Impact of environmental hygiene interventions on healthcare-associated infections and patient colonization: a systematic review

Abstract

Background Healthcare-associated infections (HAI) are one of the gravest threats to patient safety worldwide. The importance of the hospital environment has recently been revalued in infection prevention and control. Though the literature is evolving rapidly, many institutions still do not consider healthcare environmental hygiene (HEH) very important for patient safety. The evidence for interventions in the healthcare environment on patient colonization and HAI with multidrug-resistant microorganisms (MDROs) or other epidemiologically relevant pathogens was reviewed. Methods We performed a systematic review according to the PRISMA guidelines using the PubMed and Web of Science databases. All original studies were eligible if published before December 31, 2019, and if the effect of an HEH intervention on HAI or patient colonization was measured. Studies were not eligible if they were conducted in vitro, did not include patient colonization or HAI as an outcome, were bundled with hand hygiene interventions, included a complete structural rebuild of the healthcare facility or were implemented during an outbreak. The primary outcome was the comparison of the intervention on patient colonization or HAI compared to baseline or control. Interventions were categorized by mechanical, chemical, human factors, or bundles. Study quality was assessed using a specifically-designed tool that considered study design, sample size, control, confounders, and issues with reporting. The effect of HEH interventions on environmental bioburden was studied as a secondary outcome. Findings After deduplication, 952 records were scrutinized, of which 44 were included for full text assessment. A total of 26 articles were included in the review and analyzed. Most studies demonstrated a reduction of patient colonization or HAI, and all that analyzed bioburden demonstrated a reduction following the HEH intervention. Studies tested mechanical interventions (n = 8), chemical interventions (n = 7), human factors interventions (n = 3), and bundled interventions (n = 8). The majority of studies (21/26, 81%) analyzed either S. aureus, C. difficile, and/or vancomycin-resistant enterococci. Most studies (23/26, 88%) reported a decrease of MDRO-colonization or HAI for at least one of the tested organisms, while 58% reported a significant decrease of MDRO-colonization or HAI for all tested microorganisms. Forty-two percent were of good quality according to the scoring system. The majority (21/26, 81%) of study interventions were recommended for application by the authors. Studies were often not powered adequately to measure statistically significant reductions. Interpretation Improving HEH helps keep patients safe. Most studies demonstrated that interventions in the hospital environment were related with lower HAI and/or patient colonization. Most of the studies were not of high quality; additional adequately-powered, high-quality studies are needed. Systematic registration number: CRD42020204909

A randomised controlled trial investigating the effect of improving the cleaning and disinfection of shared medical equipment on healthcare-associated infections: the CLEaning and Enhanced disiNfection (CLEEN) study

“…The CLEEN study is a large cluster randomised controlled trial conducted in an Australian tertiary hospital. The study represents the first randomised controlled study in the world to provide level 1 evidence on the impact of additional cleaning of shared equipment on rates of HAIs (5). The advantages of the study design include a simple and feasible intervention, with strategies built in to ensure adherence and fidelity.…”

“…The burden of HAIs is significant, with increased levels of morbidity and mortality and, for those acquired in hospitals, increased length of stay (2,3). However, there is little level 1 evidence into the role of environmental cleaning to reduce HAIs (4,5). Prevention of infections through practical, implementable and translatable interventions is of critical importance in the era of antimicrobial resistance.…”

Bacterial and fungal communities in indoor aerosols from two Kuwaiti hospitals

“…This is attributed to the strict cleanliness and disinfection procedures followed at the Kuwaiti hospital consequent of the ongoing SARS-CoV-2 pandemic ( Habibi et al, 2021d ). A recent review published that about 80% of studies reported a decrease in hospital-associated infectious microbes upon following intensive healthcare environmental hygiene ( Peters et al, 2022 ). The LEfSe analysis revealed the key indicator taxa as Defluvicoccales, Heterophoma , and H. sylvatica in hospitals when compared to Actinobacteria, Leptobacillium , L. leptobacillium , and Cordycipitaceae at G2 (KISR), all with very low RA.…”

New frontiers in healthcare environmental hygiene: thoughts from the 2022 healthcare cleaning forum

“…The scope of HEH includes surface cleaning and disinfection, air control, water control, waste management, sterilization and device processing and laundry. Since 2015, there has been an exponential growth in good quality studies that tie improvements in HEH to a reduction in healthcare-associated infections [ 1 ]. The 2022 Healthcare Cleaning Forum at Interclean in Amsterdam had a very different atmosphere than the last edition in 2018.…”

“…The Clean Hospitals academic taskforce worked on two main pieces of research. The first was a systematic review to assess the impact of interventions in the healthcare environment on patient outcomes, wither healthcare-associated infections (HAIs) or patient colonization [ 1 ]. Eighty-eight percent of included studies showed some kind of reduction in colonization or HAI for at least one of the microorganisms tested, and 58% showed a significant reduction in all of the microorganisms tested.…”