key: cord-0303081-nvbnb9wv authors: Thomas, R. E.; Thomas, B. C.; Conly, J.; Lorenzetti, D. L. title: Cleaning and disinfecting surfaces in hospitals and long-term care facilities for reducing hospital and facility-acquired bacterial and viral infections: A systematic review date: 2021-12-23 journal: nan DOI: 10.1101/2021.12.22.21268185 sha: 2d6c5560131814ad75939232946fb93fd1149513 doc_id: 303081 cord_uid: nvbnb9wv Background: Multiply drug-resistant organisms (MDROs) in hospitals and long-term care facilities (LTCFs) of particular concern include meticillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus, multidrug-resistant Acinetobacter species and extended spectrum beta-lactamase producing organisms. Respiratory viruses include influenza and SARS-CoV-2. Aim: To assess effectiveness of cleaning and disinfecting surfaces in hospitals and LTCFs. Methods: CINAHL, Cochrane CENTRAL Register of Controlled Trials, EMBASE, Medline, and Scopus searched inception to 28 June 2021, no language restrictions, for randomized controlled trials, cleaning, disinfection, hospitals, LTCFs. Abstracts and titles were assessed and data abstracted independently by two authors. Findings: Of fourteen c-RCTs in hospitals and LTCFs, interventions in ten were focused on reducing patient infections of four MDROs and/or healthcare-associated infections (HAIs). In four c-RCTs patient MDRO and/or HAI rates were significantly reduced with cleaning and disinfection strategies including bleach, quaternary ammonium detergents, ultraviolet irradiation, hydrogen peroxide vapour and copper-treated surfaces or fabrics. Of three c-RCTs focused on reducing MRSA rates, one had significant results and one on Clostridioides difficile had no significant results. Heterogeneity of populations, methods, outcomes and data reporting precluded meta-analysis. Overall risk of bias assessment was low but high for allocation concealment, and GRADE assessment was low risk. No study assessed biofilms. Conclusions: Ten c-RCTs focused on reducing multiple MDROs and/or HAIs and four had significant reductions. Three c-RCTs reported only patient MRSA colonization rates (one significant reductions), and one focused on Clostridioides difficile (no significant differences). Standardised primary and secondary outcomes are required for future c-RCTs including detailed biofilm cleaning/disinfection interventions. . T h e e v i d e n c e f o r t h e e f f e c t i v e n e s s o f c l e a n i n g a n d d i s i n f e c t i o n i n h o s p i t a l s a n d L T C F s r e q u i r e s u p d a t i n g i n l i g h t o f n e w d e v e l o p m e n t s i n t h e r a p i d l y e v o l v i n g l a n d s c a p e i n t h i s a r e a . P u r p o s e : T o c o n d u c t a s y s t e m a t i c r e v i e w t o a s s e s s t h e e v i d e n c e f o r t h e e f f e c t i v e n e s s o f c l e a n i n g a n d d i s i n f e c t i n g s u r f a c e s i n h o s p i t a l s a n d L T C F s t o p r e v e n t M D R O s a n d H A I s , i n c l u d i n g v i r a l i n f e c t i o n a p o u r i s e d h y d r o g e n p e r o x i d e , u l t r a v i o l e t l i g h t i n g , c o p p e r -p l a t e d s u r f a c e s o r c o p p e r -t r e a t e d f a b r i c s , o r d i s i n f e c t a n t o r a n t i s e p t i c c o a t e d s u r f a c e s . C o m p a r i s o n : u s u a l c l e a n i n g m e t h o d s i n t h e i n s t i t u t i o n ( o r q u a t e r n a r y a m m o n i u m d i s i n f e c t a n t i f i t i s t h e u s u a l m e t h o d ) . O u t c o m e s : r a t e s o f n e w M D R O s a n d H A I s i n p a t i e n t s . S t u d y D e s i g n : r a n d o m i z e d o r c l u s t e r -r a n d o m i z e d c o n t r o l l e d t r i a l s . S e c o n d a r y r e s e a r c h q u e s t i o n s : ( 1 ) W h a t a r e t h e r e p o r t e d M D R O a n d H A I r a t e s i n t h e r e g i o n o f t h e i n s t i t u t i o n ? ( 2 ) D i d t h e s t u d y f o l l o w o r t e s t e v i d e n c e -b a s e d d i s i n f e c t i o n g u i d e l i n e s ? ( 3 ) D i d t h e r e s e a r c h e r s p e r f o r m g e n o m i c s t u d i e s t o t r a c k t h e t r a n s m i s s i o n o f p a t h o g e n s b e t w e e n t h e c o m m u n i t y , h o s p i t a l s a n d L T C F s ? ( 4 ) W e r e a n t i b i o t i c s t e w a r d s h i p p r o g r a m m e s a n d t h e i r e f f e c t i v e n e s s r e p o r t e d ? a n d ( 5 ) W e r e M D R O a n d H A I r a t e s r e p o r t e d f o r e n v i r o n m e n t a l s e r v i c e w o r k e r s ( E S W s ) a n d o t h e r H C W s ? D a t a C o l l e c t i o n F i v e d a t a b a s e s ( C I N A H L , C o c h r a n e C E N T R A L R e g i s t e r o f C o n t r o l l e d T r i a l s , E M B A S E , M e d l i n e , a n d S c o p u s ) w e r e s e a r c h e d f r o m i n c e p t i o n t o J u n e 2 8 , 2 0 2 1 . S e a r c h e s c o m b i n e d k e y w o r d s a n d d a t a b a s e s p e c i f i c s u b j e c t h e a d i n g s f r o m t h r e e c o n c e p t s : ( a ) h o s p i t a l s o r a c u t e / l o n g t e r m c a r e f a c i l i t i e s ( e . g . : a s s i s t e d l i v i n g , l o n g t e r m c a r e f a c i l i t i e s , n u r s i n g h o m e s ) ( b ) d i s i n f e c t a n t s ( e . g . : a n t i s e p s i s , b l e a c h , c l e a n i n g , c o p p e r p l a t i n g o f s u r f a c e s a n d c o p p e r i m p r e g n a t i o n o f t e x t i l e s , d i s i n f e c t i o n , d e c o n t a m i n a t i o n , h y d r o g e n p e r o x i d e , q u a t e r n a r y a m m o n i u m c o m p o u n d s , a n d u l t r a v i o l e t ( U V ) l i g h t ) ; a n d ( c ) r a n d o m i z e d c o n t r o l l e d t r i a l s . T h e C o c h r a n e C o l l a b o r a t i o n ' s h i g h l y s e n s i t i v e s e a r c h f i l t e r w a s u s e d t o i d e n t i f y r e l e v a n t r a n d o m i z e d c o n t r o l l e d t r i a l s [ 6 ] . N o l a n g u a g e o r d a t e l i m i t s w e r e a p p l i e d . T h e r e f e r e n c e l i s t s o f i n c l u d e d s t u d i e s w e r e a l s o s e a r c h e d t o i d e n t i f y a d d i t i o n a l s t u d i e s o f r e l e v a n c e . T h e c o m p l e t e s e a r c h s t r a t e g y i s d o c u m e n t e d i n A p p e n d i x A . S t u d y S c r e e n i n g S e a r c h r e s u l t s w e r e d o w n l o a d e d i n t o C o v i d e n c e ™ [ 7 ] f o r d e -d u p l i c a t i o n a n d s c r e e n i n g . T w o a u t h o r s s c r e e n e d a b s t r a c t s a n d f u l l -t e x t p a p e r s i n d u p l i c a t e . D i s a g r e e m e n t s w e r e r e s o l v e d t h r o u g h c o n s e n s u s . S t u d i e s w e r e i n c l u d e d i f t h e y w e r e r a n d o m i z e d o r c l u s t e r c o n t r o l l e d t r i a l s t h a t : ( 1 ) f o c u s e d o n p a t i e n t s i n h o s p i t a l s o r L T C F s ; ( 2 ) r e p o r t e d o n t h e u s e o f b l e a c h , q u a t e r n a r y a m m o n i u m d i s i n f e c t a n t s , h y d r o g e n p e r o x i d e , u l t r a v i o l e t l i g h t s , o r c o p p e r -p l a t e d s u r f a c e s / c o p p e r -t r e a t e d f a b r i c s o r a n t i s e p t i c . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint c o a t e d s u r f a c e s t o d i s i n f e c t s u r f a c e s o r r e d u c e c o l o n i s a t i o n r a t e s i n p a t i e n t s ; a n d ( 3 ) r e p o r t e d r a t e s o f p a t i e n t i n f e c t i o n o r b a c t e r i a l c o l o n i s a t i o n o f s u r f a c e s . D a t a E x t r a c t i o n a n d Q u a l i t y A s s e s s m e n t T w o a u t h o r s i n d e p e n d e n t l y e x t r a c t e d s t u d y d a t a a n d a s s e s s e d t h e q u a l i t y o f a l l i n c l u d e d s t u d i e s . T h e C o c h r a n e R i s k o f B i a s T o o l ( R o B ) [ 6 ] a n d a l s o t h e R i s k o f B i a s t o o l v e r s i o n 2 f o r c l u s t e r -r a n d o m i z e d c o n t r o l l e d t r i a l s ( R o B 2 ) [ 8 ] w e r e u s e d t o a s s e s s t h e q u a l i t y o f s t u d i e s i n c l u d e d i n t h i s r e v i e w . A l l d i s a g r e e m e n t s w e r e r e s o l v e d t h r o u g h c o n s e n s u 1 4 C -R C T s : N u m b e r s o f p a t i e n t s s t u d i e d O f t h e 1 4 c -R C T s , e l e v e n r e p o r t e d t h e n u m b e r o f p a t i e n t s ( t o t a l 3 2 9 , 2 5 4 p a t i e n t s ) , M i t c h e l l [ 2 0 ] r e p o r t e d 3 , 4 3 4 , 4 3 9 o c c u p i e d b e d d a y s b u t n o t p a t i e n t n u m b e r s , B o y c e a l s o r e p o r t e d o n 2 2 , 2 3 1 o c c u p i e d b e d d a y s b u t n o t p a t i e n t s [ 1 4 ] a n d R a y r e p o r t e d b a s i n g t h e p o w e r c o m p u t a t i o n o n 1 , 0 6 8 c a s e s a n d 1 , 6 n t h e p r e v i o u s 1 2 m o n t h s . T h e 1 1 h o s p i t a l s h a d a t o t a l o f 3 1 4 , 8 1 9 p a t i e n t s a n d t h e s e p a t i e n t s w e r e a l s o a s s e s s e d f o r w i d e r c i r c u l a t i o n o f M D R O s . T h e n e w a d m i s s i o n s w e r e r a n d o m i z e d t o r o o m s w h i c h h a d r e c e i v e d o n e o f f o u r d i s i n f e c t i o n s t r a t e g i e s . A f t e r c o m p l e t i o n o f t h e i n t e r v e n t i o n s t o r e d u c e t h e e n v i r o n m e n t a l p r e s e n c e o f t h e t a r g e t M D R O s a n d C . d i f f i c i l e , a p r i m a r y c o m p o s i t e o u t c o m e o f n e w h o s p i t a l -a c q u i r e d c o l o n i s a t i o n o r i n f e c t i o n w i t h t h e s e m i c r o o r g a n i s m s w a s s t u d i e d . T h e l o w e s t r a t e s o f M D R O / C . d i f f i c i l e a c q u i s i t i o n f o r t h e n e w a d m i s s i o n s w e r e a f t e r u s i n g u l t r a v i o l e t l i g h t ( U V ) + q u a t e r n a r y a m m o n i a d e t e r g e n t ( Q U A D ) w i t h 3 3 . 9 c a s e s / 1 0 , 0 0 0 e x p o s u r e d a y s w h i c h w a s s t a t i s t i c a l l y s i g n i f i c a n t r e s u l t ( R R 0 . 7 0 , 9 5 % C I 0 . 5 0 -0 . 9 8 ; p = 0 · 0 3 6 ) c o m p a r e d t o t h e s t a n d a r d c l e a n i n g a r m . C l e a n i n g w i t h b l e a c h r e v e a l e d 4 1 . 6 c a s e s / 1 0 , 0 0 0 e x p o s u r e d a y s , w i t h U V + b l e a c h 4 5 . 6 c a s e s / 1 0 , 0 0 0 e x p o s u r e d a y s a n d t h e n f o r t h e r e f e r e n c e s t u d y a r m ( Q U A D ) 5 1 . 3 c a s e s / 1 0 , 0 0 0 p a t i e n t d a y s . F o r C . d i f f i c i l e i n f e c t i o n a l o n e , f o r b l e a c h a n d f o r U V + b l e a c h , t h e r e w e r e 3 0 . 4 c a s e s a n d 3 1 . 6 / 1 0 , 0 0 0 e x p o s u r e d a y s , r e s p e c t i v e l y . S t a f f h a n d -h y g i e n e c o m p l i a n c e a v e r a g e d 9 0 % , r o o m d i s i n f e c t i o n c o m p l i a n c e 1 0 0 % , a n d p r o t o c o l c o m p l i a n c e w a s Q U A D 1 0 0 % ; a n d i n s t u d y a r m s U V a r m 9 3 % , B l e a c h a r m 9 6 % , B l e a c h + U V a r m 9 9 % ; a n d U V d e v i c e u s e a r m 9 2 % [ Q U A D i s a l s o r e f e r r e d t o a s Q U A T i n s o m e p u b l i c a t i o n s ] ( T a b l e I ) . T h e n e x t l a r g e s t c -R C T ( M i t c h e l l ) w a s c o n d u c t e d i n 1 1 a c u t e c a r e h o s p i t a l s i n A u s t r a l i a . T h e n u m b e r o f p a t i e n t s i n v o l v e d w a s n o t s t a t e d b u t t h e s t u d y i n v o l v e d 3 , 5 3 4 , 4 3 9 o c c u p i e d b e d d a y s . T h e f o c u s w a s o n i n c r e a s i n g c l e a n i n g t h o r o u g h n e s s w i t h t h e R E A C H b u n d l e : u s i n g o p t i m a l c l e a n i n g a g e n t s , f o l l o w i n g m a n u f a c t u r e r s ' r e c o m m e n d a t i o n s , d e f i n e d c l e a n i n g f r e q u e n c y , t r a i n i n g , a u d i t , f e e d b a c k , a n d a h o s p i t a l -w i d e c o m m i t m e n t t o i m p r o v e c l e a n i n g . T h e r e w a s a s i g n i f i c a n t r e d u c t i o n i n t h e p r i m a r y o u t c o m e s o f V R E c l i n i c a l i n f e c t i o n s f r o m 0 . 3 5 / 1 , . c o m p u t a t i o n o n t h a t r e p o r t b u t d i d n o t r e p o r t t r e n d s i n t h e i n s t i t u t i o n s h e s t u d i e d o r t h e r e g i o n [ 2 6 ] . A n d e r s o n d i d n o t r e p o r t t r e n d s i n t h e i r h o s p i t a l r e g i o n b u t i d e n t i f i e d t h a t t h e a d d i t i o n o f U V l i g h t t o s t a n d a r d c h e m i c a l d i s i n f e c t i o n i n t h e r o o m s p r e v i o u s l y o c c u p i e d b y M D R O p a t i e n t s l e d t o a s i g n i f i c a n t r e d u c t i o n i n r i s k f o r t h e o v e r a l l g r o u p o f 1 1 h o s p i t a l s o f a c q u i r i n g C . . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. s u r f a c e s i n p r e d e f i n e d c l u s t e r s u s i n g h o s p i t a l a n d L T C F p a t i e n t r e g i s t r i e s , a n d o u t c o m e s a r e l a b o r a t o r y -c o n f i r m e d i n f e c t i o n s w i t h M D R O s o r H A I s t h e r i s k o f b i a s d u e t o b l i n d i n g w a s r e v i s e d t o l o w F o r a t t r i t i o n e i g h t w e r e a t l o w a n d f o u r a t u n k n o w n r i s k . A l t h o u g h s e v e r a l v e r y l a r g e s t u d i e s h a d a c o n s t a n t t h r o u g h p u t o f p a t i e n t s d u r i n g t h e s t u d y p e r i o d , t h e t r a c k i n g o f p a t i e n t s b y p a t i e n t b e d o c c u p a n c y w h i c h u s e d t h e h o s p i t a l a d m i s s i o n a n d d i s c h a r g e s y s t e m i s l i k e l y t o f i n d a l l p a r t i c i p a n t s . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint 1 1 a p p l i e d d i r e c t l y t o t h e p a t i e n t s ' e n v i r o n m e n t a u t o m a t i c a l l y , a n d i n f o u r t h e i n t e r v e n t i o n s w e r e a p p l i e d t o t h e p a t i e n t s a n d f o l l o w e d P r o t o c o l s w i t h n o r e p o r t e d e x c e p t i o n s , a n d 4 . W e r e p e o p l e d e l i v e r i n g t h e i n t e r v e n t i o n a w a r e o f t h e p a r t i c i p a n t ' s a s s i g n e d i n t e r v e n t i o n d u r i n g t h e t r i a l ? B e c a u s e t h e i n t e r v e n t i o n s u s u a l l y l a s t e d f r o m o n e t o t h r e e y e a r s i t i s l i k e l y t h a t i n t h e f o u r w h e r e i n t e r v e n t i o n s w e r e a p p l i e d d i r e c t l y t o p a t i e n t s b y H C W s t h i s k n o w l e d g e w a s l i k e l y a p p a r e n t t o H C W s a n d c o u l d h a v e b e e n a p p a r e n t t o p a t i e n t s ( A p p e n d i x B ) . . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 23, 2021. ; n r e p o r t e d c o m p l e t e l y e r a d i c a t i n g M D R O s o r H A I s . H o w c l o s e t o z e r o t h e n u m b e r o f c f u s r e m a i n i n g a f t e r d i s i n f e c t i o n s h o u l d b e h a s n o t b e e n d e f i n e d a n d o n l y o n e o f t h e i n c l u d e d s t u d i e s p r o p o s e d a d e f i n i t i o n o f a c l e a n s u r f a c e a t < 2 . h e r e l a t i o n s h i p b e t w e e n t h e d e n s i t y o f c f u s p e r s p e c i f i e d s u r f a c e a r e a a n d t h e r i s k o f i n f e c t i o n i s l i k e l y t o v a r y w i t h t h e p e r f o r m a n c e o f t h e p a t i e n t ' s i m m u n e s y s t a m o u n t a n d f r e q u e n c y o f f e e d b a c k t o c l e a n e r s . N o s t u d y i d e n t i f i e d d i f f e r e n c e s i n e f f e c t i v e n e s s b e t w e e n i n d i v i d u a l c l e a n e r s , t h e e f f e c t o f e d u c a t i o n a l i n t e r v e n t i o n s o r f a c t o r s a s s o c i a t e d w i t h s u p e r i o r c l e a n i n g o u t c o m e s , o r u n d e r s t a n d i n g o f t h e l a n g u a g e u s e d f o r t r a i n i n g , e d u c a t i o n a l m a t e r i a l s a n d f e e d b a c k . T h e r e a r e n o s t u d i e s o f m e r i t p a y f o r s u p e r i o r c l e a n i n g o u t c o m e s . S o m e s t u d i e s c l e a n e d a l l r o o m s , s o m e o n l y k n o w n c o l o n i s e d r o o m s , t h e n u m b e r o f h i g h t o u c h p o i n t s c l e a n e d v a r i e d b e t w e e n s t u d i i d e n t i f i e d a b o v e r e l a t e d t o t h e t y p e s o f s u r f a c e s , c l e a n i n g t e c h n i q u e s a n d t h e i r e f f e c t o n b a c t e r i a l c o n t a m i n a t i o n a n d b i o f i l m s a r e r e s e a r c h g a p s w h i c h n e e d t o b e a d d r e s s e d . T r i a l s i n e c o n o m i e s i n t r a n s m i s s i o n a n d d e v e l o p i n g e c o n o m i e b e t w e e n t h e c o m m u n i t y , h o s p i t a l s a n d L T C F s , ( 4 ) r e p o r t i n g a n t i b i o t i c u s e a n d a n t i b i o t i c s t e w a r d s h i p b e f o r e a n d d u r i n g t h e i n t e r v e n t i o n p e r i o d , a n d ( 5 ) m e a s u r i n g t h e M D R O a n d H A I r a t e s i n E S W a n d o t h e r h e a l t h c a r e s t a f . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted December 23, 2021. ; e r s o n D J , M o e h r i n g R W , W e b e r D J , L e w i s S S , C h e n L F , S c h w a b J C , B e c h e r e r P , B l o c k e r M , T r i p l e t t P F , K n e l s o n L P , L o k h n y g i n a Y , R u t a l a W A , S e x t o n D J f o r t h e C D C P r e v e n t i o n E p i c e n t e r s P r o g r a m . E f f e c t i v e n e s s o f t a r g e t e d e n h a n c e d t e r m i n a l r o o m d i s i n f e c t i o n o n h o s p i t a l -w i d e a c q u i s i t i o n a n d i n f e c t i o n w i t h m u l t i d r u g -r e s i s t a n t o r g a n i s m s a n d C l o s t r i d i u m d i f f i c i l e : a s e c o n d a r y a n a l y s i s o f [ 2 3 ] M o d y L , K r e i n S L , S a i n t S , M i n L C , M o n t o y a A , L a n s i n g B , M c N a m a r a S E , S y m o n s K , F i s c h J , K o o E , R y e R A , G a l e c k i A , K a b e t o M U , F i t z g e r a l d J T , O l m s t e d R N , K a u f f m a n C A , B r a d l e y S F . A t a r g e t e d i n f e c t i o n p r e v e n t i o n i n t e r v e n t i o n i n n u r s i n g h o m e r e s i d e n t s w i t h i n d w e l l i n g d e v i c e s : a r a n d o m i z e d c l i n i c a l t r i a l . J A M A I n t e r n M e d 2 0 1 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted December 23, 2021. ; 1 8 [ 3 6 ] T e m i m e L , C o h e n N , A i t -B o u z i a d K , D e n o r m a n d i e P , D a b W , H o c i n e M N . I m p a c t o f a m u l t i c o m p o n e n t h a n d h y g i e n e r e l a t e d i n t e r v e n t i o n o n t h e i n f e c t i o u s r i s k i n n u r s i n g h o m e s : a c l u s t e r r a n d o m i z e d t r i a l . A m J I n f e c t C o n t r o l 2 0 1 T h e f a c t t h a t a 2 3 % r e d u c t i o n i n t h e h e a l t h c a r e -r e l a t e d o u t c o m e s o n I H P w a r d s w a s n o t s t a t i s t i c a l l y s i g n i f i c a n t m a y h a v e b e e n c a u s e d i n p a r t b y h a v i n g t o e x c l . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint T r a i n i n g : 3 0 i n t e r v e n t i o n s ( 1 0 P P E , h a n d h y g i e n e , e d u c a t i o n , s t e r i l e p r o c e s s e s ; 8 i n t e r v e n t i o n s f o r i m m u n i s a t i o n , h y g i e n e , d a i l y b a t h i . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. P o w e r c o m p u t a t i o n : 8 2 8 p a r t i c i p a n t s f o r 2 5 % r e d u c t i o n i n 2 . 5 y e a r p n e u m o n i a r a t e , a l p h a 0 . 0 5 , p o w e r 8 u p r i g h t p o s i t i o n i n g d u r i n g f e e d i n g c o n t r o l 1 0 0 ( 2 5 % ) ; H R 1 . 0 7 ( . 7 9 t o 1 . 4 6 , P = . 6 5 ) . D a t a S a f e t y a n d M o n i t o r i n g B o a r d t e r m i n a t e d s t u d y f o r f u t i l i t y b e c a u s e c o n d i t i o n a l p o w e b e d r a i l s , d o o r h a n d l e s i n a l l r o o m s c o p p e r p l a t e d a s s o c i a t e d u r i n a r y t r a c t i n f e c t i o n s M i t c h e l l 2 0 1 9 [ 2 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint m i x e d -e f f e c t s m u l t i l e v e l P o i s s o n r e g r e s s i o n m o d e l s u r v e i l l a n c e f o r i n f e c t i o n s , w h e n t o b e g i n a n t i b i o t i c s . D e t e c t i o n : m i c r o b i o l o g i c a l s a m p l e s a l l d e v i c e s i t e s a t b a s e l i n e , d a y 1 5 , m o n t h l y u p t o 1 y e a r N o r e d u c t i o n s i n n e w V R E o r r e s i s t a n t g r a m n e g a t i v e b a c i l l i i n f e c t i o n s o r i n n e w f e e d i n g t u b e a s s o c i a t e d p n e u m o n i a s o . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint m o n t h s c r e e n i n g r e s i d e n t s f o r M R S A ; D e t e c t i o n : c u l t u r e s f r o m n o s t r i l s , g r o i n , u l c e r s a n d u r i n e ( i f p e r m a n e n t c a t h e t e r ) D e t e c t i o n : H A I s a s s e s s e d b y c u l t u r e s A n a l y s i s : G E E d e c o n t a m i n a t i o n : c l o t h e s , l i n e n , b e d , b e d s i d e t a b l e , p h o n e , w a l k i n g a i d , w h e e l c h a i r a r m r e s t s , a n d T V c o n t r o l t o 6 . 6 % ( P = . 0 2 ) ; n o d i f f e r e n c e b e t w e e n a r m f a c i l i t i e s i n 2 0 0 9 D e t e c t i o n : a l l h o s p i t a l s u s e d n u c l e i c a c i d t e s t s f o r d i a g n o s i s ; s a m p l e s f r o m b e d r a i l , t a b l e , c a l l b u t t o n , t e l e p h o n e f o r 3 m o n t h s b e f o r e s t u d y c o m m e n c e d a n d t h e n f o r 1 c u l t u r e s a n d r e m o v a l o f f l u o r e s c e n t m a r k e r s ( 5 s u r f a c e s f o r d a i l y c l e a n i n g , 1 0 s u r f a c e s f o r p o s t -d i s c h a r g e c l e a n i n g i n e a c h h o s p i t a l f o r 1 Equipment/ 3 (assisted living or care home* or convalescence facilit* or convalescence home* or elder* care facilit* or extended care or (home adj3 aged) or (long term adj2 care) or nursing home* or old age facillit* or old age home* or old folks home* or (residential adj2 care) or retirement facilit* or retirement home*).tw,kf. 4 (hospital* or inpatient* or (patient* adj2 room*) or unit or units or ward or wards).tw,kf. 5 1 or 2 or 3 or 4 6 exp Antisepsis/ or Infection control/ or Sterilization/ or Disinfection/ or Disinfectants/ or Decontamination/ or Housekeeping/ 7 (antisepsis or asepsis or aseptic or clean* or decontaminat* or disinfect* or housekeep* or sanitis* or sanitiz*).tw,kf. 8 6 or 7 9 Ultraviolet Rays/ . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint c o r r e l a t i o n o f 0 . 0 1 a n d " B i n a r y o u t c o m e s … w e r e c o m p a r e d u s i n g r a n d o m e f f e c t s m e t a -a n a l y s i s m o d e l s t o c a l c u l a t e p o o l e d r e l a t i v e r i s k s ( 9 5 % c o n f i d e n c e i n t e r v a l s ) a n d P v a l u e s a c c o u n t i n g f o r c l u s t e r i n g w i t h i n h o m e s . " B e l l i n i 2 0 1 5 " T h e s i g n i f i c a n c e o f t h e c h a n g e i n p r e v a l e n c e b e t w e e n b a s e l i n e a n d a f t e r 1 2 m o n t h s w a s a s s e s s e d s e p a r a t e l y w i t h i n e a c h N H g r o u p u s i n g a W i l c o x o n s i g n e d r a n k t e s t . A l t e r n a t i v e l y , w e a n a l y z e d d a t a a t t h e i n d i v i d u a l l e v is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. e t w e e n i n t e r v e n t i o n g r o u p s ? R i s k o f b i a s d u e t o d e v i a t i o n s f r o m i n t e n d e d i n t e r v e n t i o n i n a c -R C T 2 . 1 a W e r e p a r t i c i p a n t s a w a r e t h a t t h e y w e r e i n a t r i a l ? N o d e v i a t i o n s f r o m P r o t o c o l . I n 1 0 c -R C T s t h e i n t e r v e n t i o n w a s a p p l i e d t o t h e p a t i e n t s ' e n v i r o n m e n t a u t o m a t i c a l l y : A n d e r s o n 2 0 1 e r e p o t e n t i a l f o r a s u b s t a n t i a l i m p a c t ( o n t h e r e s u l t ) o f t h e f a i l u r e t o a n a l y s e p a r t i c i p a n t s i n t h e g r o u p t o w h i c h t h e y w e r e r a n d o m i z e i n f e c t i o n s B l i n d i n g o f o u t c o m e a s s e s s m e n t 4 b l i n d e d , 4 n o t b l i n d e d , 6 u n c e r t a i n L o w , c o n s i d e r i n g i n t e r v e n t i o n s w e r e a p p l i e d t o i n d i v i d u a l s i n p r e d e f i n e d c l u s t e r H e r e d i a -R o d r i g u e z ( n = 1 , 0 9 7 ) , J u t h a n i -M e h t a 2 0 1 5 ( n = 8 3 4 ) , L a u t e n b a c h ( n = 1 , 0 2 1 ) . M a r i k 2 0 2 0 ( n = 1 , 2 8 2 ) B a l d w i n 2 0 1 0 ( n = 7 9 3 ) , B e l l i n i 2 0 1 5 ( n = 4 , 7 5 0 ) R a y 2 0 1 7 ( n n o t s t a t e d ; P o w e r c o m p u t a t i o n b a s e d o n 1 , 0 6 8 c a s e s a n d 1 , 6 8 3 , 9 2 8 p a t i e n t d a y s i n f a c i l i t i e s i n 2 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 23, 2021. ; https://doi.org/10.1101/2021.12.22.21268185 doi: medRxiv preprint albone or antiformin or bleach* or chlorine or clorox or copper* or crystacide or dihydrogen dioxide or hydrogen dioxide or hydrogen peroxide or hydrogenperoxide or hydroperoxide or quaternary ammoni* or quaternary bisammoni* or quaternized amine or sodium hypochlorite).tw,kf OVID) 1 nursing home/ or long term care/ or home for the aged/ or exp hospital/ or exp hospital patient/ 2 exp "laboratory and hospital equipment"/ or exp medical device/ 3 (assisted living or care home* or convalescence facilit* or convalescence home* or elder* care facilit* or extended care or (home adj3 aged) or (long term adj2 care) or nursing home* or old age facillit* or old age home* or old folks home* or asepsis/ or antisepsis/ or infection control/ or instrument sterilization/ or exp disinfection/ or disinfection system/ or disinfectant agent/ or decontamination/ or cleaning/ or housekeeping/ 7 (antisepsis or asepsis or aseptic or clean* or decontaminat* or disinfect* or housekeep* or sanitis* or sanitiz*) albone or antiformin or bleach* or chlorine or clorox or copper* or crystacide or dihydrogen dioxide or hydrogen dioxide or hydrogen peroxide or hydrogenperoxide or hydroperoxide or quaternary ammoni* or quaternary bisammoni* or quaternized amine or sodium hypochlorite) or evaluate or evaluating or assessed or assess) and (compare or compared or comparing or comparison)).ab. 24 (open adj label).tw. 25 ((double or single or doubly or singly) adj $ or match or matched or allocation) adj5 (alternate or group$1 or intervention$1 or patient$1 or subject$1 or participant$1)).tw 37 (rat or rats or mouse or mice or swine or porcine or murine or sheep or lambs or pigs or piglets or rabbit or rabbits or cat or cats or dog or dogs or cattle or bovine or monkey or monkeys or trout or marmoset$1).ti. and animal experiment EBM Reviews -Cochrane Central Register of Controlled Trials exp Nursing Homes/ or Long-Term Care/ or Homes for the Aged/ or Assisted Living Facilities/ or exp Hospitals/ or Adolescent Hospital/ or exp Surgical Equipment/ 3 (assisted living or care home* or convalescence facilit* or convalescence home* or elder* care facilit* or extended care or (home adj3 aged) or (long term adj2 care) or nursing home* or old age facillit* or old age home* or old folks home* or (residential adj2 care) or retirement facilit* or retirement home*).tw 4 (hospital* or inpatient* or Antisepsis/ or Infection control/ or Sterilization/ or Disinfection/ or Disinfectants/ or Decontamination/ or Housekeeping antisepsis or asepsis or aseptic or clean* or decontaminat* or disinfect* or housekeep* or sanitis* or sanitiz*).albone or antiformin or bleach* or chlorine or clorox or copper* or crystacide or dihydrogen dioxide or hydrogen dioxide or hydrogen peroxide or hydrogenperoxide or hydroperoxide or quaternary ammoni* or quaternary bisammoni* or quaternized amine or sodium hypochlorite) Hospital Units+") OR (MH "Patients' Rooms+") OR (MH "Emergency Service+") OR (MH "Inpatients") OR (MH "Aged, Hospitalized") OR (MH "Adolescent, Hospitalized") OR (MH "Infant, Hospitalized") OR (MH "Child, Hospitalized") OR (MH "Ancillary Services, Hospital") OR (MH "Residential Facilities") ) OR TI ( (assisted living or care home* or convalescence facilit* or convalescence home* or elder* care facilit* or extended care or (home N3 aged) or (long term N2 care) or nursing home* or old age facillit* or old age home* or old folks home* or (residential N2 care) or retirement facilit* or or retirement home*) ) OR AB ( (assisted living or care home* or convalescence facilit* or convalescence home* or elder* care facilit* or extended care or (home N3 aged) or (long term N2 care) or nursing home* or old age facillit* or old age home* or old folks home* or (residential N2 care) or retirement facilit* or or retirement home*) ) OR TI ( (hospital* or inpatient* or unit or units or Housekeeping Department") OR (MH "Cleaning Compounds") ) OR TI ( (antisepsis or asepsis or aseptic or clean* or decontaminat* or disinfect* or housekeep* or sanitis* or sanitiz*) ) OR AB ( (asepsis or aseptic or clean* or decontaminat* or disinfect* or housekeep* or sanitis Hydrogen Peroxide") OR (MH "Quaternary Ammonium Compounds+") OR (MH "Copper") ) OR TI ( (albone or antiformin or bleach* or chlorine or clorox or copper* or crystacide or dihydrogen dioxide or hydrogen dioxide or hydrogen peroxide or hydrogenperoxide or hydroperoxide or quaternary ammoni* or quaternary bisammoni* or quaternized amine or sodium hypochlorite) ) OR AB ( (albone or antiformin or bleach* or chlorine or clorox or copper* or crystacide or dihydrogen dioxide or hydrogen dioxide or hydrogen peroxide or hydrogenperoxide or hydroperoxide or quaternary ammoni* or Single-Blind Studies") OR (MH "Triple-Blind Studies") OR (MH "Double-Blind Studies") OR (MH "Random Assignment") OR (MH "Pretest-Posttest Design+") OR (MH "Cluster Sample") OR (MH "Placebos") OR (MH "Crossover Design") OR (MH Sample Size") AND AB ( (assigned OR allocated OR control) ) TI ( (randomised OR randomized or trial) ) OR AB (random*) AB (control W5 group) OR AB (cluster W3 RCT) d i v i d u a l p a r t i c i p a n t s i d e n t i f i e d a n d r e c r u i t e d ( i f a p p r o p r i a t e ) b e f o r e r a n d o m i z a t i o n o f c l u s t e r s ? I n a l l 1 4 c -R C T s t h e p a r t i c i p a n t s w e r e i d e n t i f i e d a n d r e c r u i t e d b e f o r e r a n d o m i z a t i o n . B a l d w i n 2 0 1 0 " m a t c h e d a n d p a i r e d n u r s i n g