Reviewing the Benefits Of Enhanced Terminal Room (BETR-D) Disinfection Study, C.difficile Infection Rates Unchanged

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If you are concerned about C. difficile Infections being battled in Hospitals today review the Abstract and Scientific evidence from the 2015  BETR-D Study

“….adding UV light to bleach in rooms linked to C. difficile had no effect, ” Dr. Deverick J. Anderson, MD, MPH, FIDSA, FSHEA reported

 

MedPage Today  http://www.medpagetoday.com/meetingcoverage/idweek/54043

Adding ultraviolet light or bleach plus UV light also showed a trend toward a reduced risk, Anderson said at the IDWeek meeting, held in 2015 jointly by the Infectious Diseases Society of America (IDSA), the HIV Medicine Association (HIVMA), the Society for Healthcare Epidemiology of America (SHEA), and the Pediatric Infectious Diseases Society (PIDS).

On the other hand, the benefit of what Anderson called “enhanced terminal disinfection” varied among the four pathogens, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), multidrug-resistant (MDR) acetinobacter, and Clostridium difficile.

   What was the BETR-D Study?

The BETR-Disinfection study was performed over 28 months in 9 study hospitals from 4/2012 to 7/2014.

  • Each hospital used four strategies for terminal room disinfection in a randomized sequence.
  • Each strategy was used for 7-month study arms, including a 1 month wash-in period.
  • Two of these strategies used a UV-C emitting device.
  • Standard cleaning involved the use of a quaternary ammonium (reference group A). Three enhanced cleaning strategies were evaluated and compared to the reference: quaternary ammonium + UV-C (B), bleach (C), and bleach + UV-C (D).Of  note, bleach was used for daily and terminal disinfection of all known C. difficile rooms, regardless of study arm.
  • Study cleaning strategies were employed in seed rooms, defined as a room containing a patient on contact precautions for infection or colonization due to the following 4 target MDROs was discharged: MRSA, VRE, C. difficile, or MDR Acinetobacter.
  • The next patient in the room was considered an exposed patient.
  • Primary outcome was the clinical incidence of all target MDROs in patients exposed for at least 24 hours, defined as the first positive culture of a MDRO a) during exposure to the seed room, if positivity occurred ≥48 hr post-admission to the seed room, or b) in the 90 days following seed room exposure for MRSA, VRE, and MDR-Acinetobacter and 28 days for C. difficile.
  • Rates were calculated as outcome/10,000 exposure days using intention-to-treat and per protocol principles

To read the study Abstract in its entirety please click on the following link:

https://idsa.confex.com/idsa/2015/webprogram/Paper53062.html

A study of a large cluster-randomized trial, adding bleach to the standard quaternary ammonium cleaning significantly reduced the risk of transmission of four organisms that cause healthcare-associated infections

A Cluster Randomized, Multicenter Crossover Study with 2×2 Factorial Design to Evaluate the Impact of Enhanced Terminal Room Disinfection on Acquisition and Infection Caused by Multidrug-Resistant Organisms (MDRO)

Anderson and colleagues in the Duke Infection Control Outreach Network tested the four cleaning strategies over 28 months in nine hospitals, with hospitals switching strategies every 7 months.

The goal was to see if they could reduce the overall incidence of the targeted pathogens among patients using a room immediately after a patient known to be colonized or infected by one of the four occupied it. A second primary endpoint was the effect on C. difficile.

He noted that all rooms in which a patient had had C. difficile were cleaned with bleach, so the comparisons were actually between quaternary ammonium and bleach and the same approach adding UV light.

All told, the study had 23,272 patients potentially exposed to a pathogen — they spent at least 24 hours in one of the “seed” rooms where the previous patient had been identified as having one of the pathogens.

Patients in seed rooms became cases if they developed colonization or infection by the pathogens linked to their rooms, as long as they had no history of the pathogen in the previous year and no evidence of community acquisition, he said.

In the four arms, Anderson reported:

  • There were 115 cases in 22,426 exposure days in the standard cleaning arm, for a rate of 51.3 cases per 10,000 exposure days.
  • In the arm adding ultraviolet, there were 76 cases in 22,389 exposure days for a rate of 33.9
  • When bleach was added, there were 101 cases in 24,261 exposure days, for a rate of 41.6.
  • And when both bleach and UV were added, there were 131 cases in 28,757 exposure days, for a rate of 45.6.

The reductions, compared with standard cleaning, were 30%, 15% and 9%, respectively, but only the addition of UV light to quaternary ammonium reached statistical significance (P=0.036).

There were too few cases of MDR acetinobacter to quantify, he said, but it was possible to judge the effect of the various interventions on the other three pathogens.

For MRSA, adding UV light to quaternary ammonium reduced the risk of transmission by 22%, but the difference from standard cleaning fell short of statistical significance. The other two interventions made no difference.

For VRE, on the other hand, all three test strategies reduced the risk of transmission by about 60% — 59% for UV, 57% for bleach, and 64% for bleach plus UV. However, Anderson said, the UV arm was just short of statistical significance, while the other two were significantly different from standard cleaning (P=0.049 and P=0.003, respectively).

But adding UV light to bleach in rooms linked to C. difficile had no effect, Anderson reported.

Note: Not all UV disinfecting products are the same– in the way they are scientifically developed, manufactured, and utilized in the healthcare industry.  It is favorable for Hospital and Healthcare facility decision-makers to ask some tough questions when it comes to evaluating UV technologies. The gold standard for assessing new technologies is to evaluate peer-reviewed literature published and also cited in The Lancet publication.  Please click on the The Lancet article link below to retrieve additional information focused on the BETR-D study.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31588-4/abstract

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).

The BETR-D study was supported by the CDC

 

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Listen to Deverick J. Anderson, MD, MPH, FIDSA, FSHEA discuss UV Intervention Addressing C. difficile and Other Pathogens   July 2016

https://www.voiceamerica.com/episode/94128/uv-intervention-addressing-c-difficile-and-other-pathogens

 

 

*PLEASE NOTE – The C Diff Foundation does not endorse any products, medications,  and/or clinical study in progress. All website postings are strictly for informational purposes only.