very important to prevent or reduce the infection in ICU or in the wards

1. New methods to clean
ICU ROOMS
Dr Nirmal Jaiswal
MD(Med);FCCS(instr)
Chief Intensivist and ICU Director
Suretech Hospital ,Nagpur

2.  Hand washing facilitis are inadeqauate
 Patient close together or sharing rooms
 Undrstaffing
 Lack of isolation facilitis
 No separation of dirty and clean are
 Extensive antibiotic use
 Inadequate decontamination of items and equipments
 Inadequate cleaning of environment
ICU : Factors that increase cross infection

5. ALL SURROUNDING TO BE CLEAN
All surroundings of
the ICU should be
clean if possible for
obvious reason

6. Pathways for acquisition of MDR
bacteria in ICU.
MDR: Multidrug resistant
Contaminated
environmental
surface
PATIENT
HANDS OF
HEALTH CARE
WORKERS
OTHER
SURFACES
OTHER
PATIENTSDirect/indirect
trans- Environ
to patient
Patient to
environment

7. Survival times and infectious doses
ORGANISM SURVIVAL TIME INFECTIOUS DOSE
MRSA 7DAYS – 7 MON 4 CFU
ACINETOBACTER 3DAYS – 5 MON 250 CFU
CL DIFFICILE > 5 MON 5 SPORES
VRE 5 DAYS – 4 MON < 10*5 CFU
E COLI 2 HOURS – 16 MON 10*2-10*5 CFU
KLEBSIELLA 2 HOURS – 30 MON 10*2 CFU
NOROVIRUS 8 HOURS -7 DAYS 20 VIRONS
Retrieved from different studies

8. Strategies for environmental cleaning & disinfection
Cleaning strategy Advantages Disadvantages Limitations
Detergent surface
cleaning agents
Non-toxic to staff and
environment
Inferior microbial killing
compared to
disinfectants
Can become
contaminated with
bacteria
Disinfectant surface
cleaning agents
Increased reduction in
bacterial colony count
compared to detergents
Toxic fumes and waste Efficacy depends on
concentrations, contact
time additional training
is necessary for use
Monitoring cleaninga
with ATP/fluorescent
markers
Objective assessment of
surrogate markers of
residual contamination
after cleaning
Requires purchase of
supplies for monitoring
Poor correlation with
actual microbial colony
counts on surfaces

9. Cleaning strategy Advantages Disadvantages Limitations
Monitoring cleaning via
direct observation
Easy and inexpensive Time-consuming,
perceived subjectivity
Poor correlation with
actual cleanliness of
rooms by more objective
methods
Enhanced cleaning:
addition of extra staff
to target ‘high-touch’
surfaces
Effective in decreasing
microbial surface
contamination on ‘high-
touch’ surfaces
Requires additional
human resources
Impact of reduced ‘high-
touch’ surface
contamination on
infection transmission is
unknown
Enhanced cleaning:
dedicated teams for
‘high risk’ areas
Optimization of existing
resources rather than
requiring new staff or
equipment
Shifts attention to a
specific problem area,
rather than improving
cleaning across all
areas
Efficacy difficult to assess
in isolation given use in a
bundle of other
interventions

10. Cleaning strategy Advantages Disadvantages Limitations
Antimicrobial
‘self-cleaning’
surfaces
Effective in decreasing
microbial surface
contamination
Expensive Long-term durability of
results unknown; ability
to reduce infection
transmission requires
further study
‘Touchless’ cleaning
robots
Effective in decreasing
microbial surface
contamination
Expensive, requires staff
training and human
resources for
deployment
Patients/staff may not be
present in the area
during robot cleaning
Complex surfaces may
be incompletely targeted
by robot technology

12. Problems with older techniques
Contamination of disinfectant solutions can occur, particularly if recommendations
for their use are not followed
In studies that involved culturing high-
touch surfaces in patient rooms before and
shortly after housekeepers had performed
routine cleaning, It was found that cultures
obtained from several surfaces in one
room after cleaning yielded large numbers
of Serratia and smaller numbers of
Achromobacter which were not present
before cleaning

13. Cleaning Practices Are Often Suboptimal
• Daily cleaning of surfaces
near patients is often
performed poorly
• Terminal cleaning of rooms
after patient discharge is
often inadequate
– Carling et al. found that only
47% of surfaces targeted for
terminal cleaning had been
cleaned
Overbed Table Overbed Table
Before Cleaning After Cleaning
VRE on call button after cleaningCarling PC et al. Clin Infect Dis 2006;42:385
Eckstein BC et al. BMC Infect Dis 2007;7:61

14. Advantages and Disadvantages
of Common Disinfectants
Disinfectant Advantages Disadvantages
Sodium hypochlorite
(household bleach)
Inexpensive
Fast-acting
Widely available
Active against
bacteria,spores, Mtb,
viruses
Odor can be irritating
Corrosive to metals
Inactivated by
organic material
May discolor fabrics
Ethyl or isopropyl
alcohol (70-90%)
Inexpensive
Widely available
Rapidly effective
Active against
bacteria, Mtb, viruses
Not effective against
bacterial spores
Not for large surfaces
Rutala WA et al. CDC Guideline for Disinfection & Sterilization
In Healthcare Facilities, 2008

15. Advantages and Disadvantages
of Common Disinfectants
Disinfectant Advantages Disadvantages
Quaternary ammonium
compounds
Not too expensive
Widely available
Good cleaning agents
Not effective against
bacterial spores, Mtb,
non-enveloped viruses
May become
contaminated
Phenolics Widely available Use on bassinets may
be toxic to infants
Poor activity against
bacterial spores and
non-enveloped viruses

16. Relationship between environmental bio
burden and hospital-acquired infection.
It relationship between the
number of surgical intensive
care unit (SICU)-acquired
infections and total hygiene fails
during 2-month patient and
environmental surveillance
study in a Glasgow teaching
hospital. Hygiene failures were
defined as aerobic colony
counts (ACCs) of 2.5 CFU/cm2
and/or the presence of
Staphylococcus aureus on
hand touch
site

17. Effect of detergent and disinfectant cleaning
on total Staphylococcus
aureus ( [MSSA] and [MRSA])

18. Monitoring housekeeping practices
 Recently, fluorescent marking systems and ATP bioluminescence assays
have proven useful for evaluating cleaning practices and providing
housekeepers with feedback

20. New methods for applying disinfectants
 Microfiber cloths or mops and ultra microfiber cloths are among the
relatively newer methods for applying liquid disinfectants to surfaces
 Studies have shown increased cleaning efficacy of microfiber or
ultramicrofiber cloths compared to standard cotton cloth or mops
 advantages of microfiber over cotton cloths is that microfiber is less likely
than cotton cloths to bind quaternary ammonium disinfectants

21. Ultramicrofiber (UMF)
 UMF are thinner than Microfibre: each fiber weighs less than 0,3 decitex
 UMF were more effective than standard wet cloths at removing MRSA,
Acinetobacter calcoaceticus & baumannii, Klebsiella oxytoca and spores
of Clostridium difficile on all surfaces (rough, smooth, laminated,
stainless steel) even with organic soil.
 Efficiency extended to old laminated surfaces where bacteria could be
hidden in micro-fissures.

22. Self-disinfecting surfaces
 Coating surfaces with heavy metals such as copper or silver that
have innate antimicrobial properties or applying to surfaces
compounds that retain their antimicrobial activity for weeks or
months
 Privacy curtains impregnated with silver have been shown to
reduce or delay contamination of curtains with potential pathogens
 Organosilane compounds are comprised of a surfactant plus an
antimicrobial substance such as a quaternary ammonium moiety.

23. Light-activated photosensitizers
 potential of applying of light-activated photosensitizers such as nanosized
titanium dioxide to surfaces and using UV light to generate reactive oxygen
species that can disinfect surfaces
 Activated titanium dioxide has been shown to have varying antimicrobial
activity, with the relative susceptibility of agents against pathogens.
 Research on the use of light activated photosensitizers is in early stages,
and much more information about the feasibility and safety of using this
strategy is needed.

24. No-touch room decontamination methods
 Aerosolized hydrogen peroxide,
 Hydrogen peroxide vapor systems,
 Gaseous ozone, chlorine dioxide,
 Saturated steam systems,
 Peracetic acid/hydrogen peroxide fogging,
 Mobile continuous ultraviolet devices,
 Pulsed xenon light devices,
 High-intensity narrow-spectrum (405 nm) light

25. Aerosolized hydrogen peroxide
 Utilize 3 to 7 % hydrogen peroxide with or without the addition of silver
ions
 These systems have been shown to significantly reduce bacteria,
generally a 4 log10 reduction of spores,
 Use of the aerosolized hydrogen peroxide system was associated with
a reduction in C. difficile infection and MRSA acquisition

26. (HPV) Hydrogen Peroxide Vapor and
Mist
This technique was
brought up to date
in 2001 for the
decontamination of
US government
buildings affected
by the anthrax
bacillus.

27. Hydrogen peroxide vapor (HPV)
 “dry gas” vaporized hydrogen peroxide system that utilizes 30 %
hydrogen peroxide
 Effective against a variety of pathogens, including Mycobacterium
tuberculosis, Mycoplasma, Acinetobacter, C. difficile, Bacillus
anthracis, viruses, and prions
 In before/after studies, combined with other infection control
measures, appears to have contributed to control of outbreaks of
Acinetobacter in a long-term care facility and intensive care units
 Decontaminate rooms previously occupied by patients with the Lassa
fever and Ebola virus infection

30. High-Efficiency Particulate Air (HEPA)-
Filtration
 Air filtration purifier draws the room air through a pre-filter and
then through a high-efficiency particulate air filter with an
efficiency of 99.97% for particles greater than or equal to 0.3
m in diameter
 Air filtration reduced MRSA environmental contamination by
75 to 93%.

31. Ultraviolet light devices (UVLD)
 Automated mobile ultraviolet light devices that continuously
emit UV-C in the range of 254 nm
 Number of these devices can be set to kill vegetative
bacteria or to kill spores.
 These systems often reduce the VRE and MRSA by four or
more log10, and C. difficile by 1–3 log10
Advantages : is mobile, continuous UV-C light devices include their ease of use,
minimal need for special training of environmental services personnel, and unlike
hydrogen peroxide vapor systems, the ability to utilize the devices without having
to seal room vents or doors

33. High-intensity narrow-spectrum light
(HINS)
 Visible violet-blue light in the range of 405 nm has been
tested as a means of disinfecting air and surfaces.
 Technology targets intracellular porphyrins that absorb the
light and produce reactive oxygen species
 Continuous HINS light showed a 27 to 75 % reduction in
surface contamination by staphylococci compared to control
areas

34. Photocatalytic disinfection
 Enclosed air purifying system designed for use by NASA
utilizes UV-activated titanium dioxide photocatalytic reactions
to oxidize volatile organic compounds and airborne
microorganisms
 Aerosolization of pathogens such as S. aureus and C. difficile
during patient care activities is known to occur

35. Agency for Healthcare Research
and Quality (AHRQ)
 Recently commissioned an expert panel to review data regarding
these modern technologies.
 There is a relative lack of comparative studies addressing the relative
effectiveness of various cleaning, disinfecting and monitoring
strategies
 Future studies are needed that directly compare newer disinfecting
and monitoring methods to one another and with traditional methods

36. Cleaning robots: ‘touchless’ technologies
These costly adjuncts are often employed in specific high-
risk rooms at terminal discharge, given that they require
anywhere from 15 min to a few hours in an empty patient
room to complete the disinfection process
The results are modest in comparison to the smaller, lower
quality studies on ‘touchless’ devices published in the
literature
The devices are in no way a substitute for traditional
manual cleaning; ‘touchless’ devices require the removal of
most of the bioburden and soil from surfaces to function
optimally

37. Conclusion
 HPV, UVLD and UMF in particular seem to represent the future of cleaning methods in ICU:
 UMF (with or without copper-based biocide) for daily routine cleaning;
 HPV and UVLD for terminal cleaning In addition to a “classical” terminal cleaning (by current
biocides such as quaternary ammonium compounds).
 New sterilization and disinfection technologies may provide significant advantages over existing
technologies
 New technologies hold the promise of improved patient care.

38. We should be Hygiene freak
AND like a
OBSESSIVE-COMPULSIVE
when it comes to washing of
mine and your hands
keep YOUR ICU clean
thank YOU for your patience