766 infection control & hospital epidemiology july 2017, vol. 38, no. 7


efficacy of copper-coated surfaces to reduce environmental colonization in a very challenging setting, an intensive care unit (ICU) of a Greek hospital, where multidrug-resistant organisms (MDROs) are considered endemic.


The present study was designed to further investigate the


methods Setting


The study was conducted in compartments A and B of the ICU at University General Hospital Attikon, a 650-bed ter- tiary-care academic hospital in Athens, Greece. The ICU compartments (A and B) each contain 4 beds in a common area and 2 single-bed isolation rooms. Medical and nursing staff are dedicated to each compartment, but infection control and cleaning protocols are the same throughout the ICU. Admitted patients are routinely screened biweekly for MDRO colonization.17 The preexisting cleaning protocol included the use of spray alcohol-based disinfectant (Bacillol AF, Hartmann, Germany)


on horizontal and other surfaces and twice daily cleaning of floorswith chlorine solution (1,000 ppm/L). For hand hygiene, alcohol-based hand-rub solution was used. Manual dispensers were located on the lower bed rails of each bed. The adherence of ICU personnel to hand-hygiene guidelines was routinely measured using published protocols.18


Study Design Phase 1: Preintervention. A preliminary laboratory study


was conducted to validate the optimum sampling method for the acquisition and release of the maximum concentration of bacteria from the sampled surfaces. We compared the traditional swabbing method using a dry cotton swab according to the method described by Hedin et al19 using 2 sequential flocked nylon swabs (Copan Diagnostics, Corona, CA) for each sample and Difco Dey/Engley neutralizing broth (Becton Dickinson, Sparks, MD) as the sampling solution. We spread different inocula (103–108 cfu) of Staphylococcus aureus, Klebsiella pneumoniae, or Pseudomonas aeruginosa on commonly encountered surface materials and evaluated their recovery quantitatively. We then determined the microbial burden of various surfaces in our ICU to choose the items more heavily and consistently colonized for copper coating. Phase 2 (a and b): Intervention. A comparative crossover


intervention trial was conducted in ICU compartments A and B during 2 time periods. The 6 copper alloy-coated beds and accessories (ie, the upper, lower and side bed rails, the side table, the intravenous (i.v.) pole stands, the handles of the side cart and a cover for the manual antiseptic dispenser) were introduced into the ICU compartments as follows: During phase 2a (September 2011 to February 2012) in both compartments A and B, a copper-coated bed and accessories


were placed next to a noncoated bed and accessories, which were used as controls. During phase 2b (May 2012 to January 2013), all copper-coated beds and accessories were placed in ICU compartment A, and all noncoated beds and accessories (controls) were placed in compartment B. Additionally, copper-alloy–coated handles in all nurse’s cupboards replaced regular handles in compartment A and were compared to the regular ones in compartment B. Patients were randomly assigned at admission by administrative personnel to any compartment and bed per availability. All copper-coated items were generously provided by the Hellenic Copper Development Institute (Athens, Greece). The decision to evaluate copper-coated objects in 2 differ-


ent arrangements was based on the advantages offered by each one. With the first arrangement (phase 2a), we were better able to control for healthcare personnel exposure, room conditions, and sharing the compartment with a heavily colonized/super spreader patient, as well as for potential bias due to the presence of copper surfaces in a single compartment (possibly influencing compliance with hand hygiene or cleaning protocols). With the second arrangement, we aimed to assess the importance of increasing the ratio of copper- coated surfaces in the patient’s vicinity. By comparing the controls, we were able to evaluate the possibility of a “halo effect” 20 due to the presence of copper-coated items near uncoated surfaces. During phase 2 (intervention), data describing the clinical characteristics of patients were extracted from medical files and anonymously recorded, including demographics, admis- sion diagnosis, length of ICU stay, APACHE II score, and colonization or infection by MDROs. The study was approved by the Ethics Committee of the University General Hospital Attikon.


Sampling Protocol


Sampling in phase 2a began 1 month after the introduction of copper-coated items in the ICU to allow personnel to become accustomed to the copper-containing fixtures. Sampling was performed at regular intervals during each study period and only during the morning shift, before the regular cleaning of the day. In July and August 2012, no sampling was performed due to shortage of personnel. Samples from coated and matched uncoated surfaces were collected on the same day and were similarly processed and monitored.


The sampling protocol of Hadin et al19 was applied throughout the study, with the aforementioned modifications. Results were expressed as colony-forming units (cfu) per 100cm2. Gram-negative isolates and selected gram-positive isolates (S. aureus and enterococci) were submitted to strain typing and minimum inhibitory concentration (MIC) deter- mination using the BD Phoenix automated system (Becton Dickinson). The lower limit of detection was 300 cfu/100cm2 (equivalent to 1 colony per plate).


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