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1.  Effects of physical interventions on house dust mite allergen levels in carpet, bed, and upholstery dust in low-income, urban homes. 
Environmental Health Perspectives  2001;109(8):815-819.
House dust mite allergen exposure is a postulated risk factor for allergic sensitization, asthma development, and asthma morbidity; however, practical and effective methods to mitigate these allergens from low-income, urban home environments remain elusive. The purpose of this study was to assess the feasibility and effectiveness of physical interventions to mitigate house dust mite allergens in this setting. Homes with high levels of house dust mite allergen (Der f 1 + Der p 1 > or = 10 microg/g dust by enzyme-linked immunosorbent assay) in the bed, bedroom carpet, and/or upholstered furniture were enrolled in the study. Carpets and upholstered furniture were subjected to a single treatment of either dry steam cleaning plus vacuuming (carpet only) or intensive vacuuming alone. Bed interventions consisted of complete encasement of the mattress, box spring, and pillows plus either weekly professional or in-home laundering of nonencased bedding. Dust samples were collected at baseline and again at 3 days (carpet and upholstery only) and 2, 4, and 8 weeks posttreatment. We compared pretreatment mean allergen concentrations and loads to posttreatment values and performed between-group analyses after adjusting for differences in the pretreatment means. Both dry steam cleaning plus vacuuming and vacuuming alone resulted in a significant reduction in carpet house dust mite allergen concentration and load (p < 0.05). Levels approached pretreatment values by 4 weeks posttreatment in the intensive vacuuming group, whereas steam cleaning plus vacuuming effected a decrease that persisted for up to 8 weeks. Significant decreases in bed house dust mite allergen concentration and load were obtained in response to encasement and either professional or in-home laundering (p < 0.001). Between-group analysis revealed significantly less postintervention house dust mite allergen load in professionally laundered compared to home-laundered beds (p < 0.05). Intensive vacuuming and dry steam cleaning both caused a significant reduction in allergen concentration and load in upholstered furniture samples (p < 0.005). Based on these data, we conclude that physical interventions offer practical, effective means of reducing house dust mite allergen levels in low-income, urban home environments.
PMCID: PMC1240409  PMID: 11564617
2.  Microbiological contamination of cubicle curtains in an out-patient podiatry clinic 
Background
Exposure to potential pathogens on contaminated healthcare garments and curtains can occur through direct or indirect contact. This study aimed to identify the microorganisms present on podiatry clinic curtains and measure the contamination pre and post a standard hospital laundry process.
Method
Baseline swabs were taken to determine colony counts present on cubical curtains before laundering. Curtains were swabbed again immediately after, one and three weeks post laundering. Total colony counts were calculated and compared to baseline, with identification of micro-organisms.
Results
Total colony counts increased very slightly by 3% immediately after laundry, which was not statistically significant, and declined significantly (p = 0.0002) by 56% one-week post laundry. Three weeks post laundry colony counts had increased by 16%; although clinically relevant, this was not statistically significant. The two most frequent microorganisms present throughout were Coagulase Negative Staphylococcus and Micrococcus species. Laundering was not completely effective, as both species demonstrated no significant change following laundry.
Conclusion
This work suggests current laundry procedures may not be 100% effective in killing all microorganisms found on curtains, although a delayed decrease in total colony counts was evident. Cubicle curtains may act as a reservoir for microorganisms creating potential for cross contamination. This highlights the need for additional cleaning methods to decrease the risk of cross infection and the importance of maintaining good hand hygiene.
doi:10.1186/1757-1146-3-26
PMCID: PMC2995787  PMID: 21087486
3.  Measuring the effect of enhanced cleaning in a UK hospital: a prospective cross-over study 
BMC Medicine  2009;7:28.
Background
Increasing hospital-acquired infections have generated much attention over the last decade. There is evidence that hygienic cleaning has a role in the control of hospital-acquired infections. This study aimed to evaluate the potential impact of one additional cleaner by using microbiological standards based on aerobic colony counts and the presence of Staphylococcus aureus including meticillin-resistant S. aureus.
Methods
We introduced an additional cleaner into two matched wards from Monday to Friday, with each ward receiving enhanced cleaning for six months in a cross-over design. Ten hand-touch sites on both wards were screened weekly using standardised methods and patients were monitored for meticillin-resistant S. aureus infection throughout the year-long study. Patient and environmental meticillin-resistant S. aureus isolates were characterised using molecular methods in order to investigate temporal and clonal relationships.
Results
Enhanced cleaning was associated with a 32.5% reduction in levels of microbial contamination at hand-touch sites when wards received enhanced cleaning (P < 0.0001: 95% CI 20.2%, 42.9%). Near-patient sites (lockers, overbed tables and beds) were more frequently contaminated with meticillin-resistant S. aureus/S. aureus than sites further from the patient (P = 0.065). Genotyping identified indistinguishable strains from both hand-touch sites and patients. There was a 26.6% reduction in new meticillin-resistant S. aureus infections on the wards receiving extra cleaning, despite higher meticillin-resistant S. aureus patient-days and bed occupancy rates during enhanced cleaning periods (P = 0.032: 95% CI 7.7%, 92.3%). Adjusting for meticillin-resistant S. aureus patient-days and based upon nine new meticillin-resistant S. aureus infections seen during routine cleaning, we expected 13 new infections during enhanced cleaning periods rather than the four that actually occurred. Clusters of new meticillin-resistant S. aureus infections were identified 2 to 4 weeks after the cleaner left both wards. Enhanced cleaning saved the hospital £30,000 to £70,000.
Conclusion
Introducing one extra cleaner produced a measurable effect on the clinical environment, with apparent benefit to patients regarding meticillin-resistant S. aureus infection. Molecular epidemiological methods supported the possibility that patients acquired meticillin-resistant S. aureus from environmental sources. These findings suggest that additional research is warranted to further clarify the environmental, clinical and economic impact of enhanced hygienic cleaning as a component in the control of hospital-acquired infection.
doi:10.1186/1741-7015-7-28
PMCID: PMC2700808  PMID: 19505316
4.  Pressure Ulcer Prevention 
Executive Summary
In April 2008, the Medical Advisory Secretariat began an evidence-based review of the literature concerning pressure ulcers.
Please visit the Medical Advisory Secretariat Web site, http://www.health.gov.on.ca/english/providers/program/mas/tech/tech_mn.html to review these titles that are currently available within the Pressure Ulcers series.
Pressure ulcer prevention: an evidence based analysis
The cost-effectiveness of prevention strategies for pressure ulcers in long-term care homes in Ontario: projections of the Ontario Pressure Ulcer Model (field evaluation)
Management of chronic pressure ulcers: an evidence-based analysis (anticipated pubicstion date - mid-2009)
Purpose
A pressure ulcer, also known as a pressure sore, decubitus ulcer, or bedsore, is defined as a localized injury to the skin/and or underlying tissue occurring most often over a bony prominence and caused by pressure, shear, or friction, alone or in combination. (1) Those at risk for developing pressure ulcers include the elderly and critically ill as well as persons with neurological impairments and those who suffer conditions associated with immobility. Pressure ulcers are graded or staged with a 4-point classification system denoting severity. Stage I represents the beginnings of a pressure ulcer and stage IV, the severest grade, consists of full thickness tissue loss with exposed bone, tendon, and or muscle. (1)
In a 2004 survey of Canadian health care settings, Woodbury and Houghton (2) estimated that the prevalence of pressure ulcers at a stage 1 or greater in Ontario ranged between 13.1% and 53% with nonacute health care settings having the highest prevalence rate (Table 1).
Executive Summary Table 1: Prevalence of Pressure Ulcers*
CI indicates confidence interval.
Nonacute care included sub-acute care, chronic care, complex continuing care, long-term care, and nursing home care.
Mixed health care includes a mixture of acute, nonacute, and/or community care health care delivery settings.
Pressure ulcers have a considerable economic impact on health care systems. In Australia, the cost of treating a single stage IV ulcer has been estimated to be greater than $61,000 (AUD) (approximately $54,000 CDN), (3) while in the United Kingdom the total cost of pressure ulcers has been estimated at £1.4–£2.1 billion annually or 4% of the National Health Service expenditure. (4)
Because of the high physical and economic burden of pressure ulcers, this review was undertaken to determine which interventions are effective at preventing the development of pressure ulcers in an at-risk population.
Review Strategy
The main objective of this systematic review is to determine the effectiveness of pressure ulcer preventive interventions including Risk Assessment, Distribution Devices, Nutritional Supplementation, Repositioning, and Incontinence Management.
A comprehensive literature search was completed for each of the above 5 preventive interventions. The electronic databases searched included MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature. As well, the bibliographic references of selected studies were searched. All studies meeting explicit inclusion and exclusion criteria for each systematic review section were retained and the quality of the body of evidence was determined using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) system. (5) Where appropriate, a meta-analysis was undertaken to determine the overall estimate of effect of the preventive intervention under review.
Summary of Findings
Risk Assessment
There is very low quality evidence to support the hypothesis that allocating the type of pressure-relieving equipment according to the person’s level of pressure ulcer risk statistically decreases the incidence of pressure ulcer development. Similarly, there is very low quality evidence to support the hypothesis that incorporating a risk assessment into nursing practice increases the number of preventative measures used per person and that these interventions are initiated earlier in the care continuum.
Pressure Redistribution Devices
There is moderate quality evidence that the use of an alternative foam mattress produces a relative risk reduction (RRR) of 69% in the incidence of pressure ulcers compared with a standard hospital mattress. The evidence does not support the superiority of one particular type of alternative foam mattress.
There is very low quality evidence that the use of an alternating pressure mattress is associated with an RRR of 71% in the incidence of grade 1 or 2 pressure ulcers. Similarly, there is low quality evidence that the use of an alternating pressure mattress is associated with an RRR of 68% in the incidence of deteriorating skin changes.
There is moderate quality evidence that there is a statistically nonsignificant difference in the incidence of grade 2 pressure ulcers between persons using an alternating pressure mattress and those using an alternating pressure overlay.
There is moderate quality evidence that the use of an Australian sheepskin produces an RRR of 58% in the incidence of pressure ulcers grade 1 or greater. There is also evidence that sheepskins are uncomfortable to use. The Pressure Ulcer Advisory Panel noted that, in general, sheepskins are not a useful preventive intervention because they bunch up in a patient’s bed and may contribute to wound infection if not properly cleaned, and this reduces their acceptability as a preventive intervention.
There is very low quality evidence that the use of a Micropulse System alternating pressure mattress used intra operatively and postoperatively produces an RRR of 79% in the incidence of pressure ulcers compared with a gel-pad used intraoperatively and a standard hospital mattress used postoperatively (standard care). It is unclear if this effect is due to the use of the alternating pressure mattress intraoperatively or postoperatively or if indeed it must be used in both patient care areas.
There is low quality evidence that the use of a vesico-elastic polymer pad (gel pad) on the operating table for surgeries of at least 90 minutes’ duration produces a statistically significant RRR of 47% in the incidence of pressure ulcers grade 1 or greater compared with a standard operating table foam mattress.
There is low quality evidence that the use of an air suspension bed in the intensive care unit (ICU) for stays of at least 3 days produces a statistically significant RRR of 76% in the incidence of pressure ulcers compared with a standard ICU bed.
There is very low quality evidence that the use of an alternating pressure mattress does not statistically reduce the incidence of pressure ulcers compared with an alternative foam mattress.
Nutritional Supplementation
There is very low quality evidence supporting an RRR of 15% in the incidence of pressure ulcers when nutritional supplementation is added to a standard hospital diet.
Repositioning
There is low quality evidence supporting the superiority of a 4-hourly turning schedule with a vesico-elastic polyurethane foam mattress compared with a 2-hourly or 3-hourly turning schedule and a standard foam mattress to reduce the incidence of grade 1 or 2 pressure ulcers.
Incontinence Management
There is very low quality evidence supporting the benefit of a structured skin care protocol to reduce the incidence of grade 1 or 2 pressure ulcers in persons with urinary and/or fecal incontinence.
There is low quality evidence supporting the benefit of a pH-balanced cleanser compared with soap and water to reduce the incidence of grade 1 or 2 pressure ulcers in persons with urinary and fecal incontinence.
Conclusions
There is moderate quality evidence that an alternative foam mattress is effective in preventing the development of pressure ulcers compared with a standard hospital foam mattress.
However, overall there remains a paucity of moderate or higher quality evidence in the literature to support many of the preventive interventions. Until better quality evidence is available, pressure ulcer preventive care must be guided by expert opinion for those interventions where low or very low quality evidence supports the effectiveness of such interventions.
Abbreviations
Confidence interval
Grading of Recommendation Assessment, Development, and Evaluation
Intensive care unit
Medical Advisory Secretariat
National Pressure Ulcer Advisory Panel
Risk assessment scale
Randomized controlled trial
Registered Nurses Association of Ontario
Relative risk
Relative risk reduction
PMCID: PMC3377566  PMID: 23074524
5.  Bacterial contamination of floors and other surfaces in operating rooms: a five-year survey. 
The Journal of Hygiene  1984;93(3):559-566.
Bacterial contamination of floors and other surfaces in the operating suite has been investigated by contact impression plates during the past five years. Colony counts of the floors of operating rooms, cleaned with disinfectant, were 3.3 c.f.u./10 cm2; on the floors of semi-clean and dirty areas, cleaned with detergent, colony counts were 44.8 and 71.4 c.f.u./10 cm2 respectively. The highest colony counts of 487.4 c.f.u./10 cm2 were found in the dressing rooms, the floors of which were covered with carpets, cleaned with a vacuum cleaner. Mean bacterial numbers on surfaces of various equipment in operating rooms, cleaned with disinfectant, were 2.8 c.f.u./10 cm2. Bacterial numbers on surfaces decreased markedly from 253.2 to 11.9 c.f.u./10 cm2 following the use of disinfectant. Bacterial species found from various surfaces were mainly coagulase-negative staphylococci, derived from human beings. In the light of these findings the regular use of disinfectant for cleaning of the floors and other surfaces in operating rooms is advisable.
PMCID: PMC2129451  PMID: 6512255
6.  Quality Control in Linen and Laundry Service at A Tertiary Care Teaching Hospital in India 
Introduction:
The clean bedding and clean clothes installs psychological confidence in the patients and the public and enhances their faith in the services rendered by the hospital. Being an important Component in the management of the patients, a study was carried out to find out the current quality status and its conformity with the known standards and identify the areas of intervention in order to further increase the patient and staff satisfaction regarding the services provided by linen and laundry department
Methods:
Quality control practised in the Linen and Laundry Service was studied by conducting a prospective study on the concept of Donabedian model of structure, process and outcome. Study was done by pre-designed Proforma along with observation / Interviews / Questionnaire and study of records. The input studied included physical facilities, manpower, materials, equipments and environmental factors. The various elements of manpower studied consisted of number of staff working, their qualification, training, promotion avenues, motivation and job satisfaction. Process was studied by carrying out observations in linen and laundry service through a predesigned flow chart which was supplemented by interviews with different category of staff. Patient satisfaction, staff satisfaction and microbial count of laundered linen (quality dimensions) were studied in the outcome.
Results:
The current study found that in spite of certain deficiencies in the equipment, manpower and process, the linen and laundry service is providing a satisfactory service to its users. However the services can be further improved by removing the present deficiencies both at structure and process level.
PMCID: PMC3068780  PMID: 21475509
Linen and laundry service; Hospital linen; physical facilities; Quality control
7.  Feather bedding and childhood asthma associated with house dust mite sensitisation: a randomised controlled trial 
Archives of Disease in Childhood  2011;96(6):541-547.
Introduction
Observational studies report inverse associations between the use of feather upper bedding (pillow and/or quilt) and asthma symptoms but there is no randomised controlled trial (RCT) evidence assessing the role of feather upper bedding as a secondary prevention measure.
Objective
To determine whether, among children not using feather upper bedding, a new feather pillow and feather quilt reduces asthma severity among house dust mite (HDM) sensitised children with asthma over a 1-year period compared with standard dust mite avoidance advice, and giving children a new mite-occlusive mattress cover.
Design
RCT.
Setting
The Calvary Hospital in the Australian Capital Territory and the Children's Hospital at Westmead, Sydney, New South Wales.
Patients
197 children with HDM sensitisation and moderate to severe asthma.
Intervention
New upper bedding duck feather pillow and quilt and a mite-occlusive mattress cover (feather) versus standard care and a mite-occlusive mattress cover (standard).
Main outcome measures
The proportion of children reporting four or more episodes of wheeze in the past year; an episode of speech-limiting wheeze; or one or more episodes of sleep disturbance caused by wheezing; and spirometry with challenge testing. Statistical analysis included multiple logistic and linear regression.
Results
No differences between groups were found for primary end points – frequent wheeze (OR 1.51, 95% CI 0.83 to 2.76, p=0.17), speech-limiting wheeze (OR 0.70, 95% CI 0.32 to 1.48, p=0.35), sleep disturbed because of wheezing (OR 1.17, 95% CI 0.64 to 2.13, p=0.61) or for any secondary end points. Secondary analyses indicated the intervention reduced the risk of sleep being disturbed because of wheezing and severe wheeze to a greater extent for children who slept supine.
Conclusion
No differences in respiratory symptoms or lung function were observed 1 year after children with moderate–severe asthma and HDM sensitisation were given a mite-occlusive mattress cover and then received either feather upper bedding (pillow and quilt) or standard bedding care.
doi:10.1136/adc.2010.189696
PMCID: PMC3093241  PMID: 21451166
8.  Microbial contamination of manually reprocessed, ready to use ECG lead wire in intensive care units 
Background: A number of studies have shown that non-critical medical devices can be contaminated with pathogens, including those resistant to antibiotics and thus become a potential vector for transmission. Electrocardiography (ECG) lead wire are non-critical medical device which are always attached on patient skin during their stay in intensive care unit (ICU). In view of the patient’s critical conditions and exposure to invasive procedures, identification and prevention of possible risks are important to prevent infection in ICUs.
Objective: The objective of this study was to determine the presence of bacterial and fungal contamination on cleaned and disinfected reusable ECG lead wires in intensive care units in a hospital.
Methods: A total of 408 cleaned ECG lead wires from 93 bed-side ECG devices and 43 ECG lead wires from 5 portable ECG devices from 4 intensive care units (ICUs) and 1 post-anaesthesia care unit (PACU) were sampled. ECG lead wires were stirred in 0.89% NaCl with added neutralizer for 30 seconds. Samples of the solutions were cultured directly on blood agar. The remaining solution was cultured on blood agar after sterile filtration. The number of colony forming units (CFUs) was counted and the microorganisms were identified.
Results: More than half of examined ECG lead wires (n=232; 51.4%) were contaminated with >30 CFUs/mL sample of bacteria or with risk pathogens. Gram-positive bacteria were the most frequently isolated organisms; particularly, coagulase negative staphylococci (96%) and aerobic spore forming bacteria (71.2%). Compared to ICUs, PACU had significantly lower proportion of contaminated ECG lead wires (p<0.05). The proportion of contaminated ECG lead wires, as well as mean number of cfus per ECG lead wire, was also significantly lower among multi-wire ECG leads compared to single-wire ECG leads.
Conclusions: Manually cleaned ECG lead wires may serve as a vector for transmission of nosocomial pathogens. The current reprocessing technique for ECG lead wires needs to be improved.
doi:10.3205/dgkh000207
PMCID: PMC3746603  PMID: 23967393
ECG lead wire; microbial contamination; ICU; PACU
9.  Air Cleaning Technologies 
Executive Summary
Objective
This health technology policy assessment will answer the following questions:
When should in-room air cleaners be used?
How effective are in-room air cleaners?
Are in-room air cleaners that use combined HEPA and UVGI air cleaning technology more effective than those that use HEPA filtration alone?
What is the Plasmacluster ion air purifier in the pandemic influenza preparation plan?
The experience of severe acute respiratory syndrome (SARS) locally, nationally, and internationally underscored the importance of administrative, environmental, and personal protective infection control measures in health care facilities. In the aftermath of the SARS crisis, there was a need for a clearer understanding of Ontario’s capacity to manage suspected or confirmed cases of airborne infectious diseases. In so doing, the Walker Commission thought that more attention should be paid to the potential use of new technologies such as in-room air cleaning units. It recommended that the Medical Advisory Secretariat of the Ontario Ministry of Health and Long-Term Care evaluate the appropriate use and effectiveness of such new technologies.
Accordingly, the Ontario Health Technology Advisory Committee asked the Medical Advisory Secretariat to review the literature on the effectiveness and utility of in-room air cleaners that use high-efficiency particle air (HEPA) filters and ultraviolet germicidal irradiation (UVGI) air cleaning technology.
Additionally, the Ontario Health Technology Advisory Committee prioritized a request from the ministry’s Emergency Management Unit to investigate the possible role of the Plasmacluster ion air purifier manufactured by Sharp Electronics Corporation, in the pandemic influenza preparation plan.
Clinical Need
Airborne transmission of infectious diseases depends in part on the concentration of breathable infectious pathogens (germs) in room air. Infection control is achieved by a combination of administrative, engineering, and personal protection methods. Engineering methods that are usually carried out by the building’s heating, ventilation, and air conditioning (HVAC) system function to prevent the spread of airborne infectious pathogens by diluting (dilution ventilation) and removing (exhaust ventilation) contaminated air from a room, controlling the direction of airflow and the air flow patterns in a building. However, general wear and tear over time may compromise the HVAC system’s effectiveness to maintain adequate indoor air quality. Likewise, economic issues may curtail the completion of necessary renovations to increase its effectiveness. Therefore, when exposure to airborne infectious pathogens is a risk, the use of an in-room air cleaner to reduce the concentration of airborne pathogens and prevent the spread of airborne infectious diseases has been proposed as an alternative to renovating a HVAC system.
Airborne transmission is the spread of infectious pathogens over large distances through the air. Infectious pathogens, which may include fungi, bacteria, and viruses, vary in size and can be dispersed into the air in drops of moisture after coughing or sneezing. Small drops of moisture carrying infectious pathogens are called droplet nuclei. Droplet nuclei are about 1 to 5μm in diameter. This small size in part allows them to remain suspended in the air for several hours and be carried by air currents over considerable distances. Large drops of moisture carrying infectious pathogens are called droplets. Droplets being larger than droplet nuclei, travel shorter distances (about 1 metre) before rapidly falling out of the air to the ground. Because droplet nuclei remain airborne for longer periods than do droplets, they are more amenable to engineering infection control methods than are droplets.
Droplet nuclei are responsible for the airborne transmission of infectious diseases such as tuberculosis, chicken pox (varicella), measles (rubeola), and dessiminated herpes zoster, whereas close contact is required for the direct transmission of infectious diseases transmitted by droplets, such as influenza (the flu) and SARS.
The Technology
In-room air cleaners are supplied as portable or fixed devices. Fixed devices can be attached to either a wall or ceiling and are preferred over portable units because they have a greater degree of reliability (if installed properly) for achieving adequate room air mixing and airflow patterns, which are important for optimal effectiveness.
Through a method of air recirculation, an in-room air cleaner can be used to increase room ventilation rates and if used to exhaust air out of the room it can create a negative-pressure room for airborne infection isolation (AII) when the building’s HVAC system cannot do so. A negative-pressure room is one where clean air flows into the room but contaminated air does not flow out of it. Contaminated room air is pulled into the in-room air cleaner and cleaned by passing through a series of filters, which remove the airborne infectious pathogens. The cleaned air is either recirculated into the room or exhausted outside the building. By filtering contaminated room air and then recirculating the cleaned air into the room, an in-room air cleaner can improve the room’s ventilation. By exhausting the filtered air to the outside the unit can create a negative-pressure room. There are many types of in-room air cleaners. They vary widely in the airflow rates through the unit, the type of air cleaning technology used, and the technical design.
Crucial to maximizing the efficiency of any in-room air cleaner is its strategic placement and set-up within a room, which should be done in consultation with ventilation engineers, infection control experts, and/or industrial hygienists. A poorly positioned air cleaner may disrupt airflow patterns within the room and through the air cleaner, thereby compromising its air cleaning efficiency.
The effectiveness of an in-room air cleaner to remove airborne pathogens from room air depends on several factors, including the airflow rate through the unit’s filter and the airflow patterns in the room. Tested under a variety of conditions, in-room air cleaners, including portable or ceiling mounted units with either a HEPA or a non-HEPA filter, portable units with UVGI lights only, or ceiling mounted units with combined HEPA filtration and UVGI lights, have been estimated to be between 30% and 90%, 99% and 12% and 80% effective, respectively. However, and although their effectiveness is variable, the United States Centers for Disease Control and Prevention has acknowledged in-room air cleaners as alternative technology for increasing room ventilation when this cannot be achieved by the building’s HVAC system with preference given to fixed recirculating systems over portable ones.
Importantly, the use of an in-room air cleaner does not preclude either the need for health care workers and visitors to use personal protective equipment (N95 mask or equivalent) when entering AII rooms or health care facilities from meeting current regulatory requirements for airflow rates (ventilation rates) in buildings and airflow differentials for effective negative-pressure rooms.
The Plasmacluster ion technology, developed in 2000, is an air purification technology. Its manufacturer, Sharp Electronics Corporation, says that it can disable airborne microorganisms through the generation of both positive and negative ions. (1) The functional unit is the hydroxyl, which is a molecule comprised of one oxygen molecule and one hydrogen atom.
Plasmacluster ion air purifier uses a multilayer filter system composed of a prefilter, a carbon filter, an antibacterial filter, and a HEPA filter, combined with an ion generator to purify the air. The ion generator uses an alternating plasma discharge to split water molecules into positively and negatively charged ions. When these ions are emitted into the air, they are surrounded by water molecules and form cluster ions which are attracted to airborne particles. The cluster ion surrounds the airborne particle, and the positive and negative ions react to form hydroxyls. These hydroxyls steal the airborne particle’s hydrogen atom, which creates a hole in the particle’s outer protein membrane, thereby rendering it inactive.
Because influenza is primarily acquired by large droplets and direct and indirect contact with an infectious person, any in-room air cleaner will have little benefit in controlling and preventing its spread. Therefore, there is no role for the Plasmacluster ion air purifier or any other in-room air cleaner in the control of the spread of influenza. Accordingly, for purposes of this review, the Medical Advisory Secretariat presents no further analysis of the Plasmacluster.
Review Strategy
The objective of the systematic review was to determine the effectiveness of in-room air cleaners with built in UVGI lights and HEPA filtration compared with those using HEPA filtration only.
The Medical Advisory Secretariat searched the databases of MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, INAHATA (International Network of Agencies for Health Technology Assessment), Biosis Previews, Bacteriology Abstracts, Web of Science, Dissertation Abstracts, and NIOSHTIC 2.
A meta-analysis was conducted if adequate data was available from 2 or more studies and where statistical and clinical heterogeneity among studies was not an issue. Otherwise, a qualitative review was completed. The GRADE system was used to summarize the quality of the body of evidence comprised of 1 or more studies.
Summary of Findings
There were no existing health technology assessments on air cleaning technology located during the literature review. The literature search yielded 59 citations of which none were retained. One study was retrieved from a reference list of a guidance document from the United States Centers for Disease Control and Prevention, which evaluated an in-room air cleaner with combined UVGI lights and HEPA filtration under 2 conditions: UVGI lights on and UVGI lights off. Experiments were performed using different ventilation rates and using an aerosolized pathogen comprised of Mycobaterium parafortuitum, a surrogate for the bacterium that causes tuberculosis. Effectiveness was measured as equivalent air changes per hour (eACH). This single study formed the body of evidence for our systematic review research question.
Experimental Results
The eACH rate for the HEPA-UVGI in-room air cleaner was statistically significantly greater when the UV lights were on compared with when the UV lights were off. (P < .05). However, subsequent experiments could not attribute this to the UVGI. Consequently, the results are inconclusive and an estimate of effect (benefit) is uncertain.
The study was reviewed by a scientific expert and rated moderate for quality. Further analysis determined that there was some uncertainty in the directness of the outcome measure (eACH); thus, the GRADE level for the quality of the evidence was low indicating that an estimate of effect is very uncertain.
There is uncertainty in the benefits of using in-room air cleaners with combined UVGI lights and HEPA filtration over systems that use HEPA filtration alone. However, there are no known risks to using systems with combined UVGI and HEPA technology compared with those with HEPA alone. There is an increase in the burden of cost including capital costs (cost of the device), operating costs (electricity usage), and maintenance costs (cleaning and replacement of UVGI lights) to using an in-room air cleaner with combined UVGI and HEPA technology compared with those with HEPA alone. Given the uncertainty of the estimate of benefits, an in-room air cleaner with HEPA technology only may be an equally reasonable alternative to using one with combined UVGI and HEPA technology
Conclusions
In-room air cleaners may be used to protect health care staff from air borne infectious pathogens such as tuberculosis, chicken pox, measles, and dessiminated herpes zoster. In addition, and although in-room air cleaners are not effective at protecting staff and preventing the spread of droplet-transmitted diseases such as influenza and SARS, they may be deployed in situations with a novel/emerging infectious agent whose epidemiology is not yet defined and where airborne transmission is suspected.
It is preferable that in-room air cleaners be used with a fixed and permanent room placement when ventilation requirements must be improved and the HVAC system cannot be used. However, for acute (temporary) situations where a novel/emerging infectious agent presents whose epidemiology is not yet defined and where airborne transmission is suspected it may be prudent to use the in room air cleaner as a portable device until mode of transmission is confirmed. To maximize effectiveness, consultation with an environmental engineer and infection control expert should be undertaken before using an in-room air cleaner and protocols for maintenance and monitoring of these devices should be in place.
If properly installed and maintained, in room air cleaners with HEPA or combined HEPA and UVGI air cleaning technology are effective in removing airborne pathogens. However, there is only weak evidence available at this time regarding the benefit of using an in-room air cleaner with combined HEPA and UVGI air cleaner technology instead of those with HEPA filter technology only.
PMCID: PMC3382390  PMID: 23074468
10.  Hospital Textiles, Are They a Possible Vehicle for Healthcare-Associated Infections? 
Textiles are a common material in healthcare facilities; therefore it is important that they do not pose as a vehicle for the transfer of pathogens to patients or hospital workers. During the course of use hospital textiles become contaminated and laundering is necessary. Laundering of healthcare textiles is most commonly adequate, but in some instances, due to inappropriate disinfection or subsequent recontamination, the textiles may become a contaminated inanimate surface with the possibility to transfer pathogens. In this review we searched the published literature in order to answer four review questions: (1) Are there any reports on the survival of microorganisms on hospital textiles after laundering? (2) Are there any reports that indicate the presence of microorganisms on hospital textiles during use? (3) Are there any reports that microorganisms on textiles are a possible source infection of patients? (4) Are there any reports that microorganisms on textiles are a possible source infection for healthcare workers?
doi:10.3390/ijerph9093330
PMCID: PMC3499872  PMID: 23202690
textile hygiene; disinfection; hospital-acquired infections; inanimate surfaces; infection transmission vehicles
11.  399 Daily Vacuum Cleaning Significantly Reduces House Dust Mite Allergen, Endotoxin and β-glucan Content of Mattresses 
Background
House dust mite allergic patients are advised to cover their mattresses with occlusive coverings; however, these are not cheap. We investigated whether daily vacuum cleaning of mattresses reduces house dust mite allergens, bacterial endotoxin and fungal β-glucan content.
Methods
Twenty volunteers vacuumed their mattress daily for 8 weeks. Dust samples, collected at two weekly intervals were analysed for house dust mite allergens (Der p 1 and Der f 1) by double monoclonal antibody ELISA and for endotoxin and β-glucan by the Limulus amoebocyte lysate kinetic assay. Data are presented as geometric means with 95% CI.
Results
Total house dust mite allergens (Der p 1 + Der f 1) significantly reduced from a geometric mean (95% CI) of 4.07 μg (2.44-6.79) at the start to 0.42 μg (0.21-0.81) at week 8. Total endotoxin and β-glucan were also significantly reduced from 13.6 EU (8.6-21.4) to 3.4 EU (2.3-5.0) and from 94.4 μg (57.1-156.2) to 19.7 μg (10.2-37.9) respectively (P for trend >0.0001). Percentage reductions in total house dust mite allergens, endotoxin and β-glucan after 8 weeks of daily vacuum cleaning were 85.1% (80.1-90.1), 71.0% (70.4-81.0) and 75.7% (70.4-81.0) respectively. This was mainly due to a 77.7% (70.8-84.7) reduction in total dust.
Conclusions
Daily vacuum cleaning of mattresses over time significantly reduces house dust mite allergens, endotoxin and β-glucan. This gives house dust mite allergic patients a practical and cheap alternative to reduce their exposure to indoor bio-contaminants.
doi:10.1097/01.WOX.0000412162.39736.e1
PMCID: PMC3512813
12.  Potentially dangerous sleeping environments and accidental asphyxia in infancy and early childhood. 
Archives of Disease in Childhood  1994;71(6):497-500.
Infants and young children may be exposed to a variety of dangerous situations when left sleeping in cots, chairs, or beds. A review of 30 cases of accidental asphyxia occurring in infants and young children who had been left to sleep unattended was undertaken from the necropsy and consultation files of the Adelaide Children's Hospital. Causes of death included hanging from loose restrainers, clothing, or a curtain cord (12 cases), positional asphyxia/wedging from slipping between a mattress and bed/cot sides or wall, or from moving into a position where the face was covered and the upper airway occluded (16 cases), and suffocation from plastic bed covers (two cases). Cases of co-sleeping in bed with an adult and of non-accidental asphyxia were not included in this review. As the pathological findings were on occasion identical to those that are typically found in sudden infant death syndrome, adequate death scene examination was vital in several cases to allow identification of lethal sleeping environments and to enable steps to be taken to minimise the risk of future deaths due to similar situations. For example, two cases in which infants asphyxiated in rocking cradles led to the investigation of the cradles and to formulation of specific safety recommendations regarding the angle of tilt. Two infants who died after becoming wedged between the back of a couch and a co-sleeping parent in one case and cushions in the other, would indicate that this also represents a potentially lethal sleeping position. Other dangerous situations involved infant car seat restraints, seats with loose harnesses, cots with movable sides or projecting pieces, thin plastic mattress/pillow coverings, and beds with spaces between the mattress and cot side or wall. Lack of supervision at the time of death was a feature of each case.
Images
PMCID: PMC1030084  PMID: 7726607
13.  Pressure ulcers 
Clinical Evidence  2011;2011:1901.
Introduction
Unrelieved pressure or friction of the skin, particularly over bony prominences, can lead to pressure ulcers in up to one third of people in hospitals or community care, and one fifth of nursing home residents. Pressure ulcers are more likely in people with reduced mobility and poor skin condition, such as older people or those with vascular disease.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of preventive interventions in people at risk of developing pressure ulcers? What are the effects of treatments in people with pressure ulcers? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 64 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: air-filled vinyl boots, air-fluidised supports, alternating-pressure surfaces (including mattresses), alternative foam mattresses, constant low-pressure supports, debridement, electric profiling beds, electrotherapy, hydrocellular heel supports, low-air-loss beds (including hydrotherapy beds), low-level laser therapy, low-tech constant-low-pressure supports, medical sheepskin overlays, nutritional supplements, orthopaedic wool padding, pressure-relieving overlays on operating tables, pressure-relieving surfaces, repositioning (regular "turning"), seat cushions, standard beds, standard care, standard foam mattresses, standard tables, surgery, therapeutic ultrasound, topical lotions and dressings, topical negative pressure, and topical phenytoin.
Key Points
Unrelieved pressure or friction of the skin, particularly over bony prominences, can lead to pressure ulcers, which affect up to one third of people in hospitals or community care, and one fifth of nursing home residents. Pressure ulcers are more likely in people with reduced mobility and poor skin condition, such as older people or those with vascular disease.
Alternative foam mattresses (such as viscoelastic foam) reduce the incidence of pressure ulcers in people at risk compared with standard hospital foam mattresses, although we don't know which is the best alternative to use. Low-air-loss beds may reduce the risk of pressure ulcers compared with standard intensive-care beds, and pressure-relieving overlays on operating tables may reduce the risk of pressure ulcer development. Medical sheepskin overlays may reduce the risk of pressure ulcers compared with standard care.
Hydrocellular heel supports may decrease the risk of pressure ulcers compared with orthopaedic wool padding, but air-filled vinyl boots with foot cradles and low-air-loss hydrotherapy beds may increase the risk of ulcers compared with other pressure-relieving surfaces. We don't know if other physical interventions, such as alternating-pressure surfaces, seat cushions, electric profiling beds, low-tech constant-low-pressure supports, repositioning, or topical lotions and dressings are effective for preventing pressure ulcers. We also don't know whether pressure ulcers can be prevented by use of nutritional interventions.
In people with pressure ulcers, air-fluidised supports may improve healing compared with standard care, although they can make it harder for people to get in and out of bed independently.
We don't know whether healing is improved in people with pressure ulcers by use of other treatments such as one specific specialised support surface (including alternating-pressure surfaces, low-tech constant-low-pressure supports, low-air-loss beds, and specific seat cushions) over any other specific specialised support surface, one specific wound dressing over any other specific wound dressing, or with surgery, electrotherapy, ultrasound, low-level laser therapy, topical negative pressure, topical phenytoin, or nutritional interventions.
PMCID: PMC3217823  PMID: 21524319
14.  Pressure ulcers 
Clinical Evidence  2008;2008:1901.
Introduction
Unrelieved pressure or friction of the skin, particularly over bony prominences, can lead to pressure ulcers in up to a third of people in hospitals or community care, and a fifth of nursing home residents. Pressure ulcers are more likely in people with reduced mobility and poor skin condition, such as older people or those with vascular disease.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of preventive interventions in people at risk of developing pressure ulcers? What are the effects of treatments in people with pressure ulcers? We searched: Medline, Embase, The Cochrane Library and other important databases up to February 2007 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 60 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: air-filled vinyl boots, air-fluidised supports, alternating pressure surfaces (including mattresses), alternative foam mattresses, constant low-pressure supports, debridement, electric profiling beds, electrotherapy, hydrocellular heel supports, low-air-loss beds (including hydrotherapy beds), low-level laser therapy, low-tech constant low-pressure supports, medical sheepskin overlays, nutritional supplements, orthopaedic wool padding, pressure-relieving overlays on operating tables, pressure-relieving surfaces, repositioning (regular "turning"), seat cushions, standard beds, standard care, standard foam mattresses, standard tables, surgery, therapeutic ultrasound, topical lotions and dressings, topical negative pressure, and topical phenytoin.
Key Points
Unrelieved pressure or friction of the skin, particularly over bony prominences, can lead to pressure ulcers, which affect up to a third of people in hospitals or community care, and a fifth of nursing-home residents. Pressure ulcers are more likely in people with reduced mobility and poor skin condition, such as older people or those with vascular disease.
Alternative foam mattresses (such as viscoelastic foam) reduce the incidence of pressure ulcers in people at risk compared with standard hospital foam mattresses, although we don't know which is the best alternative to use. Low-air-loss beds may reduce the risk of pressure ulcers compared with standard intensive-care beds, but we don't know whether pressure-relieving overlays on operating tables are also beneficial compared with other pressure-relieving surfaces. Medical sheepskin overlays may reduce the risk of pressure ulcers compared with standard care.
Hydrocellular heel supports may decrease the risk of pressure ulcers compared with orthopaedic wool padding, but air-filled vinyl boots with foot cradles and low-air-loss hydrotherapy beds may increase the risk of ulcers compared with other pressure-relieving surfaces. We don't know if other physical interventions, such as alternating pressure surfaces, seat cushions, electric profiling beds, low-tech constant low pressure supports, repositioning, or topical lotions and dressings are effective for preventing pressure ulcers. We also don't know whether pressure ulcers can be prevented by use of nutritional interventions.
In people with pressure ulcers, air-fluidised supports may improve healing compared with standard care, although they can make it harder for people to get in and out of bed independently.
Hydrocolloid dressings may also improve healing rates compared with standard dressings.
We don't know whether healing is improved in people with pressure ulcers by use of other treatments such as alternating pressure surfaces, debriding agents, low-tech constant low pressure supports, low-air-loss beds, seat cushions, dressings other than hydrocolloid, topical phenytoin, surgery, electrotherapy, ultrasound, low level laser therapy, topical negative pressure, or nutritional interventions.
PMCID: PMC2907959  PMID: 19450317
15.  Backboards are important when chest compressions are provided on a soft mattress☆ 
Resuscitation  2012;83(8):1013-1020.
Aim
Determine the impact of backboard placement, torso weight and bed compression on chest compression (CC) depth feedback in simulated cardiac arrest patients.
Methods
Epochs of 50 high quality CCs with real-time feedback of sternum-to-spine compression depth were provided by a blinded BLS/ACLS/PALS certified provider on manikins of two torso weights (25 vs. 50 kg), using three bed surfaces (stretcher, Stryker hospital bed with Impression mattress, soft Total Care ICU bed), with/without a backboard (BB). Two BB sizes were tested (small: 60 cm × 50 cm; large: 89 cm × 50 cm) in vertical vs. horizontal orientation. Mattress displacement was measured using an accelerometer placed internally on the spine plate of the manikin. Mattress displacement of ≥5 mm was prospectively defined as the minimal clinically important difference.
Results
During CPR (CC depth: 51.8 ± 2.8 mm), BB use significantly reduced mattress displacement only for soft ICU beds. Mattress displacement was reduced (vs. no BB) for 25 kg torso weight: small BB12.3 mm (95%CI 11.9–12.6), horizontally oriented large BB 11.2 mm (95%CI 10.8–11.7), and vertically oriented large BB 12.2 mm (95%CI 11.8–12.6), and for 50 kg torso weight: small BB 7.4 mm (95%CI 7.1–7.8), horizontally oriented large BB 7.9 mm (95%CI 7.6–8.3), and vertically oriented large BB 6.2 mm (95%CI 5.8–6.5; all p < 0.001). BB size and orientation did not significantly affect mattress displacement. Lighter torso weight was associated with larger displacement in soft ICU beds without BB (difference: 6.9 mm, p < 0.001).
Conclusion
BB is important for CPR when performed on soft surfaces, such as ICU beds, especially when torso weight is light. BB may not be needed on stretchers, relatively firm hospital beds, or for patients with heavy torso weights.
doi:10.1016/j.resuscitation.2012.01.016
PMCID: PMC3619975  PMID: 22310727
Backboard; CPR; Resuscitation; Child; Mattress; Displacement
16.  Sustained Reduction of Microbial Burden on Common Hospital Surfaces through Introduction of Copper 
Journal of Clinical Microbiology  2012;50(7):2217-2223.
The contribution of environmental surface contamination with pathogenic organisms to the development of health care-associated infections (HAI) has not been well defined. The microbial burden (MB) associated with commonly touched surfaces in intensive care units (ICUs) was determined by sampling six objects in 16 rooms in ICUs in three hospitals over 43 months. At month 23, copper-alloy surfaces, with inherent antimicrobial properties, were installed onto six monitored objects in 8 of 16 rooms, and the effect that this application had on the intrinsic MB present on the six objects was assessed. Census continued in rooms with and without copper for an additional 21 months. In concert with routine infection control practices, the average MB found for the six objects assessed in the clinical environment during the preintervention phase was 28 times higher (6,985 CFU/100 cm2; n = 3,977 objects sampled) than levels proposed as benign immediately after terminal cleaning (<250 CFU/100 cm2). During the intervention phase, the MB was found to be significantly lower for both the control and copper-surfaced objects. Copper was found to cause a significant (83%) reduction in the average MB found on the objects (465 CFU/100 cm2; n = 2714 objects) compared to the controls (2,674 CFU/100 cm2; n = 2,831 objects [P < 0.0001]). The introduction of copper surfaces to objects formerly covered with plastic, wood, stainless steel, and other materials found in the patient care environment significantly reduced the overall MB on a continuous basis, thereby providing a potentially safer environment for hospital patients, health care workers (HCWs), and visitors.
doi:10.1128/JCM.01032-12
PMCID: PMC3405627  PMID: 22553242
17.  Contamination of hospital linen by Bacillus cereus. 
Epidemiology and Infection  1994;113(2):297-306.
An investigation into two cases of post-operative Bacillus cereus meningitis revealed that hospital linen laundered by a batch continuous washing machine was heavily contaminated by B. cereus spores. The washing machine, detergents, other chemical additives and the water supply were eliminated as the source of contamination. It was found that the linen introduced into the washing machine had a high B. cereus spore content and that this was still present after the wash process. The spores were not killed by either the heat disinfection stage of the wash or the addition of chemical disinfectants and were not removed by the dilution in the process. The multiplication of B. cereus was thought to have occurred on used, damp linen stored in plastic bags, particularly when ambient temperatures were high. An increase in the water flow through the washing machine was the only measure associated with a decrease in B. cereus on laundered linen.
PMCID: PMC2271531  PMID: 7925667
18.  Comparison of the ActiDes-Blue and CARELA HYDRO-DES technology for the sanitation of contaminated cooling water systems in dental units 
Background: The hygienic-microbiological control of 6 dental units being in use for the past 16 years revealed a significantly increased microbial contamination of their cooling water system. In order to comply with the requirements of the drinking water directive (“Trinkwasserverordnung”), the commercially available production system ActiDes, producing on-site ActiDes-Blue which is based on hypochlorous acid (HOCl) and generated by anodic oxidation, was investigated.
Method: Water samples from the 6 contaminated dental units were examined for the total number of colony forming units (cfu), contamination with molds, L. pneumophila and P. aeruginosa. The control period for the total colony count was 4 weeks (8 samples/unit). The subsequent application phase of the ActiDes-Blue procedure was 6 months (31 samples/unit). Additionally, the redox potential and the pH value were measured.
Futhermore, the decontamination agent CARELA HYDRO-DES, a two component agent based on H2O2 with the addition of a mixture of sodium hydrogen sulphate and sulphuric acid in an aqueous solution effective at 0.1% and higher, was applied in a unit that had been put out of service for a month before. Before application, the system was first filled with a 5% solution of the alkaline pre-cleaning agent CARELA Solvent for bacterial slime; the system was left with this solution for 1 h. The pre-cleaning agent was then completely displaced from the system with tap water and a decontaminating solution of 5% CARELA HYDRO-DES and left in place for 1 h.
Results: Drinking water quality level was reached only twice during the control phase. The average values of the dental units ranged between 3,633 CFU/ml and 29,417 c/ml. During the application phase, drinking water level could be achieved in 11 water samples. In another 6 water samples a total colony count of <150 cfu/ml was reached. The average values for the dental units' total colony count ranged between 529 cfu/ml and 87,450 cfu/ml. No significant differences between the control phase and the action phase could be demonstrated.
During the control phase, contamination of the water samples with a mold was noticed so that examinations for molds were carried out beyond the scope of the drinking water directive. For this parameter as well, no significant differences between the phases of the study could be shown.
The Legionella load of the dental units was low. L. pneumophila were yielded in only 4 out of 130 water samples. During the control phase, twice colony counts at 50 cfu/1,000 ml and 110 cfu/1,000 ml were measured. During the action phase, counts with Legionella spp. could be measured at 5 cfu/1,000 ml for one unit only.
Also, with 1–10 cfu/100 ml, the P. aeruginosa contamination was low. During the application phase, it ranged between 0–7 cfu/100 ml.
Redox potential and pH value showed a slight decrease during the application phase.
Before treatment with CARELA Solvent and CARELA HYDRO-DES, the initial contamination of the total count of bacterial colonies was 1,432 cfu/ml at 22°C and 846 cfu/ml at 36°C as well as >1,000 cfu/100 ml for molds. 1 h after the decontamination, no bacteria and molds could be detected in 1,000 ml of tap water. Despite the fact that the unit was not used any longer, after 7 d the bacterial colony count was 3 cfu/ml at 22°C and 2 cfu/ml at 36°C while molds could not be detected. Even after a rest time of 14 d only 167 cfu/ml or 42 cfu/ml could be yielded. Molds were further not cultivable. A material damage could not be observed.
Discussion: Pertaining to the ActiDes technology’s effectiveness, it has to be pointed out that the dental units investigated were those used for dental students' teaching and therefore were clearly less frequently used than clinically used units in a dental practice. This resulted in distinctly longer stagnation periods which favored formation of biofilms.
Conclusions: In summary, the ActiDes technology and ActiDes-Blue showed not to be sufficiently effective for the sanitation of contaminated water reservoirs in dental units under aggravated conditions of repeated and longer periods of non-use in connection with longer water stagnation periods. In comparison, the biofilm was sustainably eliminated through the combined application of CARELA® Solvent for Bacterial Slime with subsequent decontamination using CARELA® HYDRO-DES.
doi:10.3205/dgkh000193
PMCID: PMC3334952  PMID: 22558043
microbial contamination; dental unit; decontamination; anodic oxidation of NaCl; CARELA® Solvent for Bacterial Slime; CARELA® HYDRO-DES; ActiDes; ActiDes-Blue
19.  Potentially Infectious Agents Associated with Shearling Bedpads 
Applied Microbiology  1970;19(1):53-59.
Glutaraldehyde-tanned woolskin pads which are used for the prevention of decubitus ulcers in bed patients were experimentally contaminated with polio or vaccinia viruses. Two methods of exposure, direct contact and aerosol, were used in separate experiments. Attempts were made to remove or inactivate these virus contaminants by laundering the woolskins in a quaternary ammonium disinfectant, a phenolic disinfectant, or alkalinized glutaraldehyde, in combination with an anionic detergent or a nonionic detergent. The effect of a commercial detergent-sanitizer was also studied. The virus titers were significantly reduced in all experiments, but only laundering in glutaraldehyde in combination with either detergent lowered the vaccinia virus titers to below detectable limits. High concentrations of glutaraldehyde altered the texture of the wool and leather apparently by precipitating a component of the detergent onto the fibers. In all the poliovirus experiments, the virus was still detectable on either or both the wool and the leather of the pads after laundering. The rinse water from each experiment was tested for the presence of virus. No vaccinia virus was recovered, but poliovirus was demonstrated in titers up to 103 cell culture 50% infectious doses.
PMCID: PMC376608  PMID: 4313311
20.  Characterisation of Clostridium difficile Hospital Ward–Based Transmission Using Extensive Epidemiological Data and Molecular Typing 
PLoS Medicine  2012;9(2):e1001172.
A population-based study in Oxfordshire (UK) hospitals by Sarah Walker and colleagues finds that in an endemic setting with good infection control, ward-based contact cannot account for most new cases of Clostridium difficile infection.
Background
Clostridium difficile infection (CDI) is a leading cause of antibiotic-associated diarrhoea and is endemic in hospitals, hindering the identification of sources and routes of transmission based on shared time and space alone. This may compromise rational control despite costly prevention strategies. This study aimed to investigate ward-based transmission of C. difficile, by subdividing outbreaks into distinct lineages defined by multi-locus sequence typing (MLST).
Methods and Findings
All C. difficile toxin enzyme-immunoassay-positive and culture-positive samples over 2.5 y from a geographically defined population of ∼600,000 persons underwent MLST. Sequence types (STs) were combined with admission and ward movement data from an integrated comprehensive healthcare system incorporating three hospitals (1,700 beds) providing all acute care for the defined geographical population. Networks of cases and potential transmission events were constructed for each ST. Potential infection sources for each case and transmission timescales were defined by prior ward-based contact with other cases sharing the same ST. From 1 September 2007 to 31 March 2010, there were means of 102 tests and 9.4 CDIs per 10,000 overnight stays in inpatients, and 238 tests and 15.7 CDIs per month in outpatients/primary care. In total, 1,276 C. difficile isolates of 69 STs were studied. From MLST, no more than 25% of cases could be linked to a potential ward-based inpatient source, ranging from 37% in renal/transplant, 29% in haematology/oncology, and 28% in acute/elderly medicine to 6% in specialist surgery. Most of the putative transmissions identified occurred shortly (≤1 wk) after the onset of symptoms (141/218, 65%), with few >8 wk (21/218, 10%). Most incubation periods were ≤4 wk (132/218, 61%), with few >12 wk (28/218, 13%). Allowing for persistent ward contamination following ward discharge of a CDI case did not increase the proportion of linked cases after allowing for random meeting of matched controls.
Conclusions
In an endemic setting with well-implemented infection control measures, ward-based contact with symptomatic enzyme-immunoassay-positive patients cannot account for most new CDI cases.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Hospital-acquired infections are common and occur when patients are infected with an organism found in the hospital or health-care environment. Hospital-acquired infections can sometimes cause no symptoms but often lead to illness or even death. A leading hospital-acquired infection is with the anaerobic bacterium Clostridium difficile, which causes gastrointestinal problems, including diarrhea, leading to severe illness and even death, especially in older patients or patients who are already seriously ill. Between 7% and 26% of elderly adult inpatients in hospitals may be asymptomatic carriers of C. difficile, and the spores that are formed by this organism can live outside of the human body for long periods of time and are notoriously resistant to most routine surface-cleaning methods. Following major hospital-associated outbreaks around the world, C. difficile infection has become a prime target for expensive prevention and infection control strategies.
Why Was This Study Done?
Prevention strategies and infection control measures have contributed to reducing the incidence of C. difficile infection, however, to date, there have not been any robust evaluations of the impact of such strategies in reducing the spread of infection at the individual level. In order to implement improved, cost-effective policies, and to work out how to reduce incidence even further, a better understanding of person-to-person spread is crucial, especially as infection with C. difficile depends on a combination of factors, such as antibiotic exposure and host susceptibility. Therefore, the researchers conducted this study to examine in detail the transmission of C. difficile in hospital wards in order to give more insight and information on the nature of person-to-person spread.
What Did the Researchers Do and Find?
The researchers used a population-based study in Oxfordshire, UK, to investigate hospital ward–based transmission of defined C. difficile strains from symptomatic patients by identifying C. difficile infection from routine clinical microbiological samples from 1 September 2007 to 31 March 2010. Throughout this period, Oxfordshire hospitals operated a rigorous infection control policy monitored by infection control staff, in which stool samples for C. difficile testing were taken from admitted patients with persistent diarrhea, and from patients with any diarrhea who were 65 years or older. The researchers tested all stool samples for C. difficile toxins by enzyme immunoassay, cultured positive samples, and genotyped C. difficile isolates by using multi-locus sequence typing (to identify strains, that is, sequence types), and finally, constructed networks of cases and potential transmissions (by tracing contacts for up to 26 weeks) for each sequence type identified.
In order to show which ward-based contacts potentially incorporated direct person-to-person spread and indirect transmission via the environment during shared ward exposure, the researchers analysed links (ward contacts) between the first case (the donor) and the second case (the recipient) for all pairs of cases with the same sequence type. The researchers then calculated the minimum infectious period by measuring the time between the first infected stool sample from the donor and ward contact with the recipient, and calculated the incubation period as the time between this ward contact and the first infected stool sample in the recipient. To reduce the possibility of shared ward contacts occurring by chance, the researchers used patients with negative enzyme immunoassay stool samples as controls to estimate how often such ward contacts reflected actual transmission rather than chance.
Over the study period, almost 30,000 stool samples from almost 15,000 patients were tested for C. difficile, with 4.4% (1,282) found positive for C. difficile in enzyme immunoassay and culture. With genotyping, the researchers identified 69 strains (sequence types) of C. difficile. The researchers found that the majority (66%) of cases of C. difficile infection were not linked to known cases, and only 23% had a credible ward-based donor sharing the same sequence type of C. difficile. Furthermore, the researchers found that most probable transmissions occurred less than one week after the onset of symptoms, with a minority (10%) occurring after eight weeks. Most incubation periods were less than four weeks, but a few (13%) were more than 12 weeks. Importantly, even after allowing for the random meeting of matched controls and for persistent ward contamination, the proportion of linked cases did not increase following ward discharge of a C. difficile infection case.
What Do These Findings Mean?
These findings show that in an endemic setting with well-implemented infection control measures, ward-based contact with symptomatic, enzyme-immunoassay-positive patients cannot account for most new cases of C. difficile infection. Crucially, these findings mean that C. difficile infection might not be effectively controlled by current strategies to prevent person-to-person spread. Although the researchers were able to distinguish different strains of C. difficile, there were insufficient numbers of these different strains to deduce whether the results they obtained might be different if there was a different combination of strain types, that is, if some strains were spreading more in hospitals than others. Finally, in order to determine what other types of control interventions are required to reduce the spread of C. difficile, a better understanding of other routes of transmission and reservoirs of infectivity is needed.
Additional Information
Please access these web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001172.
This study is further discussed in a PLoS Medicine Perspective by Stephan Harbarth and Matthew Samore
The US Centers for Disease Control and Prevention provides information about C. difficile infection, as does the UK Health Protection Agency
The World Health Organization has published a guide for preventing hospital-acquired infections
doi:10.1371/journal.pmed.1001172
PMCID: PMC3274560  PMID: 22346738
21.  Quantitative Studies on Fabrics as Disseminators of Viruses 
Applied Microbiology  1971;21(2):227-234.
The effects of laundering with both anionic and nonionic detergents in cold, warm, and hot water on poliovirus-contaminated cotton sheeting, cotton terry cloth, washable wool shirting, wool blanketing, dull nylon jersey, and dacron/cotton shirting were determined. The fabrics were exposed to virus by aerosolization and direct contact (pipette) in separate studies. Although the results varied with each factor used in the study, virus titers on all the fabrics were generally reduced considerably by the laundering process. When the fabrics were dried for 20 hr after laundering, an additional decline in virus titers was seen, often to below detectable levels. The type of detergent used made little difference in effect on virus titer reduction, but the hot wash water markedly reduced the detectable virus. Fabric type was not a major factor in the majority of the experiments, although virus tended to be eliminated more readily from the nylon jersey, and in warm water the virus persisted longer on wool blanketing material laundered in anionic detergent. Sterile fabrics of each type laundered with similar fabrics which contained virus often became contaminated by the virus during the laundering process. Virus titers ranging from undetectable to 103.9 cell culture 50% infectious doses/ml were obtained from samples of the rinse water after warm- and cold-water laundering.
PMCID: PMC377153  PMID: 5544282
22.  EVOTECH® endoscope cleaner and reprocessor (ECR) simulated-use and clinical-use evaluation of cleaning efficacy 
BMC Infectious Diseases  2010;10:200.
Background
The objective of this study was to perform simulated-use testing as well as a clinical study to assess the efficacy of the EVOTECH® Endoscope Cleaner and Reprocessor (ECR) cleaning for flexible colonoscopes, duodenoscopes, gastroscopes and bronchoscopes. The main aim was to determine if the cleaning achieved using the ECR was at least equivalent to that achieved using optimal manual cleaning.
Methods
Simulated-use testing consisted of inoculating all scope channels and two surface sites with Artificial Test Soil (ATS) containing 108 cfu/mL of Enterococcus faecalis, Pseudomonas aeruginosa and Candida albicans. Duodenoscopes, colonoscopes, and bronchoscopes (all Olympus endoscopes) were included in the simulated use testing. Each endoscope type was tested in triplicate and all channels and two surface sites were sampled for each scope. The clinical study evaluated patient-used duodenoscopes, bronchoscopes, colonoscopes, and gastroscopes (scopes used for emergency procedures were excluded) that had only a bedside flush prior to being processed in the ECR (i.e. no manual cleaning). There were 10 to 15 endoscopes evaluated post-cleaning and to ensure the entire ECR cycle was effective, 5 endoscopes were evaluated post-cleaning and post-high level disinfection. All channels and two external surface locations were sampled to evaluate the residual organic and microbial load. Effective cleaning of endoscope surfaces and channels was deemed to have been achieved if there was < 6.4 μg/cm2 of residual protein, < 1.8 μg/cm2 of residual hemoglobin and < 4 Log10 viable bacteria/cm2. Published data indicate that routine manual cleaning can achieve these endpoints so the ECR cleaning efficacy must meet or exceed these to establish that the ECR cleaning cycle could replace manual cleaning
Results
In the clinical study 75 patient-used scopes were evaluated post cleaning and 98.8% of surfaces and 99.7% of lumens met or surpassed the cleaning endpoints set for protein, hemoglobin and bioburden residuals. In the simulated-use study 100% of the Olympus colonoscopes, duodenoscopes and bronchoscopes evaluated met or surpassed the cleaning endpoints set for protein, and bioburden residuals (hemoglobin was not evaluated).
Conclusions
The ECR cleaning cycle provides an effective automated approach that ensures surfaces and channels of flexible endoscopes are adequately cleaned after having only a bedside flush but no manual cleaning. It is crucial to note that endoscopes used for emergency procedures or where reprocessing is delayed for more than one hour MUST still be manually cleaned prior to placing them in the ECR.
doi:10.1186/1471-2334-10-200
PMCID: PMC2914053  PMID: 20618935
23.  Pressure-Redistributing Support Surface Use and Pressure Ulcer Incidence in Elderly Hip Fracture Patients 
OBJECTIVES
To evaluate the association between pressure-redistributing support surface (PRSS) use and incident pressure ulcers in older adults with hip fracture.
DESIGN
Secondary analysis of data from prospective cohort with assessments performed as soon as possible after hospital admission and on alternating days for 21 days.
SETTING
Nine hospitals in the Baltimore Hip Studies network and 105 postacute facilities to which participants were discharged.
PARTICIPANTS
Six hundred fifty-eight people aged 65 and older who underwent surgery for hip fracture.
MEASUREMENTS
Full-body examination for pressure ulcers; bedbound status; and PRSS use, recorded as none, powered (alternating pressure mattresses, low-air-loss mattresses, and alternating pressure overlays), or nonpowered (high-density foam, static air, or gel-filled mattresses or pressure-redistributing overlays except for alternating pressure overlays).
RESULTS
Incident pressure ulcers (IPUs), Stage 2 or higher, were observed at 4.2% (195/4,638) of visits after no PRSS use, 4.5% (28/623) of visits after powered PRSS use, and 3.6% (54/1,496) of visits after nonpowered PRSS use. The rate of IPU per person-day of follow-up did not differ significantly between participants using powered PRSSs and those not using PRSSs. The rate also did not differ significantly between participants using nonpowered PRSSs and those not using PRSSs, except in the subset of bedbound participants (incidence rate ratio = 0.3, 95% confidence interval = 0.1–0.7).
CONCLUSION
PRSS use was not associated with a lower IPU rate. Clinical guidelines may need revision for the limited effect of PRSS use, and it may be appropriate to target PRSS use to bedbound patients at risk of pressure ulcers.
doi:10.1111/j.1532-5415.2011.03446.x
PMCID: PMC3601674  PMID: 21649630
pressure ulcers; prevention; mattresses; overlays; guidelines
24.  Encasing bedding in covers made of microfine fibers reduces exposure to house mite allergens and improves disease management in adult atopic asthmatics 
Background
Studies of avoidance of exposure to group 1 allergens of the Dermatophagoides group (Der p 1) have not yielded consistent improvements in adult asthma through avoidance. We explored whether the use of pillow and bed covers and allergen-avoidance counseling resulted in Der 1-level reduction, as measured by enzyme-linked immunosorbent assay, and thus improved asthma symptoms in adult patients.
Methods
Twenty-five adult patients with moderate or severe atopic asthma were randomized into intervention and control groups. Intervention patients slept on pillows and mattresses or futons encased in microfine-fiber covers and were counseled in allergen avoidance through bedroom cleaning. Control patients received neither special covers nor counseling. In the period August to October in 2009 (pre-intervention) and 2010 (post-intervention), dust samples were collected in open Petri dishes placed in bedrooms for 2 weeks and by rapid lifting of dust from bedding and skin using adhesive tape on the morning of 1 day of Petri dish placement. We examined the associations between changes in Der 1 level (as measured by enzyme-linked immunosorbent assay) and clinical symptom score, minimum % peak expiratory flow, and fraction of exhaled nitric oxide.
Results
Der 1 allergen levels on the mattress/futon covers and near the floor of the bedrooms of intervention patients, but not controls, were lower in 2010 than in 2009. From 2009 to 2010, asthma symptom scores decreased significantly, and minimum % peak expiratory flow increased significantly, in intervention patients. The fall in Der p 1 concentration was correlated with a reduction in the fraction of exhaled nitric oxide.
Conclusions
Minimization of Der 1 allergen exposure by encasing pillows and mattresses or futons and receiving counseling on avoiding exposure to indoor allergens improved asthma control in adult patients.
doi:10.1186/1710-1492-9-44
PMCID: PMC3829998  PMID: 24499343
Adult intervention; Allergen; Atopic asthma; Bed cover; Dermatophagoides; Group 1 mite antigen
25.  Bacterial Survival in Laundered Fabrics 
Applied Microbiology  1975;29(3):368-373.
Bacterial survival was determined in linens (i) inoculated with Staphylococcus aureus (ii), taken from hospital isolation patients' beds, and (iii) used by students in their homes. Two different washers using temperatures of 38, 49, 54 and 60 C, respectively, for different times were employed along with a commercial tumbler dryer. Findings, after macerating the linens in a Waring blender and enumerating on nonselective media, indicate that acceptable levels of survivors can be achieved in motel and hotel linens by an 8- to 10-min wash cycle at 54 C followed by adequate drying. However, it is recommended that a wash cycle with 60 C for 10 to 13 min be employed for linens in health care factilities. The microbial significance of various laundering practices is discussed.
PMCID: PMC186982  PMID: 1090256

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