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No routine surface disinfection

      To the Editor:
      We write in response to the article by Rutala and Weber
      • Rutala W.A.
      • Weber D.J.
      The benefits of surface disinfection.
      in the American Journal of Infection Control, on which we wish to comment.
      We admire Dr Rutala's continued crusade for routine surface disinfection in hospitals, although the Hospital Infection Control Practices Advisory Committee (HICPAC), which he serves as a consultant, suggests and does not recommend routine surface disinfection in noncritical patient areas. In other words, their advice is based on suggestive studies only (category II). W. Rutala and J. Weber's knowledge of the scientific literature is remarkable. However, their knowledge of the German language and, correspondingly, interpretation of the German literature demand some improvement. By no means does the Robert Koch-Institute in Germany recommend “the use of surface disinfectants for patient equipment surfaces and non-critical housekeeping surfaces in patient care areas.” Rather, the Robert Koch-Institute divides the hospitals into different areas, according to infectious risks for patients and recommends cleaning for most surfaces, and surface disinfection only for surfaces in frequent contact with hands and skin of patients and personnel. Thus, most surfaces should be cleaned and not disinfected, even in operating theatres and intensive care and isolation units (see Table 1). Category IB denotes an expert opinion, and category II means neither recommended nor required, but only “suggested” for implementation. Thus, a targeted strategy is recommended, but not routine disinfection of all noncritical patient care surfaces.
      Anforderung an die Hygiene bei der Reinigung und Desinfektion von Flächen. Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention beim Robert Koch-Institut (RKI).
      Table 1Surface cleaning and disinfection in various risk areas (translation of the Robert Koch-Institute recommendations, Germany)
      Areas without infectious risk (eg, staircases, floors, administration, offices, cafeterias, auditorium)Areas with possible infectious risk (general wards, outpatient departments, radiology, dialysis units, delivery rooms, intensive care units)Areas with special infectious risk (operating theatres, burns units, transplantation units, hematology-oncology units)Areas with patients who could transmit pathogens (isolation units)
      All surfaces: cleaningSurfaces with frequent hand/skin contact: disinfection (Category II);Surfaces with frequent hand/skin contact: disinfection (Category lB);Surfaces with frequent hand/skin contact: disinfection (Category lB);
      Floors: cleaning;Floors: disinfection (Category II);Floors: disinfection (Category II);
      Other surfaces: cleaningOther surfaces: cleaningOther surfaces: cleaning
      May we also correct the authors interpretation of our German paper.
      • Dettenkofer M.
      • Merkel H.
      • Mutter J.
      • Daschner F.
      Ein health technology assessment. Was ist wissenschaftlich gesichert zur Prävention und Kontrolle vom MRSA?.
      By no means do we recommend “that the MRSA-patient room be disinfected three times a day on intensive care units and once a day on normal wards (including floors).” In this paper, we recommend disinfection only of surfaces frequently touched by patients, which does not include the floors, and we only recommend floor disinfection after discharge of a multidrug-resistant Staphylococcus aureus (MRSA) patient.
      The main reason we recommend surface disinfection in certain patient areas with MRSA patients is that the United Kingdom and Germany are the 2 countries in Europe with the highest annual increase in MRSA; therefore, we have increased our MRSA-infection control efforts to keep the MRSA level from reaching that of the United States.
      We are also intrigued as to the type of computer search used by Dr. Rutala for his review of the literature from 1996 to April 2004, which provided no evidence that the use of low-level disinfectants results in allergic symptoms in health care workers. In just 10 minutes of searching, we found 2 articles describing allergy to benzalkonium chloride in health care workers.
      Polish authors examined 223 nurses with suspected occupational dermatoses and found benzalkonium chloride (23.8%), nickel (21.5%), and formaldehyde (20%) as the most frequent sensitizers.
      • Kiec-Swierczynska M.
      • Krecisz B.
      Occupational skin diseases among the nurses in the region of Lodz.
      Nettis et al
      • Nettis E.
      • Colanardi M.C.
      • Soccio A.L.
      • Ferrannini A.
      • Tursi A.
      Occuptaional irritant and allergic contact dermatitis among health care workers.
      reviewed their data base from 1994 to 1998 and selected 360 consecutive patients working in health care environments who experienced contact dermatitis on their hands, wrists, and forearms. The major relevant agents that induced occupational allergic contact dermatitis were nickel, glutaraldehyde, benzalkonium chloride, and rubber chemicals.
      David J Weber, one of the authors of the article
      • Rutala W.A.
      • Weber D.J.
      The benefits of surface disinfection.
      addressed here, personally saw 5500 employees in 12,500 to 18,000 visits per year in his occupational health service and never found an employee with an allergic reaction to low-level disinfectants in the 11 years he has provided this service. On average, 15,000 visits per year means that he personally sees 60 patients a day. We doubt that that allows enough time for careful “skin history,” or even some fundamental tests to detect allergy to any kind of medical products.
      The paper by Schnuch et al
      • Schnuch A.
      • Uter W.
      • Geier J.
      • Frosch P.J.
      • Rustmeyer T.
      Contact Allergies in healthcare workers. Results from the IVDK.
      on contact allergies in health care workers can be interpreted from different perspectives. It is true that there was no statistically increased sensitization to benzalkonium chloride in all groups of health care workers compared with a control group (2% vs 1.6%), but benzalkonium was among the 8 leading allergens in health care personnel: 2.4% of 703 nurses and 2.0% of 159 physicians were sensitive to benzalkonium compared with only 0.6% of 159 receptionists.
      Rutala and Weber doubt the evidence that using disinfectants selects for antibiotic-resistant organisms in nature and that mutants survive in nature. Interestingly enough, an article in the same issue of the American Journal of Infection Control describes the antibiotic susceptibility of glutaraldehyde-tolerant Mycobacterium chelonae.
      • Nomura K.
      • Ogawa M.
      • Miyamotot H.
      • Muratani T.
      • Taniguchi H.
      Antibiotic susceptibility of glutaraldehyde-tolerant Mycobacterium chelonae from bronchoscope washing machines.
      One hundred percent of glutaraldehyde-tolerant isolates and only 11% of the glutaraldehyde-sensitive isolates were either resistant or immediately resistant to 2 or 3 classes of antibiotics. Scherpe and Kaulfers
      • Scherpe S.
      • Kaulfers P.M.
      Induktion von Benzalkoniumchlorid-Resistenz und deren Auswirkungen auf Antibiotika-Resistenzen bei Enterobakterien. Abstract DKV 005. 55th Congress of the Deutsche Gesellschaft für Hygiene und Mikrobiologie-DGHM (German Society for Hygiene and Microbiology), Dresden 28.09.-01.10.2003.
      tested the in vitro activity of benzalkonium chloride against 2840 gram-negative clinical isolates and found minimum inhibitory concentrations of benzalkonium chloride higher than 300 μg/mL in 4.5% and of more than 500 μg/mL in 1.1% of the strains (usual in-use concentration 500-1000 μg/mL). Strains with minimum inhibitory concentrations of more than 500 μg/mL benzalkonium chloride increased from 0.4% to 1% from 1994 to 2001.
      Citing their own study, Rutala and Weber state that antibiotic-resistant bacteria are as susceptible to germicides as antibiotic-susceptible strains.
      • Rutala W.A.
      • Stiegel M.M.
      • Sarubbi F.A.
      • Weber D.J.
      Susceptibility of antibiotic-susceptible and antibiotic-resistant hospital bacteria to disinfectants.
      However, Aiello and Larson offer quite a different interpretation of Rutala's study, stating that, when resistance to biocides among antibiotic-resistant hospital bacteria were measured, 1 of 5 antibiotic-resistant strains of K pneumoniae also turned out to be significantly more resistant to a quarternary ammonium compound at its commonly used dilution.
      • Aiello A.E.
      • Larson E.
      Antibacterial cleaning and hygiene products as an emerging risk factor for antibiotic resistance in the community.
      MRSA isolates with decreased susceptibility to benzalkonium chloride have also been shown to be resistant to β-lactam antibiotics.
      • Akimitsu N.
      • Hamamoto H.
      • Inoue R.
      • Shoji M.
      • Akaminie A.
      Increase in resistance of methicillin-resistant Staphylococcus aureus to β-lactam caused by mutations conferring resistance to benzalkonium chloride, a disinfectant widely used in hospitals.
      Although we agree with the Centers for Disease Control and Prevention recommendation that high-level disinfectants should not be used for surface disinfection of critical patient areas, we published our paper in the American Journal of Infection Control, which is an international journal, and does not only specifically address the American market or the American infection control situation. Unfortunately, in Germany, there are 459 surface disinfectants on the market, of which 330 contain quaternary ammonium compounds and 128 aldehydes, some of which are also components of high-level disinfectants.
      Rutala and Weber recommend that rigorous studies be undertaken to assess any perceived adverse environmental and health consequences of using disinfectants in the hospital, but where are the rigorous studies including “epidemiologic, clinical, or experimental data” that support their recommendation for use of hospital disinfectants on noncritical patient care surfaces such as bedside tables, bed rails, and radiograph machines. Have bed rails and radiograph machines ever been described as being a significant source of nosocomial infection?

      References

        • Rutala W.A.
        • Weber D.J.
        The benefits of surface disinfection.
        Am J Infect Control. 2004; 32: 226-231
      1. Anforderung an die Hygiene bei der Reinigung und Desinfektion von Flächen. Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention beim Robert Koch-Institut (RKI).
        Bundesgesundheitsblatt-Gesundheitsforsch Gesundheitsschutz. 2004; 47: 51-61
        • Dettenkofer M.
        • Merkel H.
        • Mutter J.
        • Daschner F.
        Ein health technology assessment. Was ist wissenschaftlich gesichert zur Prävention und Kontrolle vom MRSA?.
        Klinikarzt. 2004; 33: 15-20
        • Kiec-Swierczynska M.
        • Krecisz B.
        Occupational skin diseases among the nurses in the region of Lodz.
        Int J Occup Med Environ Health. 2000; 13: 179-184
        • Nettis E.
        • Colanardi M.C.
        • Soccio A.L.
        • Ferrannini A.
        • Tursi A.
        Occuptaional irritant and allergic contact dermatitis among health care workers.
        Contact Dermatitis. 2000; 46: 101-107
        • Schnuch A.
        • Uter W.
        • Geier J.
        • Frosch P.J.
        • Rustmeyer T.
        Contact Allergies in healthcare workers. Results from the IVDK.
        Acta Derm Venerol. 1998; 78: 358-363
        • Nomura K.
        • Ogawa M.
        • Miyamotot H.
        • Muratani T.
        • Taniguchi H.
        Antibiotic susceptibility of glutaraldehyde-tolerant Mycobacterium chelonae from bronchoscope washing machines.
        Am J Infect Control. 2004; 32: 185-188
        • Scherpe S.
        • Kaulfers P.M.
        Induktion von Benzalkoniumchlorid-Resistenz und deren Auswirkungen auf Antibiotika-Resistenzen bei Enterobakterien. Abstract DKV 005. 55th Congress of the Deutsche Gesellschaft für Hygiene und Mikrobiologie-DGHM (German Society for Hygiene and Microbiology), Dresden 28.09.-01.10.2003.
        Int J Med Microbiol. 2003; 293: 150
        • Rutala W.A.
        • Stiegel M.M.
        • Sarubbi F.A.
        • Weber D.J.
        Susceptibility of antibiotic-susceptible and antibiotic-resistant hospital bacteria to disinfectants.
        Infect Control Hosp Epidemiol. 1997; 18: 417-421
        • Aiello A.E.
        • Larson E.
        Antibacterial cleaning and hygiene products as an emerging risk factor for antibiotic resistance in the community.
        Lancet. 2003; 3: 501-505
        • Akimitsu N.
        • Hamamoto H.
        • Inoue R.
        • Shoji M.
        • Akaminie A.
        Increase in resistance of methicillin-resistant Staphylococcus aureus to β-lactam caused by mutations conferring resistance to benzalkonium chloride, a disinfectant widely used in hospitals.
        Antimicrob Agents Chemother. 1999; 43: 3042-3043

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