Highlights
- •Environmental contamination plays a role in hospital-acquired infections (HAI) transmission.
- •A 24- hour continuous approach to environmental cleaning and disinfection is an effective strategy in significantly reducing bioburden and HAI incidence.
- •Dry Hydrogen Peroxide (DHP) is successful in preventing Clostridoides difficile infections in the intensive care unit.
- •DHP as an adjunct to manual cleaning and disinfection impacts HAI reduction efforts.
Abstract
Background
This study aims to describe the effect of Dry Hydrogen Peroxide (DHP), as an adjunct to environmental cleaning and disinfection, on the incidence of hospital-acquired infections (HAIs) at Unidad Nacional de Oncologia Pediatrica (UNOP) in Guatemala City, Guatemala.
Methods
A retrospective study of all HAI data from the hospital's surveillance system, which follows Centers for Disease Control and Prevention (CDC) protocols, was conducted from January 2019 to November 2020. DHP was installed in all Pediatric Intensive Care Unit (PICU) rooms in January 2020, but nowhere else in the hospital, including the Intermediate Care Unit (IMCU).
Results
There were 189 HAI cases during the study period, with 173 occurring in either the PICU or IMCU. A statistically significant decrease in HAI incidence rates occurred in the PICU in 2020 compared to 2019 (P = .028), including Clostridiodes-associated gastroenteritis (P = .048). Logistic multivariate regression yielded a significant association between DHP exposure and reduced odds of developing an HAI during the study (OR = 0.3857, P = .029).
Conclusion
The use of DHP as an adjunct technology for environmental cleaning and disinfection contributed to the reduction in HAIs in the PICU. Our study highlights the value of such an approach as an addition to manual cleaning to decrease the risk of infection from environmental contamination.
Key Words
Background
Hospital-acquired infections (HAIs) are severe adverse events affecting children with cancer, often resulting in significant morbidity and mortality.
1
, 2
These patients are at high risk for HAI due to their immunocompromised state, particularly those children with acute lymphoblastic leukemia (ALL). Children with ALL are ten times more likely to die from infection complications in countries with limited resources.3
Central line-associated bloodstream infections (CLABSI), multidrug-resistant organisms (MDROs), gastrointestinal-related infections, and viral infections are the most commonly seen HAIs affecting pediatric hematology-oncology patients.4
, 5
, 6
There is growing knowledge about the role of the healthcare environment as a reservoir of and vehicle for the transmission of various pathogens and how environmental cleaning and sterilization practices can help decrease the transmission of HAIs.7
, 8
, 9
Pathogens can survive in the environment from several hours to 2 weeks for Norovirus, 7 days up to 5 years for methicillin-resistant Staphylococcus aureus (MRSA), greater than 5 months for Clostridioides difficile and from 5 days-5 years for vancomycin-resistant enterococci (VRE).9
These organisms can thereby be a continuous source of hospital-acquired infection transmission.For patients with cancer who are in constant contact with the healthcare environment, this role is of paramount importance. Manual cleaning and disinfection play an important role in reducing pathogens in the healthcare environment and minimizing the risk of infection transmission. However, studies have shown that manual cleaning is not predictable and often suboptimal. It is dependent on the education of cleaning personnel and nurses and the appropriate amounts and application of disinfectant solutions. Previous healthcare studies have indicated that as few as 47% of surfaces are appropriately disinfected.
4
Studies have shown that enhanced disinfection strategies, including adjunctive 'no-touch’ technologies, can help achieve more comprehensive reductions in environmental bioburden.10
, 11
, 12
While these technologies are effective, they are limited by logistical constraints, including the need to operate in unoccupied spaces because of safety concerns, operational staffing, and efficacy parameters such as device placement and run-time. Further, because many of these same technologies are necessarily episodic, they cannot address the active, ongoing recontamination of the environment that occurs between device uses.Our study uses Dry Hydrogen Peroxide (DHP) as a supplemental approach to environmental cleaning and disinfection. It is an automated and continuous microbial reduction system. The technology catalytically produces DHP from ambient humidity and oxygen, delivering it throughout the treated space. Notably, the system is safe to operate in occupied areas, thereby addressing contamination of the environment while avoiding disruptions to workflow or patient throughput. Several studies have shown that DHP effectively reduces both air and surface bioburden within the healthcare environment.
13
, 14
, 15
, 16
In previously published work, the study team demonstrated that using DHP technology as an adjunct to standard cleaning practices resulted in significant reductions in microbial bioburden within a Pediatric Oncology Intensive Care Unit (PICU).13
In the present study, the objective was to assess the impact of DHP on HAIs.Methods
Four hundred forty-three (443) patients were admitted to the PICU and IMCU of the Unidad Nacional de Oncologia Pediátrica (UNOP) in Guatemala City, Guatemala between January 2019 and November 2020. The PICU has nine (9) beds, and the IMCU has fifteen (15) beds. The two areas shared the same hospital personnel during the entirety of the study. DHP was installed as a supplemental approach to the standard environmental cleaning and disinfection in the PICU, while routine standard cleaning alone occurred in the IMCU. It should be noted that, owing to the COVID-19 pandemic, a variety of mitigation measures were implemented throughout the hospital including social distancing, masking, and reduced visitation; however, there were no changes to the hospital's standard cleaning protocol and no other adjunct environmental cleaning technologies were employed.
HAI determinations follow standardized surveillance definitions adapted from CDC/National Healthcare Safety Network (NHSN) protocol.
17
The study included all types of HAI in the review. Data collected included basic demographics, visit encounters, risk factors such as invasive devices, diagnostics, and microbiological cultures.National Healthcare Safety Network. Identifying healthcare-associated infections for NHSN surveillance. Accessed August 4, 2021. https://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf.
The institution's ethics review board and hospital leadership approved the use of DHP in accordance with the study protocol.
Demographics
Patients' ages ranged from 1 month-22 years old, with an average of 7.7 years of age. The majority of the patients (61%) had leukemia, while the remainder included patients diagnosed with other forms of cancer (ie, sarcoma, blastoma, lymphoma, etc.) The duration of hospitalizations in the entire hospital during this period ranged from 1-146 days, with an average of 25.4 days. The lengths of stay in the PICU were much shorter than the hospital average, ranging from 1-73 days with an average of 9.6 days.
Statistical methods
The HAI cases at UNOP were enumerated and tabulated by type of infection and the area of the hospital in which they occurred for 2019 and 2020 (Tables 1 and 2). The incidence rates of the different types of infections that occurred in the PICU and IMCU in 2019 and 2020 were calculated, and then the incidence rate difference (IRD) was calculated for each type of infection. These IRD values were individually analyzed using a contingency table chi-square test using Stata 17 (College Station, TX) to determine if statistically significant changes occurred in the incidence of any particular type of infection in either the PICU or IMCU between 2019 and 2020. A logistic multivariate regression model was then created using Stata 17 software (College Station, TX) to determine the existence of an association between exposure to DHP and HAI incidence. The following covariates were also included in the model: age of the patient (stratified), cancer type of the patient (binary: leukemia or other), the year of the hospitalization, the ward in which the patient was hospitalized, and the length of the patient's stay (stratified). The year of the hospitalization was included in this model to account for possible variation in HAI incidence due to changes in protocols related to the COVID-19 pandemic (ie, mask usage, reduced familial visits, social distancing, etc.) A P-value of < .05 was considered significant throughout the entirety of the analysis.
Hospital areas other than the PICU and IMCU.
Hospital areas other than the PICU and IMCU.
Table 1Types of HAI by hospital area in retrospective cohort study of pediatric cancer patients at Unidad Nacional de Oncologia Pediatrico (UNOP) in Guatemala City during the period of January 1, 2019-December 31, 2019
| 2019 Infection type demographics | UNOP cases | PICU cases | IMCU cases | Other area cases |
|---|---|---|---|---|
| Bloodstream Infections | 27 | 9 | 12 | 6 |
| 13 | 6 | 5 | 2 |
| 14 | 3 | 7 | 4 |
| Respiratory Infections | 26 | 11 | 14 | 1 |
| 24 | 11 | 12 | 1 |
| 2 | 0 | 2 | 0 |
| Gastroenteritis | 26 | 12 | 12 | 2 |
| 21 | 9 | 10 | 2 |
| 5 | 3 | 2 | 0 |
| Skin and Soft Tissue Infections | 11 | 2 | 9 | 0 |
| 8 | 1 | 7 | 0 |
| 3 | 1 | 2 | 0 |
| Urinary Tract Infections (UTIs) | 4 | 2 | 2 | 0 |
| Surgical Site Infections | 4 | 3 | 1 | 0 |
| Other | 8 | 1 | 5 | 2 |
| Total HAI Cases | 106 | 40 | 55 | 11 |
All infections contracted by patients admitted to UNOP during 2019 are included.
HAI, hospital-acquired infections; IMCU, intermediate care unit; PICU, pediatric intensive care unit; UNOP, Unidad Nacional de Oncologia Pediatrica.
† Patient medical records are the source of all infection data.
Table 2Types of HAI by hospital area in retrospective cohort study of pediatric cancer patients at UNOP in Guatemala City during the period of January 1, 2020-November 30, 2020
| 2020 Infection type demographics | UNOP cases | PICU cases | IMCU cases | Other area cases |
|---|---|---|---|---|
| Bloodstream Infections | 27 | 8 | 14 | 5 |
| 9 | 6 | 3 | 0 |
| 18 | 2 | 11 | 5 |
| Respiratory Infections | 24 | 5 | 19 | 0 |
| 13 | 4 | 9 | 0 |
| 11 | 1 | 10 | 0 |
| Gastroenteritis | 16 | 4 | 12 | 0 |
| 12 | 2 | 10 | 0 |
| 4 | 2 | 2 | 0 |
| Skin and Soft Tissue Infections | 7 | 1 | 6 | 0 |
| 3 | 0 | 3 | 0 |
| 4 | 1 | 3 | 0 |
| Urinary Tract Infections (UTIs) | 3 | 2 | 1 | 0 |
| Surgical Site Infections | 0 | 0 | 0 | 0 |
| Other | 6 | 1 | 5 | 0 |
| Total HAI Cases | 83 | 21 | 57 | 5 |
† Includes patients diagnosed with hospital-acquired Covid-19 who did not develop pneumonia.
‡ Patient medical records are the source of all infection data. All infections contracted by patients admitted to UNOP during January-November 2020 are included.
To verify the presence of DHP, a Picarro PI2114 gas concentration analyzer was utilized. A positive detection test for the presence of DHP was conducted in a centrally located area in the PICU. Positive detection was defined as 95% confidence intervals of the average measurements with a lower boundary greater than the instrument's Level of Detection (LOD) of 0.3 ppb.
Results
HAI incidence
The incidence rates of different categories of HAIs were calculated, and the statistical significance of the incidence rate differences (IRD) of these categories between 2019 and 2020 in the PICU and IMCU were determined (Tables 3 and 4). In the PICU, there was a statistically significant decrease in the incidence rate of the overall number of HAIs between 2019 and 2020 (IRD = -21.20, P = .0277). Additionally, there was a statistically significant decrease in the incidence rate of the number of Clostridioides-associated gastroenteritis (GE) infections between 2019 and 2020 in the PICU (IRD=-8.23, P = .0482). Conversely, in the IMCU, no statistically significant decreases in incidence rates occurred for either the overall number of HAIs or any particular type of infection between 2019 and 2020. The IMCU did, however, experience a statistically significant increase in non-pneumonia respiratory infections (RI) in 2020 compared to 2019 (IRD = 2.52, P = .0276).
Incidence measured in Cases per 1,000 patient days.
Incidence measured in Cases per 1,000 patient days.
Table 3Incidences of HAIs by type of infection in the PICU in retrospective cohort study of pediatric cancer patients at UNOP in Guatemala City during the period of January 1- 2019-November 30, 2020
| PICU | 2019 cases | 2019 incidence | 2020 cases | 2020 incidence | IRD | P-value |
|---|---|---|---|---|---|---|
| Bloodstream Infections | 9 | 10.77 | 8 | 10.15 | -0.61 | .9088 |
| 6 | 7.18 | 6 | 7.61 | 0.44 | .9201 |
| 3 | 3.59 | 2 | 2.54 | -1.05 | .7342 |
| Respiratory Infections | 11 | 13.16 | 5 | 6.35 | -6.81 | .1777 |
| 11 | 13.16 | 4 | 5.08 | -8.08 | .0971 |
| 0 | 0.00 | 1 | 1.27 | 1.27 | .4852 |
| Gastroenteritis | 12 | 14.35 | 4 | 5.08 | -9.28 | .0637 |
| 9 | 10.77 | 2 | 2.54 | -8.23 | .0482 |
| 3 | 3.59 | 2 | 2.54 | -1.05 | .7342 |
| Skin and Soft Tissue Infections | 2 | 2.39 | 1 | 1.27 | -1.12 | .6586 |
| 1 | 1.20 | 0 | 0.00 | -1.20 | .5148 |
| Soft Tissue Infection | 1 | 1.20 | 1 | 1.27 | 0.07 | .9704 |
| Urinary Tract Infections | 2 | 2.39 | 2 | 2.54 | 0.15 | .9557 |
| Surgical Site Infections | 3 | 3.59 | 0 | 0.00 | -3.59 | .1364 |
| Other | 1 | 1.20 | 1 | 1.27 | 0.07 | .9704 |
| Total HAI Cases | 40 | 47.85 | 21 | 26.65 | -21.20 | .0277 |
| Total Patient Days | 836 | 788 |
NOTE. P-values in bold reflects statistical significance.
† Incidence Rate Difference: (2020-2019).
‡ P-values all generated by contingency table chi-square test. P-values < .05 were considered statistically significant.
§ Includes patients diagnosed with hospital-acquired COVID-19 who did not develop pneumonia.
¶ Patient medical records are the source of all infection data. All infections contracted by patients admitted to UNOP PICU during January 2019-November 2020 are included.
Table 4Incidences of HAIs by type of infection in the IMCU in retrospective cohort study of pediatric cancer patients at UNOP in Guatemala City during the period of January 1, 2019-November 30, 2020
| IMCU | 2019 cases | 2019 incidence | 2020 cases | 2020 incidence | IRD | P-value |
|---|---|---|---|---|---|---|
| Bloodstream Infections | 12 | 3.56 | 14 | 4.36 | 0.80 | .7934 |
| 5 | 1.48 | 3 | 0.93 | -0.55 | .4664 |
| 7 | 2.08 | 11 | 3.43 | 1.35 | .4145 |
| Respiratory Infections | 14 | 4.15 | 19 | 5.92 | 1.76 | .4719 |
| 12 | 3.56 | 9 | 2.80 | -0.76 | .4549 |
| 2 | 0.59 | 10 | 3.11 | 2.52 | .0276 |
| Gastroenteritis | 12 | 3.56 | 12 | 3.74 | 0.18 | 0.9067 |
| 10 | 2.97 | 10 | 3.11 | 0.15 | .9150 |
| 2 | 0.59 | 2 | 0.62 | 0.03 | .9638 |
| Skin and Soft Tissue Infections | 9 | 2.67 | 6 | 1.87 | -0.80 | .4010 |
| 7 | 2.08 | 3 | 0.93 | -1.14 | .1995 |
| 2 | 0.59 | 3 | 0.93 | 0.34 | .7256 |
| Urinary Tract Infections | 2 | 0.59 | 1 | 0.31 | -0.28 | .5980 |
| Surgical Site Infections | 1 | 0.30 | 0 | 0 | -0.30 | .4879 |
| Other | 5 | 1.48 | 5 | 1.56 | 0.07 | .9406 |
| Total HAI Cases | 55 | 16.32 | 57 | 17.75 | 1.43 | .9465 |
| Total Patient Days | 3370 | 3211 |
NOTE. P-values in bold reflects statistical significance.
† Incidence Rate Difference: (2020-2019)
‡ P-values all generated by contingency table chi-square test. P-values < .05 were considered statistically significant.
§ Includes patients diagnosed with hospital-acquired COVID-19 who did not develop pneumonia.
¶ Patient medical records are the source of all infection data. All infections contracted by patients admitted to UNOP IMCU during January 2019-November 2020 are included.
To investigate the possible association between exposure to DHP and the odds of developing an HAI, a logistic multivariate regression model was created. Multiple covariates were controlled in the model, including the duration of the patient's visit, the age of the patient, the year in which the visit occurred, the patient's type of cancer, and the area of the hospital into which they were admitted. The model yielded a statistically significant odds ratio, associating exposure to DHP with a reduced odds of a patient developing an HAI during their stay, when controlling for the aforementioned covariates (OR = 0.386, P = .029). Of the included covariates, only the length of patient stay was significantly associated with a patient's odds of contracting an HAI, with patients who stayed longer than 10 days having significantly higher odds of developing an HAI than patients who stayed 5 days or fewer (OR = 15.563; P = < .00001). The year of the patient's stay was not significantly associated with whether the patient developed an HAI (P = .506), indicating that factors related to the COVID-19 pandemic (ie, emergence of SARS-CoV-2, social distancing, mask usage, reduced visitations) were not significantly associated with the odds of patients developing an HAI in this study. The presence of DHP in the PICU range between 0.8-1.6 ppb. DHP measurements were obtained using the Picarro PI2114 device instrument.
Discussion
This study attempts to describe the impact of DHP on HAI at a pediatric oncology hospital after its implementation in the PICU at the beginning of 2020, in comparison to the IMCU, which did not have DHP deployed. Prior studies have found that DHP effectively reduced environmental surface contamination.
13
, 14
, 15
, 16
The HAI surveillance process at the hospital follows the standardized CDC/NHSN methods and case definitions.17
The hospital recorded 189 HAI events between 2019 and 2020 (Tables 1 and 2). The HAI incidence throughout the entire hospital was 17.29/1,000 patient-days in 2019 and 16.15/1,000 patient-days in 2020, which are consistent with the findings of Urrea et al.National Healthcare Safety Network. Identifying healthcare-associated infections for NHSN surveillance. Accessed August 4, 2021. https://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf.
18
A significant decrease in HAI incidence was observed during 2020 in the PICU compared to 2019 (P = .028), which aligns with the deployment of DHP. Conversely, there was no significant change in HAI incidence in the adjacent IMCU during the same period, where DHP was not deployed (P = .947). Additionally, the regression model yielded that a patient in this study that had been exposed to DHP had a 61.4% reduced odds of contracting an HAI during their stay (OR = 0.386; P = .029), when controlling for length of stay, area of hospital, patient age, patient's type of cancer, and the year of the patient's visit.The most commonly observed types of infection events were bloodstream infections (BSI), pneumonia, gastroenteritis, skin and soft tissue infections, urinary tract infections, and surgical site infections. These were consistent with previously reported studies in Latin America and from a major pediatric cancer center in the USA.
6
,19
While any type of HAI event can have serious consequences, the incidence of Clostridoides difficile infections (CDI) has been problematic since these events cause cancer treatment delays and prolonged length of stay.20
During the study period, 31 CDI events were observed in total between the PICU and IMCU. In the PICU, incidence of CDI events reached 10.77 cases/1,000 patient days in 2019, but then significantly reduced to 2.54 in 2020, after DHP was installed (P = .048). In the IMCU, where there was no DHP, CDI incidence slightly increased from 2.97 cases/1,000 patient-days in 2019 to 3.11 in 2020. CDI incidence in the literature has been reported between 2.6 to 4.0/1,000 admissions among hospitalized children.21
The IMCU also experienced a sharp increase in non-pneumonia respiratory infections in 2020 due to hospital-acquired cases of COVID-19 (IRD = 2.52; P = .028) with 90% of all IMCU hospital-acquired non-pneumonia respiratory infections that year attributable to COVID-19. Conversely, only one such case occurred in the PICU, where DHP was installed. This is consistent with recent studies that indicate DHP inactivates SARS-CoV-2 both in the air and on surfaces.22
,23
This increase in the number of respiratory infections in the IMCU occurred during the early months of the COVID-19 pandemic in the region, which is consistent with a recent review and meta-analysis that noted that 44% of nosocomial COVID-19 infections due to occurred during the early periods of the pandemic.Synexis. Efficacy of the Synexis Sphere against SARS-CoV-2 Delta. 2021. Accessed December 20, 2021. https://synexis.com/wp-content/uploads/2021/12/SARS-Cov-2-Delta-Variant-12-8-FINAL93.pdf.
24
While this sharp increase in respiratory infections was observed in the IMCU, the PICU, where DHP was installed, did not have a similar increase. The environmental cleaning practices between the PICU and IMCU are the same. The hospital uses quaternary and chlorine-based surface disinfectants for manual cleaning and disinfection.Interestingly, there were no changes in these practices or shortages in cleaning supplies despite the challenges faced by countries globally due to the COVID-19 pandemic.
25
Optimizing the environmental cleaning process in the PICU with the addition of DHP has proven its value in terms of its outcome as previously discussed. Recommendations to improve environmental cleaning and disinfection using supplemental cleaning technologies have been described.American Cleaning Institute. Cleaning Products Industry Impact Report: COVID-19. 2020. Accessed July 5, 2021. https://www.cleaninginstitute.org/sites/default/files/documents/Coronavirus/2020ACIImpactReport_COVID19.pdf.
10
, 11
, 12
Furthermore, in terms of pathogens, our study showed a reduction in HAI in the PICU caused by Clostridiodes difficile, Klebsiella pneumoniae, and Candida spp. These pathogens can cause serious infection complications among children with cancer.
26
, 27
, 28
, 29
, 30
These pathogens can also survive on inanimate surfaces for long periods of time and can be a source of infection transmission unless the surface has been cleaned and disinfected correctly.31
DHP offers the value of continuous cleaning and disinfection of the space, making it safer and reducing the risk of acquiring an infection from environmental contamination including active recontamination.The COVID-19 pandemic created additional pressure and heightened awareness of the overall infection prevention processes and interventions. There were COVID-positive patients admitted to the PICU and IMCU; however, our study showed a reduction in HAI in the PICU in contrast to reports from the US and other countries.
32
, 33
, 34
Reports from these countries did not indicate the use of continuously-operating adjunct technology for environmental cleaning and disinfection.Our study has some limitations. First, data were limited to HAIs between 2019 and 2020 so we could not address the sustainability of the outcomes over time. Second, we did not review information on antimicrobial use and other treatment interventions for HAI events reported. Third, the PICU and IMCU have different structural designs, with some IMCU patient rooms containing two patients instead of one, thereby limiting the ability for direct comparisons of incidence rates between the two areas. Additionally, patients in the PICU were likely more susceptible to develop an HAI due to the greater severity of their conditions. Lastly, the analysis did not control for confounding variables such as illness severity, staffing, and other medical supply resources related to the COVID-19 pandemic.
Conclusions
Our study showed that DHP influenced our HAI reduction among the highest risk patients at the hospital. These results demonstrate the value of DHP technology to augment and optimize manual environmental cleaning and reduce the risk of microbial contamination, thereby making the hospital space safer for everyone. Further studies need to demonstrate the sustainability of adjunct technologies’ impact on HAIs over time
Acknowledgment
The authors would like to thank EpiClear Consulting, LLC. for their assistance with the statistical analysis of the data.
Appendix
2019-2020 PICU Clostridioides-Associated Gastroenteritis IRD Contingency Table
2019-2020 PICU Total HAI IRD Contingency Table
2019-2020 IMCU non-Pneumonia Respiratory Infection IRD Contingency Table
2019-2020 PICU non-Pneumonia Respiratory Infection IRD Contingency Table
Logistic Multivariate Regression Model Associating Odds of HAI Development with Exposure to DHP
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Article info
Publication history
Published online: December 28, 2021
Footnotes
Funding/support: Synexis provided the DHP technology devices to UNOP. Synexis provided the Picarro device to measure the DHP levels. Statistical analysis provided by EpiClear Consulting.
Conflicts of interest: None to report.
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