Effectiveness of targeted enhanced terminal room disinfection on hospital-wide acquisition and infection with multidrug-resistant organisms and Clostridium difficile: a secondary analysis of a multicentre cluster randomised controlled trial with crossover design (BETR Disinfection)

Abstract

Summary Background The hospital environment is a source of pathogen transmission. The effect of enhanced disinfection strategies on the hospital-wide incidence of infection has not been investigated in a multicentre, randomised controlled trial. We aimed to assess the effectiveness of four disinfection strategies on hospital-wide incidence of multidrug-resistant organisms and Clostridium difficile in the Benefits of Enhanced Terminal Room (BETR) Disinfection study. Methods We did a prespecified secondary analysis of the results from the BETR Disinfection study, a pragmatic, multicentre, crossover cluster-randomised trial that assessed four different strategies for terminal room disinfection in nine hospitals in the southeastern USA. Rooms from which a patient with a specific infection or colonisation (due to the target organisms C difficile, meticillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci (VRE), or multidrug-resistant Acinetobacter spp) was discharged were terminally disinfected with one of four strategies: standard disinfection (quaternary ammonium disinfectant, except for C difficile, for which 10% hypochlorite [bleach] was used; reference); standard disinfection and disinfecting ultraviolet light (UV-C), except for C difficile, for which bleach and UV-C was used (UV strategy); 10% hypochlorite (bleach strategy); and bleach and UV-C (bleach and UV strategy). We randomly assigned the sequence of strategies for each hospital (1:1:1:1), and each strategy was used for 7 months, including a 1-month wash-in period and 6 months of data collection. The prespecified secondary outcomes were hospital-wide, hospital-acquired incidence of all target organisms (calculated as number of patients with hospital-acquired infection with a target organism per 10 000 patient days), and hospital-wide, hospital-acquired incidence of each target organism separately. BETR Disinfection is registered with ClinicalTrials.gov, number . Findings Between April, 2012, and July, 2014, there were 271 740 unique patients with 375 918 admissions. 314 610 admissions met all inclusion criteria (n=73 071 in the reference study period, n=81 621 in the UV study period, n=78 760 in the bleach study period, and n=81 158 in the bleach and UV study period). 2681 incidenct cases of hospital-acquired infection or colonisation occurred during the study. There was no significant difference in the hospital-wide risk of target organism acquisition between standard disinfection and the three enhanced terminal disinfection strategies for all target multidrug-resistant organisms (UV study period relative risk [RR] 0.89, 95% CI 0.79–1.00; p=0.052; bleach study period 0.92, 0.79–1.08; p=0.32; bleach and UV study period 0.99, 0.89–1.11; p=0.89). The decrease in risk in the UV study period was driven by decreases in risk of acquisition of C difficile (RR 0.89, 95% CI 0.80–0.99; p=0.031) and VRE (0.56, 0.31–0.996; p=0.048). Interpretation Enhanced terminal room disinfection with UV in a targeted subset of high-risk rooms led to a decr...

An overview of automated room disinfection systems: When to use them and how to choose them

“…Patients admitted to rooms disinfected using UVC were significantly less likely to acquire MRSA and VRE when admitted to rooms where the previous occupant had these pathogens; there was no significant reduction in C. difficile infections. A reanalysis of data from the same study evaluated whole-hospital outcomes, and found a significant reduction in VRE and C. difficile [122]. Several before-after studies have shown that adding UVC to disinfection protocols reduces the transmission of MDROs [123,124].…”

“…Study performed over a long period; changes made in MRSA diagnostic protocols. Anderson [122] UVC Cluster RCT Significant MDRO acquisition reduction on the hospital level Monitored potential confounders Anderson [12] UVC Cluster RCT Significant MDRO acquisition reduction on an individual level Monitored potential confounders Pegues [124] UVC 2 yr before-after Significant reduction in C. difficile compared with control wards…”

Preventable Patient Harm: a Multidisciplinary, Bundled Approach to Reducing Clostridium difficile Infections While Using a Glutamate Dehydrogenase/Toxin Immunochromatographic Assay/Nucleic Acid Amplification Test Diagnostic Algorithm

“…Environmental cleaning and disinfection. Environmental cleaning has been shown to be an integral part of CDI prevention (18,19). Enhanced cleaning practices in enteric precautions rooms include the use of an EPA-registered cleaner with known sporicidal activity during daily cleans and at patient discharge.…”

Prevention of Clostridium difficile Infection in Critically Ill Adults

“…The 2017 SHEA/IDSA guidelines also highlight the role of terminal room cleaning with a sporicidal agent, with consideration of daily sporicidal room cleaning in hyperendemic settings . So‐called no‐touch disinfection technologies showed promise in several studies to reduce C. difficile spores and CDI incidence, and, recently, the use of ultraviolet light disinfection of rooms induced a prolonged CDI‐free interval in a burn ICU . Unfortunately, the available analyses for these automated methodologies had significant limitations when the SHEA/IDSA guideline was released, leading the expert panel to conclude that no recommendation could be made regarding their incorporation into a CDI prevention program …”

“…11 So-called no-touch disinfection technologies showed promise in several studies to reduce C. difficile spores and CDI incidence, and, recently, the use of ultraviolet light disinfection of rooms induced a prolonged CDI-free interval in a burn ICU. 17,18 Unfortunately, the available analyses for these automated methodologies had significant limitations when the SHEA/IDSA guideline was released, leading the expert panel to conclude that no recommendation could be made regarding their incorporation into a CDI prevention program. 11 Robust hand hygiene programs should be foundational in every ICU and include objective components such as so-called secret shopper audits (anonymous trained observers who monitor hand hygiene practices), volumebased utilization of hand disinfectants, and routine feedback for ICU staff.…”