CLEAN CURTAINS SAVE LIVES
Hospital acquired infections (HAIs)
Hospital acquired infections (HAIs), also known as healthcare-associated infections (HCAIs) or nosocomial infections; refer to infections that are contracted in the hospital or healthcare environment within 48-72 hours of admission. They are the most frequent adverse events in the delivery of care worldwide and are a leading cause of death in the developed world. It is estimated that in the US and UK alone, HAIs contribute to approximately 100,000 and 20,000 deaths each year, respectively [Klevens et al. 2002; National Audit Office, 2009].
Despite significant advances in both technology and practice over the past decade, hospital cleanliness and environmental disinfection remain key battlegrounds in the fight against healthcare-associated infections. The high density and turnover of patients, coupled with increasing reliance on antibiotics, provides a unique challenge to infection prevention as a growing number of HCAIs are caused by drug- and multi-drug resistant (MDR) pathogens. The rate at which pathogens are developing resistance outpaces the rate at which new antibiotics are being discovered and in an age in which many existing antibiotics are completely ineffective against MDR ‘superbugs’, there is a concern that medicine is on the cusp of a post-antibiotic era. This is of particular concern for infection preventionist’s who are increasingly challenged in effectively controlling and treating the spread of drug-resistant infections.
Environmental contamination and privacy curtains
Figure 1: The average reported percentage of environmental sites contaminated in both endemic and outbreak scenarios. These were collected from various studies. The highest proportion of contamination is found on bedlinen (41%), overbed tables (40%), and privacy curtains.
Hospital surfaces are rapidly contaminated with pathogenic microorganisms, and environmental contamination is often the root cause of HAIs [Chemaly et al. 2014]. Touchpoint surfaces that are routinely touched by staff, patients and visitors have consistently been shown to be a source of cross-contamination in and around the patient-environment [Cheng et al. 2015]. Microbes can survive on these surfaces for months or years at a time if they are not regularly cleaned [Otter and Galletly, 2018].
Privacy curtains are one of the most frequently touched surfaces in the near-patient environment and are readily contaminated with microorganisms, acting as a vector in the transmission of HAIs. Healthcare professionals and patients often touch privacy curtains before, during and after care encounters. Furthermore, pathogens survive on non-disinfectant surfaces for long periods of time, as detailed in Table 1 [Havill et al. 2014; Kramer et al. 2006; Stiefel et al. 2011]. While hand hygiene is widely acknowledged to be a cornerstone of good infection prevention practice, compliance is a notorious issue as protocols are often not always fully observed. In one study hospital staff failed to follow procedure in 60% of their interactions with the patient and patient environment [Carling and Bartley 2010].
Despite these issues, privacy curtains often remain ignored as a threat to patient safety. Leading infection prevention and control practitioners are urgently seeking new tools to improve hospital hygiene and must utilize every innovation available to effectively sanitize the hospital environment and protect patients from unnecessarily contracting HAIs.
|Table 1: Survival time of pathogens on non-disinfectant surfaces|
|Microorganism||Duration of persistence (extreme ranges)|
|Carbapenem-resistant Acinetobacter Baumanii||Up to 5 months|
|Clostridium difficile (spore)||Up to 5 months|
|Escherichia coli||Up to 16 months|
|Vancomycin-resistant Enterococcus (VRE)||Up to 4 months|
|Methicillin-resistant Staphylococcus aureus (MRSA)||Up to 7 months|
|Pseudomonas aeruginosa||Up to 16 months|
|Streptococcus||Up to 6 months|
|Klebsiella pneumoniae||Up to 30 months|
Patient Privacy Curtains and Infection Transmission
Although now seldom seen in UK healthcare facilities, linen privacy curtains are still used in a large proportion of hospital wards worldwide even though it has long been established that they are quickly and heavily contaminated with pathogens [Ohl et al. 2012]. Linen curtains are soft and absorbent, acting as fomites in which organisms can grow and multiply. This is particularly problematic for infection prevention. In fact, in one study, after just one week of hanging, 92% of curtains were found to be contaminated by various pathogens [Ohl et al. 2012]. Other studies have shown that microorganisms on linen privacy curtains, including MRSA and C. difficile, transfer onto healthcare workers’ hands [Trillis et al. 2008]. Linen curtains were found to be the major source of infection in an outbreak of Carbapenem-resistant Acinetobacter [Das et al. 2002] and were also identified as a key factor in a Group A Streptococcus outbreak [Mahida et al. 2014]. Regular cleaning of linen hospital curtains is logistically challenging [Klakus et al. 2008], and they are also at risk from contaminants found in the laundry process itself [DeAngelis et al. 2013; Duffy et al. 2014; Hosein et al. 2013; Sehulster 2015].
Disposable privacy curtains manufactured from non-woven fabrics are generally considered a more hygienic alternative to their traditional equivalents. The polymeric surface (usually made of polypropylene) is unable to harbor as heavy a pathogenic load as the woven fabric found in linen curtains. However, it is a common misconception that polypropylene disposable curtains remain clean and hygienic during use. Woven fabrics become visibly dirty more quickly than non-woven on high-touchpoint areas. The false assumption that disposable curtains remain clean often leads to hazardously infrequent changing. In fact, testing of standard disposable curtains shows that they are just as susceptible to contamination with pathogenic microorganisms as linen curtains.
Disinfectant Disposable Curtains
Due to the rapid contamination of both linen and standard disposable privacy curtains, many infection prevention practitioners have instead opted to use disinfectant disposable curtains. These are manufactured using non-woven polypropylene and treated with an agent that has antimicrobial properties. For a disinfectant disposable curtain to reduce contamination and, consequently, the transmission of healthcare-associated infections within a hospital, it must offer rapid, long-lasting and potent efficacy against a broad spectrum of harmful pathogens.
Linen, untreated disposable, and antimicrobial disposable curtains were tested for contaminants to examine the impact of Fantex® on reducing contamination on the disinfectant curtains:
Disinfectant Curtains vs. Linen Curtains
Linen and Fantex® disinfectant curtains from a busy inner-city hospital were sampled for contaminants. An average of 30 CFUs/paddle were observed for the linen curtains tested. Identification of the organisms ranged from CNS Staphylococcus species, S. aureus including MRSA, several colonies of mold, and several Gram negatives. Disinfectant curtains showed no measurable contamination after 6 months of usage. Out of the 67 disinfectant curtains tested, only 1 colony of Staphylococcus species was observed. A further 40 curtains from the Emergency Room and ICU were tested and only 1 unidentified bacterial colony was observed.
Disinfectant Curtains vs Untreated Disposable Curtains
Fantex® disinfectant curtains and untreated disposable curtains were removed from the ICU of Barnet Hospital (UK) after 4 months of hanging for comparative contamination testing by an independent accredited laboratory (MGS Laboratories Ltd). As demonstrated in Figure 2, there was no contamination emanating from the sampled Fantex® disinfectant curtain fabric; whereas the standard disposable curtains carried a considerable microbial load (Figure 2).
Figure 2: Curtain contamination analysis of non-antimicrobial polypropylene disposable curtains (1 and 2) and Fantex® Disinfectant Curtain (3) recovered from a hospital after 4 months of hanging. Untreated disposable curtains show moderate to heavy contamination of bacteria (cultured on TSA) and fungi (cultured on SDA) emanating from the fabric of sampled.
Fantex® Disinfectant Curtains Vs Antimicrobial Disposable Curtains
A disposable curtain incorporating silver-based antimicrobial agent from a competitor was obtained and tested to ISO 20645 alongside Fantex® fabric by an independent laboratory as set out in Table 2. The manufacturer of silver incorporated curtains claims log 2 efficacy against a non-specific microorganism over a 24-hour contact time. However, the test microorganisms grew vigorously in contact with the silver-incorporated fabric samples, failing to support the manufacturer’s efficacy claims. In contrast, the Fantex® fabric demonstrated ‘good effect’ against pathogens in contact with the sample and in the surrounding environment (illustrated by the zone of inhibition) (Table 2).
|Table 2: Determination of antibacterial activity according to BS EN ISO 20645 agar diffusion plate test|
|Pathogen||Fantex® Curtain||Competitor Siliver-based Curtain|
|MRSA||Clear zone of inhibition||Heavy growth under fabric|
|Escherichia coli||Clear zone of inhibition||Moderate growth under fabric|
|Aspergillus brasiliensis||Clear zone of inhibition||Heavy growth under fabric|
|Candida albicans||Clear zone of inhibition||Heavy growth under fabric|
|Result||Good Effect||Insufficient Effect|
Fingertip Transmission of Contaminants
To replicate the transfer of contaminants from curtains to fingertips, microbiological analysis of gloved fingertips was conducted after handling curtain fabric inoculated with S. aureus. The level of bacterial contamination applied to the curtains is typical of that observed on visibly clean hands. The difference in the level of contaminants transferred to fingertips after interaction with treated and untreated curtain fabric was also examined.
There was a dramatic decrease in the number of CFUs on the plates where gloved hands interacted with Fantex® -treated fabric when compared to those which interacted with untreated control fabric (Figure 3). The test was repeated 3 times with 3 different volunteers and the same results were obtained for each repeat. Figure 3 shows a typical example of the results observed. In addition, further analysis demonstrated that, on gloved fingertips, a Log >4.7 reduction was achieved after interaction with Fantex® -coated fabric when compared to the untreated control fabric.
These results demonstrate that micro-organisms present on curtains can be transferred to the fingertips of those interacting with untreated curtains, but not to the fingertips of those interacting with disinfectant curtains (with zero CFUs resulting from interaction with disinfectant-coated fabric).
Figure 3: Fingertip Transmission of Contaminants via Curtain Fabric inoculated with S. aureus. Colonies of S. aureus transferred onto gloved fingertips after interaction with untreated polypropylene fabric (1) and Fantex® -coated polypropylene fabric (2). Many colonies of S. aureus were transferred onto the fingertips of gloves that handled untreated polypropylene, whereas only a single colony of S. aureus was found on fingertips of gloves that handled Fantex® coated fabric.
The Impact of Privacy Curtains on HAI Incidence in UK Hospitals
Surveillance reporting data on the incidence of MRSA, MSSA and C. difficile infections in UK hospitals from Public Health England (PHE) was used to perform a comparison of HAI incidence reported by hospitals that had adopted Fantex® disinfectant curtains, versus non-intervention hospitals using linen, plain disposable or other antimicrobial disposable curtains (n=32). The NHS trust-apportioned reports detailing the number of infections were analyzed for both the 12 months prior- and post–intervention with Fantex® HAI Prevention Curtains. As a control, the infection incidence data for non-intervention hospitals (non-adopters of Fantex® HAI Prevention Curtains) were also analyzed over the same time period.
85% of the hospitals that adopted disinfectant privacy curtains observed a reduction in HAIs during the 12 months post-intervention. Of these hospitals, the median average reduction in HAI incidence reported within the first year of intervention was 20.1%. Overall, a median average of 94 HAI cases per hospital were recorded in the year prior to the introduction of disinfectant curtains, decreasing to 78 HAIs in the year following their installation (Figure 4).
The significance of the 20.1% decrease in infection incidence reported by hospitals that implemented disinfectant curtains can be better contextualized when compared with the baseline reduction registered at hospitals without the intervention over the same period. The median reduction in infection incidence reported by hospitals within the non- intervention group was just 0.7% — a 28-fold lower reduction than reported by the intervention group hospitals that adopted disinfectant curtains (Figure 5).
Figure 4: Comparison chart of the number of reported HAI cases in UK hospitals using Fantex® disinfectant curtains before (marked as black) and one year after introduction (marked as blue).
Figure 5: Comparison of the median HAI reduction (in one year) between hospitals using Fantex® technology (marked as blue) vs hospitals that had not implemented this technology (marked as black).
Changing linen or standard disposable curtains on a weekly basis is not a practical or cost-effective option and may contribute to the current compromise between protecting privacy and patient safety. The data shown in this study indicates that disinfectant curtains with residual efficacy (≥Log 3 within 1 minute) effectively maintain patient dignity while reducing the environmental contamination associated with increased nosocomial infection incidence. In the absence of credible efficacy data that is compliant with international testing standards, any other curtain alternative – whether linen, plain disposable, or antimicrobial disposable – should be considered as high risk in relation to patient safety.
Considering the impending AMR crisis, these data warrant the consideration of IP&C practitioners engaged in modernizing infection control programs to effectively sanitize the hospital environment and protect patients from drug- and multi-drug resistant pathogens.
- Carling, P. C. and Bartley, J. M. (2010). ‘Evaluating hygienic cleaning in healthcare settings: What you do not know can harm your patients’. American Journal of Infection Control, 38 (5), S41-S50. < https://www.ajicjournal.org/article/S0196-6553(10)00406-2/abstract?code=ymic-site >
- Chemaly, R. F., Simmons, S., Dale, C., Ghantoii, S.S., Rodriguez, M., Gubb, J., Stachowiak, J., Stibich, M. (2014), ‘The role of the healthcare environment in the spread of multidrug-resistant organisms: Update on current best practices for containment’, Therapeutic Advances in Infectious Disease, 2 (3-4), 79-90. < http://journals.sagepub.com/doi/abs/10.1177/2049936114543287 >
- Cheng, V. C. C., et al. (2015). ‘Hand-touch contact assessment of high -touch and mutual-touch surfaces among healthcare workers, patients, and visitors’. Journal of Hospital Infection, 90 (3), 220-25. < hyperlink not available >
- Klevens, R.M., Edwards, J.R., Richards, C.L., Horan, T.C., Gaynes, R.P., Pollock, D.A., Cardo, D.M. (2002). ‘Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002’. Public Health Reports, 122, 160-166. < http://journals.sagepub.com/doi/abs/10.1177/003335490712200205 >
- Das, I., Lambert, P., Hill, D., Noy, M., Bion, J., Elliot, T. (2002). ‘Carbapenem-resistant acinetobacter and role of curtains in an outbreak in intensive care units’. Journal of Hospital Infection, 50 (2), 110-14. < https://www.journalofhospitalinfection.com/article/S0195-6701(01)91127-2/pdf >
- DeAngelis, D. L., Khakoo, R., DeAngelis, D. L. (2013). ‘Hospital privacy curtains: cleaning and changing policies – Are we doing enough?’. American Journal of Infection Control, 41 (6), S33. < https://www.ajicjournal.org/article/S0196-6553(13)00359-3/abstract >
- Duffy J., Harris, J., Gade, L., Sehulster, L., Newhouse, E., O’Connell, H., Noble-Wang, J., Rao, C., Balajee, S.A., Chiller, T. (2014). ‘Mucormycosis outbreak associated with hospital linens’. The Pediatric Infectious Disease Journal, 33, 472–6. < https://journals.lww.com/pidj/Abstract/2014/05000/Mucormycosis_Outbreak_Associated_With_Hospital.9.aspx>
- Havill, N. L., Boyce, J. M., and Otter, J. A. (2014). ‘Extended survival of Carbapenem-resistant enterobacteriaceae on dry surfaces’. Infection Control & Hospital Epidemiology, 35 (4), 445-47. < https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/extended-survival-of-carbapenemresistant-enterobacteriaceae-on-dry-surfaces/E6AE3F0FDA52473EDB8F04603C06325E >
- Hosein I.K., Hoffman, P.N., Ellam, S., Asseez, T.M., Fakokunde, A., Silles, J., Devereux, E., Kaur, D., Bosanquet, J. (2015). ‘Summertime Bacillus cereus colonization of hospital newborns traced to contaminated, laundered linen’. Journal of Hospital Infection, 85, 149–54. < https://www.sciencedirect.com/science/article/pii/S019567011300217X >
- Klakus, J., Vaughan, N. L., Boswell, T. C. (2008). ‘Meticillin- resistant Staphylococcus aureus contamination of hospital curtains’. Journal of Hospital Infection, 68 (2), 189-90. < https://www.journalofhospitalinfection.com/article/S0195-6701(07)00421-5/abstract?code=yjhin-site >
- Kramer, A., Schwebke, I., and Kampf, G. (2006). ‘How long do nosocomial pathogens persist on inanimate surfaces? A systematic review’. BMC Infectious Diseases, 6, 130-30. < https://bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-6-130 >
- Mahida, N., Beal, A., Trigg, D., Vaughan, N., Boswell, T. (2014). ‘Outbreak of invasive group A streptococcus infection: contaminated patient curtains and cross-infection on an ear, nose and throat ward’. Journal of Hospital Infection, 87 (3), 141-44. < https://www.ncbi.nlm.nih.gov/pubmed/24928787 >
- National Audit Office (2000), ‘The management and control of hospital acquired infection in acute NHS trusts in england’, (London: House of Commons). < https://www.nao.org.uk/report/the-management-and-control-of-hospital-acquired-infection-in-acute-nhs-trusts-in-england/ >
- Ohl, M., Schweizer, M., Graham, M., Heilmann, K., Boyken, L., Diekema, D. (2012). ‘Hospital privacy curtains are frequently and rapidly contaminated with potentially pathogenic bacteria’. American Journal of Infection Control, 40 (10), 904-06. < https://www.ncbi.nlm.nih.gov/pubmed/22464039 >
- Otter, J., Galletly, T. (2018). Environmental decontamination 1: what is it and why is it important? Nursing Times. 114: 7, 32-34. < https://www.nursingtimes.net/clinical-archive/infection-control/environmental-decontamination-part-1-what-is-it-and-why-is-it-important/7025083.article >
- Sehulster L.M. (2015). ‘Healthcare laundry and textiles in the united states: Review and commentary on contemporary infection prevention issues’. Infection Control & Hospital Epidemiology, 36, 1073–88. < https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/healthcare-laundry-and-textiles-in-the-united-states-review-and-commentary-on-contemporary-infection-prevention-issues/B7147B34277B774EBF8D9A902AD7E83E >
- Stiefel, U., Cadnum, J.L., Eckstein, B.C., Guerrero, D.M., Tima, M.A., Donskey, C.J. (2011). ‘Contamination of hands with methicillin- resistant Staphylococcus aureus after contact with environmental surfaces and after contact with the skin of colonized patients’. Infection Control & Hospital Epidemiology, 32 (2), 185-87. < https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/contamination-of-hands-with-methicillinresistant-staphylococcus-aureus-after-contact-with-environmental-surfaces-and-after-contact-with-the-skin-of-colonized-patients/AC937E27A497104A1F3C6BBB98C64D98 >
- Trillis, F., Eckstein, E.C., Budavich, R., Pultz, M.J., Donskey, C.J. (2008). ‘Contamination of hospital curtains with healthcare-associated pathogens’. Infection Control & Hospital Epidemiology, 29 (11), 1074-76. < https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/contamination-of-hospital-curtains-with-healthcareassociated-pathogens/DBAFCC4113820461B62311BC211FC8E5 >
- World Health Organization (2017). ‘Health care-associated infections: Fact sheet’. 1-4. <http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf>, accessed 27 June, 2018.