Introduction

While the COVID-19 pandemic appears to be slowing down, the next pandemic is knocking at our door – infections caused by antibiotic resistant organisms (ARO). The post-antibiotic era isn’t coming – it’s here.1 According to Dr. Arjun Srinivasan with the Centers for Disease Control & Prevention (CDC), “The COVID-19 pandemic has created the perfect storm for antibiotic resistance. Prolonged lengths of stay; crowding; and infection control challenges, such as training gaps and shortages in PPE, all contribute.”2 It is estimated that in the next 30 years, deaths caused by AROs will surpass those caused by all cancers combined.3

The two AROs we’ll focus on are Candida auris (C. auris) and Clostridioides difficile (C. diff), both of which are considered urgent threats, according to the CDCs most recent Antibiotic Resistance Threats Report. What these two pathogens hold in common is their ability to cause severe infections, survive in the environment for prolonged periods, and spread easily between hospitalized patients and nursing home residents. In 2018, there were only 323 known clinical cases of C. auris.1 As of November 2020, the total has climbed to 1,595 which represents a nearly 400% increase in just two years.4 Moreover, to demonstrate how quickly the C. auris yeast can spread, in March 2017, a single case of C. auris was identified on a ventilator unit in Chicago. Sixteen months later, C. auris prevalence on the unit was 71%.5

Regarding C. diff, while we have made progress in reducing healthcare-onset rates in recent years, some studies show that these rates may have increased during the pandemic.6 But there are also studies that show a decrease.7,8,9 With the CMS reporting waivers during the pandemic, we may never know the true impact, at least not for a while. Regardless, C. diff remains the most common cause of healthcare-associated infections, more than half of which occur among recently hospitalized long-term care facility residents.1

Deviations from recommended infection control practices during the pandemic, fueled by fear of a novel pathogen, staffing challenges and supply chain challenges may have contributed to outbreaks of these two pathogens. For example, at one facility, a C. auris outbreak involving 35 patients was attributed to such deviations. In addition to missed hand hygiene opportunities, the CDC investigators found incorrect use of PPE and inconsistent disinfection of mobile computers and medical equipment between uses. . However, one of the control measures that helped in stopping this outbreak was enhanced cleaning and disinfection practices.10

Take Action to Prevent the Spread

The importance of infection prevention and control measures cannot be over-emphasized. The strategies to control these two pathogens are similar and include antibiotic stewardship, surveillance, diagnostic testing, transmission-based precautions, hand hygiene, inter-facility communication, and cleaning and disinfection of environmental surfaces and medical equipment. In this final section, we will focus on cleaning and disinfection.

Both of these contact-spread pathogenscan survive for prolonged periods on surfaces.  C. auris can survive for weeks and C. diff can survive up to 5 months making cleaning and disinfecting an imperative practice.11,12 Below are some key points around cleaning and disinfection when C. diff or C. auris are present:

Conclusion

These two urgent threat pathogens have many factors in common, which include an affinity for environmental surfaces, including medical equipment and for causing outbreaks. Robust cleaning and disinfecting programs are a key infection control measure.

References

  1. CDC. (2019). Antibiotic Resistance Threats in the United States. [online]. [cited 2021 Mar 13]. Available from https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf.
  2. Medscape Nurses. (2020). CDC Doc Addresses Today’s Pandemic and the Next. [online]. [cited 2021 Mar 13]. Available from https://www.medscape.com/viewarticle/941169.
  3. WHO. [2019]. New Report Calls for Urgent Action to Avert Microbial Resistance Crisis. [online]. [cited 2021 Mar 13]. Available from https://www.who.int/news/item/29-04-2019-new-report-calls-for-urgent-action-to-avert-antimicrobial-resistance-crisis.
  4. CDC. (2021). Tracking Candida auris. [online]. [cited 2021 Mar 14]. Available from https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html
  5. Chicago Department of Public Health. (2018). 23rd Annual Infection Control Conference: Candida auris Emergence and Containment Efforts in the Chicago Region. [online].[cited 2021 Mar 14]. Available from https://www.chicagohan.org.
  6. Lewandowski K, Rosołowski M, Kaniewska M, Kucha P, Meler A, Wierzba W, et al. Clostridioides difficile Infection In Coronavirus Disease (COVID-19): An Underestimated Problem? Pol Arch Intern Med. 2021 Feb 26;131(2):121-127.
  7. Assi M, Doll M, Pryor R, Cooper K, Bearman G, Stevens MP. Impact of COVID-19 on Healthcare-Associated Infections: An Update and Perspective. Infect Control Hosp Epidemiol. 2021 Mar 12:1-9.
  8. Bentivegna E, Alessio G, Spuntarelli V, Luciani M, Santino I, Simmaco M, et al. Impact of COVID-19 Prevention Measures on Risk of healthcare-Associated Clostridioides difficile Infection. Am J Infect Control. 2020 Oct 5:S0196-6553(20)30891-9.
  9. Ponce-Alonso M, Sáez de la Fuente J, Rincón-Carlavilla A, Moreno-Nunez P, Martínez-García L, Escudero-Sánchez R, et al. Hospital-Onset Clostridioides difficile Infections During the COVID-19 Pandemic. J.Infect Control Hosp Epidemiol. 2020 Sep 8:1-5.
  10. CDC. (2021). MMWR Vol. 70: Candida auris Outbreak in a COVID-19 Specialty Care Unit – Florida, July-August 2020. [online].[cited 2021 Mar 15]. Available from https://www.cdc.gov/mmwr/volumes/70/wr/mm7002e3.htm
  11. Fekety R, Kim KH, Brown D, Batts DH, Cudmore M, Silva. Epidemiology of antibiotic-associated colitis; isolation of Clostridium difficile from the hospital environment. Am. J. Med. 1981; 70:906–908.
  12. CDC. (2019). Candida auris: Healthcare Professional FAQ.[online]. [cited 2021 Mar 14]. Available from https://www.cdc.gov/fungal/candida-auris/c-auris-health-qa.html  
  13. CDC. (2020).Infection Prevention and Control for Candida auris. [online]. [cited 2021 Mar 14]. Available from https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html#disinfection.
  14. EPA. (nd). Pesticide Product and Label System. [online]. [cited 2021 Mar 19]. Available from https://iaspub.epa.gov/apex/pesticides/f?p=PPLS:1.
  15. CDC. (2019). Strategies to Prevent Clostridioides difficile Infection in Acute Care Facilities. [online]. [cited 2021 Mar 15]. Available from https://www.cdc.gov/hai/prevent/cdi-prevention-strategies.html.
  16. Donskey C, Cadnum J, Jenscon A, Livingston S, Li D, Redmond S, et al. (2020). Evaluation of an electrostatic sprayer disinfectant technology for rapid decontamination of portable equipment and large open areas in the era of SARS-CoV-2. AJIC, (48):951-954.

The COVID-19 pandemic has created unprecedented and continuing difficulties for healthcare providers, health systems, and patients alike. With any novel pathogen such as SARS-CoV-2, the virus that causes COVID-19, public health professionals, and healthcare providers continuously evolve their approach to the pandemic response. During times of increased focus on certain infection control practices such as hand hygiene agents and environmental disinfectants, challenges to the supply chain can rapidly emerge. Still, they can be addressed by implementing a robust pandemic response plan to facilitate appropriate product substitutions.

The Centers for Disease Control and Prevention (CDC) and the Environmental Protection Agency (EPA) have released extensive guidance regarding the use of EPA-registered disinfectants during the ongoing COVID-19 pandemic. In addition, the EPA created a specific list, List N. Disinfectants for Coronavirus (COVID-19). This is a list of EPA-registered disinfectants that are deemed effective against SARS-CoV-2. The use of products on this validated list from the EPA provides healthcare users an additional level of assurance of efficacy against the virus that causes COVID-19.

Many disinfectant manufacturers offer the same active ingredient formulations in multiple product formats (ready-to-use wipes, liquids, sprays, etc.), which can mitigate any significant impacts for healthcare facilities during pandemic scenarios. Similar to stockpiling certain medical equipment and supplies such as Personal Protective Equipment (PPE), it would be advisable for healthcare facilities to have a comprehensive pandemic plan in place to address increased environmental disinfection needs across the healthcare continuum of care.

Analogous to the CDC’s approach to the use of PPE, a comparable process can easily be created for identifying appropriate disinfectant product substitutes during a pandemic crisis. As such, a three-tiered approach can be implemented to include:

When selecting product substitutes, healthcare users should consult the EPA’s master label for the product being evaluated, review any technical information on surface compatibility, as well as carefully review the product’s Safety Data Sheet (SDS). The intended location of use for the product can also impact the ideal product to be used such as inpatient vs. outpatient settings where risks would be substantially different. Certain inert or inactive ingredients, for example, may increase the risk for equipment degradation, so healthcare users should contact the disinfectant manufacturers and request a complete listing of all product ingredients and information on known equipment compatibility with commonly found surfaces and medical devices used in healthcare settings. Healthcare users of disinfectants should also consult the product instructional manual from the medical equipment manufacturer for specific cleaning and disinfection instructions.

When forced to select alternative disinfectants or disinfectant chemistries, Infection Preventionists and Environmental Services Leaders should evaluate these substitutes in terms of three primary criteria:

The COVID-19 pandemic continues to place significant strains on our healthcare systems and providers. Infection control practices such as disinfection, hand hygiene, and the appropriate use of PPE remain important aspects of decreasing the spread of SARS-CoV-2. Disinfectant manufacturers are the primary sources of expertise in the areas of product formulation, product format, contact times, material compatibility, and product safety. Infection Preventionists and EVS Leaders should closely collaborate with their preferred disinfectant manufacturer and medical suppliers on pandemic preparedness needs and the most appropriate product substitutions.

Moreover, many disinfectant manufacturers have created product substitution tools that can help ensure that all new products utilized within a facility will continue to meet the stringent infection control needs as identified by the Infection Prevention and Control Team. Pandemics require a collaborative, transparent, and highly communicative approach to overcome their impacts. While the healthcare industry continues to face challenges, it is certainly possible to maintain a safe standard of care related to environmental cleaning and disinfection by following a standardized approach.

For additional information:

Dr. Hudson Garrett Jr. is a paid consultant for Clorox Healthcare.

A Little About Me

I have been a nurse since 1993 and have worked as an Infection Preventionist (IP) for the past 20 years. Throughout my infection control career, I’ve faced challenges such as the potential weaponizing of smallpox after 9/11, the SARS outbreak in 2003, the H1N1 pandemic in 2009, and the Ebola outbreak in 2014 (just to name a few). I have seen a lot of tragedy and hardship, most of which I never would have dreamed of seeing in a million years.

In 2018, I made a big change in my infection control path. I was afforded an opportunity to join the Clorox Healthcare team as a Senior Infection Preventionist. After completing my first year in my new role, the COVID-19 pandemic was just beginning – a monumental pandemic that we will likely never see again in our lifetimes. In a matter of a few months, COVID-19 spread like wildfire to nearly every continent. We spent most of 2020 in lockdown, and infection prevention became more relevant than ever.

My COVID-19 Pandemic Story

In March of 2020, as part of the emergency response to COVID-19, California Governor Gavin Newsom released an executive order allowing the state of California to commandeer hotels and medical facilities to treat COVID-19 patients. This was termed “Project Roomkey 2 and local counties were tasked with manning these shelters.1

In my local county, some of these hotels are being used as temporary isolation housing for unsheltered residents. The intent is to reduce transmission in the community from infected persons who are experiencing homelessness or live in congregate or over-crowded settings (e.g., prisons, etc.). Meanwhile, some of the hotels (named Safer Ground sites) are designated for medically fragile persons who meet the above criteria and have not been diagnosed with COVID.2 

The other hotels (named Operation Comfort sites) serve as shelters to quarantine or isolate COVID-positive or COVID-exposed individuals who meet the criteria listed above. Project Roomkey takes referrals from hospitals, clinics, prisons, emergency shelters, and homeless outreach teams.

Last summer, I learned through a friend that our local county public health department was looking for nurses to replace the public health nurses at the shelters, who were desperately needed by the county to return to their usual public health roles. With a full-blown pandemic underfoot, I had been chomping at the bit to be able to put my IP skills to work and contribute in a substantive way. I was hired part-time to supervise nurses at the COVID-positive shelters. Since July 2020, I have been working every other weekend with medically fragile COVID-positive individuals in the hotels in an underserved area of East Oakland, California.

Challenges from the Front Lines

Since an “isolation/quarantine” hotel had never been created or utilized in modern times, we’ve had to continuously learn and adapt to new situations. This often means that our protocols, along with the CDC guidance for COVID-19, is also continuously evolving. Furthermore, as is often the case in public health nursing, we are with faced limited resources. This includes things as simple as having a consistent supply of environmental surface disinfectants.  Just about every time I report for duty, we have a different disinfectant which means having to learn the instructions for use, including the contact time.  Also, with the supply chain shortages, it means we have to remember to save our empty bottles and trigger sprays for refilling.

As if fighting COVID-19 were not enough, we’ve also had to address the complicated health and social issues our patients face on a daily basis outside of the pandemic, such as mental health and/or substance abuse disorders. My fellow nurses and I must simultaneously monitor our patients’ COVID symptoms as well as any withdrawal or suicidal ideation indicators. Some of our patients also have complex health issues (e.g., diabetes) so we work diligently to coordinate the appropriate care.

Additionally, patients at Project Roomkey come from all types of socioeconomic backgrounds. For low-income community members, having to quarantine for 14 days or stay isolated at a hotel could mean missing a paycheck or risking the next meal for their family. Meeting these patients’ social or other medical needs is not easy when your patient also has an infectious disease like COVID-19. I quickly realized that it’s not the same as working in the hospital outside the pandemic where virtually every resource you need to do your job is on-hand.

In addition to our patients, our nursing staff also come from a variety of backgrounds, which range from new graduates to veteran caregivers. Clinical backgrounds include hospital (ICU, OR, and Medical-Surgical), long-term care, home care, infection prevention and control, behavioral health, public health, and even nurses from academia. What I appreciated this past year was that no one used their specialty to appear superior to anyone else. We simply leaned on each other’s strengths and got the work done.

Finding Inspiration Among the Hardship

Since this work takes place in addition to my regular “day job” with Clorox Healthcare, I’ve had to find inspiration to keep showing up every other weekend. Fortunately, this did not prove to be too difficult as I’ve found great inspiration in both my patients and my coworkers. The most vulnerable in our community needed us during this historic event and as a nurse, I felt that it was my duty to help.

Like me, many of my fellow hotel coworkers took on this work in addition to their “day jobs.” Their dedication motivates me to keep showing up week after week. These amazing individuals not only give their time and skills, but they often donate items to these families in need - things like winter clothing, children’s toys, and games to keep them occupied during quarantine. In addition to nurses, the healthcare team includes nurse practitioners, physicians, mental health providers, substance abuse providers, and pharmacists. Meanwhile, we couldn’t do any of this without the relentless work of the facilities team, housing support staff, housekeepers, cooks and security guards in the hotels. The team collaboration and the comradery of this group has been truly something amazing to be a part of. 

Finally, I would be remiss if I didn’t recognize the inspiration provided by all of my fellow IPs out there wherever they have been working during this pandemic. Your dedication to our profession is nothing short of remarkable.

Relief is in Sight

When both the Moderna and Pfizer vaccines were granted Emergency Use Authorization (EUA) from the Federal Drug Administration in December 2020, I was beyond elated to help run the staff vaccination clinic.3 Along with a few of my coworkers, we administered nearly 140 first doses to our fellow shelter workers, which included nurses, medical assistants, housing support staff, housekeepers, cooks, and security guards. I was more than happy to do it all over again four weeks later, too. Being able to offer hope through a vaccine has brought me such joy that I have volunteered to administer vaccinations to the general public as well.

As public health officials, healthcare workers, and members of our community continue to come together to help fight the spread of COVID-19, I’m grateful for the resilience I’ve witnessed first-hand over the past year. This virus is not done with us yet and we are not done fighting, but I have hope for the future. Before the pandemic struck, 2020 had been designated the International Year of the Nurse in honor of the 200th anniversary of Florence Nightingale’s birthday.4  While this may have been lost in the chaos of the pandemic, we nurses will never forget the additional meaning behind this past year.

References

  1. Alameda County Public Health Care for the Homeless. Isolation Housing for COVID-19 [nternet]. [cited 2021 Mar 7]. Available from: https://www.achch.org/isolation-housing.html
  2. Office of the Governor Gavin Newsom. Governor Newsom Issues New Executive Order Further Enhancing State and local Government’s Ability to Respond to COVID-19 Pandemic [internet]. [cited 2021 Mar 7]. Available from: https://www.gov.ca.gov/2020/03/12/governor-newsom-issues-new-executive-order-further-enhancing-state-and-local-governments-ability-to-respond-to-covid-19-pandemic/
  3. Federal U.S. Food & Drug Administration. COVID-19 Vaccines [internet]. [cited 2021 Mar 7]. Available from: https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/covid-19-vaccines
  4.  World Health Organization. Executive Board Designates 2020 as the “Year of the Nurse and midwide.” [internet]. [cited 2021 Mar 7]. Available from: https://www.who.int/news/item/30-01-2019-executive-board-designates-2020-as-the-year-of-the-nurse-and-midwife-

The world of touchless disinfection is growing quickly and there is a lot of varying information available. Taking on a new technology can be daunting. Maybe you have done your homework and you are interested in adding electrostatic sprayers at your facility. Or maybe you have already added them in and still have questions. Below I have laid out some best practice recommendations. Ultimately, there is no one-size-fits-all for acute healthcare settings, but hopefully some of these give you and your team a place to start.

  1. Educate Internally
    Electrostatics, foggers, misters, oh my! You might have these technologies straight in your mind (if not, check out Breaking Down Electrostatic Technology: Everything You Need to Know), but there is a good chance your colleagues are not completely clear on the key differentiators. As with all areas of Infection Prevention and Public Health, education up front can do a lot to mitigate concerns and misinformation. It can also help to identify those on the Environmental Services (EVS) team that will be your key operators and trainers. I recommend leveraging trainings offered by your electrostatic sprayer and/or disinfectant manufacturer. Many offer online training videos and resources to assist you in setting up a plan for initial and ongoing training.
  2. Confirm your Disinfectant is EPA Approved for Electrostatic Use
    This one seems obvious, but I think it is an important reminder. Your electrostatic sprayer manufacturer should provide a list of safe chemicals that have been tested and approved by the United States Environmental Protection Agency (EPA) for use through an electrostatic sprayer. This ensures safety not only for the operators but also for patients and other staff members in the area. Not all devices are created equally. Similarly, not all disinfectants are safe or effective when used through an electrostatic sprayer. If you are not sure if a disinfectant has been approved for electrostatic use, you can look up the Master Label on the EPA website by using the EPA Registration Number.
  3. Target Your Electrostatic Disinfectant Based on Area
    Once you have identified the list of safe EPA-approved chemicals, consider selecting more than one electrostatic disinfectant for your facility. Your decision to use one disinfectant versus another may vary depending on the type of area, surface compatibility, frequency of use, and the number of devices you are planning on employing. The same strategies you use in your protocols now with wipes and trigger sprays should also be considered when you are adding electrostatic sprayers to your arsenal. For example, you may choose to use a sporicidal product in your patient areas where the risk of C. difficile is a concern and then use a more general hospital disinfectant in your lobby and waiting rooms. Your individual risk assessments can also help to drive these decisions.
  4. Develop a Step-by-Step Protocol
    Having a clear and easy-to-understand protocol will help to prevent any potential issues. Here are some suggestions for setting electrostatic sprayer operators up for success in your protocol development:
    • Always recommend gathering supplies in advance, performing hand hygiene, and putting on appropriate personal protective equipment (PPE) prior to spraying.
    • Have operators remove all linens, paper products and trash from the spray area. I recommend placing a sign outside to indicate that cleaning is in progress. Of note, most products do not recommend use of an electrostatic sprayer while bystanders are in the area. Re-entry time will depend on the disinfectant in use and can be affected by other factors such as air exchange rates, temperature, and humidity.
    • Be sure to include a step for cleaning visible soil. Electrostatic sprayers can be an adjunct to routine manual cleaning and disinfection or a stand-alone step if there is no visible soil on the surface.
  5. Don’t Forget About Spraying Strategy
    • Make sure to clearly spray target surfaces and avoid just spraying into the air.
    • Stick to one spraying path: clockwise or counterclockwise.
    • Use a zone approach to spray, starting with the far side of the area and working towards the door.
    • Spray using a slow, side-to-side motion, working from high to low surfaces.
    • Stand the appropriate distance from surfaces when spraying. The required distance may vary by electrostatic sprayer. Your goal is to have surfaces wet but not saturated. HINT: If you see dripping or pooling of liquid, you have sprayed too much!
    • Try to maintain a consistent spraying approach with the exception of sensitive electronics and glass or mirrored surfaces. These surfaces may require a wiping step after the contact time has been reached to remove residue and to keep surfaces looking polished.

The dynamics of healthcare disinfection are constantly changing, especially as a result of the ongoing COVID-19 pandemic. Given the large volume of environmental surfaces that can become contaminated during the routine delivery of clinical care, healthcare facilities are constantly evaluating the most efficient solutions for large-scale disinfection.

There are multiple different modalities that healthcare providers and Environmental Services (EVS) technicians can use to disinfect commonly contaminated environmental surfaces. Most notably, ultraviolet (UV) light devices and electrostatic sprayers are being used on a large scale across the United States to combat potential COVID-19 transmission. Both of these solutions afford the ability to more effectively and easily disinfect large surface areas, especially for terminal turnover of patient care environments.

Healthcare facilities may even use a combination of these different types of devices across the health system to meet specific disinfection needs. During pandemics like the COVID-19 pandemic in high-flow patient settings such as Emergency Departments, room turnover time is a key metric for healthcare delivery efficiency. The use of technologies such as UV devices or electrostatic sprayers can be extremely beneficial as part of an overall Environment of Care and Infection Prevention and Control program.

When using these types of technologies, users should receive specific training on the appropriate use of the technology prior to deploying it in the facility. Additionally, both UV devices and electrostatic sprayers require the patient care room to be unoccupied to maintain patient safety while the technologies are being used. The healthcare marketplace is filled with various different devices that each have unique capabilities. When selecting an electrostatic device, healthcare and EVS leaders should evaluate all technologies using a standardized approach which includes a review of:

Novel technologies such as UV devices and electrostatic sprayers are important aspects of a comprehensive Environment of Care program and the reduction of healthcare-associated infections. These technologies must be carefully evaluated prior to use, implemented and used according to the manufacturer’s instructions for use, and then environmental monitoring principles should be followed in accordance with the recommendations from the Centers for Disease Control and Prevention. Whether during a pandemic or for regular disinfection purposes, electrostatic sprayer technologies are playing a larger role in the reduction of cross transmission across both healthcare and non-healthcare sectors.

For additional information:

Dr. Hudson Garrett Jr. is a paid consultant for Clorox Healthcare.

Guidelines from several government and professional organizations lead one to believe that the use of spray disinfectants in healthcare settings is “taboo”.  The primary rationale cited for this is concern for the production of aerosols and also for contaminated solutions. In true Infection Preventionist form, I decided to take a closer look at the evidence that informs these guidelines. The bottom line is that I could not find much evidence to support NOT using sprays disinfectants when appropriate, at least nothing current.  Let’s take a closer look.

The Evidence

What evidence was used to inform these guidelines? For their recommendations around use of spray disinfectants in healthcare settings, the Centers for Disease Control and Epidemiology (CDC) Guidelines cite four studies ranging from 21-49 years old with little relevance to spray disinfectants.1 As I chased the evidence trail, the studies just got older and older. The most curious finding was the lack of relevance of these studies. The guideline authors are generalizing results from studies that looked at floor care and vacuuming with outdated and faulty equipment, construction activities, use of porous insulation in buildings as a source of pathogens, and prevention of opportunistic infections in stem cell transplant patients to support their stance on not using spray disinfectants.

As for the guidelines from the key professional organizations, most simply cite the CDC’s guidance. Take for example the Association for periOperative Registered Nurses (AORN) Perioperative Practice Guidelines which recommend against the use of spray bottles in the operating room.2  AORN cites the CDC guidelines and states that “sprayed disinfectants produce more aerosols compared to other formats”.2 They also provide the rationale that “if the cleaning solution is contaminated, spraying may provide a route for airborne transmission which may contaminate the surgical wound, sterile supplies, or the sterile field”.2

With today’s pre-diluted, ready-to-use (RTU) sprays and liquids, the chance of contaminated product is virtually zero3. I would also like to call out that we should not be carrying out environmental cleaning tasks when the patient with a surgical wound or sterile supplies are present anyway - regardless of the disinfectant format used!

The Association for the Healthcare Environment (AHE) Practice Guidance provides no rationale or evidence for their recommendation to “apply chemicals using pour spouts, rather than sprayers”.4 Like AORN, AHE recommends “no spraying or misting bottles in the OR as they may aerosolize the disinfectant”.  The source for this guidance? AORNs guidelines which point to the CDC Guidance addressed above. As you can see, we are traversing quite the rabbit hole!

Most importantly, I could find no mention on use of spray disinfectants from the Association for Professionals in Infection Control & Epidemiology (APIC) or from the Centers for Medicare & Medicaid (CMS), the latter of which is a regulatory agency.

The basis for non-use of sprays largely centers on the concern of contaminated disinfectants made from concentrate. While this may be possible, this can eliminated with the use of RTU sprays, and the risk decreased by emphasizing the need to clean and dry spray bottles rather than “topping off”.

Modern Day Sprays

Some of today's manufactures have engineered sprayers that create larger droplets rather than an aerosolized mist which would reduce the risk that spray bottles aerosolize microorganisms or pose an occupational hazard. So if we connect the dots of what we have learned so far, spray disinfectants do have a place for use in healthcare settings.

Think about conducting a risk assessment to determine when and where in your facility that the use of spray bottles might be appropriate. Some examples might include: vacant spaces such as operating rooms between patients or at end of the day, waiting rooms, public restrooms, conference rooms, and public spaces to list a few. When considering a spray disinfectant, include the following in your assessment:

  1. The conditions in which it would be appropriate to use spray disinfectants.
  2. Information provided in the Safety Data Sheet (SDS).
  3. Product instructions for use (IFUs), including personal protective equipment (PPE).  

Summary

A reassessment of the evidence from past studies is needed. But in the meantime, we must remember that these are guidelines and not regulations and that healthcare facilities can conduct their own risk assessments and implement the appropriate use of spray disinfectants.

References

  1. Centers for Disease Control & Prevention (CDC). (2003). Environmental infection Control Guidelines from https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html.
  2. Association for periOperative Registered Nurses (AORN). (2020). Guidelines for periOperative Practice from https://www.aorn.org/guidelines/about-aorn-guidelines (subscription required).
  3. Weber, D., Rutala, W., Sickbert-Bennett, E. (2007) Outbreaks Associated with Contaminated Antiseptics and Disinfectants. Antimicrobial Agents and Chemotherapy, p. 4217-4224.
  4. Association for the Health Care Environment (AHE). (2020). Practice Guidance for Health Care Environmental Cleaning, 3rd edition from https://www.ahe.org/ahe-publications-home (subscription required).

This is the fourth post of a six-part blog series, Infections Inside Out, by Dr. Kelly Cawcutt. Read part three here.

The rise of antibiotic resistance is one of the greatest threats in healthcare today. According to the Centers for Disease Control and Prevention (CDC), every year in the United States approximately 2.8 million people develop an infection from antibiotic-resistant bacteria and over 35,000 people die.

"She was in her 70s when she was admitted to the hospital with sepsis. Her right hip was infected, and unfortunately, this was not the first infection. Two years prior, she had fractured her femur and developed osteomyelitis. She had several prior hospitalizations, but they were all in another country. Now, cultures were obtained from the head of the femur and yielded Klebsiella pneumoniae. This member of the Enterobacteriaceae family is usually easily killed by many antibiotics. However, this time testing showed that not only did this bacteria demonstrate resistance to a powerful class of antibiotics known as carbapenems (due to the presence of New Delhi metallo-betalactamase (NDM), but even more frightening, it was resistant to all other antibiotics available. The patient ultimately succumbed to septic shock."

- Chen, Lei, et al. "Notes from the Field: Pan-Resistant New Delhi Metallo-Beta-Lactamase-Producing Klebsiella pneumoniae-Washoe County, Nevada, 2016." MMWR. Morbidity and mortality weekly report 66.1 (2017): 33-33

How did this happen?

In truth, this has always been happening. Since the discovery of penicillin in 1928, we have been faced with the reality of the ongoing evolution of antibiotic resistance. So much so, that in his Nobel lecture, Sir Alexander Fleming addressed the risk of resistance if caution was not used in the administration of penicillin.

"But I would like to sound one note of warning. Penicillin is to all intents and purposes non-poisonous so there is no need to worry about giving a penicillin overdose and poisoning the patient. There may be a danger, though, in underdosage. It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body. The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant."

- Sir Alexander Fleming, Nobel Lecture, 1945

Since the onset of our first antibiotic, we have continued to see bacteria with resistance to antibiotics, including within 1–2 years from the release of the antibiotic to the description of the new resistance. Based on this, the CDC publishes a report on the biggest antibiotic-resistant threats in the U.S. The 2019 report has 18 pathogens listed as either an urgent, serious or concerning threat. Several of these bacteria will be familiar to you from prior posts — Methicillin-resistant Staphylococcus aureus (MRSA) and Carbapenem-Resistant Enterobacteriaceae (CRE), C. diff, and Candida auris (C. auris).  Others, such as carbapenem-resistant Acinetobacter and multi-drug resistant Pseudomonas aeruginosa are of urgent and serious concern, respectively, and still play significant roles in many healthcare-associated infections (HAIs).

What can we do about it?

With multiple antibiotic resistant organisms (AROs) threatening human health, focusing on prevention of continued resistance is of paramount importance. This profound public health threat resulted in a national action plan for combating antibiotic-resistant bacteria in 2015. Key aspects of this plan include improving antibiotic stewardship and adherence to infection prevention and control strategies.

Sir Alexander Fleming had it right — inappropriate use of penicillin, or any antibiotic, can result in resistance. And just as resistance has been with us since the discovery of penicillin, so has unnecessary antibiotic use. Approximately 30% of antibiotics given in US hospitals are inappropriate - based on suboptimal choice or unnecessary overall. Yet, we know that it is exposure to antibiotics that drives the evolution of resistance, and not just exposure of antibiotics to a single individual. Overuse of antibiotics in a hospital, or ward, may portend resistance to multiple patients.

Therefore, improving antibiotic use through stewardship principles is a critical step towards preventing further antibiotic resistance. The CDC has published Core Elements of Hospital Antibiotic Stewardship Programs, yet uptake of these principles is incomplete. The Infectious Diseases Society of America (IDSA) has also published guidance for implementing stewardship programs. Additionally, the Centers for Medicare and Medicaid Services have instituted requirements for antimicrobial stewardship, further highlighting the importance of this intervention. Finally, each healthcare professional can join in public health advocacy for stewardship through the CDC U.S. Antibiotic Awareness Week (scheduled for November 18-24, 2021).

But, combating antibiotic-resistant with stewardship is not enough. Infection prevention and control practices synergistically help prevent ongoing spread of these organisms. Practices that decrease the bioburden of bacteria from the environment, including from the hands of healthcare workers, are absolutely necessary. These strategies then decrease the likelihood of transmission of AROs from one patient to another.  From hand hygiene to transmission-based precautions to decrease transmission of multidrug resistant organisms (MDROs) to environmental cleaning and disinfection, infection prevention and control is quintessential in the fight against antibiotic resistance.

Thankfully, Antibiotic Resistant Doesn’t Mean Disinfectant Resistant

Monitoring for these organisms within the facility aids in recognition of possible developing outbreaks and assists in determining where the transmission may have occurred. For instance, the Agency for Healthcare Research and Quality (AHRQ) has a toolkit to assist with CRE control and prevention, which would have been a critical component for preventing both the infection and death of our patient above.

As part of these programs, we must recognize that environmental contamination with AROs or MDROs, is an essential weapon in this fight. Ensuring that the physical environment is clean, specifically frequently touched areas, cannot be understated in importance.

As infection prevention and control professionals, it is imperative that we recognize the profound threat that antibiotic resistance plays in our fight against HAIs. With inevitable use of antibiotics during our lives, we are all at risk and we all need to do our part to wage war on these formidable foes.

Kelly Cawcutt, MD, MS, FACP is a paid consultant for Clorox Healthcare.

The following is an abridged article featured in the December 2020 issue of Healthcare Hygiene Magazine (see page 32).

As a healthcare provider that is part of a Regional COVID-19 response team, I have sadly seen the direct and indirect impacts of the ongoing threat posed by COVID-19. Countless lives have been directly or indirectly impacted including those of many healthcare providers at the front lines and healthcare executives charged with leading their organizations during challenging pandemic times. This ongoing pandemic is not expected to cease anytime soon, and the upcoming fall and winter respiratory infections season could potentially produce a new dilemma with concurrently circulating infectious pathogens such as Influenza, RSV, Rhinovirus, and SARS-CoV-2, the novel coronavirus that causes COVID-19. Due to this concurrent circulation of respiratory viruses during the Fall and Winter, it is all the more important for healthcare facilities to not succumb to infection prevention fatigue and maintain an appropriate level of vigilance to the core practices of infection prevention and control.  

The Centers for Disease Control and Prevention (CDC) has identified several core recommendations that can dramatically reduce the potential risk for the transmission of respiratory viruses. Below are several key steps that healthcare providers and infection prevention professionals should take to reduce the transmission of infectious respiratory illnesses:

Each of the steps referenced above plays a pivotal role in reducing the potential transmission of infectious respiratory viruses, keeping patients and healthcare providers safe, and also ensuring the continuity of clinical care operations. Every stakeholder in the healthcare delivery system must play an active role in recognizing and preventing the spread of these common respiratory pathogens. Through interprofessional collaboration, the use of efficacious infection prevention products such as disinfectants, hand sanitizers, and PPE, we can help effectively curb the transmission of respiratory illnesses.

For additional information:

To learn more about the EPA List N, visit: https://www.epa.gov/pesticide-registration/list-n-disinfectants-coronavirus-covid-19.

Dr. Hudson Garrett Jr. is a paid consultant for Clorox Healthcare.

This post is part of our “Ask The Pros” blog series for which our internal panel of experts address the latest questions from industry professionals. This month’s query,

“Adjunct disinfection methods such as electrostatics seem to be gaining in popularity. Is a manual cleaning step always required?”

Introduction

Because Infection Preventionists have oversight of all cleaning and disinfection practices within their facilities, it’s really important to keep current on emerging disinfectant technologies, including new adjunct disinfection technologies. One such technology in high demand given the “new normal” is electrostatic sprayers. In addition to getting disinfectant into nooks and crannies, these devices can disinfect large areas in a very short time. This blog post will provide a brief overview of the technology, how best to employ its use within a healthcare facility, and safety considerations.

Electrostatic Sprayer Technology 101

Despite its growing popularity, electrostatic technology is actually not new. It’s been used for many years in other industries such as agriculture, automotive painting, and spray tanning. In healthcare, this adjunct technology is a new way to apply familiar disinfectants. The device charges the disinfectant droplets as they exit the nozzle where the disinfectant is attracted to the surface/object like a magnet. The end result is a uniform coating of disinfectant that wraps 360 degrees around targeted objects. This makes for a fast and efficient disinfecting process.

Incorporating Electrostatic Sprayer Technology into Current Processes

A study conducted by Bhalla et al (2004) showed that only 50% of healthcare surfaces were properly disinfected with manual cleaning1, creating the need for supplemental disinfectant technologies such as electrostatics. Electrostatic sprayers are intended to be an adjunct to routine manual cleaning and disinfection.

For example, consider using an electrostatic sprayer as a finishing step for terminal cleaning of C. diff, COVID, or other isolation rooms. Other considerations include terminal cleaning of operating rooms, waiting rooms, and transport equipment such as wheelchairs and gurneys.

With that said, much like we use hand sanitizer for much of our hand hygiene opportunities and reserve hand washing for specific times such as removing visible soil or C. diff spores from our hands, we can consider using an electrostatic sprayer in a similar way.

If a surface is not visibly soiled or the area did not house a C. diff patient, a manual cleaning step is not required prior to disinfection so consider using electrostatic sprayer technology in these instances. Consider that operating rooms (OR) are manually cleaned multiple times during the day (e.g., after each procedure), so why couldn’t terminal cleaning of the OR be completed using an electrostatic sprayer to apply the disinfectant?

Additionally, consider objects or areas that are likely not getting cleaned and disinfected as often as we would like because they are large spaces, or difficult to clean, such as waiting rooms or wheelchairs. Electrostatic sprayers are a great option and the Donskey study (2020) provides great evidence to support this. Keep in mind, however, just like our hands, we do still need to periodically perform manual cleaning.  

Electrostatic Sprayer Safety

First and foremost, be sure to select EPA-registered products approved for use through an electrostatic sprayer. Use of a disinfectant or sanitizer in a non-approved manner is a violation of federal law. It’s equally important to adhere to the manufacturer’s directions for use (DFUs), including contact time.

Be sure to wear personal protective equipment (PPE) according to both the manufacturer’s DFUs for the selected product and also per Standard Precautions.

We often get asked if it’s safe to use an electrostatic sprayer when other people are in the area being disinfected. In addition to following the manufacturer’s DFUs for both the device and the disinfectant, we recommend that only the operator be present in the room while the device is being used. Another question that frequently gets asked is “what is the room re-entry time after applying the disinfectant?”  The answer: there is none!

The Clorox® Total 360® System

Clorox Healthcare offers an electrostatic sprayer technology called the Total 360® System. The table below is quick overview of the current products in our portfolio that can be used with the Total 360 electrostatic sprayer.

Total 360 DisinfectantsActive IngredientSuggested Use LocationsContact timePersonal Protective Equipment (PPE)
Spore10 Defense™ Cleaner DisinfectantSodium hypochloritePatient care areas where C. diff is a concern (e.g., terminal cleaning, etc)5 minutesEye protection; Wear other PPE in accordance with Standard Precautions.
Total 360® Disinfectant Cleaner1Quaternary ammonium compoundPatient care areas when C. diff is not a concern2 minutesEye protection; Wear an N95 respirator for prolonged use; Wear other PPE in accordance with Standard Precautions.
Anywhere® Hard Surface Sanitizing SpraySodium hypochloriteNon-patient care areas such as offices and conference rooms and anywhere that a food safe product is indicated such as the cafeteria.2 minutesEye protection; Wear other PPE in accordance with Standard Precautions.
 

Summary

Adjunct disinfection technologies such as electrostatic sprayers can be a great addition to your current cleaning and disinfection routines. The technology has been around for many years and it is both safe and efficient.

Related Resources


References

  1. Bhalla A., Pultz N.J., Gries D.M. et al. “Acquisition of Nosocomial Pathogens on Hands After Contact With Environmental Surfaces Near Hospitalized Patients.” Infection Control Hospital Epidemiology. 2004 Feb;25(2): 164–7

The Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal committee that provides guidance on infection prevention practices in the U.S. to the federal Department of Health and Human Services and the Centers for Disease Control and Prevention (CDC) in US healthcare settings. As Infection Preventionists (IPs), we are all familiar with the HICPAC guidelines including, but not limited to, the Hand Hygiene and the Environmental Infection Control Guidelines. HICPAC meets several times each year, where among other activities, new guidelines are developed and older guidelines are updated. For a more detailed overview, please see our HICPAC 101 blog post by Dr. Hudson Garrett.

Participating in HICPAC meetings puts context and rationale to the recommendations. Furthermore, as an IP, your voice can be heard or questions answered during the public comment period of the meeting. Because of the lengthy delay from meeting to posting of the minutes, we hope you will find our HICPAC meeting summary blog posts helpful to keep you informed in a timely manner.  

Lessons Learned from the COVID-19 Response

Dr. Denise Cardo from the CDC’s Division of Healthcare Quality Promotion presented on the gaps across the healthcare delivery system, the critical needs in post-acute care (PAC), and health equity and access issues that the COVID-19 pandemic has unmasked. There is a huge need to integrate infection prevention across the entire healthcare continuum to be as robust as it is in acute care settings. For example, if you have watched the news in recent months, you have seen the challenges that nursing homes have faced during this time. In fact, 42% of all COVID-19 deaths have occurred in nursing homes.1

This pandemic has certainly highlighted the need for policies for accountability. Dr. Cardo identified three cultural changes that need to happen:

While we may not know exactly how this culture change will take place, it’s reassuring to know that the CDC is keenly aware of these issues and will be working on providing guidance to facilities.

Project Firstline

Dr. Mike Bell, Deputy Director for the CDC talked about the Project Firstline, a new national training collaborative for healthcare infection prevention and control for frontline healthcare and public health workers. The project was kicked off at the end of October 2020 with a key objective to effectively communicate infection prevention messaging directly to frontline workers.

The educational materials and tools provided to targeted audiences are short, convenient, and provided in easily accessible formats such as videos and podcasts. And to help make the messaging stick, the rationale behind the recommendations is strongly emphasized. Keep an eye on the Project Firstline website as the portfolio continues to expand. IPs can follow this initiative on Facebook or Twitter or sign up for email updates.

Work Group Update: Long-Term Care/Post-Acute Care

HICPAC members JoAnne Reifsnyder and Michael Lin provided an update from the Long-Term Care (LTC)/PAC Work Group. This group is working to move from a culture-based to a task-based risk for determining precautions and personal protective equipment (PPE) in LTC and PAC settings. For example, PPE decisions would be based on patient care tasks, like bathing or wound care, rather than on what is growing (or not growing) in a specimen culture.

This comes on the coat tails of the new set of precautions, Enhanced Barrier Precautions, introduced last year. With the lessons learned from the pandemic, this work group is in the process of drafting a white paper on how nursing homes should implement PPE used for resident care activities. The workgroup plans to employ human factors engineering to design their recommended interventions.

Summary

            Because we understand how difficult it is for busy IPs (especially during a pandemic!) to attend HICPAC meetings, we hope that you find these meeting summaries helpful in your practice. Don’t forget to check out Project Firstline and be on the lookout for the CDCs Enhanced Barrier Precautions white paper (final title to be determined). For additional information, the HICPAC meeting minutes can be reviewed once they are posted.

References

  1. The New York Academy of Medicine, “Virtual Summit for Infection Prevention in Nursing Homes”, [cited 12/2/2020].

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