A Fresh and Appropriate Approach to Hygienic Cleaning of Environmental Surfaces

1. A Fresh and Appropriate Approach to Hygienic Cleaning of EnvironmentalSurfaces

5. Public attitudes towards bacterial resistance: a qualitative study Although members of the public can contribute to containing bacterial resistance, most do not feel that they have a personal role in either the problem or its solution. Campaigns should identify bacterial resistance as both a hospital and a community problem that individuals have the power to influence through specific actions April 21, 2007 Journal of Antimicrobial Chemotherapy,

8. In certain settings, antibacterial agents are essential to fight against infection. However, if used too frequently and indiscriminately, certain antibacterial agents—those that leave trace chemical residues and that target particular processes in the life cycle of bacteria—may, like antibiotics, select for resistant strains. To insure that these agents continue to be effective when they are needed, products containing these antibacterials should only be used when they are essential to fight against infection. In other situations, when more information is not available, it is wiser to disinfect with agents that are unlikely to select for resistant strains of bacteria.

12. Antimicrobial Products In The HomeCanadian Pediatric Society, 2006 Where appropriate, alcohol, bleach or peroxidase-based agents are preferred because they dissipate readily and are less likely to exert prolonged antimicrobial pressure. Agents such as triclosan, chlorhexidine and quaternary ammonium compounds exert more prolonged antimicrobial pressure.

13. Current Practices Surfactant based cleaning and disinfecting contribution to microbial resistance to biocides and antibiotics.

14. Current Practices There is growing evidence today that leaving toxic detergent surfactants and disinfectant residues on environmental surfaces and in our waste water contributes to development of bacterial resistance to biocides and antibiotics.

15. Resistance of biofilm pathogens following exposure to either continuous (1 µg ml-1) or intermittent (10 µg ml-1 for 10 min daily) benzalkonium chloride (BC) was examined. Biofilm pathogens that adapted to BC exposure over 144-hours could survive a normally lethal BC challenge (500 µg ml-1 for 10 min) and then regrow Antimicrobial Agents Chemother. 2006 November; 50(11): 3588–3596.

16. There are concerns that the inappropriate use (inadequate concentrations, insufficient cleaning before the application, or the presence of sub lethal residual disinfectants following cleaning) of these biocidal compounds may contribute to the spread of bacterial resistance to these compounds, as well as cross-resistance to certain therapeutic antibiotics.

17. Susceptibility of multiresistant Pseudomonas aeruginosa isolates to a hospital disinfectant and molecular typing We found isolates with reduced susceptibility to the QAC disinfectant. Resistance to quaternary ammonium may co-select for antibiotic resistance via class 1 integrons and vice-versa.

18. Our work demonstrates that subinhibitory concentrations of disinfectants, which might occur during poor disinfection and cleaning procedures, can lead to selection of strains with reduced susceptibility, or even resistance to antibiotics. These effects were more pronounced with a quaternary ammonium based biocide and with the use of high concentrations of triclosan. Journal of Antimicrobial Chemotherapy (2007) 60, 947–955Advance Access publication 13 September 2007

20. Genomics of IncP-1 plasmids isolated from wastewater treatment plants Based on genomic analysis of IncP-1 resistance plasmids: These plasmids encode resistance to clinically relevant antimicrobial drug classes including tetracyclines, aminoglycosides, macrolides, ß-lactams, chloramphenicol, sulphonamides and trimethoprim. Additional genes were identified that encode resistance to heavy metals (mercury and chromate) or quaternary ammonium compounds (used in detergents). Integrons were frequently found on IncP-1 plasmids ‘Since these elements play an important role in the acquisition and exchange of genes encoding resistance to antibiotics and QACs, their presence on conjugative, broad-host-range plasmids is worrying. Indeed, linkage of genes encoding both antibiotic and QAC resistance allows for selection of drug resistance determinants by disinfectants “

21. Disinfectant-resistant bacteria in Buenos Aires city hospital wastewater Disinfectants present in the hospital wastewater may act as selective pressure for the retention of the plasmids that often contain the genes for resistance to numerous antibiotics (14,22,23,26). It is generally agreed that the selection and dissemination of resistant bacteria in nature should be avoided in order to ensure effective treatment against infectious diseases in humans and maintain an ecological balance that favors the predominance of a susceptible bacterial flora in nature. The indiscriminate use of antimicrobial agents may disrupt the microbial balance in favor of resistance bacteria. In particular, wastewater from hospital plants could play a role in the selection of resistance bacteria in sewage (6,16).

22. The association between biocide tolerance and the presence or absence of qac genes among hospital-acquired and community-acquired MRSA isolates In this study, Hospital Acquired MRSA isolates displayed significantly higher MBC to a quat than MSSA isolates. This would suggest that there is a correlation between antibiotic resistance and biocide tolerance. Our study reinforces this link in S. aureus and the issue of biocide–antibiotic co-resistance should no longer be ignored.

23. The association between biocide tolerance and the presence or absence of qac genes among hospital-acquired and community-acquired MRSA isolates The continued exposure of bacteria to residual levels of biocides in the hospital environment is causing concern. The presence of qac genes in the clinical S. aureus population and their ability to develop increased tolerance highlights the importance of effective and rigorous infection cleaning and infection control strategies. Journal of Antimicrobial Chemotherapy Advance Access published November 2, 2007

24. Importance of environmental decontamination: a critical view As with proper cleaning procedures, targeted surface disinfection is indispensable in modern hospitals. However, disinfectants may be hazardous to personnel and patients, as well as the environment, and require special safety precautions. An uncritical use of biocides, especially in low concentrations, may lead to the development of resistance.

25. Use of antibacterial consumer products containing quaternary ammonium compounds and drug resistance in the community Quaternary ammonium compounds (QACs), such as benzalkonium chloride (BAC), are broad-spectrum antimicrobials widely used for decades to disinfect environmental surfaces in clinical and industrial settings. Reports examining the relationships between biocide use and bacterial resistance among isolates from the community setting are limited.1 We assessed the effect of antibacterial product usage in the home environment on susceptibility to BAC to determine whether there is a correlation between BAC and triclosan MICs and antibiotic resistance. This is the first randomized intervention study to assess the relationships between antibacterial product usage, BAC MICs, triclosan MICs and antibiotic susceptibility among isolates obtained from the household setting. We found that after 1 year of assigned product usage, bacterial isolates with high BAC MICs were more likely to have high MICs of triclosan and be resistant to one or more antibiotics. Our findings raise concern that the exposure of bacteria to antibacterial-containing products, such as QACs, may exert a selective pressure resulting in the co-selection of genes encoding reduced susceptibility for both biocides and antibiotics. As the potential role of disinfectants and biocides in minimizing the spread of infectious diseases in homes has not been established, concern over potential decreased susceptibility to biocides and resistance to antibiotics is warranted Robyn T. Carson1, Elaine Larson2, Stuart B. Levy3, Bonnie M. Marshall3 and Allison E. Aiello4,* JAC Advance Access published online on August 11, 2008 

26. Household Antibacterial Product Use May Promote Microbial Resistance July 3, 2008 — Antibacterial product use may lead to decreased susceptibility to other antibacterial ingredients and antibiotic resistance in the home, according to the results of a study reported at the 2008 Annual Conference on Antimicrobial Resistance held in Bethesda, Maryland. "Quaternary ammonium compounds (QACs), such as benzalkonium chloride [BZK], are broad-spectrum antimicrobials that have been widely used for decades to disinfect environmental surfaces in clinical and industrial settings," "With increasing use of cleaning and hygiene products containing QACs in the home, there is a valid public health concern that biocide resistance may emerge in the community environment," she said. "Antibacterial consumer products leave residues on home surfaces, exposing bacterial species to low levels of the agent and creating conditions favorable for development of resistance to both biocides and antibiotics." Dr. Aiello said

27. Household Antibacterial Product Use May Promote Microbial Resistance "Our study reports, for the first time, a significant relationship between use of a common antibacterial cleaning agent ([BZK]) and cross-resistance with antibiotics and another antibacterial ingredient (triclosan) in the household setting," Dr. Aiello said. "The results of our study suggest that the growing concern over the emergence of cross-resistance between biocides used in the household and clinically used antibiotics is warranted."

29. Multidrug efflux pump overexpression in Staphylococcus aureus after single and multiple in vitro exposures to biocides and dyes Exposures to MDR pump substrates, whether those substrates are clinically relevant antimicrobial agents or compounds used to disinfect the hospital environment, can result in the emergence of S. aureus strains adapted to the presence of these compounds. Acquisition of such strains by patients may compromise the therapy of infections caused by them. Prudent use of antimicrobial agents and the use of biocides that are not known to be MDR pump substrates may reduce the frequency at which MDR-pump-overexpressing strains are found. Microbiology 154 (2008

31. Frequently Asked Questions 5. Can the use of household disinfectants or antiseptics contribute to resistance? The association between the use of household disinfectants/antiseptics that contain antibacterial agents and the development of AMR has been widely reported. Widespread use may lead to increased emergence of resistance in microorganisms. Resistance may develop not only against the disinfectants, but cross-resistance to antimicrobials used in human medicine may also appear.

32. Detergent Surfactant and Antimicrobial Usage 80 % of detergent and antimicrobial surfactant consumption is from households. 20% of detergent and antimicrobial consumption is from institutional use.

33. Surfactants are Toxic Surfactants used in cleaning and disinfecting of environmental surfaces are all rated as toxic to aquatic life. Surfactants used in cleaning of environmental surfaces all have toxic effects on microbial populations bactericidal and/or bacteriostatic. Surfactant toxic effects on microbial populations contributes to bacterial adaptation and resistance development.

34. Induction of multiple antibiotic resistance by benzene and benzene- derived active compounds Objectives: To determine the potential of active compounds (ACs) present in commonly used analgesics/antiseptics and cleaning agents (detergents and disinfectants) to induce multiple antibiotic resistance (MAR) in Bacteroides fragilis.

35. Tested inorganic compounds(sodium hypochlorite, ammonium hydroxide and hydrogen peroxide) were essentially non-inducing.

36. Toxicity of anionic detergents determined by Saccharomycescerevisiae microarray analysisSophon Sirisattha, Yuko Momose, Emiko Kitagawa, Hitoshi Iwahashi* The mRNA expression profiles suggest that LAS and SDS cause damage to membranes and alterations in carbon metabolism, and induce the oxidative stress response. We also found that LAS and SDS induce the pleiotropic drug-resistance network,

37. Some studies have demonstrated that these residues can increase the persistence of C. Difficile

38. In vitro effects of environmental disinfectants on spore formation (ii)

40. Journal of Antimicrobial Agents Volume 28, Issue 6, December 2006

41. Toxicity of anionic detergents determined by Saccharomycescerevisiae microarray analysisSophon Sirisattha, Yuko Momose, Emiko Kitagawa, Hitoshi Iwahashi* The concentrations of LAS and SDS that cause growth inhibition were studied after screening of the various concentrations of LAS and SDS that affect cellular growth. The growth curves showed that, at 0.02% LAS and 0.01% SDS, there was a 50% decrease in the specific growth (IC50) after a 2 h treatment.

42. International Symposium on Environmental Biotechnology 2006, Leipzig, Germany288Effects of detergent shock loads on anaerobic granular sludge morphologyand methanogenic activity After exposure to 0.30 g/L of detergent the COD removal efficiency decreased drastically.

43. Effect of Surfactants on Soil Bacteriaby LUDWIG HARTMANNHead, Laboratory o] Engineering-BiologyTechnische H ochschule Karlsruhe, Germany

45. ANTIBIOTIC RESISTANCE “The term antimicrobial refers to both natural and synthetic substances like antibiotics and disinfectants which can kill or block the reproduction of microorganisms.”

46. Antimicrobial One should consider surfactants antimicrobials as they either kill or slow the growth of microbes.

47. Consumption of Surfactants It is commonly accepted that 0.015 % of the world oil production is used in the manufacturing of surfactants. This equates to an estimated 61,476,428 metric tons of oil and 46,107,321 metric tons of surfactants annually.

48. Consumption of Antibiotics In 1998 it has been estimated that the U.S. consumption of antibiotics was 12,500 metric tons and that it has taken 50 years to consume 1,000,000 metric tons of antibiotics from all sources. The estimated annual surfactant consumption is 46,107,432 metric tons world wide.

49. What is drug resistance?Antimicrobial resistance is the ability of microbes, to grow in the presence of a chemical (drug) that would normally kill it or inhibit its growth.

50. Antimicrobial Resistance Increasing use of antimicrobials in humans, animals, and agriculture has resulted in many microbes developing resistance Many infectious diseases are increasingly difficult to treat because of antimicrobial-resistant organisms Between 5 and 10 percent of all hospital patients develop an infection, leading to an increase of about $5 billion in annual U.S. healthcare costs. About 120,000 of these patients die each year as a result of their infection, up from 13,300 patient deaths in 1992

51. In certain settings, antibacterial agents are essential to fight against infection. However, if used too frequently and indiscriminately, certain antibacterial agents—those that leave trace chemical residues and that target particular processes in the life cycle of bacteria—may, like antibiotics, select for resistant strains. To insure that these agents continue to be effective when they are needed, products containing these antibacterials should only be used when they are essential to fight against infection. In other situations, when more information is not available, it is wiser to disinfect with agents that are unlikely to select for resistant strains of bacteria.

52. Current Practices Low Level disinfectant cleaners like quats are used for damp dusting environmental surfaces with a simple wipe and go technique. More potent disinfectant cleaners are used in isolation areas, for cases of Noroviruses or C. difficile and simply when a higher degree of confidence is required. Because it is not common practice to maintain anappropriate wet contact time, cleaning staff are using antimicrobial products as disinfectant cleaners. Legally concerns claiming when claiming to disinfect but not following manufacturers instructions for use?

53. Separate Cleaning From Disinfecting One Step Cleaning and Disinfecting is contradictory to the science of disinfection.

54. Focus on Cleaning Use best cleaning practices. Prevent spreading contaminants. DFC Sodium hypochlorite Disinfectant/Disinfectant Cleaners without surfactants are the ideal choice for removing C.difficile from the environment. Cleaning to remove C.difficile from the environment ensures removal of other pathogens.

55. Sodium Hypochlorite Disinfectant/Disinfectant Cleaning. Changing the chemistry of cleaning and disinfecting environmental surfaces. Replaces residue depositing cleaner disinfectants containing surfactants. Replaces one step cleaner disinfectants which have failed to reduce hospital acquired infections. Cost effective concentrate in safe closed looped containers . Stabilized sodium hypochlorite cleaning and disinfecting without the hazards associated with bleach.

59. One Third of Hospital Toilets Not Properly Cleaned: C. Difficile Germs LingerScienceDaily (May 12, 2008) C. difficile was still detected in 40% of samples taken from the cleanest toilets (i.e. those with no detectable UV marker). "This suggests that both the physical cleaning action as well as the disinfectant/cleaning agent were ineffective for killing and/or removing C. difficile from toilets," notes Alfa.

60. Sodium Hypochlorite Disinfecting/Disinfecting Cleaner For cleaning fecal organic soils in toilets, commodes and other environmental surfaces. C. difficile is spread by fecal contamination. 20% of all patients in active treatment health care facilities carry C. difficile and 50% in long term care facilities. Clean toilets and commodes to remove C.difficile .

61. Sodium Hypochlorite Disinfectant/Disinfectant Cleaners Products can have a health rating of 1. Non corrosive to skin and eyes. Reduced environmental impacts due to the short life cycle of sodium hypochlorite on environmental surfaces and our waste water. Cleaning and disinfecting without surfactants.

62. Sodium Hypochlorite Disinfectants/Disinfectant Cleaners For use on hard non porous environmental surfaces in health care facilities, institutions, schools, and the hospitality industries, where organic soils may be present.

63. Sodium Hypochlorite Disinfectant/Disinfectant Cleaners Cogent Hygienic Cleaning COAR Clean Oxidize and Remove/Disinfect. Cleaning to protect public health.

65. How does Antimicrobial Resistance Develop? 3. Use of antibacterial cleaning products such as community or household disinfectants or antiseptics and personal hygiene products. Industry produces and markets a number of disinfectants for hand and surface cleanliness, resulting in the frequent and unnecessary use of products that contain antimicrobials. In fact, overuse of antibacterial cleaning products in the home, community and in health care facilities may lead to increased development of resistance in common microorganisms.

66. How does Antimicrobial Resistance Develop? 4. Environmental contamination caused by the use of cleaning and disinfectant products as well as veterinary antimicrobial drugs for use in farm and veterinary practice. Limit the use of products that claim to fight bacteria or are labeled as antimicrobial. Plain soap and water or a mild bleach solution is usually adequate for cleaning your home.