Can Antimicrobial Coatings on

Environmental Surfaces and

Fabrics Prevent HAIs?: Current
Evidence or Lack There of
Eli Perencevich, MD MS
Source of HAI
In ICU
40-60% Endogenous flora
20-40% Cross infection from hands of HCW
20-25% Antibiotic driven changes in flora
20% Other (including environment)
Lower means harder to study
1. Weber DJ and Rutala WA, Infect Control Hosp Epidemiol, May 2013
2. Weinstein RA, Am J Med 1991; 91 (suppl 3B): 179-184S
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Endogenous Iceberg
1. Weinstein RA, Am J Med 1991; 91 (suppl 3B): 179-184S
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Patient A
Patient B
Environment &
Equipment
Healthcare
Workers



Linking Environment to Textiles

Contamination of HCW during care of
MDRO colonized patient

What role does the environment play in
contamination and transmission?
1. Morgan D, et al, Infect Control Hosp Epidemiol 2010; 31:716-721
2. Snyder G, et al, Infect Control Hosp Epidemiol 2008; 29(7):584-589
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Protocol
Swab hands
prior to entry
Observe
activities
in room
Perform
environmental
cultures
Swab gown/
gloves/hands
after exit
Textile contamination
Organism
HCW
Room
Entries
Hand +
Before
(%)
Gown
and/or
Glove +
After %
Gowns
Positive
%
Hands +
After
Removal
Effectiveness
of PPE
A.
baumannii
1
202 1.5% 38.7% 11.1% 4.5% 88%
P.
aeruginosa
1
133 0% 8.2% 4.5% 0.7% 90%
VRE
2
94 0% 9% 4.3% 0% 100%
MRSA
2
81 2% 19% 6.2% 2.6% 85%
1. Morgan D, et al, Infect Control Hosp Epidemiol 2010; 31:716-721
2. Snyder G, et al, Infect Control Hosp Epidemiol 2008; 29(7):584-589
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Environmental
Sites Cultured
Note: Excluded
call buttons
Environmental Sampling
71% percent of rooms had positive
environmental cultures with organism
known to be colonizing patient

78% Acinetobacter
35% VRE
28% MRSA
22% P. aeruginosa
1. Morgan D, et al, Crit Care Med 2012 Apr;40(4):1045-51
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Independent Predictors of HCW
Contamination
Odds
Ratio
95% Confidence
Interval
Duration in room >5
minutes
2 1.2-3.4*
Physical Exam 1.7 1.1-2.8*
Contact with ventilator 1.8 1.1-2.8*
+ Environmental
cultures
4.2 2.7-6.5*
* All p < 0.05
1. Morgan D, et al, Crit Care Med 2012 Apr;40(4):1045-51
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Patient A
Patient B
Nosocomial Transmission
Environment
Equipment
Healthcare
Workers
Transfer of Vancomycin-
Resistant Enterococci via Health
Care Worker Hands

Amy Dukro et al
Arch Intern Med 2005; 165:302-7
VRE from contaminated to
clean skin/environmental sites

Cultured intact skin of 22 VRE+ patients
Cultured environmental sites in patients
rooms before/after HCW visits
Cultured HCW hands before/after care
PFGE
Duckro AN, Arch Intern Med 2005; 165:302-7
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VRE Transfer
Healthcare workers touched 151 negative
sites after touching a VRE+ site

16 sites (10.6%) became positive for VRE
12 from body sites
9 were either body source or environmental
source
Remaining had multiple possible sources
Duckro AN, Arch Intern Med 2005; 165:302-7
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Patient Source
Duckro AN, Arch Intern Med 2005; 165:302-7
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Possible Textile or Coating Target
Duckro AN, Arch Intern Med 2005; 165:302-7
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Role of Professional Attire?
Contamination in the clinical setting:
White coats
Study Pathogen N % positive
Wong D
1991
S. aureus 100 29
Loh W
2000
S. aureus
Acinetobacter
100
5
7
Osawa K
2003
MRSA 14 79
Treakle AM
2008
S. aureus 149 23
Uneke CJ
2010
S. aureus
Ps. aeruginosa
103
19
10
Munoz-Price LS
2012
S. aureus
Acinetobacter
Enterococcus
22
32
32
5
Study Pathogen N % positive
Perry C
2001
MRSA
VRE
57
14
38
Munoz-Price LS
2012
S. aureus
Acinetobacter
Enterococcus
97
11
11
3
Krueger CA
2012
S. aureus 268 33
Contamination in the clinical setting:
Scrubs & Uniforms
Frequency of Laundering
Mean frequency (days)
Munoz-Price LS et al. Am J Infect Control 2013;41:565-7.
N=160
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Options for contaminated apparel?
Bare below the elbows
Short sleeves, no jewelry/watches/ties/white coats

Access to frequent/free laundering

Antimicrobial fabrics and attire
Maintain professional attire
Expensive need cost analyses
Role in transmission prevention?
Benefits of Silver Antimicrobial Scrubs
Study Population Design N Findings
Freeman
AI, 2012
Veterinary
Hospital
RCT 127
Surface bacterial counts
same at 4 & 8 hours

Gro S,
2010
Ambulance,
EMS
personnel
Cross-
over
10
Higher contamination out
to 7 days with silver in
jackets

RCT of antimicrobial scrubs
109 clinicians randomized

Standard (pants, short-sleeved shirt)

Antimicrobial (A): polyester &
antimicrobial chemical

Antimicrobial scrub (B): polyester-
cotton+silver+two antimicrobial
chemicals
Burden M et al. J Hospital Med 2013;8(7): 380-385
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No difference in colony counts
Total bacterial count after 8 hour day
Burden M et al. J Hospital Med 2013;8(7): 380-385
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VTT-003 Scrubs
Impregnated fabric with an organosilane-based
quaternary ammonium antimicrobial agent and a
copolymer emulsion

30 HCW in ICU, randomized, cross-over trial
4 months, crossover at 4 weeks
458 participant weeks studied
2,000 apparel swabs
1,324 hand swabs

Bearman GML et al. Infect Control Hosp Epidemiol 2012:33(3): 268-75
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No difference by scrub type,
shift or location swabbed
Bearman GML et al. Infect Control Hosp Epidemiol 2012:33(3): 268-75
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No difference in hand
contamination
Bearman GML et al. Infect Control Hosp Epidemiol 2012:33(3): 268-75
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No difference in hand
contamination
Bearman GML et al. Infect Control Hosp Epidemiol 2012:33(3): 268-75
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Privacy Curtains
The forgotten fomite

Cleaned every 4 months or never
Changed when visibly soiled

Often touched AFTER practicing
hand hygiene or donning gloves
Contamination in the clinical setting:
Privacy Curtains
Study Pathogen N % positive
Ohl M
2012*
All
MRSA
VRE
180
95
21
42
Klakus J
2008
MRSA 200 16
Trillis
MRSA
VRE
C. difficile
50
22
42
4
* 12/13 (92%) new curtains contaminated at 1 week
Antimicrobial Privacy Curtains
University of Iowa
Randomized trial 30 ICU rooms
15 standard vs 15 complex element
compound
Curtains identical in shape/size
Blinded data collection and microbiology
Blinded removed post analysis

1. Schweizer ML et al. Infect Control Hosp Epidemiol 2012 (33)11: 1081-85
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Sampling method
Curtains sampled 1 meter, leading edge
of curtain
2x / week for 23 days
Time to contamination survival analysis
234 curtains sampled

1. Schweizer ML et al. Infect Control Hosp Epidemiol 2012 (33)11: 1081-85
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Time to Contamination
1. Schweizer ML et al. Infect Control Hosp Epidemiol 2012 (33)11: 1081-85
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Antimicrobial Privacy Curtains
Longer median time to contamination (14
days vs 2 days, p<0.01)

Sub-analyses
8 standard vs 1 CEC curtain were VRE+,
unadjusted relative risk [RR], 8.0; p<0.01)
29% lower contamination with CEC curtain,
adjusted* RR, 0.71; 95% CI, 0.481.07

Adjusted for ICU type (MICU vs SICU), # beds per room
Self-disinfecting Surfaces
Suboptimal cleaning of surfaces
<50% cleaned
~75% with education and feedback
UV and vaporized hydrogen peroxide
Restricted to terminal cleaning
Costs
Increased turnover time

Weber DJ and Rutala WA et al. Am J Infect Control 2013(41)S31-35
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Self-disinfecting Technologies
Weber DJ and Rutala WA et al. Am J Infect Control 2013(41)S31-35
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Costs, benefits and data?
Weber DJ and Rutala WA et al. Am J Infect Control 2013(41)S31-35
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Advantages
Continuous disinfection without effort
Broad-spectrum, low toxicity
Disadvantages
Cant coat all surfaces, durability
Efficacy in reducing HAI has not been
demonstrated in clinical trials
Cost and Resistance
Copper
Copper Surfaces in ICU: An RCT
ICUs in 3 US Hospitals
Screen for MRSA at three facilities
VRE screening at 2 hospitals

Primary outcome: Incident rate of HAI
and/or MRSA or VRE colonization

8 copper vs 8 control rooms

Salgado CD et al. Infect Control Hosp Epidemiol. 2013:34(5):479-486
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6 Surfaces Treated
All ICUs had these four:
Bed rails, overbed tables, IV poles, arms
of visitor chairs

Additional two:
Nurses call button, computer mouse, bezel
of touchscreen monitor, palm rest of laptop
computer

Salgado CD et al. Infect Control Hosp Epidemiol. 2013:34(5):479-486
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Exposure
614 patients randomized

Copper exposed patients: 47% had all
days with 6 copper surfaces treated

Controls: 13% exposed to copper
Salgado CD et al. Infect Control Hosp Epidemiol. 2013:34(5):479-486
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Outcomes
46 developed an HAI (7.5%)

26 became colonized with MRSA or VRE

Primary outcome
HAI and/or VRE/MRSA colonization
0.071 vs 0.128. p=0.013 (45% reduction)
Salgado CD et al. Infect Control Hosp Epidemiol. 2013:34(5):479-486
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Concerns
http://haicontroversies.blogspot.com/2013/04/the-environment-and-hai-where-does_25.html
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Complex system of outcomes
SINGLE Outcomes
(a) any episode HAIs
(b) colonization with MRSA or VRE
COMPOSITE outcomes
(c) both HAI and colonization (both)
(d) HAI and/or colonization (either)**
(e) HAI only but no colonization (# of patients who had
HAI minus the ones who had both HAI & colonization)**
(f) colonization only but no HAI**
** Salgado et al only reported d-f
Harbarth et al. Infect Control Hosp Epidemiol (letter) 2013;34(9):996-997
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Harbarth et al. Infect Control Hosp Epidemiol (letter) 2013;34(9):996-997
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Criticisms
Selectively not reporting primary outcomes
(a) and (b)

MRSA/VRE colonization acquisition was not
defined; one site didnt collect VRE data

Most HAI reduction was BSI (3 vs 11) but
no data on CVC-related vs secondary and
no denominator data (1,000 CVC days)

Harbarth et al. Infect Control Hosp Epidemiol (letter) 2013;34(9):996-997
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Biological Plausibility?
How can suboptimal placement of copper
on 6 surfaces reduce HAI by 50%?
Only 10% of surfaces were coated
And 13% controls exposed to copper

50% reduction is beyond our current
understanding of endogenous sources
being primary
Harbarth et al. Infect Control Hosp Epidemiol (letter) 2013;34(9):996-997
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Conclusion
The importance of the environment in
nosocomial transmission is not disputed
Antimicrobial textiles and coated surfaces
have the theoretical potential to limit the
environmental burden and prevent
infection
Data in hospital settings is sorely lacking