Monitoring the effectiveness of daily cleaning practices in an intensive care unit (ICU) setting using an adenosine triphosphate (ATP) bioluminescence assay

Published:December 26, 2019DOI:


      • Surfaces in ICU environments are frequently contaminated by microbial pathogens.
      • ICU common area surfaces had higher bacterial burden than those in patient's rooms.
      • ATP bioluminescence can provide rapid feedback on ICU surface cleanliness.


      The degree to which daily intensive care unit (ICU) cleaning practices impacts bacterial burden is controversial. The study aimed to assess the utility of using adenosine triphosphate (ATP) bioluminescence assays for monitoring effectiveness of daily cleaning in ICU environments.


      We sampled 364 total samples from 57 patient rooms and 18 common areas in 3 medical ICUs over 12 weeks, before and after routine daily cleaning. Endpoints were ATP levels (relative light units, RLU) and bacterial bioburden (colony forming units, CFU).


      High-touch surfaces in ICU patient rooms and common areas were contaminated before and after cleaning. Routine cleaning significantly reduced bacterial burden in patient rooms (0.14 log10 CFU reduction, P = .008; 0.21 log10 RLU reduction, P < .001) and in ICU common areas (1.18 log10 CFU reduction, P < .001; 0.72 log10 RLU reduction, P < .001). Among sites with colony counts >20 CFUs, the proportion of sites with ATP readings >250 RLU was significantly higher than those with ATP readings ≤250 RLU (90.0% vs 10.0%, P < .05).


      Routine cleaning significantly reduced bacterial burden on ICU environment surfaces. Although not an alternative to culture methods, ATP assays may be a useful technique to provide rapid feedback on surface cleanliness in ICU settings.

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        • Magill SS
        • O’Leary E
        • Janelle SJ
        • et al.
        Changes in prevalence of health care-associated infections in U.S. hospitals.
        N Engl J Med. 2018; 379: 1732-1744
        • Drees M
        • Snydman DR
        • Schmid CH
        • et al.
        Prior environmental contamination increases the risk of acquisition of vancomycin-resistant enterococci.
        Clin Infect Dis. 2008; 46: 678-685
        • Nseir S
        • Blazejewski C
        • Lubret R
        • et al.
        Risk of acquiring multidrug-resistant gram-negative bacilli from prior room occupants in the intensive care unit.
        Clin Microbiol Infect. 2011; 17: 1201-1208
        • Otter JA
        • Yezli S
        • Salkeld JA
        • et al.
        Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings.
        Am J Infect Control. 2013; 41: S6-11
        • Wilson APR
        • Smyth D
        • Moore G
        • et al.
        The impact of enhanced cleaning within the intensive care unit on contamination of the near-patient environment with hospital pathogens: a randomized crossover study in critical care units in two hospitals.
        Crit Care Med. 2011; 39: 651-658
        • Hu H
        • Johani K
        • Gosbell IB
        • et al.
        Intensive care unit environmental surfaces are contaminated by multidrug-resistant bacteria in biofilms: combined results of conventional culture, pyrosequencing, scanning electron microscopy, and confocal laser microscopy.
        J Hosp Infect. 2015; 91: 35-44
        • Vickery K
        • Deva A
        • Jacombs A
        • et al.
        Presence of biofilm containing viable multiresistant organisms despite terminal cleaning on clinical surfaces in an intensive care unit.
        J Hosp Infect. 2012; 80: 52-55
        • Thompson AC
        • Wilder BJ
        • Powner DJ
        Bedside resuscitation bags: a source of bacterial contamination.
        Infect Control. 1985; 6: 231-232
        • Sole ML
        • Poalillo FE
        • Byers JF
        • et al.
        Bacterial growth in secretions and on suctioning equipment of orally intubated patients: a pilot study.
        Am J Crit Care. 2002; 11: 141-149
        • Catalano M
        • Quelle LS
        • Jeric PE
        • et al.
        Survival of Acinetobacter baumannii on bed rails during an outbreak and during sporadic cases.
        J Hosp Infect. 1999; 42: 27-35
        • Ohl M
        • Schweizer M
        • Graham M
        • et al.
        Hospital privacy curtains are frequently and rapidly contaminated with potentially pathogenic bacteria.
        Am J Infect Control. 2012; 40: 904-906
        • Hartmann B
        • Benson M
        • Junger A
        • et al.
        Computer keyboard and mouse as a reservoir of pathogens in an intensive care unit.
        J Clin Monit Comput. 2004; 18: 7-12
        • Panhotra BR
        • Saxena AK
        • Al-Mulhim AS
        Contamination of patients’ files in intensive care units: an indication of strict handwashing after entering case notes.
        Am J Infect Control. 2005; 33: 398-401
        • Heyba M
        • Ismaiel M
        • Alotaibi A
        • et al.
        Microbiological contamination of mobile phones of clinicians in intensive care units and neonatal care units in public hospitals in Kuwait.
        BMC Infect Dis. 2015; 15: 434
        • Nante N
        • Ceriale E
        • Messina G
        • et al.
        Effectiveness of ATP bioluminescence to assess hospital cleaning: a review.
        J Prev Med Hyg. 2017; 58: E177-E183
        • Sanna T
        • Dallolio L
        • Raggi A
        • et al.
        ATP bioluminescence assay for evaluating cleaning practices in operating theatres: applicability and limitations.
        BMC Infect Dis. 2018; 18: 583
        • Adams CE
        • Smith J
        • Watson V
        • et al.
        Examining the association between surface bioburden and frequently touched sites in intensive care.
        J Hosp Infect. 2017; 95: 76-80
        • Xu H
        • Chen B
        • Ni X
        • et al.
        Computer keyboard and mouse: an intervention study on methicillin-resistant staphylococcus aureus decontamination in 4 intensive care units.
        J Crit Care. 2017; 37: 266-267
        • Snyder GM
        • Holyoak AD
        • Leary KE
        • et al.
        Effectiveness of visual inspection compared with non-microbiologic methods to determine the thoroughness of post-discharge cleaning.
        Antimicrob Resist Infect Control. 2013; 2: 26
        • Hung IC
        • Chang HY
        • Cheng A
        • et al.
        Application of a fluorescent marker with quantitative bioburden methods to assess cleanliness.
        Infect Control Hosp Epidemiol. 2018; 39: 1296-1300
        • Knape L
        • Hambraeus A
        • Lytsy B
        The adenosine triphosphate method as a quality control tool to assess ‘cleanliness’ of frequently touched hospital surfaces.
        J Hosp Infect. 2015; 91: 166-170
        • Boyce JM
        • Havill NL
        • Dumigan DG
        • et al.
        Monitoring the effectiveness of hospital cleaning practices by use of an adenosine triphosphate bioluminescence assay.
        Infect Control Hosp Epidemiol. 2009; 30: 678-684