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Dos and don'ts for hospital cleaning

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REVIEW

CURRENT
OPINION Dos and don’ts for hospital cleaning
Stephanie J. Dancer a,b

Purpose of review
More evidence is emerging on the role of cleaning and decontamination for reducing hospital-acquired
infection. Timely and adequate removal of environmental pathogens leads to measurable clinical benefits
for patients. This article considers studies published from 2013 examining hospital decontamination
technologies and evidence for cost-effectiveness.
Recent findings
Novel biocides and cleaning products, antimicrobial coatings, monitoring practices and automated
equipment are widely accessible. They do not necessarily remove all environmental pathogens, however,
and most have yet to be comprehensively assessed against patient outcome. Some studies are confounded
by concurrent infection control and/or antimicrobial stewardship initiatives. Few contain data on costs.
Summary
As automated dirt removal is assumed to be superior to human effort, there is a danger that traditional
cleaning methods are devalued or ignored. Fear of infection encourages use of powerful disinfectants for
eliminating real or imagined pathogens in hospitals without appreciating toxicity or cost benefit.
Furthermore, efficacy of these agents is compromised without prior removal of organic soil. Microbiocidal
activity should be compared and contrasted against physical removal of soil in standardized and
controlled studies to understand how best to manage contaminated healthcare environments.
Keywords
decontamination, detergent, disinfectant, environment, hospital cleaning

INTRODUCTION published evidence for environmental impact

Hospital cleaning has provoked much debate on its
importance in controlling healthcare-associated
infection (HAI) [1,2]. Hospital pathogens survive
in the hospital environment until removed
through some cleaning process but the best way
to achieve this remains elusive [1,3,4]. Many stud-
ies have demonstrated persistent contamination
following domestic attention, including high-risk
hand-touch sites beside the patient [5–9,10 ]. If
&
a patient is admitted into a room previously occu-
pied by a patient colonized or infected with a
specific pathogen, then the new admission has
an increased risk of acquiring the same organism
[11–15]. Although this much needed evidence has
silenced the cleaning sceptics, it has encouraged
commercial interest in a wide range of decontami-
nation strategies. These tend to be expensive, and
can be disruptive to hospital routine. Some have
become popular despite lack of evidence for cost
benefit, prompting a request for an evidentiary
hierarchy to assess clinical impact of all environ-
mental disinfection technologies [16]. This piece
summarizes a selection of new products, equip-
ment and practices and offers comments on
and cost effectiveness.
NOVEL DISINFECTANTS
Detergent-based cleaning might reduce surface
bioburden, but will not necessarily eliminate patho-
gens. There are numerous examples of contami-
nated cleaning cloths and equipment that spread
microbes across surfaces rather than removing them
[17–22]. This has encouraged disinfectant use,
which kills pathogens but can be expensive and
environmentally unfriendly [23,24]. Products may
also incite tolerance among habitually exposed
pathogens, itself linked with antimicrobial resist-
ance [25,26]. Most formulations persist unchanged
a
Department of Microbiology, Hairmyres Hospital, NHS Lanarkshire,
Glasgow and bEdinburgh Napier University, Edinburgh, Scotland, UK
Correspondence to Stephanie J. Dancer, Department of Microbiology,
Hairmyres Hospital, Eaglesham Road, East Kilbride G75 8RG, UK.
Tel: +44 01355 585000; fax: +44 01355 584350;
e-mail: stephanie.dancer@lanarkshire.scot.nhs.uk
Curr Opin Infect Dis 2016, 29:415–423
DOI:10.1097/QCO.0000000000000289

0951-7375 Copyright ß 2016 Wolters Kluwer Health, Inc. All rights reserved. www.co-infectiousdiseases.com
Nosocomial and healthcare related infections
KEY POINTS
 There is increasing interest in decontamination
strategies for healthcare environments.
 Novel practices include ‘green’ disinfectants,
antimicrobial surfaces, automated decontamination
devices and monitoring strategies for
housekeeping staff.
 Even powerful disinfectants cannot eliminate all
healthcare pathogens, and particularly so if microbial
soil is not physically removed before disinfection.
 Expensive technologies are being routinely used despite
lack of evidence for cost–benefit.
 Although there is increasing support for physical
removal of dirt, detergent cleaning has been
overlooked as a cost-effective and nontoxic practice for
routine daily use.
in the environment and exert long-term effects
on other biological systems. The search for ‘green’
disinfectants continues, with a summary of altern-
atives beneath.
Electrolysed water
Electrolysed water is produced by passing an electric
current through tap water with added salt, creating a
cocktail of hypochlorous acid and activated oxygen
radicals [27]. Neutral electrolysed water has been
evaluated for cleaning community care homes
and hospital and rapidly and effectively removes
microbial soil [28,29]. Electrochemically activated
solutions exert a greater microbiocidal effect than
&
chlorinated products on different surfaces [30 ].
They are sporicidal, nontoxic (no gloves required),
cheap and degrade to water. They can be used for
general surfaces and clinical equipment [28,29,31–
33]. Spraying equipment with an electrochemically
activated saline solution is a simple and effective
mean to reduce contamination with Clostridium
difficile and other pathogens [32]. Even sensitive
electrical equipment can be decontaminated with
these products [33].
No adverse effects of electrolysed water disin-
fection have been reported. One study describes
rebound Staphylococcus aureus and methicillin-resist-
ant S. aureus (MRSA) on hospital surfaces 24 h after
cleaning [29]. This was attributed to removal of
biofilm by the disinfectant allowing release of plank-
tonic staphylococci from microscopic crevices on
&
the surfaces [34 ]. There are no other studies to
substantiate this or provide further data on the
effect of disinfectants on hard surface biofilm.
416 www.co-infectiousdiseases.com
Probiotic disinfectants
Probiotic decontaminants are based on the principle
of biological competition, whereby applied
solutions replace the bad bacteria with a friendlier
version [35,36]. The products contain Bacillus spores
(e.g. Bacillus subtilis, Bacillus pumilus and Bacillus
megaterium), which are termed ‘innocuous’ since
they exert no biocidal activity [36]. These organisms
germinate and spread along dry surfaces, thereby
inhibiting proliferation survival of other microbial
soil.
Both laboratory and hospital-based studies
report reduction of pathogens such as S. aureus,
pseudomonas, candida, enterococci, enterobacter-
iaceae and acinetobacter on hard surfaces [35,36].
Although results look promising, the studies are
confounded by the effect from mechanical removal
of soil because the solution is wiped over surfaces
with cloths, including microfiber. Furthermore,
reported levels of contamination may reflect con-
tinued shedding by staff and patients during field
trials. This is particularly evident from the data on S.
aureus, because this organism appears to persist long
&
term despite decontamination efforts [35,37 ]. Stud-
ies mention local ethical approval for use of a
spore-containing agent but there is no reference
to international standard testing, perhaps because
existing standards do not yet encompass probiotic
disinfectants.
Recent studies have tested surfaces such as
floors, bed footboard and sinks, perhaps due
to natural reticence in incorporating near-patient
sites and clinical equipment. A decontaminant is
expected to eliminate all pathogen reservoirs,
including those on hand-touch sites, so it must be
well tolerated for areas used for food, medicines and
clinical procedures. Widespread use of composite
spore mixtures requires robust assurance that these
could never result in pathogenic potential or trans-
fer of antimicrobial resistance genes [38]. The latter
concerns have been addressed in a recent report,
&
although the numbers were small [37 ]. Probiotic
disinfectants require further study before they
become universally accepted as cleaning products.
Disinfectants containing phages
Disinfectants based on bacteriophage solutions have
been investigated in food and water industries but
&
not yet healthcare settings [39 ]. A range of lytic
phages are known to infect many hospital patho-
gens, including multidrug-resistant (MDR) Klebsiella
pneumoniae, Acinetobacter baumannii, S. aureus (and
MRSA), C. difficile, Mycobacterium tuberculosis, Pseu-
domonas aeruginosa and salmonella [39 ,40–42].
&
Phage solutions eliminate specific food pathogens
Volume 29  Number 4  August 2016

on carrier surfaces, with data suggesting superior
activity to conventional disinfectants [43]. Effects
are reduced by the presence of food residues,
biofilm and artificially created microcrevices on
test surfaces.
Phage-containing disinfectants for hospitals
would be expected to contain phages targeted
against all known healthcare pathogens. We do
not know how these would interact with each other,
nor impinge on the usual components within
surface bioburden. There is also the possibility of
mutation inciting antimicrobial resistance or patho-
genic potential [42]. Given the capacity of microbes
to evolve survival mechanisms, any benefit con-
ferred from surface application of phage cocktails
might be short lived, if not actually dangerous. More
research into phage pharmacokinetics, unintended
consequences and characterization of formulations
in controlled trials should be undertaken before
phage products can be considered for clinical
application [42].
BIOFILM AND RELEVANCE TO CLEANING
Biofilm is a heterogeneous collection of organisms
enmeshed within a supportive polymer matrix,
which helps attach the conglomerate to a surface.
The best chance for biofilm survival is location,
usually buried in tiny cracks on a surface and thus
protected from shearing forces. There is currently
little known about hard surface biofilm in the
healthcare environment other than demonstrating
presence and association with potential pathogens
&
[34 ,44]. Surface cleaning may strip off the super-
ficial layer to release planktonic residents, which
then poses a potential risk to patients [29]. It is also
possible that less-aggressive cleaning fails to disrupt
adherent biofilm, thus begging the question as
to whether biofilm is relevant from the infection
control point of view. Not all biofilm residents are
viable, but pathogens such as S. aureus, MRSA and
MDR Acinetobacter are known to survive long term
[44,45]. Biofilm may explain why indistinguishable
genotypes of MRSA and MDR Klebsiella reappear in
clinical and environmental specimens months after
&
first isolation [46,47 ]. Organisms inevitably evolve
characteristics to help them survive desiccation
stress, although there is a trade-off between the
capacity for multidrug resistance and survival in
biofilm [48]. The relevance of biofilm for hospital
cleaning remains to be fully ascertained [49].
THE WIPING EFFECT
There are increasing reports that suggest physical,
rather than biocidal, removal of bioburden is key to
0951-7375 Copyright ß 2016 Wolters Kluwer Health, Inc. All rights reserved.
Hospital cleaning dos and don’ts Dancer
the cleaning process [50–58]. This is not necessarily
due to the fact that surface soil is known to impede
microbiocidal activity of a disinfectant [59]. Even
powerful disinfectants fail to eliminate all surface
soil, including pathogens. Disinfectant wipes add
cost without necessarily greater efficacy at pathogen
removal [60].
Physical removal of bioburden using detergents
needs to be compared against biocides for cost
benefits as well as longer term efficacy and environ-
mental issues [25,59]. A recent study demonstrates
the effect of detergent-based cleaning over a 48-h
period for near-patient high-touch hospital surfaces
[61]. The study measured total bioburden including
S. aureus and MRSA and found that once daily wip-
ing of these surfaces with detergent wipes reduced
microbial soil to acceptable levels. In practice, how-
ever, this relies upon the ‘one site, one wipe and one
direction’ application, so that nonmicrobiocidal
wipes do not spread pathogens throughout the
patient environment [60].
The physical effect of wiping requires standard-
ization to rank products and examine the cleaning
&
effect more closely [62 ]. This has been attempted
for disinfectant wipes, but measurements generally
encompass both microbiocidal effect as well as
physical removal [63,64]. More studies are required
on all types of wipes, preferably carried out in the
healthcare environment rather than laboratories.
These will help distinguish between microbiocidal
impact and physical removal, and allow definitive
examination of product claims. Standardization
of physical effort, low-level microbiocidal effect
of detergents, age and types of surface and people
traffic in hospitals all pose a challenge to establish-
&
ing the cleaning impact from wipes [62 ].
HOUSEKEEPER-BASED CLEANING
STRATEGIES
Cleaning practices
One of the main actions implemented in an out-
break of extreme-drug resistant (XDR) A. baumanii
in three Spanish ICUs was a revision of cleaning
practices intended to avoid sharing wipes between
rooms [65]. These practices also included increasing
the cleaning frequency of high-touch surfaces from
3 to 6 times/day, establishing cleaning responsibil-
ities (specifically clinical equipment), use of micro-
fiber products and measures to ensure consistent
cleaning by housekeepers. There was an impressive
reduction in XDR A. baumanii, which the authors
attributed to enhanced cleaning processes as well as
prompt management of colonized patients. They
stated that the ‘one wipe and one room’ approach
www.co-infectiousdiseases.com 417
Nosocomial and healthcare related infections
should be considered a standard measure for
cleaning hospitals to avoid cross-contamination.
This should be considered analogous to the ‘one
site, one wipe and one direction’ policy. Wipes
should never be reused between individual patient
zones or even between different items of clinical
equipment [60].
Monitoring cleaning
How important is it to measure the cleaning effec-
tiveness of an individual housekeeper? Despite
ultraviolet (UV) marking gels and ATP systems,
cost-effective methods for monitoring are still
required [66,67]. Cleaning activity was evaluated
through ATP detection for 17 housekeepers engaged
in terminal cleaning nearly 300 hospital rooms [68].
A subgroup of housekeepers was identified who
were significantly more effective and efficient than
their coworkers. The authors suggested that these
optimum outliers may be used in performance
improvement activities to determine behaviours
and factors that enhance environmental cleaning
[68]. They went on to show that monthly feedback
of performance data in face-to-face meetings with
frontline personnel was crucial in maintaining the
quality of cleaning in adult critical care units [69].
ATP monitoring was used in two Taiwanese
ICUs to improve overall cleaning [70]. Baseline data
helped construct a new cleaning protocol as well as
an educational training programme. After the inter-
vention, the authors claimed a 50% reduction in
ICU-acquired infection along with commensurate
reductions in organic soil on tested surfaces [70].
ATP systems clearly encourage cleaning effective-
ness, but they do not necessarily provide an accurate
measure of surface cleanliness [71]. Several studies
point out discrepancies with sensitivity of different
commercial monitoring systems, as well as the risk
of aberrant results due to organic soil, disinfectants
and cleaning materials [72,73]. ATP results should
not be interpreted as surrogate indicators for the
presence of microbial pathogens [74].
Surface ATP detection has been evaluated
against fluorescent markers and microbiological
culture, using the latter as a gold standard for assess-
ment of cleanliness [75]. The markers were useful in
determining how often frequently touched sites are
wiped during cleaning but surfaces classified as
clean, according to marker criteria, were less likely
to be soil free when evaluated against microbiolog-
ical and ATP standards. It appears that ATP
monitoring is best if you want to identify which
surfaces need cleaning, whereas microbiological
monitoring will tell you how well a surface has been
cleaned [75].
418 www.co-infectiousdiseases.com
Another study used fluorescent markers to
benchmark efficacy of different disinfectants
&
[76 ]. As application of these markers leads to a
more accurate assessment of cleaning, the study
design utilized the system to standardize the
testing of two different disinfectants. The results
equivocally demonstrated that one agent was
better than the other for removing bioburden
despite the low level of soil on surfaces before
cleaning [77].
Although visual inspection, microbial recovery,
fluorescent markers and ATP are useful for monitor-
ing cleaning outcomes, they measure different
aspects of the cleaning process. Each method
provides just one type of dataset when used alone.
If all four are combined in a logical sequence, how-
ever, the failure modes noted for each system can be
complemented by the strengths of the alternatives,
thereby circumventing the risk of failure for any
&
individual method [78 ].
AUTOMATED DECONTAMINATION
METHODS
There has been a huge increase in use of automated
decontamination equipment emitting hydrogen
peroxide (H2O2) or microbiocidal light in one
&
form or another [79,80,81 ,82]. All come with claims
of efficacy against specific pathogens including
reduced hospital infection rates. Although some
studies are well done, these reports should be
considered carefully because there are often concur-
rent interventions that confound the findings.
Furthermore, few offer robust cost–benefit analyses,
even though the devices are expensive and none
obviate the continued requirement for basic
cleaning [83]. There are also technical constraints
which make routine use of robots problematic for
busy hospitals [84].
Hydrogen peroxide
H2O2 devices utilize aerosolized and vapour
products, which are released into rooms requiring
decontamination. They offer a range of different
concentrations, which require careful consideration
by purchasers and evaluators alike. As H2O2 is toxic
to humans, people cannot enter the room when
the device is running and any ventilatory ducts
(including windows) need to be completely sealed.
Delivery takes several hours, with some areas need-
ing longer exposure. Hydrogen peroxide vapour
decontamination is therefore practical only for ter-
minal, and not daily, room disinfection. Staff need
training to operate these devices, and the room has
to be prepared for decontamination because H2O2,
Volume 29  Number 4  August 2016

whichever formulation, cannot penetrate linen or
soft furnishings [84].
Although in-vitro studies demonstrate potent
microbiocidal effect of H2O2 against hospital patho-
gens, not all react to the same degree. MRSA escapes
total elimination attributed to catalase production,
which inactivates H2O2. One study compared killing
of Geobacillus stearothermophilus against MRSA
following 30 min exposure to H2O2 vapour [85].
Recovery of MRSA was between 1.5 and 3.5 log10
higher than surviving G. stearothermophilus spores
(P < 0.05). Another study examined the effects of
two different H2O2 systems in rooms containing
coupons seeded with standardized inocula of differ-
ent pathogens [86]. Again, MRSA survived on over
a quarter of coupons, regardless of time or concen-
tration. C. difficile could not be recovered from the
coupons but persisted on the floor. Over half the
sites screened following H2O2 exposure yielded
background microbial flora with no discernible
difference between the systems tested [86].
A prospective crossover study in a French
hospital investigated whether H2O2 exposure after
terminal cleaning had any effect on multidrug-
resistant organism (MDRO) acquisition for critical
care patients [87]. Rooms were cleaned with a
quaternary ammonium compound and sodium
hypochlorite, followed by either H2O2 vapour or
aerosolized H2O2 combined with peracetic acid.
After terminal cleaning and before any H2O2
disinfection took place, only 23 (1.5%) of 1456
sampled surfaces and 15 (8%) of 182 rooms were
actually MDRO-positive, so there was little chance
of additional H2O2 having much effect. H2O2 only
reduced residual extended-spectra beta-lactamase-
producing coliforms in sinks as no other MDROs
could be recovered [87]. Another study using
adjunctive H2O2 for terminal cleaning reported that
patients were 64% less likely to acquire MDROs
following H2O2 decontamination [88]. This effect
was due solely to the reduction in vancomycin-
resistant enterococcus (VRE), however, which was
the main endemic pathogen in study institution
[84,89]. There was no significant reduction for
patient acquisition of other monitored pathogens
(C. difficile, MRSA and MDR Gram-negative bacilli).
An editorial in NEJM Journal Watch stated that,
‘This will not be the last study of cleaning with
hydrogen peroxide vapour’ [89].
Ultraviolet C light devices
Microbiocidal light is subject to many of the prob-
lems beset by H2O2 devices [90]. Other than
&
high-intensity narrow-spectrum light [81 ], ultra-
violet C (UV-C) delivery is aimed at terminal, rather
0951-7375 Copyright ß 2016 Wolters Kluwer Health, Inc. All rights reserved.
Hospital cleaning dos and don’ts Dancer
than routine, cleaning and requires preparation,
training, maintenance and adjustment during
decontamination. A recent study examining con-
tinuous (mercury) versus pulsed (xenon) UV systems
for killing C. difficile, MRSA and VRE showed that
neither totally eradicated the pathogens tested [91].
The effect on C. difficile was particularly unimpres-
sive, with less than 1 log10 cfu reduction from an
original inoculum of 5 log10 cfu. Continuous UV-C
achieved significantly greater log10 cfu reductions
than pulsed-UV but the continuous system uses
mercury bulbs, which can be short-lived and pose
problems for waste disposal. The same study also
investigated the effect of distance and shading on
log kill of target pathogens, showing poor killing
efficacy when the pathogens were out of line of
emitted light [91].
UV-C devices, like H2O2 systems, have been
introduced into decontamination regimens with
monitoring of HAI rates. A community hospital
instituted a 2-year study to assess the effect of
UV-C after terminal cleaning [92]. Although the
incidence of C. difficile decreased by 41% (VRE by
50%), MRSA increased by 20% throughout the
institution. Another community hospital also
initiated UV-C decontamination with the intention
of reducing C. difficile [93]. There was a 51%
reduction in C. difficile infection (CDI)–HAI rate
after using UV-C for a year, but quinolone consump-
tion declined during the intervention, making it
difficult to ascribe the rate reduction to UV-C rather
than antibiotic stewardship. Similarly, C. difficile
incidence dropped among patients after introduc-
ing pulsed UV-C into an academic hospital during
2011 [94]. There was an overall decrease in MDRO
acquisition but significance (<0.001) was only
gained by pooling the statistics for extended-spectra
beta-lactamase-producing coliforms, C. difficile,
MRSA and VRE. None reached significance individ-
ually. The findings were confounded by the fact that
several other environmental interventions occurred
during this study, including a new cleaning con-
tractor, DAZO fluorescent gel use (Ecolab Healthcare
North America, St. Paul, Minnesota, USA) and a
discharge cleaning checklist for supervisors. There
was no information provided on antimicrobial
consumption [94].
Another study investigated the effect of pulsed
xenon UV-C on surface MRSA in the absence
of manual cleaning and showed that MRSA
(2–84 cfu) persisted on near-patient hand touch sites,
despite sampling areas devoid of visible soil [95]. A
significant outlier on the call button surface (116 cfu
MRSA) was attributed to ‘cross-contamination’ and
removed from the final analysis [95]. As few as 4 cfu
MRSA can initiate infection in a patient [96].
www.co-infectiousdiseases.com 419
Nosocomial and healthcare related infections
Domestic staff react strongly to any form of
monitoring or the implementation of a new clean-
ing strategy [61,97]. A Canadian study introduced
three sequential interventions over a 21-month
&
period [10 ]. The first intervention was fluorescent
markers, monitoring, education and feedback; the
second was UV-C devices targeting CDI rooms; and
the third had a dedicated daily disinfection team
targeting high risk sites in CDI rooms with Clorox
(The Clorox Company, Oakland, California, USA)
wipes. UV-C failed to make much difference; it was
the small team of cleaners that produced the final
reduction in C. difficile contamination during the
third intervention. The message from this study was
that motivating and educating cleaning staff ulti-
mately achieved the result wanted, not introduction
&
of costly UV-C technology [10 ].
Concerns have already been raised over
efficacy and cost–benefits of automated devices
because laboratory testing does not necessarily
predict what happens on hospital surfaces
[79,80,82,83,91,98,99]. Furthermore, the situation
during outbreaks is rather different and managers
quickly find resources for new technologies.
Such a reaction, along with the effect from the
systems themselves, inevitably procures a successful
outcome. It would be wise to consider the use of
no-touch systems for routine disinfection and out-
break control separately rather than assume that
published outcome covers both situations. These
systems obviously offer an alternative strategy
for disinfecting hospitals, but their logistical com-
plexities, requirements and costs, make it impera-
tive that objective, controlled and independent
studies should be performed to establish overall
cost–benefits [83,100].
ANTIMICROBIAL SURFACES
Numerous guidelines emphasize the importance
of adequate cleaning but rarely provide practical
advice on how to achieve this, or how often sites
should be cleaned. As all sites rapidly become con-
taminated after cleaning, surface coatings with pro-
longed biocidal activity might be a useful adjunct
for controlling recontamination [61,98,101,102].
This would relieve the pressure on both surface
cleaning and hand hygiene, provided such coatings
demonstrate uniform and long-term activity [103].
Bioactive surfaces include heavy metals (or their
derivatives) such as copper, zinc, silver or titanium,
or biocides and phages [102,104–106]. There are
electrostatic and inhibitory surfaces that repel
microbial adhesion; and ‘self-cleaning’ coatings that
rely upon hydrophilic and hydrophobic properties
[102,107]. Novel coatings include nanoparticles
420 www.co-infectiousdiseases.com
combined with titanium dioxide (TiO2) to form
reactive TiO2 following exposure to both natural
and artificial light [108,109]. One recent study
used polyvinyl chloride (PVC) coated with photo-
catalytic nano-TiO2 and demonstrated a significant
reduction in MRSA compared with ordinary PVC
[109]. Another in-vitro study showed reduced
survival of S. aureus and MRSA following application
onto an acrylic ‘Sharklet’ micropattern surface
&
[110 ]. The Sharklet surface was more effective at
inhibiting staphylococcal transfer than pure copper
alloy. Although there have been studies examining
antimicrobial coatings in healthcare environments,
a recent systematic review found few low-quality
studies and no conclusive findings [111]. More work
is required on these futuristic surfaces.
CONCLUSION
Although the importance of decontaminating
hospitals is now universally accepted, most of the
options discussed constitute a costly minefield for
healthcare managers to assimilate. There are a range
of products and practices emerging in response to
the debate on environmental decontamination but
both short and longer term consequences of many
of these have yet to be clarified. They offer a modern
response to labour-intensive cleaning but all require
further evaluation to make the best decisions for
patients and future patients [16]. The seemingly easy
option may not necessarily be the best or least costly
way forward.
It goes without saying that traditional deter-
gent-based cleaning ought to receive a full and
thorough appraisal [9]. Surprisingly, this has not
yet happened. Simply increasing the cleaning
frequency of high-risk sites could be a crucial factor
in controlling environmental risk, rather than gam-
ble with an environmentally unfriendly alternative
[46,112]. It should be remembered that the effect of
any cleaning/disinfectant agent tested is dependent
on physical action [7]. In defence of the products
reviewed, they provide some assurance that we will
be able to control environmental dirt when it mat-
ters. Furthermore, the human element in delivering
cleaning services remains unexplored, especially
when considering the immense psychosocial efforts
to improve hand hygiene. Offering a multilevel
training structure for domestic staff could well reap
dividends in the overall quality of cleaning. Business
and industry already play a central role in bringing
novel methods onto the market; working together,
doctors, scientists, government and cleaners can
help to choose cost-effective cleaning strategies
for hospitals in a world of increasing antimicrobial
resistance [113].
Volume 29  Number 4  August 2016

Acknowledgements
NHS Lanarkshire R&D and Edinburgh Napier University
supported the writing of this article.
Financial support and sponsorship
No funding was received from external sources.
Conflicts of interest
There are no conflicts of interest.
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100. Dancer SJ. Controlling hospital-acquired infection: focus on the role of the
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