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	There	were	over	100,000.00	Americans	dying	from	
hospital	acquired	infections	(HAI)	on	annual	basis.	These	
pathogens	are	frequently	shed	by	patients	and	staff,	
whereupon	they	contaminate	surfaces	for	days	infect	other	
patients,	who	may	have	a	lower	immunity.	Pathogens	such	
as	vancomycin-resistant	enterococci	(VRE),	methicillin-
resistant	Staphylococcus	aureus(MRSA),	multiresistant	Gram-
negative	bacilli,	norovirus,	and	Clostridium	difficile	remain	for	
days	in	the	air	and	on	the	surfaces	all	over	the	hospitals.	
Health	care	workers'	hands	are	liable	to	touch	these	
contaminated	surfaces	during	patient	care	increasing	the	risk	
of	transmission	to	patients	or	actually	or	actually	
contaminating	multiple	areas	in	a	health	care	institution	and	
infect	patients	directly.	
	
	When	hospitals	screen	equipment,	patients’	rooms	and	
bed	spaces	for	harmful	organism	presence,	they	find	
repeated	colonization	of	such	spaces	by	anti-biotic	resistant	
strains	described	above.	The	survival	length	of	time	for	these	
multidrug-resistant	pathogens	can	lasts	from	days	to	months:
Methicillin-resistant	Staphylococcus	aureus	7	days–>7	
months;	Acinetobacter	3	days–>5	months;	Clostridium	
difficile	>5	months;	
Vancomycin-resistant	Enterococcus 	5	days–>4	months;	
Escherichia	coli	2	h–16	months;	
Klebsiella	2	h–>30	moths;	Norovirus 	8	h–7	days.	
Traditional	cleaning	methods	are	notoriously	inefficient	
for	decontamination,	and	new	approaches	have	been	
proposed,	including	disinfectants,	steam,	automated	
dispersal	systems,	and	antimicrobial	surfaces.		
		
	In	the	United	States,	penalties	may	be	imposed	on	
hospitals	that	report	preventable	HAI	and	poor	
environmental	hygiene.	The	latter	is	more	usually	based	
upon	patient	experience	and	perceptions	of	cleanliness	
rather	than	scientific	measurement	as	there	are	no	
national	standards	(some	exist	in	VA	hospitals)	nor	any	
consistent	policy	of	hospital	sanitization	anywhere.	The	
combination	of	incentives,	financial	sanctions,	and	public	
reporting	requirements	affects	operational	behaviors	and	
outcomes	in	hospitals	subjected	to	mandatory	inspection.	
When	forced	to	deal	with	an	out	break	of	a	particular	
infection,	hospitals	spend	much	more	money	on	battling	
or	controlling	such	outbreak	then	they	do	on	its	
prevention,	which	is	much	less	expensive.
Additionally	employees	actually	conducting	the	sanitation	
process,	often	receive	little	or	no	training	for	what	they	are	
supposed	to	be	doing,	and	they	lack	the	career	progression	
enjoyed	by	most	other	professions.	There	are	fewer	
opportunities	for	advancement	in	housekeeping	positions,	
often	compounded	by	language	and	literacy	problems.	The	
status	of	cleaning	personnel,	depicted	by	lower	pay	scales	and	
basic	conditions,	does	not	necessarily	reflect	the	physical	
cleaning	effort	and	personal	risks	required	to	protect	patients	
from	hospital	pathogens.	Janitorial,	housekeeping,	and	
domestic	staff	are	regularly	confronted	by	risk	of	injury,	
poisoning,	or	scalding	from	cleaning	equipment	and	fluids,	as	
well	as	infection	risks	from	cleaning	facilities	accommodating	
patients	with	transmissible	pathogens.	
		
	Current	protocols	using	disinfectants	can	be	effective	if	
near-patient	surfaces,	such	as	bed	rails,	and	frequently	touched	
surfaces,	such	as	door	handles,	are	physically	scrubbed	at	least	
once	daily.	Other	areas	require	more	frequent	applications,	
which	is	rarely	done	due	to	lack	of	resources	or	ability	to	use	
certain	disinfectants.	It	appears	that	even	stringent	manual	
cleaning	with	disinfection	does	not		
eliminate	Acinetobacter	completely	from	the	environment.	The	
reasons	for	this	are	unknown	but	probably	include	poor	
cleaning	practices,	missing	high-risk	sites	as	well	as	
ineffectiveness	of	disinfectant.	While	the	role	of	cleaning	in	
controlling	Acinetobacter	outbreaks	is	now	accepted,	the	same	
cannot	be	said	in	relation	to	outbreaks	of	multidrug-resistant	
(MDR)	Gram-negative	bacilli.	As	for	any	outbreak,	enhanced	
cleaning	usually	comes	as	part	of	an	overall	bundle	of	activities	
in	reaction	to	cross-infection	incidents.
Water	sources	provide	a	reservoir	
for	Pseudomonas	and	Stenotrophomonas	spp.	in	the	health	
care	environment.	These	opportunistic	organisms	pose	a	risk	
of	colonization	and	infection	for	particularly	vulnerable	
patients.	Pseudomonas	aeruginosa	may	be	transmitted	from	
contaminated	sinks	to	hands	during	hand	washing.	Bacteria	
present	within	biofilm	are	more	likely	to	be	able	to	
withstand	chlorine-containing	and	other	types	of	
disinfectants.	They	are	also	likely	to	demonstrate	an	
increased	capacity	for	antimicrobial	resistance.	
		
Outbreaks	of	norovirus	can	be	particularly	ferocious	in	
closed	or	semiclosed	communities,	such	as	transport	
vehicles	and	a	variety	of	public	venues.	Sudden	and	
widespread	outbreaks	can	escalate	without	warning	in	
nursing	and	residential	homes,	schools,	hotels,	and	prisons.	
CDC	reported	an	outbreak	of	norovirus	in	a	primary	school	
that	affected	over	100	staff	members	and	pupils.	The	
investigation	following	this	outbreak	identified	person-to-
person	contact	as	a	major	factor	in	viral	transmission,	but	
there	was	evidence	that	the	environment	was	also	
implicated.	Despite	intensive	cleaning	with	bleach	soon	after	
notification,	norovirus	was	recovered	from	computer	
components	in	a	frequently	used	classroom	the	next	day.
In	hospitals,	environmental	surfaces	are	routinely	cleaned,	
or	cleaned	and	disinfected,	according	to	predetermined	
cleaning	policies	(e.g.,	hourly,	daily,	twice	weekly,	etc.)	or	
when	surfaces	appear	visibly	dirty,	if	there	are	spillages,	
and	always	after	patient	discharge.	The	type	and	
frequency	of	routine	cleaning	depend	upon	clinical	risk,	
patient	turnover,	intensity	of	people	traffic,	and	surface	
characteristics.	Frequent	and	stringent	cleaning	
specifications	are	applied	to	areas	within	operating	
theaters,	intensive	care	units,	transplant	wards,	and	so-
called	“clean”	rooms,	where	sterile	medications	are	
decanted	and/or	processed.	Hospital	kitchens,	restaurants,	
and	cafes	also	require	targeted	frequent	cleaning,	as	do	
the	laboratories	and	staff	on-call	rooms.	Less	
comprehensive	cleaning	regimens	are	carried	out	for	
corridors	and	stairwells,	offices	and	waiting	rooms,	and	
selected	outpatient,	storage,	general	purpose,	and	
entrance	areas.	
Frequently	touched	items	such	as	telephones,	handles,	
taps,	light	switches,	levers,	knobs,	buttons,	keyboards,	
push	plates,	toys,	etc.,	are	found	in	most	health	care	
institutions.	Repeated	handling	increases	the	risk	of	
contamination	by	pathogens,	which	then	leads	to	hand-
based	transmission.	These	items	are	likely	to	benefit	from	
enhanced	cleaning,	including	disinfection.	High-touch	sites	
or	surfaces	can	be	identified	through	direct	observation	or	
environmental	screening	using	fluorescent	or	other	
markers.
All	hospitals	should	provide	a	written	specification	of	
cleaning	services	and	their	delivery	for	all	areas	of	the	
hospital,	whether	provided	by	in-house	or	externally	
contracted	staff	These	should	be	reviewed	on	a	regular	
basis	by	cleaning	supervisors,	hospital	managers,	and	
structural	facilities	and	infection	control	personnel.	Recent	
recommendations	on	innovation	and	research	in	infection	
control	support	the	opportunity	for	hospitals	to	test	new	
cleaning	and	decontamination	technologies	and	publish	
their	findings.	
Near-patient	hand	touch	sites	constitute	the	bulk	of	critical	
surfaces	in	a	ward.	Routine	decontamination	is	usually	
included	within	institutional	cleaning	policies,	including	
designated	tasks	for	a	range	of	staff.	This	can	vary	between	
occupied	and	non-occupied	beds,	electrical	and	
nonelectrical	items,	and	clinical	and	nonclinical	equipment,	
all	of	which	illustrates	cleaning	complexities	and	the	
potential	for	fragmented	responsibility	between	
housekeeping,	nursing,	and	other	clinical	staff.	Daily	
attention	with	detergent	wipes	may	be	sufficient	to	control	
bio-burden	on	an	acute-care	ward,	but	high-risk	sites	in	
intensive	care	units	may	require	more	frequent	attention.	
Two	studies	have	clearly	shown	how	MRSA	rapidly	re-
contaminates	high-touch	sites	in	the	ICU	setting	after	
cleaning.
All	clinical	equipment	should	be	cleaned	and/or	
decontaminated	before	and	after	use	for	all	patients	
regardless	of	how	often	it	is	used,	where	it	is	used,	or	
what	it	is.	An	item	intended	for	patient	use	should	be	
inspected	carefully	before	it	is	employed,	and	if	prior	
cleaning	is	not	evident	by	either	notification	or	obvious	
soiling,	then	it	should	be	immediately	cleaned	
according	to	local	policies.	Many	hospitals	now	ask	staff	
to	flag	specific	pieces	of	equipment	to	show	that	they	
were	appropriately	cleaned	and/or	decontaminated	
after	use.	This	is	especially	important	for	items	such	as	
commodes	and	other	non-disposable	apparatus	used	
for	toileting	and	therefore	at	high	risk	of	
contamination.	There	are	other	utensils	that	might	
come	into	contact	with	blood	and/or	body	fluids,	e.g.,	
pulse	oximeters,	thermometers,	blood	sugar	test	kits,	
saturation	probes,	etc.,	and	these	should	also	be	
subjected	to	stringent	cleaning	and	disinfection	before	
and	after	use.	Doctors'	stethoscopes	have	long	been	
the	subject	of	cleaning	audits	and	remain	a	likely	source	
of	contamination	for	a	range	of	microbial	flora.	Wiping	
with	alcohol	is	effective	for	decontaminating	
stethoscopes,	but	it	appears	that	even	this	simple	
procedure	is	abandoned,	ignored,	or	forgotten	when	
staff	are	overworked.
There	are	alternative	ways	of	assessing	the	health	care	
environment,	notably	monitoring	the	efforts	of	cleaning	staff	
rather	than	measuring	residual	bi-oburden	on	surfaces.	Most	
environmental	failures	are	likely	due	to	personnel	themselves,	
not	products	or	practices.	Assessment	of	the	cleaning	process	
can	be	introduced	by	using	educational	strategies,	direct	and	
indirect	cleaning	inspections,	observation,	scientific	
monitoring,	and	feedback	to	staff.	that	the	use	of	fluorescent	
markers	is	linked	with	decreased	transmission	of	hospital	
pathogens.

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