Cleaning and disinfection methods in hospitals and clinics

Surface cleaning and disinfection products and technologies have been widely studied, but current expert opinion has reached a consensus in favor of products specifically designed for the healthcare sector. This is because these solutions, often alcohol- or chlorine-based, are the primary disinfectants used for routine hospital room disinfection, with hypochlorites often recommended for rooms of patients infected with C. difficile. The use of disinfectant-impregnated wipes can be an alternative, as can chlorine for manual surface sanitization, but studies supporting their efficacy have only recently emerged.

Enhancing manual surface hygiene and disinfection with the help of automated technologies has been increasingly examined in recent years. Nine studies on UV light and seven studies on hydrogen peroxide vapor machines demonstrate their potential value, but product, maintenance, and staff training costs may discourage hospitals from purchasing these devices. Coating surfaces with copper or silver is another approach that has recently begun to generate interest, and seven studies on coated surfaces have been published.

A major limitation of the evidence base, frequently highlighted by researchers, is the gap between the appropriate use of surface cleaning/disinfecting agents in studies and their implementation in real-world settings. While surface disinfectants work best when applied properly to all relevant surfaces for a sufficient contact time, factors such as chemical concentration consistency and the effect of hard water on disinfectants play a role in product efficacy. Furthermore, manufacturers typically provide recommendations for the correct use of products, but most studies do not report cleaning thoroughness or adherence to disinfectant contact time; this information also remains largely unknown in daily practice.

If studies do not ensure proper application and contact time of chemical agents, the results may be biased against a particular product or in favor of a newer, alternative modality. Conversely, if study results reflect optimal product use, failure to adhere to proper product application and contact time in practice can lead to suboptimal outcomes. A related major concern is end-user uncertainty regarding the applicability of manufacturer recommendations. Technical data sheets accompanying products may be based on laboratory tests under ideal conditions rather than clinical settings. Also, recommendations may be developed based on specific types of pathogens, but users may choose to implement a product or technology for broader effects. KLINTENSIV® – Ready-to-use surface disinfectant

Another challenge in interpreting the results of specialized studies is the role of numerous confounding factors, including factors related to patients, hand hygiene, and other direct patient care practices that affect the risk of pathogen infection. Preventing infections in the hospital environment comprises many critical components beyond cleaning hard surfaces, including instrument sterilization, laundry washing, implementing appropriate isolation precautions, and proper hand washing/hygiene.

These and other elements can sometimes be included as interventions within a broader, multi-component infection prevention strategy, which limits the ability to discern the specific impact of any single disinfection approach. These factors also have the potential to alter the efficacy of interventions. It is emphasized that proper hand hygiene is the most important step for preventing infections associated with acute hand infections and that failure to achieve good hand hygiene practices can minimize the value of surface cleaning and disinfection techniques.

Several significant gaps in the current evidence base limit efforts to improve infection prevention programs and reduce pathogen contamination rates. Four important questions outline the identified evidence needs: (1) Which surfaces should be cleaned and disinfected? (2) How should surfaces be cleaned and disinfected? (3) How should cleaning and disinfection be monitored and measured? and (4) How should interventions be implemented?

Which surfaces should be cleaned and disinfected?

A general limitation is the uncertainty regarding which surfaces should be targeted during the cleaning and disinfection process. Focusing on surfaces that most frequently come into contact with both patients and healthcare workers is practical, but there is little consensus on the specific objects that pose the highest risk of transmitting potentially dangerous microorganisms. Studies on cleaning, disinfection, and monitoring modalities vary widely in the selection of surfaces to evaluate, with some studies focusing only on 2 or 3 surfaces, while others evaluate 15 or more, making it difficult to determine which surfaces pose the highest risk of microbial contamination and infection transmission.

Also, a large number of researchers have expressed concern that there is almost no evidence to clarify whether one surface poses a higher risk of pathogen transmission to patients than another, and that additional work is needed to establish which objects and surfaces are "high-risk" rather than just "high-touch." Future research should identify which objects and surfaces pose the greatest risk of pathogen transmission and determine how that risk varies based on the type of pathogen. Studies that correlate surface contamination with patient colonization or infection will be important for clarifying which surfaces require the most attention from medical staff. PROXY RTU – Professional disinfectant

How should surfaces be cleaned and disinfected?

Certain chemical-based cleaning and disinfecting agents are widely used and have been studied in many settings. However, most studies have used historical controls and focused on documenting the elimination of surface contamination. Direct comparisons measuring patient-centered outcomes, such as colonization or infection rates, are needed to provide data on their comparative efficacy. Similarly, numerous studies have examined touchless devices using hydrogen peroxide vapor or emitting ultraviolet light, but most studies have not directly compared them with each other or with various manual modalities.

In addition to these approaches, there are several emerging technologies that require further research to establish their efficacy in eliminating or preventing surface contamination, as well as evaluating their efficacy in reducing pathogen transmission and patient infection. These include enhanced surface coatings, peracetic acid or hydrogen peroxide wipes, microfiber mops and cloths, and electrolyzed water. KLINOMED WIPES® 85% alcohol wipes

How should surface sanitization and disinfection be monitored and measured?

Similarly, more studies are needed to examine how cleanliness is monitored. Future research should evaluate the comparative efficacy of different products as well as the standard practice of visual observation. Furthermore, in the absence of validated benchmarks or widespread consensus regarding which surface contamination thresholds are safe or acceptable, interpreting and comparing studies on the efficacy of cleaning, disinfection, and monitoring tools will be difficult. Additional research is needed to correlate cleanliness parameters measured by these modalities with clinical outcomes, such as patient colonization or infection. Finally, the use of polymerase chain reaction-based tests to assess surface contamination is an emerging field for future studies.

How should disinfection protocols be implemented in hospitals?

Factors affecting real-world implementation are crucial but are rarely studied systematically or in depth. While previous studies have addressed organizational culture, staff training, and feedback loops, there is still little knowledge about the effect of these factors on the spread of infection-causing pathogens.

Patient-centered outcomes

Surface contamination is the most commonly reported outcome in studies on cleaning/disinfection and monitoring strategies. Patient infection rates are rarely measured and do not always accurately reflect reality. Measurements of patient colonization are rarely recorded. Among the potential benefits of monitoring is that it is a more clinically meaningful outcome than surface contamination and a more frequent outcome than infection, thus giving studies greater power to detect significant differences between interventions. Baseline infection rates within the studied populations are also important factors for understanding the evidence. Because many of the studies in this analysis took place during outbreaks, the magnitude of the effect of the interventions may have been overestimated.

Patients also have preferences beyond clinical outcomes. Specifically, patients often expect their room to "look and smell clean." Although these preferences are imprecise and may not correlate with scientific measures of cleanliness, patients may express concern to hospital staff or management or through satisfaction surveys when expectations are not met.