Are High-Touch Surfaces A Reservoir for Infection-Causing Pathogens?

Research Suggests, Yes.

Surface contamination is frequently downplayed as a significant means of pathogen transmission and infection, however the COVID-19 pandemic has brought this topic back to the surface (literally). This blog will walk you through some of the research conducted on surface contamination and considerations to improve disinfection practices to reduce surface contamination and the risk or transmission.

As we delve in, research suggests that high-touch surfaces in the environment and inanimate objects may act as a reservoir for infection-causing pathogens [1]. Environmental contamination in patient rooms and operating rooms is a significant contributing factor for the risk of HAIs [2]. Patients have an increased risk of acquiring an infection if the previous occupant of the patient care room was positive for infection. One study demonstrated a 40% increased risk of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) transmission when a patient occupied a room previously occupied by a MRSA or VRE-positive patient, despite rigorous, manual terminal cleaning [3]. Research also suggests that the time spent cleaning does not correlate with clean surfaces and microbes left on dry inanimate surfaces may persist for a long time after terminal manual cleaning [2,3].

The dry inanimate surfaces of portable medical equipment (PME) can also act as a reservoir for infection-causing pathogens. One systematic review found that pathogens and multidrug resistant organisms were present on up to 86% of PME, and Gram-negative organisms (Pseudomonas spp. and/or Enterobacteriaceae) were present on up to 38% of PME. In addition, multidrug resistant organisms were isolated from up to 25% of PME [4]. The lack of hand hygiene and movement of contaminated PME may further increase the transmission of infection-causing pathogens. One study found that gloves and/or hand hygiene was only used in half of patient encounters [5]. The top ten items touched in a patient room are: the patient, workstation on wheels (WOW), bedrail, IV pump, bed surface, tray table, vitals machine, wall shelf, door, and in-room computer [5]. Another study found the hands of anesthesiologists served as vectors for between-case MRSA transmission associated with provider-to-provider (attending to nurse anesthetist) and provider-to-environment contamination [6]. This highlights the need for greater emphasis on enhancing cleaning and disinfection techniques in patient care areas, including portable equipment.

Cleaning is the process of removing visible soil, such as dust, dirt, blood, and other bodily fluids [7]. Disinfection is the process of applying antimicrobial agents to the surface of non-living objects to destroy microorganisms that are living on the object [7]. The CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) recommends that environmental surfaces in patient rooms should be cleaned and disinfected on a regular basis, when visibly soiled, and following patient discharge [8]. Environmental surfaces are a major reservoir for pathogens in the patient care area. One study by Carling and colleagues found that up to 49% of the surfaces in the patient care environment are missed during manual cleaning, missed surfaces ranged from 35 to 81% [9]. Manual cleaning and disinfection of environmental surfaces is prone to human error. It is dependent on: 1) correct use and application of the disinfectant, 2) the order of cleaning to prevent cross-contamination, and 3) allowing for appropriate dwell times [9].

Research has found that environmental and medical equipment surfaces are missed during manual cleaning in the operating room [10]. One study found that manual cleaning in the operating room missed the bed control 64% of the time and IV poles were missed 55% of time [11]. Portable medical equipment (PME) is a potential reservoir for infection-causing pathogens. Research suggests that PME is disinfected 6% of the time and often not cleaned between patient use [12]. One study using a DNA marker on PME, found that the DNA marker was disseminated widely to surfaces in patient rooms and common work areas and to other types of medical equipment. The hands of healthcare workers played a major role in the transfer from contaminated PME to other sites in the hospital or healthcare facility. In the operating room, the contaminated hands of anesthesiologists may serve as a significant source of patient environmental and IV stopcock set contamination [12]. The interaction of healthcare workers hands, the environment, and PME may serve as a vector for dissemination of infectious organisms [6].

The current state of cleaning and disinfection has several opportunities for improvement. The distribution of cleaning responsibilities for PME needs to be clearly delineated with nursing and environmental services (EVS) having clear expectations for who cleans what and when. For example, EVS and nursing need to have defined roles and responsibilities for the cleaning and disinfection of PME [13]. To understand the roles and responsibility for cleaning and disinfecting, consider educational trainings with staff to demonstrate competency related to cleaning. Employees should receive training on cleaning and disinfection at hire, annually, and when new equipment is purchased [13]. Consider adopting policies and procedures that clearly define the roles and responsibilities for cleaning and disinfecting PME.

— Author: Deborah Passey, PhD

References
Chemaly RF, Simmons S, Dale Jr C, Ghantoji SS, Rodriguez M, Gubb J, Stachowiak J, Stibich M. The role of the healthcare environment in the spread of multidrug-resistant organisms: update on current best practices for containment. Therapeutic advances in infectious disease. 2014 Jun;2(3-4):79-90.
Otter JA, Yezli S, Salkeld JA, French GL. Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings. American journal of infection control. 2013 May 1;41(5):S6-11.
Cohen B, Cohen CC, Løyland B, Larson EL. Transmission of health care-associated infections from roommates and prior room occupants: a systematic review. Clinical epidemiology. 2017;9:297.
Livshiz-Riven, I., Borer, A., Nativ, R., Eskira, S., & Larson, E. (2015). Relationship between shared patient care items and healthcare-associated infections: a systematic review. International journal of nursing studies, 52(1), 380-392.
Rupp ME, Adler A, Schellen M, Cassling K, Fitzgerald T, Sholtz L, Lyden E, Carling P. The time spent cleaning a hospital room does not correlate with the thoroughness of cleaning. Infection Control & Hospital Epidemiology. 2013 Jan;34(1):100-2.
Jinadatha, C., Villamaria, F. C., Coppin, J. D., Dale, C. R., Williams, M. D., Whitworth, R., & Stibich, M. (2017). Interaction of healthcare worker hands and portable medical equipment: a sequence analysis to show potential transmission opportunities. BMC infectious diseases, 17(1), 800.
Chou, T. (2014) Chapter 107 Environmental Services. APIC Text Online. Edited by Grotta, P. http://text.apic.org/
Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee (HICPAC) Guidelines for Environmental Infection Control in Health-Care Facilities (2003), Updated February 15, 2017: https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines.pdf. Accessed April 26, 2018.
Carling PC, Parry MF, Von Beheren SM, Healthcare Environmental Hygiene Study Group. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infect Control Hosp Epidemiol 2008;29:1-7. DOI: 10.1086/524329.
Russotto, V., Cortegiani, A., Raineri, S. M., & Giarratano, A. (2015). Bacterial contamination of inanimate surfaces and equipment in the intensive care unit. Journal of intensive care, 3(1), 54.
Edmiston CE, Seabrook GR, Cambria RA, Brown KR, Lewis BD, Sommers JR, Krepel CJ, Wilson PJ, Sinski S, Towne JB. Molecular epidemiology of microbial contamination in the operating room environment: is there a risk for infection?. Surgery. 2005 Oct 1;138(4):573-82.
John, A., Alhmidi, H., Cadnum, J. L., Jencson, A. L., & Donskey, C. J. (2017). Contaminated portable equipment is a potential vector for dissemination of pathogens in the intensive care unit. Infection Control & Hospital Epidemiology, 38(10), 1247-1249.
Jinadatha, C., Bridges, A. (2018) Chapter 31 Cleaning, Disinfection, and Sterilization. APIC Text Online. Edited by Grotta, P. http://text.apic.org/

Credit Kim Manganello