Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study

Deverick J. Anderson, Luke F. Chen, David J. Weber, Rebekah W. Moehring, Sarah S. Lewis, Patricia F. Triplett, Michael Blocker, Paul Becherer, J. Conrad Schwab, Lauren P. Knelson, Yuliya Lokhnygina, William A. Rutala, Hajime Kanamori, Maria F. Gergen, Daniel J. Sexton, CDC Prevention Epicenters Program

Research output: Research - peer-reviewArticle

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Abstract

Background Patients admitted to hospital can acquire multidrug-resistant organisms and Clostridium difficile from inadequately disinfected environmental surfaces. We determined the effect of three enhanced strategies for terminal room disinfection (disinfection of a room between occupying patients) on acquisition and infection due to meticillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, C difficile, and multidrug-resistant Acinetobacter. Methods We did a pragmatic, cluster-randomised, crossover trial at nine hospitals in the southeastern USA. Rooms from which a patient with infection or colonisation with a target organism was discharged were terminally disinfected with one of four strategies: reference (quaternary ammonium disinfectant except for C difficile, for which bleach was used); UV (quaternary ammonium disinfectant and disinfecting ultraviolet [UV-C] light except for C difficile, for which bleach and UV-C were used); bleach; and bleach and UV-C. The next patient admitted to the targeted room was considered exposed. Every strategy was used at each hospital in four consecutive 7-month periods. We randomly assigned the sequence of strategies for each hospital (1:1:1:1). The primary outcomes were the incidence of infection or colonisation with all target organisms among exposed patients and the incidence of C difficile infection among exposed patients in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT01579370. Findings 31 226 patients were exposed; 21 395 (69%) met all inclusion criteria, including 4916 in the reference group, 5178 in the UV group, 5438 in the bleach group, and 5863 in the bleach and UV group. 115 patients had the primary outcome during 22 426 exposure days in the reference group (51·3 per 10 000 exposure days). The incidence of target organisms among exposed patients was significantly lower after adding UV to standard cleaning strategies (n=76; 33·9 cases per 10 000 exposure days; relative risk [RR] 0·70, 95% CI 0·50–0·98; p=0·036). The primary outcome was not statistically lower with bleach (n=101; 41·6 cases per 10 000 exposure days; RR 0·85, 95% CI 0·69–1·04; p=0·116), or bleach and UV (n=131; 45·6 cases per 10 000 exposure days; RR 0·91, 95% CI 0·76–1·09; p=0·303) among exposed patients. Similarly, the incidence of C difficile infection among exposed patients was not changed after adding UV to cleaning with bleach (n=38 vs 36; 30·4 cases vs 31·6 cases per 10 000 exposure days; RR 1·0, 95% CI 0·57–1·75; p=0·997). Interpretation A contaminated health-care environment is an important source for acquisition of pathogens; enhanced terminal room disinfection decreases this risk. Funding US Centers for Disease Control and Prevention.

LanguageEnglish (US)
Pages805-814
Number of pages10
JournalThe Lancet
Volume389
Issue number10071
DOIs
StatePublished - Feb 25 2017

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Clostridium difficile
Disinfection
Cross-Over Studies
Multicenter Studies
Infection
Incidence
Disinfectants
Ammonium Compounds
Acinetobacter
Methicillin
Ultraviolet Rays
Centers for Disease Control and Prevention (U.S.)
Staphylococcus aureus
Delivery of Health Care
Population
Vancomycin-Resistant Enterococci

ASJC Scopus subject areas

  • Medicine(all)

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Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study) : a cluster-randomised, multicentre, crossover study. / Anderson, Deverick J.; Chen, Luke F.; Weber, David J.; Moehring, Rebekah W.; Lewis, Sarah S.; Triplett, Patricia F.; Blocker, Michael; Becherer, Paul; Schwab, J. Conrad; Knelson, Lauren P.; Lokhnygina, Yuliya; Rutala, William A.; Kanamori, Hajime; Gergen, Maria F.; Sexton, Daniel J.; CDC Prevention Epicenters Program.

In: The Lancet, Vol. 389, No. 10071, 25.02.2017, p. 805-814.

Research output: Research - peer-reviewArticle

Anderson, DJ, Chen, LF, Weber, DJ, Moehring, RW, Lewis, SS, Triplett, PF, Blocker, M, Becherer, P, Schwab, JC, Knelson, LP, Lokhnygina, Y, Rutala, WA, Kanamori, H, Gergen, MF, Sexton, DJ & CDC Prevention Epicenters Program 2017, 'Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study' The Lancet, vol 389, no. 10071, pp. 805-814. DOI: 10.1016/S0140-6736(16)31588-4
Anderson, Deverick J. ; Chen, Luke F. ; Weber, David J. ; Moehring, Rebekah W. ; Lewis, Sarah S. ; Triplett, Patricia F. ; Blocker, Michael ; Becherer, Paul ; Schwab, J. Conrad ; Knelson, Lauren P. ; Lokhnygina, Yuliya ; Rutala, William A. ; Kanamori, Hajime ; Gergen, Maria F. ; Sexton, Daniel J. ; CDC Prevention Epicenters Program. / Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study) : a cluster-randomised, multicentre, crossover study. In: The Lancet. 2017 ; Vol. 389, No. 10071. pp. 805-814
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T1 - Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study)

T2 - The Lancet

AU - Anderson,Deverick J.

AU - Chen,Luke F.

AU - Weber,David J.

AU - Moehring,Rebekah W.

AU - Lewis,Sarah S.

AU - Triplett,Patricia F.

AU - Blocker,Michael

AU - Becherer,Paul

AU - Schwab,J. Conrad

AU - Knelson,Lauren P.

AU - Lokhnygina,Yuliya

AU - Rutala,William A.

AU - Kanamori,Hajime

AU - Gergen,Maria F.

AU - Sexton,Daniel J.

AU - CDC Prevention Epicenters Program

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N2 - Background Patients admitted to hospital can acquire multidrug-resistant organisms and Clostridium difficile from inadequately disinfected environmental surfaces. We determined the effect of three enhanced strategies for terminal room disinfection (disinfection of a room between occupying patients) on acquisition and infection due to meticillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, C difficile, and multidrug-resistant Acinetobacter. Methods We did a pragmatic, cluster-randomised, crossover trial at nine hospitals in the southeastern USA. Rooms from which a patient with infection or colonisation with a target organism was discharged were terminally disinfected with one of four strategies: reference (quaternary ammonium disinfectant except for C difficile, for which bleach was used); UV (quaternary ammonium disinfectant and disinfecting ultraviolet [UV-C] light except for C difficile, for which bleach and UV-C were used); bleach; and bleach and UV-C. The next patient admitted to the targeted room was considered exposed. Every strategy was used at each hospital in four consecutive 7-month periods. We randomly assigned the sequence of strategies for each hospital (1:1:1:1). The primary outcomes were the incidence of infection or colonisation with all target organisms among exposed patients and the incidence of C difficile infection among exposed patients in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT01579370. Findings 31 226 patients were exposed; 21 395 (69%) met all inclusion criteria, including 4916 in the reference group, 5178 in the UV group, 5438 in the bleach group, and 5863 in the bleach and UV group. 115 patients had the primary outcome during 22 426 exposure days in the reference group (51·3 per 10 000 exposure days). The incidence of target organisms among exposed patients was significantly lower after adding UV to standard cleaning strategies (n=76; 33·9 cases per 10 000 exposure days; relative risk [RR] 0·70, 95% CI 0·50–0·98; p=0·036). The primary outcome was not statistically lower with bleach (n=101; 41·6 cases per 10 000 exposure days; RR 0·85, 95% CI 0·69–1·04; p=0·116), or bleach and UV (n=131; 45·6 cases per 10 000 exposure days; RR 0·91, 95% CI 0·76–1·09; p=0·303) among exposed patients. Similarly, the incidence of C difficile infection among exposed patients was not changed after adding UV to cleaning with bleach (n=38 vs 36; 30·4 cases vs 31·6 cases per 10 000 exposure days; RR 1·0, 95% CI 0·57–1·75; p=0·997). Interpretation A contaminated health-care environment is an important source for acquisition of pathogens; enhanced terminal room disinfection decreases this risk. Funding US Centers for Disease Control and Prevention.

AB - Background Patients admitted to hospital can acquire multidrug-resistant organisms and Clostridium difficile from inadequately disinfected environmental surfaces. We determined the effect of three enhanced strategies for terminal room disinfection (disinfection of a room between occupying patients) on acquisition and infection due to meticillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, C difficile, and multidrug-resistant Acinetobacter. Methods We did a pragmatic, cluster-randomised, crossover trial at nine hospitals in the southeastern USA. Rooms from which a patient with infection or colonisation with a target organism was discharged were terminally disinfected with one of four strategies: reference (quaternary ammonium disinfectant except for C difficile, for which bleach was used); UV (quaternary ammonium disinfectant and disinfecting ultraviolet [UV-C] light except for C difficile, for which bleach and UV-C were used); bleach; and bleach and UV-C. The next patient admitted to the targeted room was considered exposed. Every strategy was used at each hospital in four consecutive 7-month periods. We randomly assigned the sequence of strategies for each hospital (1:1:1:1). The primary outcomes were the incidence of infection or colonisation with all target organisms among exposed patients and the incidence of C difficile infection among exposed patients in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT01579370. Findings 31 226 patients were exposed; 21 395 (69%) met all inclusion criteria, including 4916 in the reference group, 5178 in the UV group, 5438 in the bleach group, and 5863 in the bleach and UV group. 115 patients had the primary outcome during 22 426 exposure days in the reference group (51·3 per 10 000 exposure days). The incidence of target organisms among exposed patients was significantly lower after adding UV to standard cleaning strategies (n=76; 33·9 cases per 10 000 exposure days; relative risk [RR] 0·70, 95% CI 0·50–0·98; p=0·036). The primary outcome was not statistically lower with bleach (n=101; 41·6 cases per 10 000 exposure days; RR 0·85, 95% CI 0·69–1·04; p=0·116), or bleach and UV (n=131; 45·6 cases per 10 000 exposure days; RR 0·91, 95% CI 0·76–1·09; p=0·303) among exposed patients. Similarly, the incidence of C difficile infection among exposed patients was not changed after adding UV to cleaning with bleach (n=38 vs 36; 30·4 cases vs 31·6 cases per 10 000 exposure days; RR 1·0, 95% CI 0·57–1·75; p=0·997). Interpretation A contaminated health-care environment is an important source for acquisition of pathogens; enhanced terminal room disinfection decreases this risk. Funding US Centers for Disease Control and Prevention.

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