Major Article| Volume 50, ISSUE 3, P289-294, March 2022

Hygienic monitoring in long-term care facilities using ATP, crAssphage, and human noroviruses to direct environmental surface cleaning

Published:February 23, 2022DOI:


      • All surfaces were contaminated with crAssphage or high levels of organic debris
      • Without a recent outbreak, noroviruses were not found on the LTC facility surfaces
      • The highest levels of ATP and/or crAssphage were in patient rooms and public areas.
      • Hygienic monitoring identified where cleaning efforts could be heightened
      • Information is helpful in guiding infection control procedures in LTC facilities



      Norovirus and C. difficile are associated with diarrheal illnesses and deaths in long-term care (LTC) facilities and can be transmitted by contaminated environmental surfaces. Hygienic monitoring tools such as adenosine triphosphate (ATP) bioluminescence and indicators of fecal contamination can help to identify LTC facility surfaces with cleaning deficiencies.


      High-touch surfaces in 11 LTC facilities were swabbed and tested for contamination by norovirus, a fecal indicator virus, crAssphage, and ATP which detects organic debris. High levels of contamination were defined as log ATP relative light unit values or crAssphage log genomic copy values in the 75th percentile of values obtained from each facility.


      Over 90% of surfaces tested positive for crAssphage or gave failing ATP scores. Norovirus contamination was not detected. Handrails, equipment controls, and patient beds were 4 times more likely than other surfaces or locations to have high levels of crAssphage. Patient bed handrails and tables and chairs in patient lounges had high levels of both ATP and crAssphage.


      Surfaces with high levels of ATP and crAssphage were identified. Quantifying levels of contamination longitudinally and before and after cleaning might enhance infection prevention and control procedures for reducing diarrheal illnesses in LTC facilities.

      Key Words


      C. difficile (Clostridioides difficile), CDI (C. difficile infection), LTC (long-term care), ATP (adenosine triphosphate), PCR (polymerase chain reaction), RT-PCR (reverse transcriptase PCR)
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