Advertisement

Role of hospital surfaces in the transmission of emerging health care-associated pathogens: Norovirus, Clostridium difficile, and Acinetobacter species

      Health care-associated infections (HAI) remain a major cause of patient morbidity and mortality. Although the main source of nosocomial pathogens is likely the patient's endogenous flora, an estimated 20% to 40% of HAI have been attributed to cross infection via the hands of health care personnel, who have become contaminated from direct contact with the patient or indirectly by touching contaminated environmental surfaces. Multiple studies strongly suggest that environmental contamination plays an important role in the transmission of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus spp. More recently, evidence suggests that environmental contamination also plays a role in the nosocomial transmission of norovirus, Clostridium difficile, and Acinetobacter spp. All 3 pathogens survive for prolonged periods of time in the environment, and infections have been associated with frequent surface contamination in hospital rooms and health care worker hands. In some cases, the extent of patient-to-patient transmission has been found to be directly proportional to the level of environmental contamination. Improved cleaning/disinfection of environmental surfaces and hand hygiene have been shown to reduce the spread of all of these pathogens. Importantly, norovirus and C difficile are relatively resistant to the most common surface disinfectants and waterless alcohol-based antiseptics. Current hand hygiene guidelines and recommendations for surface cleaning/disinfection should be followed in managing outbreaks because of these emerging pathogens.

      Key Words

      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Klevens R.M.
        • Edwards J.R.
        • Richards C.L.
        • Horan T.C.
        • Gaynes R.P.
        • Pollack D.A.
        • et al.
        Estimating health care-associated infections and deaths in US hospitals, 2002.
        Public Health Rep. 2007; 122: 160-166
        • Weinstein R.A.
        Epidemiology and control of nosocomial infections in adult intensive care units.
        Am J Med. 1991; 91: S179-S184
        • Kramer A.
        • Schwebke I.
        • Kampf G.
        How long do nosocomial pathogens persist on inanimate surfaces? A systematic review.
        BMC Infect Dis. 2006; 6: 130
        • Hota B.
        Contamination, disinfection, and cross-colonization: are hospital surfaces reservoirs for nosocomial infection?.
        Clin Infect Dis. 2004; 39: 1182-1189
        • Boyce J.
        Environmental contamination makes an important contribution to hospital infection.
        J Hosp Infect. 2007; 65: 50-54
        • Huang S.S.
        • Datta R.
        • Platt R.
        Risk of acquiring antibiotic-resistant bacteria from room occupants.
        Arch Intern Med. 2006; 166: 1945-1951
        • Weber D.J.
        • Rutala W.A.
        • Miller M.B.
        • Huslage K.
        • Sickbert-Bennett E.
        Role of hospital surfaces in transmission of emerging healthcare-associated pathogens.
        in: Rutala W.A. Disinfection, sterilization, and antisepsis. Association for Professionals in Infection Control and Epidemiology, Inc, Washington, DC2010
        • Center for Disease Control and Prevention
        Guideline for Hand Hygiene in Healthcare Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
        MMWR. 2002; 51: 1-44
        • Kampf G.
        • Kramer A.
        Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs.
        Clin Microbiol Rev. 2004; 17: 863-893
      1. Schulster LM, Chinn RYW, Arduino MJ, et al. Guidelines for environmental infection control in health-care facilities. Available from: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Enviro_guide_03.pdf. Accessed January 2, 2010.

      2. Rutala WA, Weber DJ. Guideline for disinfection and sterilization in healthcare facilities, 2008. Available from: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf. Accessed January 2, 2010.

        • Dancer S.J.
        The role of environmental cleaning in the control of hospital-acquired infection.
        J Hosp Infect. 2009; 73: 378-385
        • Goodman E.R.
        • Platt R.
        • Bass R.
        • et al.
        Impact of environmental cleaning intervention on the presence of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci on surfaces in intensive care units.
        Infect Control Hosp Epidemiol. 2008; 29: 593-599
        • Hayden M.K.
        • Bonten M.J.M.
        • Blom D.W.
        • Lyle E.A.
        • van de Vijver D.A.M.C.
        • Weinstein R.A.
        Reduction in acquisition of vancomycin-resistant enterococcus after enforcement of routine environmental cleaning measures.
        Clin Infect Dis. 2006; 42: 1552-1560
        • Dancer S.J.
        • White L.F.
        • Lamb J.
        • Girvan E.K.
        • Robertson C.
        Measuring the effect of enhanced cleaning in a UK hospital: a prospective cross-over study.
        BMC Med. 2009; 7: 28
        • Atmar R.L.
        • Estes M.K.
        The epidemiologic and clinical importance of norovirus infection.
        Gastroenterol Clin North Am. 2006; 35: 275-290
        • Glass R.I.
        • Parashar U.D.
        • Estes M.K.
        Norovirus gastroenteritis.
        N Engl J Med. 2009; 361: 1776-1785
        • Said M.A.
        • Perl T.M.
        • Sears C.L.
        Gastrointestinal flu: norovirus in health care and long-term care facilities.
        Clin Infect Dis. 2008; 47: 1202-1208
        • Greig J.D.
        • Lee M.B.
        Enteric outbreak in long-term care facilities and recommendations for prevention: a review.
        Epidemiol Infect. 2009; 137: 145-155
        • Harris J.P.
        • Lopman B.A.
        • O'Brien S.J.
        Infection control measures for norovirus: a systematic review of outbreaks in semi-enclosed settings.
        J Hosp Infect. 2010; 74: 1-9
        • Hansen S.
        • Stamm-Balderjahn S.
        • Zuschneid I.
        • et al.
        Closure of medical departments during nosocomial outbreaks: data from a systematic analysis of the literature.
        J Hosp Infect. 2007; 65: 348-353
        • D'Souza D.H.
        • Sair A.
        • Williams K.
        • et al.
        Persistence of caliciviruses on environmental surfaces and their transfer to food.
        Int J Food Microbiol. 2006; 108: 84-91
        • Clay S.
        • Maherchandani S.
        • Malik Y.S.
        • Goyal S.M.
        Survival on uncommon fomites of feline calicivirus, a surrogate of noroviruses.
        Am J Infect Control. 2006; 34: 41-43
        • Lee J.
        • Zoh K.
        • Ko G.
        Inactivation and UV disinfection of murine norovirus with TiO2 under various environmental conditions.
        Appl Environ Microbiol. 2008; 74: 2111-2117
        • Barker J.
        • Vipond I.B.
        • Bloomfield S.F.
        Effects of cleaning and disinfection in reducing the spread of norovirus contamination via environmental surfaces.
        J Hosp Infect. 2004; 58: 42-49
        • Evans M.R.
        • Meldrum R.
        • Lane W.
        • et al.
        An outbreak of viral gastroenteritis following environmental contamination at a concert hall.
        Epidemiol Infect. 2002; 129: 355-360
        • Estes M.K.
        • Prasad B.V.V.
        • Atmar R.L.
        Noroviruses everywhere: has something changed?.
        Curr Opin Infect Dis. 2006; 19: 467-474
        • Gehrke C.
        • Steinmann J.
        • Goroncy-Bermes P.
        Inactivation of feline calicivirus, a surrogate of norovirus (formerly Norwalk-like viruses), by different types of alcohol in vitro and in vivo.
        J Hosp Infect. 2004; 56: 49-55
        • Liu P.
        • Yuen Y.
        • Hsiao H.-M.
        • Jaykus L.-A.
        • Moe C.
        Effectiveness of liquid soap and hand sanitizer against Norwalk virus on contaminated hands.
        Appl Environ Microbiol. 2010; 76: 394-399
        • Magulski T.
        • Paulmann D.
        • Bischoff B.
        • et al.
        Inactivation of murine norovirus by chemical biocides on stainless steel.
        BMC Infect Dis. 2009; 9: 1-7
        • Whitehead K.
        • McCue K.A.
        Virucidal efficacy of disinfectant actives against feline calicivirus, a surrogate for norovirus, in a short contact time.
        Am J Infect. 2010; 38: 26-30
        • Malik Y.S.
        • Maherchandani S.
        • Goyal S.M.
        Comparative efficacy of ethanol and isopropanol against feline calicivirus a norovirus surrogate.
        Am J Infect Control. 2006; 34: 31-35
        • Jimenez L.
        • Chiang M.
        Virucidal activity of a quaternary ammonium compound disinfectant against feline calicivirus: a surrogate for norovirus.
        Am J Infect Control. 2006; 34: 269-273
      3. Siegel JD, Rhinehart E, Jackson M, Chiarella L. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. Available from: http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf. Accessed January 2, 2010.

        • Bartlett J.G.
        Antibiotic-associated diarrhea.
        N Engl J Med. 2002; 346: 334-339
        • Kelly C.P.
        • LaMont J.T.
        Clostridium difficile—more difficult than ever.
        N Engl J Med. 2008; 359: 1932-1940
        • Gould C.V.
        • McDonald L.C.
        Bench-to-bedside review: Clostridium difficile colitis.
        Crit Care. 2008; 12: 1-8
        • Kim K.H.
        • Fekety R.
        • Batts D.H.
        • et al.
        Isolation of Clostridium difficile from the environment and contacts of patients with antibiotic-associated colitis.
        J Infect Dis. 1981; 143: 42-50
        • McFarland L.V.
        • Mulligan M.E.
        • Kwok R.Y.
        • Stamm W.E.
        Nosocomial acquisition of Clostridium difficile infection.
        N Engl J Med. 1989; 320: 204-210
        • Mutters R.
        • Nonnenmacher C.
        • Susin C.
        • Albrecht U.
        • Kropatsch R.
        • Schumacher S.
        Quantitative detection of Clostridium difficile in hospital environmental samples by real-time polymerase chain reaction.
        J Hosp Infect. 2009; 71: 43-48
        • Samore M.H.
        • Venkataraman L.
        • DeGirolami P.C.
        • Arbeit R.D.
        • Karchmer A.W.
        Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial Clostridium difficile diarrhea.
        Am J Med. 1996; 100: 32-40
        • Fawley W.N.
        • Parnell P.
        • Verity P.
        • Freeman J.
        • Wilcox M.H.
        Molecular epidemiology of endemic Clostridium difficile infection and the significance of subtypes of the United Kingdom epidemic strain.
        J Clin Microbiol. 2005; 43: 2685-2696
      4. Shaughnessy M, Micielli R, Depestel D, et al. Evaluation of hospital room assignment and acquisition of Clostridium difficile associated diarrhea (CDAD), 48th Annual Interscience Conference on Antimicrobial Agents and Chemotherapy and the Infections Disease Society of America. Washington, DC. Abstract K-4194, 2008.

        • Wilcox M.H.
        • Fawley W.N.
        • Wigglesworth N.
        • Parnell P.
        • Verity P.
        • Freemen J.
        Comparison of the effect of detergent versus hypochlorite cleaning of environmental contamination and incidence of Clostridium difficile infection.
        J Hosp Infect. 2003; 54: 109-114
        • Boyce J.M.
        • Havill N.L.
        • Otter J.A.
        • et al.
        Impact of hydrogen peroxide vapor room decontamination on Clostridium difficile environmental contamination and transmission in a healthcare setting.
        Infect Control Hosp Epidemiol. 2008; 29: 723-729
        • Gerding D.N.
        • Muto C.A.
        • Owens Jr., R.C.
        Measures to control and prevent Clostridium difficile infection.
        Clin Infect Dis. 2008; 46: 43-49
        • Dubberke E.R.
        • Gerding D.N.
        • Classen D.
        • et al.
        Strategies to prevent Clostridium difficile infections in acute care hospitals.
        Infect Control Hosp Epidemiol. 2008; 29: S81-S92
        • Vonberg R.P.
        • Kuijper E.J.
        • Wilcox M.H.
        • et al.
        Infection control measures to limit the spread of Clostridium difficile.
        Clin Microbiol Infect Dis. 2008; 14: 2-20
        • Oughton M.T.
        • Loo V.G.
        • Dendukuri N.
        • Fenn S.
        • Libman M.D.
        Hang hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile.
        Infect Control Hosp Epidemiol. 2009; 30: 939-944
        • Rupp M.E.
        • Fitzgerald T.
        • Puumala S.
        • et al.
        Prospective, controlled, cross-over trial of alcohol-based hand gel in critical care units.
        Infect Control Hosp Epidemiol. 2008; 29: 8-15
        • Maragakis L.L.
        • Perl T.M.
        Acinetobacter baumannii: epidemiology, antimicrobial resistance, and treatment options.
        Clin Infect Dis. 2008; 46: 1254-1263
        • Munoz-Price L.S.
        • Weinstein R.A.
        Acinetobacter infection.
        N Engl J Med. 2008; 358: 1271-1281
        • Karageorgopoulos D.E.
        • Falagas M.
        Current control and treatment of multidrug-resistant Acinetobacter baumannii infections.
        Lancet Infect Dis. 2008; 8: 751-762
        • Wendt C.
        • Dietze B.
        • Dietz E.
        • Ruden H.
        Survival of Acinetobacter baumannii on dry surfaces.
        J Clin Microbiol. 1997; 35: 1394-1397
        • Jawad A.
        • Seifert H.
        • Snelling A.M.
        • Heritage J.
        • Hawkey P.M.
        Survival of Acinetobacter baumannii on dry surfaces: comparison of outbreak and sporadic isolates.
        J Clin Microbiol. 1998; 36: 1938-1941
        • Catalano M.
        • Quelle L.S.
        • Jeric P.E.
        • Martino A.
        • Maimore S.M.
        Survival of Acinetobacter baumannii on bed rails during an outbreak and during sporadic cases.
        J Hosp Infect. 1999; 42: 27-35
        • Musa E.K.
        • Desai N.
        • Casewell M.W.
        The survival of Acinetobacter calcoaceticus inoculated on fingertips and Formica.
        J Hosp Infect. 1990; 15: 219-227
        • Markogiannakis A.
        • Fildisis G.
        • Tsiplakou S.
        • et al.
        Cross-transmission of multidrug-resistant Acinetobacter baumannii clonal strains causing episodes of sepsis in a trauma intensive care unit.
        Infect Control Hosp Epidemiol. 2008; 29: 410-417
        • Rodriquez-Bano J.
        • Garcia L.
        • Ramirez E.
        • et al.
        Long-term control of hospital-wide, endemic multidrug-resistant Acinetobacter baumannii through a comprehensive "bundle" approach.
        Am J Infect Control. 2009; 37: 715-722
        • Cardoso C.L.
        • Pereira H.H.
        • Zequim J.C.
        • Guihermetti M.
        Effectiveness of hand-cleansing agents for removing Acinetobacter baumannii strain from contaminated hands.
        Am J Infect Control. 1999; 27: 327-331