infection control & hospital epidemiology october 2015, vol. 36, no. 10 original article
Relationships Among Cleaning, Environmental DNA, and Healthcare-Associated Infections in a New Evidence-Based Design Hospital
Emil Lesho, DO;1 Philip Carling, MD;2 Eve Hosford, MS;1 Ana Ong, BS;1 Erik Snesrud, MS;1 Michael Sparks, PhD;1 Fatma Onmus-Leone, MS;1 Nicole Dzialowy, MSc;3 Susan Fraser, MD;4 Yoon Kwak, MS;1 Sonia Miller, EdD;4 Uzo Chukwuma, MPH;3 Michael Julius, PMP;1 Patrick McGann, PhD;1 Robert Clifford, PhD1
objective. Hospital environments influence healthcare-associated infection (HAI) patterns, but the role of evidenced-based design (EBD) and residual bacterial DNA (previously thought to be clinically inert) remain incompletely understood.
methods. In a newly built EBD hospital, we used culture-based and culture-free (molecular) assays, pulsed-field gel electrophoresis (PFGE), and whole-genome sequencing (WGS) to determine: (1) patterns of environmental contamination with target organisms (TOs) and multidrug- resistant (MDR) target organisms (MDR-TOs); (2) genetic relatedness between environmentally isolated MDR-TO and those from HAIs; and (3) correlation between surface contamination and HAIs.
results. A total of 1,273 high-touch surfaces were swabbed before and after terminal cleaning during 77 room visits. Of the 2,546 paired swabs, 47% had cultivable biomaterial and 42% had PCR-amplifiable DNA. The ratios of TOs detected to surfaces assayed were 85 per 1,273 for the culture-based method and 106 per 1,273 for the PCR-based method. Sinks, toilet rails, and bedside tables most frequently harbored biomaterial. Although cleaned surfaces were less likely to have cultivable TOs than precleaned surfaces, they were not less likely to harbor bacterial DNA. The rate of MDR-TOs to surfaces swabbed was 0.1% (3/2546). Although environmental MDR-TOs and MDR-TOs from HAIs were genetically related by PFGE, WGS revealed that they were unrelated. Environmental levels of cultivable Enterococcus spp. and E. coli DNA were positively correlated with infection incidences (P<.04 and P<.005, respectively).
conclusion. MDR-TOs were rarely detected during surveillance and were not implicated in HAIs. The roles of environmental DNA and EBD, particularly with respect to water-associated fixtures or the potential suppression of cultivable environmental MDR-TOs, warrant multicenter investigations.
Infect. Control Hosp. Epidemiol. 2015;36(10):1130–1138
Eliminating healthcare-associated infections (HAI) is a national priority,1 and accumulating evidence implicates environmental contamination in HAI transmission.2–5 Ade- quate cleaning of environmental surfaces is an important HAI prevention strategy,6 and because cleaning efficacy and/or HAI transmission rates may varywith differences in hospital design, the built environment, with respect to evidence-based design (EBD), is receiving increased attention.7–10 EBD seeks to improve patient, staff, and organizational
outcomes through hospital design. It assumes that such built environmental features as the layout of patient rooms, natural lighting, views of nature, and state-of-the-art technology can have a positive impact.
Our EBD cleaning study is unique in that, unlike any others
with whichwe are familiar, it was conducted in a newly opened EBD hospital, which permitted a post-construction/pre- opening assessment of baseline contamination. Furthermore, it allowed a more reliable reconsideration of potentially underreported and underestimated results. For example, although nosocomial bacteria persist on environmental surfaces for weeks or months,11 important Gram-negative bacteria, such as Escherichia coli, may be underreported with culture based methods due to their lower viability and envir- onmental bioburden.12 DNA on hospital surfaces may also be another under- estimated driver of antimicrobial resistance and/or virulence
Affiliations: 1. Multidrug-Resistant Organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, Maryland;
2. Department of Medicine, Boston University School of Medicine, Boston, Massachusetts; 3. Navy and Marine Corps Public Health Center, Epidata Center Department, Portsmouth, Virginia; 4. Fort Belvoir Community Hospital, Fort Belvoir, Virginia.
The views expressed herein are solely those of the authors and are not to be construed as official or to represent the US Army or the Department of Defense.
© 2015 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2015/3610-0002. DOI: 10.1017/ice.2015.151 Received April 2, 2015; accepted June 5, 2015; electronically published July 8, 2015
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