Infection Control & Hospital Epidemiology
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Table 3. Comparison of Costs Associated With the Use of Antimicrobial Curtains and Standard Curtains in an 8-Bed Cohort Cubicle of an Acute-Care Medical Ward for a 6-Month Period
Antimicrobial Curtain A
Direct costs of 10 curtains (6 short & 4 long)
Indirect costs Routine frequency of curtain change in 6 monthsa Curtain change post-dischargesa
Time to replace Curtains, min
Staff cost (average, $1.05/min)
Lost revenue while curtains were replaced as routine & postdischargec [(average 24-h bed charge=$5,210, ie, $3.62/min) × time to replace (min)]
Laundering cost (average, $7.24 per piece) Total
Routine (10 curtains)a After 200 discharges (2 curtains) 3,380
Once No
6.9 × 10=69 0 72.45
Antimicrobial Curtain B
4,810
Once No
2.4 × 10=24 0 25.20
Standard Curtainb
354
Every 2 weeks or 13 times Yes
4.95 × 13 × 10=643.5
4.95 × 200 × 2=1,980 2,754.68
3.62 × 69=249.65 3.62 × 24=$86.83 3.62 × (643.5 + 1,980)=9,491.97 0 3,702.10 0 4,922.03
patient’s bed would be replaced). bThe normal lifespan of the standard curtain is 60 months, therefore the direct cost of standard curtains=direct cost of new purchase/10. cBecause patients could not be admitted to a bed while curtains were being replaced, loss of avenue=bed charges × time to replace curtains.
−13.2%) compared with the standard curtain, even after pro- longed use (median hanging time, 173 days). For the curtain surfaces next to patients having history of MDROs within the past 12 months, the differences in MDRO contamination were even more drastic: MRSA, −39.7%; CRA, −41.9%; and MDRA, −25.8%. Notably, the same surfaces of antimicrobial curtain B that were culture positive for MRSA and CRA became negative upon repeated sampling a week later even though 1 patient with a history of CRA continued to reside in the cubicle during this period. We were unable to determine the time elapsed from the contamination of the curtain to the time of sample collection. A trial comparing antimicrobial curtain B and untreated poly- propylene revealed 3–4 log reductions in CFU of Bacillus cereus, Enterococcus faecalis, and Serratia marcescens on imprint agar culture after 1 minute of inoculation (as stated in the manu- facturer’s brochure). In our study, the time might not be sufficient for MDROs to be killed on curtains that had been contaminated just before sample collection. In addition, for antimicrobial cur- tain B, the median time to first contamination by MDROs sub- stantially increased. On average, the standard curtain became contaminated within 5 days, whereas antimicrobial curtain B took >19 weeks to become contaminated. One hospital continued to use antimicrobial curtain B in a cubicle for 345 days, and the bioburden remained low: mean TAC, 1.58 CFU/100cm2; MRSA count, 0.01 CFU/100cm2; and CRA and MDRA counts, 0 CFU/ 100cm2. In contrast to the study of Schweizer et al,14 who cul- tured all nosocomial pathogens from the curtains, our study focused on the isolation of MDROs related to intense transmis- sion in our local healthcare setting.17 Among S. aureus isolates identified in the public hospitals, 43.1% were MRSA, and 55% and 8.6% of Acinetobacter spp were carbapenem-resistant and mul- tidrug-resistant, respectively (unpublished data). Given the speed of MDRO contamination of the standard curtain and the practical difficulty of changing curtains frequently, curtains that resist
MDRO contamination for >19 weeks in an active clinical setting could potentially improve patient safety by eliminating a source of healthcare-associated pathogens. With the widespread use of antimicrobial curtain B for a
prolonged period, the development of microbial resistance to QAC should be seriously considered, given the well-documented examples related to its application in human medicine and industry.18 Importantly, because of the diversity of resistance mechanisms, including overexpression of efflux pumps and reduced membrane permeability, microbial cross-resistance to clinically important antimicrobial agents is expected. When an antimicrobial curtain is applied in clinical settings, regular sam- pling of the curtain should be performed, and the susceptibility of the recovered microbes toward QAC and other antimicrobial agents should also be monitored. Concerning cost benefits, replacing the standard curtain with
an antimicrobial curtain could be cost saving if indirect costs such as laundering, time taken for staff to change curtains, and revenue loss are considered. Applying the practice in an 8-bed cohort cubicle of an acute-care medical ward for 6 months could offer a savings of US$1,476.39 ($HK 11,515.82). This finding was in accordance with previous studies.15,16 In addition, most sup- porting staff regarded the weight of an antimicrobial curtain to be lighter than that of standard curtain, without any adverse contact effects reported. Also, frequent handling of heavy standard cur- tains on ladders could be avoided, reducing safety risks to the staff. Our study had some limitations. Patient screening and mole-
cular typing of MDRO isolates were not performed; therefore, we were unable to determine the transmission dynamics and patient acquisition of infections. Nevertheless, Trillis et al3 demonstrated the frequent transfer of pathogens from curtains to the gloved hands of healthcare workers. Without proper hand hygiene, the transferred pathogens could be transmitted to vulnerable patients
7.24 × (10 × 13 + 200 × 2)=3,837.20 16,437.85
Note. Data are $HK, unless otherwise indicated. aAntimicrobial curtains are replaced every 6 months; standard curtains are replaced every 2 weeks (ie, 13 times within 6 months) and upon discharge of patients (2 curtains alongside a
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