County Project: MDRO Prevalence in 21 NHs and LTACHs in So Cal. Clin Infect Dis. 2019;69(9):1566-1573.
12. CMS. State Operations Manual-Appendix PP – Guidance to Surveyors for Long-Term Care Facilities, 2017. [Internet]. [Cited 2022 July 16]. Available from
13. Landers T, Davis J, Christ K, Malik C. APIC MegaSurvey: Methodology and Overview. AJIC. 2017; 1;45(6):584-588.
14. Ogundimu, A. Proceedings from APIC 2019: Association for Professionals in Infection Control and Epidemiology on Infection Prevention and Control (IPC) Practices in Nursing Homes: Findings from a CMS Infection Control Pilot Project. Philadelphia, PA.
15. 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
16. 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.
17. Haenen A, Greeff S, Voss A, Liefers J, Hulscher M, Huis A. Hand hygiene compliance and its drivers in LTCFs; observations and a survey. Antimicrob Resist Infect Control. 2022; 11(50)
18. Suleyman G, Alangaden G, Bardossy A. The Role of Environmental Contamination in the Transmission of Nosocomial Pathogens and HAIs. Curr Infect Dis Rep. 2018; 20:12

The importance of environmental hygiene has never been greater than it is today. With our focus on a single pathogen over the past two years, other pathogens have gotten away from us. The U.S. lost a decade of progress in the reduction of healthcare-associated infections (HAI), including Clostridioides difficile and multidrug-resistant organisms (MDROs).1 Candida auris, an emerging threat, saw an 85% increase in clinical cases in 2020 from the previous year.2 This particular pathogen has a very high mortality rate, persists in the environment, and has proven to spread rapidly in and between healthcare facilities. With nearly 80% of all infectious diseases being spread by contact (or touch), addressing environmental transmission of pathogens is as important as any other patient safety activities, including the implementation of bundles and stewardship programs.3 This article will introduce a new framework, highlighting the importance of environmental hygiene and elevating it to that of well-established bundles and stewardship programs.

So, what is a bundle? The concept of bundles was developed in 2001 by the Institute for Healthcare Improvement (IHI) as an improvement tool. The earliest bundles targeted prevention of central line-associated bloodstream infection (CLABSI) and ventilator-associated pneumonia (VAP). A bundle is a core set of accepted evidence-based practices that when implemented together result in significantly better outcomes (e.g., HAI rates), than when implemented alone. Bundles are just one strategy among many towards preventing patient harm.4

Other strategies for patient safety are stewardship programs. Stewardship means “to take care of something.” A stewardship program is a set of key principles to guide improvement efforts. Two of the most common stewardship programs are antimicrobial stewardship and diagnostic stewardship — both are intended as a means to combat antimicrobial resistance. For example, antimicrobial stewardship programs aim to preserve antimicrobials for future use by preventing over- and inappropriate use. We saw during the pandemic resources being redirected from stewardship to COVID-19 related activities. But with increases in HAIs and MDROs during this time, we must again prioritize our stewardship efforts.

This brings us to the new framework which I call the “Stewardship Triad” (see figure). Part of this 3-pronged bundle of stewardship programs is a new stewardship program: Environmental Hygiene Stewardship. The key evidence-based practices for this program include:

Stewardship Triad to Reduce Environmentally Spread Pathogens (including MDROs & C. difficile)

A stewardship bundle for the post-antibiotic era

*NEW* Environmental Hygiene Stewardship Core Elements

Antimicrobial Stewardship Core Elements

Diagnostic Stewardship Core Elements

High compliance with environmental hygiene stewardship means breaking the chain of infection and by doing so, lessening the need for antimicrobial and diagnostic stewardship. Environmental hygiene stewardship not only elevates the importance of cleaning and disinfection but also our hard-working environmental services professionals.


1. Weiner-Lastinger LM, Pattabiraman V, Konnor RY, Patel PR, Wong E, Xu SY, et al. The impact of COVID-19 on healthcare-associated infections in 2020: A summary of data reported to NHSN. Infection Control & Healthcare Epidemiology. 2020; 1-14.
2. Centers for Disease Control and Prevention. Tracking Candida auris. [Internet]. [cited 2020 Feb 15]. Available from
3. Tierno, P. The Secret Life of Germs. New York, NY, USA: Atria Books, 2001.
4. Resar R, Griffen FA, Haraden C, Nolan TW. Using Care Bundles to Improve Health Care Quality, 2012 [Internet]. [cited 2022 Feb 15]. Available from

Over the past two years, with our attention singularly focused on COVID-19, facility outbreaks with other pathogens have been particularly problematic. In a systematic review, Thoma et al (2022) identified 17 outbreaks of multidrug-resistant pathogens, most caused by Candida auris and carbapenem-resistant Acinetobacter baumannii (CRAB) with an overall mortality rate of 35%.1 With resources diverted to pandemic-related activities pathogens such as these and others have gone undetected. Additional contributing factors including staffing shortages and pandemic fatigue have led to breaches in standard infection prevention and control (IPC) practices.

Outbreaks are a serious threat to patient safety and can also damage a facility’s reputation. Management of outbreaks is costly and resource intensive. Because outbreaks are an infrequent occurrence in any given facility, it’s crucial that infection preventionists (IPs) understand how to promptly identify and control outbreaks.

 4 Simple Steps to Outbreak Management

The definitions for levels of disease, including outbreaks, are provided in Table 1. Ideally, we want to identify cases early before we have a full-blown outbreak on our hands.

Definitions for Levels of Disease
EndemicThe usual (baseline) prevalence of a pathogen in a given population within a geographic area (e.g., a usual flu season)
EpidemicA sudden increase above expected levels in the amount of disease in a population (e.g., more cases than is typically expected during the flu season)
OutbreakSame definition as epidemic, but is often used for a more limited geographic area such as a single healthcare facility
Pseudo-OutbreakThe recovery of the same organisms from cultures of patients who are not infected or colonized with the organism
ClusterAn aggregation of cases grouped in place and time that are suspected to be greater than the number expected (e.g., isolated to a single unit in a healthcare facility)
PandemicAn epidemic that has spread over several countries or continents, usually affecting a large number of people (e.g., Spanish Influenza, COVID-19)

Adapted from CDC’s Principles of Epidemiology in Public Health Practice (2012).2

Outbreaks are often first noticed by an astute clinician. Should such a clinician reach out to you, take the time to investigate. Sometimes the concern is unfounded or coincidental but too often it’s found to be valid. Also, trust your gut. If you are concerned over what you are seeing in your surveillance activities, then investigate. I recall a single day when I identified not one, but two patients who had respiratory isolates growing the same Penicillium species. Since the patients were on separate units, I took a wait-and-see approach. The next day, two additional patients were identified. Despite being a new IP, I knew this was a problem. But where does one start? Let’s take a look at the 4 key steps to managing an outbreak:

Step 1 — Verify the Existence of an Outbreak:

Step 2 — Develop a Case Definition:

A case definition is a set of objective and measurable criteria for deciding whether an individual should be classified as a case. It should be restricted by person, place, and time. A common mistake is to include the exposure or risk factors of interest. For example, in my Penicillium example, it was tempting initially to limit my definition to only patients on the units where positive patients resided. Consider having case definitions for confirmed, probable, and possible cases. As you gather more information, your definition may change. Note: no case definition is perfect – some mild cases may be excluded while others with similar symptoms but a different illness may be included. For an example of a case definition based on my Penicillium example, see Table 2.

Definition for the Penicillium Outbreak Example
Clinical criteriaAsymptomatic
Lab criteriaRespiratory specimen growing Penicillium spp.
PersonAll inpatients
PlaceAll inpatient units
TimeWithin the past 6 months
Case classification
Suspected: A case that meets the clinical criteria
Probable: A suspected case with signs and symptoms consistent with the disease and epidemiological link to a confirmed case
Confirmed: A suspected or probable case with lab confirmation

Adapted from CDC’s Principles of Epidemiology in Public Health Practice (2012).

Step 3 — Develop and Test Your Hypothesis:

The hypothesis is a proposed explanation for the outbreak made with limited evidence as a starting point for further investigation. It may address the source, transmission mode, and exposures of the pathogen. To test the hypothesis, compare it with the facts such as the clinical, laboratory, environmental, and/or epidemiologic evidence. In my Penicillium example, I hypothesized that the source of the pathogen was a flaw in the HVAC system. To test my hypothesis, I had the facility engineering staff inspect the HVAC duct servicing the effected floor. They found that the HEPA filter was too small for the HVAC duct. This allowed unfiltered outdoor air — where mold spores are ubiquitous — to enter the building. I further hypothesized that if the incorrect filter was replaced with the correct one, we should see no further isolates growing Penicillium. I was right. With the outbreak confirmed, I promptly notified my facility leadership. Also, since most state require reporting of outbreaks of any disease or the occurrence of any unusual disease, be sure to notify local public health authorities.

Step 4 — Implement Control Measures:

In my pseudo-outbreak example, placement of the correct HEPA filter immediately resolved the problem. I was very fortunate as most outbreaks do not resolve this simply and more often than not, the root cause is never identified.

Once you have identified the culprit and understanding its epidemiological traits such as reservoirs and mode of transmission, consider ways in which the chain of infection can be broken. Ensure compliance with basic IPC protocols such as hand hygiene and environmental cleaning and disinfection. Because many pathogens can persist in the environment for prolonged periods, environmental contamination can play a key role in outbreak management. For example, environment surfaces — particularly portable medical equipment — have been implicated in many of the C. auris outbreaks.3

 Key Take-Aways

Be sure to add this article as a tool for your IPC toolbox. Trust your gut — you likely know more than you think you do! Take the time to investigate concerns but always verify that there is indeed a problem. Graph the frequency distribution and develop a case definition. Test your hypothesis. Once you have confirmed the existence of an outbreak, promptly implement IPC measures. Last, be sure to document your outbreak “story” in a report for facility recording purposes.


1. Thoma R, Seneghini M, Seiffert SN, Vuichard G, Scanferla G, Haller S, et al. The challenge of preventing and containing outbreaks of multidrug-resistant organisms and Candida auris during the coronavirus disease 2019 pandemic: report of carbapenem-resistant Acinetobacter baumannii outbreak and a systematic review of the literature. Antimicrob Resist Infect Control. 2022 Jan 21;11(1):12.
2. Centers for Disease Control and Prevention. Principles of Epidemiology in Public Health Practice — Lesson 6: Investigating and Outbreak [Internet]. [Cited 2022 Feb 5, 2022]. Available from
3. Centers for Disease Control and Prevention. Infection Prevention and Control for Candida auris [Internet]. [Cited 2022 Feb 5]. Available from

With healthcare-associated infection rates and multidrug-resistant organisms on the rise, and new pathogens emerging, a robust environmental cleaning and disinfection program is more important today than ever before. This article outlines a framework that can help healthcare facilities establish their cleaning and disinfection program, called the 5 Rights of Cleaning & Disinfection. The 5 Rights of Cleaning & Disinfection is a concept based on the nursing professions 5 Rights of Medication Administration. The 5 Rights include the:

#1 — Right Products: A clean and sanitary environment is key to patient safety. In fact, it’s a requirement to participate in the Centers for Medicare and Medicaid Services (CMS) programs.1 CMS requires the use of EPA-registered hospital-grade disinfectants.2 While you will likely never see this language on a product label, a hospital-grade disinfectant must have kill claims for Staphylococcus aureus and Pseudomonas aeruginosa at a minimum.3 When selecting disinfectants, consider the pathogens of interest in the facility as well as the ideal properties which include:4

Reference: Rutala et al. (2014). Selection of the Ideal Disinfectant. ICHE; Vol 35(7)

Be sure to include stakeholders in the decision-making process such as the facility infection preventionist, environmental services (EVS) leadership and frontline workers, biomedical staff, facility safety officer, supply chain, and finance.

#2Right Location: Hospitals are complex communities, like small cities. There are many different areas in the hospital and cleaning and disinfection needs may differ based on transmission risks. With the current staffing challenges, certain areas might have to be deprioritized – such as office spaces. In fact, some facilities are having office staff clean their own spaces during this challenging time.

Another important element of Right Location are protocols. Ideally, there should be a protocol for each location in the hospital that addresses things like which product to use, the frequency of cleaning, and any nuances unique to that space.

#3 — Right People: While EVS has primary responsibility to ensure a clean environment, everyone plays a role. Just like no healthcare workers are exempt from performing hand hygiene, no one should be exempt from performing cleaning and disinfection tasks. Non-EVS staff should clean and disinfect the non-critical equipment that they use – especially mobile equipment. They should also clean and disinfect high-touch surfaces in their work spaces at least once per shift. Nursing staff need to understand that for patient safety reasons, EVS does not clean equipment that is in use – at least they should not. Nursing staff really should be disinfecting the high-touch surfaces of this equipment like control panels, knobs & dials, handles and so on at least once per shift. Responsibility grids, like the example shown here, are a great way to communicate roles and responsibilities as it pertains to cleaning and disinfection.

#4 - Right Moments: Includes cleaning frequencies. In general, the guidance from the Centers for Disease Control and Prevention (CDC) states that cleaning should be performed in patient care areas at least once daily.5 However, there was no data to back this recommendation. But with the volume of foot traffic in facilities and patient rooms, is once a day really enough? Especially for touchable surfaces. In fact a 2015 study showed that it only took 4 hours for a surrogate virus to spread from HCW hands to almost half of the surfaces in a facility. The right frequency of cleaning should be targeted based on contamination events such as equipment that has been used with a patient or a bedside table before a patient eats.6

Some of the specific moments to consider increasing the frequency of cleaning and disinfection include when a facility is seeing an uptick in cases, during seasonal outbreaks, and of course, during epidemics or pandemics such as the current COVID-19 pandemic.

Additionally, the ideal time of the day for performing cleaning and disinfection should be determined. For example, some areas are more amenable to after-hours cleaning such as waiting rooms and other public spaces, operating rooms, and physician offices.

A final and very important moment is after equipment use – particularly portable or mobile equipment. Several outbreaks of Candida auris have linked such equipment as a source.

#5 — Right Application: Consider the most appropriate format of the product for the situation. Format types include ready-to-use wipes, spray bottles, pull-tops, and dilutables for example. Just like we have hand sanitizer available at every patient room, we should also have disinfecting wipes readily available for clinical staff.

The Right Application means that the product directions for use are followed – it’s the law! These include contact time and personal protective equipment. Cleaning should be methodical such as cleaning in a clockwise pattern around the room, from high surfaces to lower surfaces, and from clean to dirty.

Use of no-touch disinfection technologies like UV-C or electrostatic devices exploded during the pandemic. For areas where we may not have the resources to manually clean and disinfect as often or as thoroughly as we would like – such as waiting rooms and office spaces – use of these technologies could at least get us closer to the ideal.


 A robust cleaning and disinfection program is critical to reducing the risk of infection transmission. The 5 Rights of Cleaning and Disinfection format will help you to think through what is needed in establishing such a program.

For a video walkthrough of the 5 Rights of Cleaning and Disinfection, please visit


1. Centers for Medicare and Medicaid Services.  State Operations Manual Appendix A, 2018. [Internet]. [Cited 2021 Dec 29]. Available from
2. Centers for Medicare and Medicaid Services. Hospital Infection Control Worksheet. [Internet]. [Cited 2021 Sep 20]. Available from
3. Environmental Protection Agency. Antimicrobial Performance Evaluation Program [Internet]. [Cited 2021 Sep 20]. Available from
4. Rutala WA and Weber DJ. (2014). Selection of the Ideal Disinfectant. ICHE; Vol 35(7).
5. Centers for Disease Control and Prevention. Disinfection and Sterilization, 2008. [Internet]. [Cited 2021, Dec 29]. Available from
6. Sassi H, Sifuentes L, Koenig D, Nichols E, Clark-Greuel J, Wong L, et al. Control of the spread of viruses in a long-term care facility using hygiene protocols. AJIC. 2015 Jul 1;43(7):702-6.

In 2009, the world was entrenched in another pandemic, albeit much smaller in scale as compared to the current COVID-19 pandemic. It was H1N1 or Swine Flu. But this wasn’t the only pathogen to emerge that year. A new Candida species was isolated from the ear of a patient in Japan — Candida auris (C. auris). Auris means “ear” in Latin, hence its name. Growth of this pathogen over the past decade has been exponential and during the pandemic, while we were singularly focused on SARS-CoV-2, C. auris rates (Table 1) were accelerated with several outbreaks reported. In this article, the key problems with this newcomer will be addressed and solutions will be provided.

* Clinical cases only (colonization excluded). Table adapted from CDC's Tracking Candida auris.

The Yeast That Behaves Like Bacteria

Candida auris is a unique Candida species in that it behaves more like a bacteria than a yeast and these traits include:

Problem #1: C. auris Is Difficult to Identify

Because C. auris is often misidentified as other Candida species, specialized laboratory technology is required to correctly identify this pathogen. Additionally, many clinical laboratories do not routinely identify yeasts at the species-level when isolated from a non-sterile body site.

Solution: It’s important to know when to suspect and to seek out speciation for C. auris. There are essentially four situations in which this should be done and these are when:

  1. Yeast isolated from normally sterile body sites such as the bloodstream or cerebrospinal fluid. Speciation guides appropriate initial treatment which can be administered based on the typical, species-specific susceptibility patterns.2
  2. Candida is isolated from non-sterile body sites. In this scenario, consider species-level identification when:2
    1. its clinically indicated for the patient’s care
    2. in the previous year, a patient has had an overnight stay in a healthcare facility outside of the United States
    3. A Candida species is isolated from surveillance cultures collected when actively looking for additional cases when a case has been detected in a facility or a unit
  3. A fungal isolate is identified that is known to represent potential misidentification of C. auris, such as C. haemulonii.2
  4. You are seeing an increase in infections due to Candida species in a given care unit or there has been an increase of Candida isolated from urine specimens.2

This algorithm in Figure 2 may help in determining when to speciate:2,4

Figure 2.

If your facility lab does not have the technology to identify C. auris, the CDC has a really helpful table which summarizes misidentifications by the type of lab test used. The recommendation is that if any of these species are identified or if species level cannot be determined, further characterization using appropriate testing methods should be sought through your local public health dept.2

Problem #2: C. auris Persists in the Environment

Surface transmission is the primary route in which C. auris is spread and once it gets a foothold in a facility, it can be very difficult to eradicate. Colonized patients shed the pathogen into the environment where this pathogen can survive on environmental surfaces for several weeks. Additionally, portable medical equipment has been implicated as a reservoir in several outbreaks.

For these reasons, a robust infection prevention and control plan including cleaning and disinfection is critically important. The CDC recommends the use of EPA-registered disinfectants that have kill claims for either C. auris or C. difficile.2 Use of diluted bleach is another alternative.2 In fact, enhanced cleaning with bleach 3 times daily is how one facility stopped a C. auris outbreak.5 It’s important to note that quaternary ammonium compounds (“quats”) are not as effective against this C. auris.2 Disposable ready-to-use disinfecting wipes should be readily accessible for staff at point of use. And because 50% of surfaces are missed during manual cleaning, use of adjunct disinfection technologies such as electrostatic disinfection systems can help to ensure that nothing gets missed and no C. auris is left behind.

Problem #3: C. auris Spreads Rapidly In and Between Healthcare Facilities

Outbreaks with C. auris have proven challenging to control.This pathogen can spread in healthcare settings through contact with contaminated environmental surfaces, medical equipment, and fomites or from person-to-person such as from unclean hands. Recent investigations have demonstrated that one-third to half of all patients on a given unit can become colonized with C. auris within a matter of weeks of an index case entering the facility.6 Other studies have found that C. auris may be found not only in patient’s rooms but also in hallways, on countertops, and medical equipment - particularly portable equipment. Shared multi-use patient care equipment such as temperature probes and pulse oximeters may act as reservoirs for this drug-resistant fungus.7 In addition to robust cleaning and disinfection, the CDC recommends contact isolation precautions in addition to standard precautions to contain C. auris.2


With our attention on a single pathogen during the pandemic — SARS-CoV-2 — a few emerging pathogens like C. auris have been able to get a foot hold in this country. C. auris is a problematic pathogen which has proven to be a very challenging and difficult to contain pathogen. The evidence-based recommendations provided in this article should be considered in the event that you are faced with C. auris.


1. Centers for Disease Control and Prevention. 2019 Antimicrobial Resistance Threats Report. [Internet]. [Cited 2021 Dec 14]. Available from
2. Centers for Disease Control and Prevention. Candida auris. [Internet]. [Cited 2021 Dec 14]. Available from
3. Hayden M, et al. Characterization of Skin Microbiota, and Relation of Chlorhexidine Gluconate (CHG) Skin Concentration to C. auris Detection Among Patients at a High-Prevalence Ventilator-Capable Skilled Nursing Facility (vSNF) with Established CHG Bathing. Open Forum Infect Dis. 2019; 6(Supple 2): S25-S26.
4. Minnesota Department of Health. Admission Screening Recommendations. [Internet]. [Cited 2021 Dec 14. Available from
5. Schelenz S, Hagen F, Rhodes J, Abdolrasouli A, Chowdhary A, et al. First Hospital Outbreak of the Globally Emerging Candida auris in a European Hospital. Antimicrob Resist Infect Control. 2016; 5:35.
6. Council of State and Territorial Epidemiologists. Standardized Case Definition for Candida auris clinical and colonization/screening cases and National Notification of C. auris, clinical. (nd). [Internet]. [Cited 2021 Dec 17]. Available from
7. Sikora A, Zahra F. Candida Auris: Continuing Education Activity. 2021. StatPearls [Internet]. [Cited 2021 Dec 17]. Available from

I often present in multiple forums on environmental cleaning and disinfection in healthcare spaces. Most recently, I had the pleasure of speaking at the APIC 2021 Cleaning, Disinfection, and Sterilization (CDS) conference. My talk was titled “The Next Normal for Cleaning & Disinfection in a Post-Pandemic World.” The session, along with others, was recorded and can be accessed here. This blog shares the questions and answers to some of the more common questions that I receive in the course of my work. Let’s get to it:

Question 1: Can you describe the pros and cons of ATP testing?


  Pros Cons
Adenosine Triphosphate (ATP)
  • Quick and easy to use
  • Immediate results allowing feedback to staff
  • Evaluates residual bioburden and organic matter remaining after cleaning and disinfecting
  • Moderate cost (~$1/swab) — be sure to factor in how many high-touch points will be tested per room
  • ATP doesn’t differentiate between living and dead bacteria (but note viruses do not have ATP)
  • This study showed significant difference in results depending on ATP meters used
  • Disinfectants can quench ATP readings (same study as above)
  • Determining the relative light unit (RLU) cut point for clean is not clearly defined
Fluorescent marker and black light
  • Low cost
  • Easy to use
  • Immediate results allowing feedback to staff
  • Evaluates how effectively a surface was cleaned (pass/fail)
  • More closely mimics environmental culturing than ATP.1
  • Does not detect microorganisms rather it’s a method of measuring cleaning adequacy
  • Operationalizing can be challenging – the tester must be able to get into the room after discharge to mark high-touch surfaces before the cleaning staff enter to clean
  • Some markers can be difficult to remove, requiring more elbow grease than one might normally apply. Consider giving partial credit for smearing the mark

As ATP and fluorescent markers measure different aspects of the cleaning process, I suggest using a combination of both.

Question 2: Are you aware of any certifications for healthcare cleaning professionals?


Question 3: For environmental and high-touch surfaces is it generally acceptable to use a disinfectant wipe for the cleaning step followed with a new wipe for disinfection?


It depends. If your product is a 1-step cleaner-disinfectant and the surface is not visibly soiled or the pathogen of concern is not Clostridioides difficile (“C. diff”) or Candida auris, then one wipe can be used to clean and disinfect at the same time. Now if the surface is visibly soiled or C. diff or C. auris are involved, regardless of whether your product is a 1-step or 2-step product, cleaning and disinfection need to be completed in separate steps — and you definitely want to use a new wipe for the second (disinfection) step.

Question 4: Some IFUs for medical devices and equipment state “moist cloth,” but do not state a particular agent. How do you disinfect them?


It is a regulatory requirement to follow the manufacturers cleaning and disinfection IFUs. With that said, if the IFUs are not clear or seem inappropriate — for example, a device that comes into contact with a patient skin but the IFUs say clean only with soap and water — there are two actions that can be taken. First, reach out to the manufacturer for clarity. If not provided or still seems inappropriate, submit an FDA Med Watch report. The FDA does not know what they don’t know unless we report these concerns.

Question 5: Can you briefly talk about low-level disinfection versus intermediate-level disinfection?


Low-level disinfection is appropriate for the vast majority of your environmental disinfection needs. Intermediate-level disinfection was also required to comply with OSHA’s bloodborne pathogen standard when it was issued in 1992. However, low-level disinfection using products with HIV/HBV claims also comply with the standard.

Question 6: What is the typical contact time for electrostatic disinfection?


It depends on the chemistry (disinfectant) being used — be sure to follow the product IFUs for contact time. Now application of the disinfectant by way of electrostatic application is very fast — an entire patient room can be sprayed in a 1–2 minutes depending on the room size.

Question 7: Does electrostatic disinfection technology replace the manual “elbow grease” cleaning?


Electrostatics are primarily an adjunct, however, they can be used to disinfect surfaces that are not visibly soiled in between routine cleaning. This Donskey study showed significant reduction in C. diff spores on wheelchairs without a manual cleaning step. Here is one way I think about it, using the wheelchairs again; if these items are getting a thorough cleaning say daily AND they are not visibly soiled, you could spray them between uses using an electrostatic sprayer- I guarantee that it is more disinfection than they would get otherwise in the course of a day.  Another example, OR walls can be spot cleaned and then the entire surface disinfected with the electrostatic device - consider the time savings! Regarding the need to clean first. This depends on 2 key things: 1) is the product a one-step cleaner-disinfectant (so many are these days) or is it a 2-step product, and 2) is the surface visibly soiled or is C. diff or C. auris involved?  If the surface is not visibly soiled and you have a 1-step cleaner-disinfectant, then a pre-cleaning step is not required. You also have to follow the IFUs — if it says a pre-cleaning step is required, then you must do so. See the EPA's 6 steps for safe and effective disinfectant use. Even they say pre-clean if the directions mention pre-cleaning or if the surface is visibly soiled.

Question 8: Are there any alternatives to using microfiber with quaternary ammonium compounds (“quats”)?


Alternatives to using microfiber would be to use a disposable ready-to-use disinfectant wipe. Also, electrostatic application of disinfectant does not have the quat binding issue as no manual wiping required.

I hope you found this Q&A helpful. Keep those questions coming — you can find me on Twitter or LinkedIn. You can also learn more in our Resource and Education Center.


1. Rutala, W. (2019, Aug). Best Practices in Disinfection of Noncritical Surfaces in the Healthcare Setting: A Bundle Approach [PowerPoint Slides]. AHE Exchange Conference.


We were all hopeful this summer was going to bring the end of the COVID-19 pandemic and we could get back to life as we once knew it. We may be done with this virus, but it certainly is not done with us as variants continue to stoke the flames. Although we are still in the thick of this pandemic, the optimist in me likes to think that we should start to think about the future, beyond COVID-19. This pandemic changed everything including the way we clean and disinfect our facilities. In this post, I will highlight practices that can be discontinued and those that should be hard-wired.

Extreme Cleaning and Disinfection

Early in the pandemic, before much was known about the SARS-CoV-2 virus and how it was transmitted, extreme cleaning was a common occurrence – both inside and outside of healthcare facilities. Some have referred to this as “Hygiene Theatre,” which is the act of increasing hygiene protocols that may make patients, visitors and workers feel safe, but has no real correlation to lowering the risk of infection. An unprecedented awareness and focus on infection prevention including hand hygiene and cleaning and disinfecting catalyzed across healthcare. Healthcare workers banded together in their shared responsibility for infection control practices to protect patients and each other.

Over time, as more was learned about the virus, the CDC de-emphasized the importance of cleaning and disinfection, citing low risk of transmission from environmental surfaces. This is generally true, however, the risk does increase when a COVID-19 positive patient is present and is shedding the virus into their immediate environment. Hopefully, by now, we have all stopped extreme cleaning. However, continued diligence to cleaning and disinfection is still necessary as it plays an imperative role as part of a holistic strategy to protect patients, visitors, and staff from other pathogens that are easily transmitted via surfaces.

While we are still in the midst of a global pandemic, enhanced cleaning and disinfection protocols that align with Centers for Disease Control and Prevention guidance and the Occupational Safety and Health Administration Emergency Temporary Standard (OSHA ETS) requirements. I like to think of enhanced cleaning and disinfection as somewhere between our routine processes and extreme cleaning and disinfection — it’s the “happy middle.” Frequent disinfection of high-touch surfaces should be included in these enhanced measures.

It is important to apply the lessons learned during this pandemic. This is an opportune time for Infection Preventionists (IPs) to collaborate with Environmental Services (EVS) to assess whether the cleaning procedures they’ve adopted at the onset of the pandemic still serve the facility’s needs and meet regulatory requirements.

COVID-19: Not the Only Pathogen of Concern

Over the past year and a half, with our focus on a single pathogen — SARS-CoV-2, other pathogens have gone under the radar. One that is highly concerning is drug-resistant Candida auris (C. auris). Several facility outbreaks have been reported in the U.S. and case counts have nearly doubled during the pandemic.1,2 This pathogen can survive for prolonged periods on environmental surfaces, including portable equipment. Its primary route of transmission is contact with contaminated environmental surfaces, including medical equipment, fomites, and from person-to-person such as from unclean hands. One recommended strategy to reduce the risk of transmission of a broader range of pathogens, like C. auris, is a horizontal and standardized approach to cleaning and disinfection.3 Even a pathogen like Clostridioides difficile can be managed under a horizontal approach as many of today’s sporicidal disinfectants have great surface compatibility for everyday use.

Everyone Plays a Role in Cleaning and Disinfection

This pandemic highlighted the importance of a sanitary healthcare environment to keep patients, visitors, and staff safe. While we don’t want to slow down their cleaning and disinfecting efforts, it is time to give some tasks back to the cleaning professionals. For example, early in the pandemic when supplies were limited, nurses took on occupied daily room cleaning to conserve personal protective equipment (PPE). Now that PPE supplies have normalized, EVS should perform this task. This begs the question, what should nurses continue to do?

At least once per shift in their assigned patient rooms, nurses should clean and disinfect high-touch surfaces, including medical equipment — particularly the high-touch surfaces like control panels. We don’t hesitate to clean our hands frequently, but it’s important to note that our hands are only as clean as the environment around us, so it is important to routinely clean and disinfection surfaces as well.

Nurses aren’t the only healthcare workers, so you are probably wondering, what should other staff members do? Much like the nursing staff, they too should ensure that their work spaces are clean. Remember, EVS is only required to clean any given area once per day, and we must question if this is enough given the high traffic in hospitals. All staff should clean and disinfect work spaces at least once per shift as well as clean and disinfect any patient care equipment after each use. With many EVS department’s short staffed, it’s important that office workers do their part by cleaning and disinfecting their desk areas and high-touch items such telephones and printer control panels.


A sanitary environment is key to infection prevention and control efforts, regardless of pathogen. Hopefully, the next normal for cleaning and disinfection in healthcare will mean more collaboration among disciplines as well as more appreciation for IPs and EVS professionals.

For the latest information on COVID-19 and variants, visit our CloroxPro COVID-19 Hub.


1. Pan-American Health Organization. (2021). Epidemiological Alert: Candida auris outbreaks in health care services in the context of the COVID-19 pandemic – 6 February 2021. [Internet]. [Cited 2021 Sep 13]. Available from
2. CDC. (2021). Tracking Candida auris. [Internet]. [Cited 2021 Sep 13]. Available from
3. Wenzel R, Edmond M. Infection Control: The Case for Horizontal Rather than Vertical Interventional Programs. International Journal of Infectious Diseases. 2010; S3-5.

Infection prevention and control (IP&C) has always been a cornerstone of protecting public health, though often taken for granted when it comes to its place in healthcare delivery. The COVID-19 pandemic has started to shift mindsets towards a deeper awareness of the criticality of the role across the continuum of care, and a new recognition of the role infection preventionists (IPs) play behind the scenes. Every year, International Infection Prevention Week (IIPW) aims to shine a light on IP&C, and this year will be no different. But as the pandemic continues to reshape healthcare, people have learned that we all share the responsibilities of IP&C and play a crucial role in keeping each other and our patients safe. This year’s IIPW theme of “Make Your Intention Infection Prevention” could not be more fitting. Meet Pallavi, Brandi and Michelle, three women awarded scholarships by Clorox Healthcare and the Association for Professionals in Infection Control and Epidemiology (APIC), and hear their stories on how they joined the IP ranks in the midst of the pandemic.

Pallavi Bekal, BS, MS — Infection Preventionist, Community Medical Centers

For Pallavi Bekal, infection prevention fell into her lap. With a background in laboratory sciences, she transitioned early last year from clinical research and teaching to an IP position at Clovis Community Medical Center, an acute care hospital in Clovis, California. At first, she questioned if her background would be a fit, but she soon discovered that although nurses have traditionally become IPs, other disciplines and experiences like her own are widely accepted. Bekal’s rich clinical background, in fact, prepared her for many of the analytical aspects of the job, which complemented her peers who may have started in nursing.

In her experience, infection prevention often has a perception as being focused narrowly on being the resident hand-hygiene police. But as we continue to navigate the COVID-19 pandemic, Bekal is watching a shift in how the role is gaining a whole new cultural and industry-wide recognition. People now realize how much more IPs are than hand hygiene police. “I think one of the biggest challenges moving forward is going to be empowering healthcare staff to feel capable of handling infection prevention themselves,” said Bekal. “All of a sudden, everyone is aware of the shared responsibility to stay up to date on public health guidelines and recommendations, not just the IPs.”

Brandi Ford, BSN, RN, CIC — Board Certified Infection Control Nurse, Artesia General Hospital

Growing up, infection prevention was part of Brandi Ford’s everyday life. With both her parents dedicated to the well-being of their small community of Artesia, New Mexico, Ford learned the importance of infection control at an early age. Ford was unfamiliar with having a career in Infection Prevention until the only Infection Preventionist (IP) nurse at the hospital she was working at announced her retirement and spoke to her about the position. It seemed like a natural next step for Ford — one that combined her passions for environmental hygiene and care delivery.

With Artesia located approximately four hours from the nearest trauma center, Ford’s hospital serves as the first port-of call to nearly 12,000 residents within the community. When the COVID-19 pandemic hit, Ford and the hospital team came together to care for patients with only six ventilators, no ICU and no infectious disease doctors on staff. “If the pandemic has taught us anything, it’s that infection prevention is often overlooked and misunderstood,” said Ford. “Eyes have definitely opened over the past year and a half.” She hopes that this experience will lead to an influx of new IPs and a deeper appreciation of infection prevention practices at hospitals nationwide.

Michelle Clark, BSN, RN, CPN – Infection Prevention Specialist, Valley Children’s Hospital

Infection prevention was not at the top of Michelle Clark’s career ambitions. As a nurse working the night shift at Valley Children’s Hospital in Madera, California, Clark didn’t have the opportunity to work with those in other departments who worked traditional business hours. That all changed when the COVID-19 pandemic hit. After being tapped to act as an onsite “COVID-19 RN coordinator,” she quickly became the go-to resource for the entire hospital. The longer she spent as a “COVID-19 RN coordinator,” the more she understood the infection prevention role that she was naturally evolving into. Ultimately, she pursued a career as an IP, which has enriched and expanded her background in psychobiology, microbiology and chemistry.

For Clark, and many other healthcare professionals, the COVID-19 pandemic has been a catalyst that has heightened awareness of what infection prevention is. Though IPs are continuing to do behind-the-scenes work that defined their role prior to the pandemic, infection prevention is getting new recognition across the continuum of care. While day-to-day in healthcare has never been routine, Clark believes the future of care delivery will be centered around accepting constant change and remaining flexible when it comes to flexing traditional roles to include enhanced infection prevention practices.

IPs fight to keep our patients, visitors, and staff — and more and more — our communities safe — whether from a global pandemic or everyday cold and flu season. While IIPW and infection prevention conferences alike aim to inspire the next generation of IPs to join the fight, we all have a shared responsibility to help prevent infection. As we begin a week focused on celebrating IPs for their bravery and tireless efforts, ask yourself this: How can I make a difference in the fight against infections in my day-to-day life?

On January 31, 2020, the US Department of Health and Human Services declared the COVID-19 situation a public health emergency.1 Nearly year and a half later in June 2021, the Occupational Safety and Health Administration (OSHA) issued the COVID-19 Emergency Temporary Standard (ETS) CFR 1910.502.2 The ETS requires employers in all healthcare settings to develop and implement a COVID-19 Plan to identify and control COVID-19 hazards in order to protect workers when treating suspected or confirmed COVID-19 patients This blog post will focus on the cleaning and disinfection requirements of the ETS.

Employers must conduct a hazard assessment of the entire workplace to identify and understand where COVID-19 hazards might exist and what controls must be implemented to minimize the risk of COVID-19 transmission. High risk areas, tasks, and occupations must be identified in the assessment. This includes the identification of high-touch surfaces. Facilities are expected to follow both the CDCs “Guidelines for Environmental Infection Control in Healthcare Facilities” for standard practices for cleaning and disinfection of surfaces and equipment as well as the COVID-specific recommendations found in the CDCs “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic”.  The latter guidance calls for the following:

Furthermore, the ETS requires that employers have cleaning and disinfecting policies and procedures. The cleaning frequencies to be included in the policies are outlined below:

To avoid costly citations, you may wish to familiarize yourself with the OSHA Inspection Procedures.3

When will the OSHA ETS end? In all likelihood, when the public health emergency is declared over, the ETS will “end” with the many of the elements being absorbed into other existing OSHA standards such as the general respiratory protection standard.


On December 27, 2021, OSHA issued a statement that the ETS will remain in effect as they continue to work on a permanent standard, however they have withdrawn the non-record keeping portions of the ETS. In OSHA's language: "given OSHA's anticipated finalization of this rule, OSHA strongly encourages all healthcare employers to continue to implement the ETS's requirements in order to protect employees from a hazard that too often causes death or serious physical harm to employees." My recommendation in order to avoid confusion with staff (e.g., start-stop-start again) is to continue to follow the ETS as originally written as the elements will, in likelihood, be included in the final rule.

1. U.S. Department of Health and Human Services. Determination that a Public Health Emergency Exists [internet]. [cited 2021 Aug 21]. Available from
2. Occupational Safety and Health Administration. COVID-19 Emergency Temporary Standard. COVID-19 Healthcare ETS [internet]. [cited 2021 Aug 21]. Available from
3. Occupational Safety and Health Administration. Inspection Procedures for the COVID-19 Emergency [internet]. [cited 2021 Aug 21]. Available from

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