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Survival of Microorganisms on Inanimate Surfaces

Survival of Microorganisms on Inanimate Surfaces Chapter 2 Survival of Microorganisms on Inanimate Surfaces Axel Kramer and Ojan Assadian Contents 2.1 Introduction ................................................................................. 8 2.2 The Role of Surfaces in the Transmission of Pathogenic Microorganisms Causing Healthcare-Acquired Infections (HAI) ..................................................... 9 2.3 Persistence of Microorganisms on Inanimate Surfaces ................................... 10 2.3.1 Persistence of Bacteria ............................................................. 11 2.3.2 Persistence of Viruses .............................................................. 11 2.3.3 Persistence of Fungi ................................................................ 13 2.3.4 Persistence of Other Pathogenic Microorganisms ................................. 15 2.3.5 Factors Influencing the Survival of Microorganisms in the Environment ....... 15 2.3.6 Limitations on the Knowledge of Microbial Survival on Inanimate Surfaces . . . 17 2.4 Mechanisms of Transmission from Inanimate Surfaces to Susceptible Patients and Consequences Thereof ................................................................. 18 References ........................................................................................ 19 Abstract In healthcare settings microbial contaminated surfaces play an important role in indirect transmission of infection. Especially surfaces close to the patients’ environment may be touched at high frequencies, allowing transmission from animated sources to others via contaminated inanimate surfaces. Therefore, the knowledge on the survival of bacteria, fungi, viruses and protozoa on surfaces, and hence, in a broader sense, in the human environment, is important for implementing tactics for prevention of Healthcare-acquired Infections (HAI). A. Kramer, M.D., Ph.D. Institute of Hygiene and Environmental Medicine, Universita¨tsmedizin Greifswald, Ernst-Moritz-Arndt University Greifswald, Walther-Rathenau-Str. 49A, 17485 Greifswald, Germany e-mail: kramer@uni-greifswald.de O. Assadian, M.D., DTMH (*) Department for Hospital Hygiene and Infection Control, Medical University of Vienna, Wa¨hringer Guertel 18-20, 1090 Vienna, Austria e-mail: ojan.assadian@meduniwien.ac.at G. Borkow (ed.), Use of Biocidal Surfaces for Reduction of Healthcare 7 Acquired Infections, DOI 10.1007/978-3-319-08057-4_2, © Springer International Publishing Switzerland 2014 8 A. Kramer and O. Assadian This chapter will elaborate the role of surfaces in the transmission of pathogens. Particular emphasis is laid on the current knowledge of the survival time and conditions favouring survival of the pathogens. Finally, mechanisms of transmis- sion from inanimate surfaces to patients are highlighted. Within the multi-barrier strategy of the prevention of HAI, environmental disinfection policies should be based on risk assessments for surfaces with different risks for cross contamination such as high- and low-touched surfaces with appro- priate standards for adequate disinfection measures under consideration of the persistence and infectious dose of the pathogens. As a result, surface disinfection is indicated in the following situations: – Frequently touched surfaces adjacent to patients – Surfaces with assumed or visible contamination – Terminal disinfection in rooms or areas where infected or colonized patients with easily transferable nosocomial pathogens are cared for, and – in outbreak situations. Furthermore, the knowledge of the persistence of pathogens will also support ensuring the biosafety in microbiological and biomedical laboratories, food- handling settings, and for hygienic behaviour in the everyday life to prevent transmission of infectious diseases. Keywords Persistence • Bacteria • Fungi • Viruses • Protozoa transmission mechanisms • Surface disinfection List of Abbreviations HAI Healthcare-acquired infections MRSA Methicillin-resistant Staphylococcus aureus MSSA Methicillin-sensible Staphylococcus aureus RH Relative humidity SARS Severe acute respiratory syndrome VRE Vancomycin-resistant enterococci 2.1 Introduction Microorganisms may be transmitted from animated sources to inanimate environ- mental sources, which may become secondary reservoirs if they meet the needs of transmitted pathogens to survive and to multiply. In healthcare settings, however, contaminated surfaces, which may not always be optimal for microbial survival and multiplication, still may play a role in the chain of infection, since surfaces close to the patients’ environment may be touched at high frequencies, allowing transmis- sion from animated sources to others via contaminated inanimate surfaces. 2 Survival of Microorganisms on Inanimate Surfaces 9 Because of this, the knowledge on the survival of bacteria, fungi, viruses and protozoa on surfaces, and hence, in a broader sense, in the human environment, is important for planning and implementing tactics for prevention of Healthcare-acquired Infections (HAI). Furthermore, such knowledge will also assist ensuring the biosafety in microbiological and biomedical laboratories, food-handling settings, and for hygienic behaviour in the everyday life to prevent transmission of infectious diseases. One example of microorganisms with relatively short ability of persisting in the environment is the severe acute respiratory syndrome (SARS) coronavirus (CoV), which became pandemic within months in China in 2002. This virus retains infectivity on different substrates up to 9 days, as compared to the influenza virus, which demonstrates a relatively long persistence in the environment up to 4 weeks [112]. Both viruses are airborne transmitted infectious agents, however, they may also be transmitted via hand-surface contacts, supporting the relevance of hand hygiene and personal protection against infection. Because of a number of microorganisms’ ability to persist and survive for long- term periods on surfaces, particularly in healthcare settings, the usage of antimicrobially impregnated surfaces is increasingly discussed [82]. However, because of the required long contact times of microorganisms on antimicrobial surfaces [64, 65, 25, 45], such technologies may be useful for surfaces with low frequency of hand contacts. 2.2 The Role of Surfaces in the Transmission of Pathogenic Microorganisms Causing Healthcare-Acquired Infections (HAI) In healthcare settings, bacteria, bacterial spores, viruses and yeasts are mainly transmitted from infected and/or colonized patients, but also from staff, and in some situations from visitors to the inanimate hospital environment, particularly to areas adjacent to patients and frequently touched surfaces by hands (“high-touch surfaces”). Potential pathogenic microbial flora of the respiratory tract and of the vestibulum nasi, such as methicillin- sensible (MSSA) or resistant Staphylococcus aureus (MRSA), is correlated with a higher risk of contamination of surrounding surfaces through direct or indirect contact with hands [81]. Intestinal infections caused i.e. by Clostridium difficile and Norovirus, or enteral colonization with nosocomial pathogens such as vancomycin-resistant enterococci (VRE) may also be associated with a risk of widespread environmental contamination [30]. Compared with the large number of published literature on environmental contamination with MRSA, VRE, and C. difficile, there are relatively few published studies on environ- mental contamination by Gram-negative bacteria [64, 65]. Aside of a possible publication bias in the past, one reason for this is the different ability of Gram- positive and Gram-negative bacteria to survive in the inanimate environment. The level of microbial bio-burden on surface in healthcare settings is low compared to the numbers on patients’ skin or in faeces. However, even at low particle numbers 10 A. Kramer and O. Assadian Table 2.1 Infectious doses for selected pathogens Infectious dose Organisms Reference (1)-10–100 Norovirus, Rotavirus, EHEC, Ward et al. [122], Paton and Paton [88], Pang viable ETEC, C. difficile, Enterococci et al. [85], Lawley et al. [68], Porter particles incl. VRE et al. [92], Yezli and Otter [130], Robine et al. [97] 1 viable Oocysts of cryptosporidia Chappell et al. [17] particle in water >10 viable Salmonella enteritidis Craven et al. [24] particles there is a risk of transmission (Table 2.1). In immuno-compromised patients, the required numbers of microorganisms for causing infectious diseases is even lower, increasing the risk of HAI in these populations. Inanimate surfaces have been described as source for HAI-outbreaks. Hayden et al. [49] demonstrated that touching the environment contaminated with relatively low pathogen concentrations in a room occupied by a patient colonized with VRE is associated with approximately the same risk of VRE acquisition on hands as touching an affected patient directly. Evidence of the importance of environmental transmission is further provided by studies showing an increased risk of infection in patients admitted to the same rooms previously occupied by other infected/colonised cases. This has been shown for C. difficile [101], VRE and MRSA ([54, 55], and also own observations). Environmental Norovirus contamination has been repeatedly found to be correlated with continuing outbreaks [128], although the significance of this pathway has not been fully elucidated. The importance of surface contamination is also shown by reduction in the rate of HAI when effective measures of environmental disinfection are implemented [50, 10, 26]. A recent observational study showed a significant reduction in C. difficile infection rates following the introduction of sporicidal wipes in an environmental cleaning regimen in an acute London trust [16]. However, not all studies have shown a direct link between surface disinfection and reduction in infection rates, probably because of the complex interactions and transmission routes in the clinical practice. Yet, in summary it is undisputed that contaminated surfaces may contribute to the transmission of pathogens and may thus pose a critical element in the chain of transmission of microorganisms [41]. 2.3 Persistence of Microorganisms on Inanimate Surfaces The risk for transmission of HAI depends of the persistence of nosocomial pathogens on surfaces. The longer a microorganism may persist on a surface, the longer the contaminated surface may be a source of transmission and thus endanger a susceptible patient or healthcare worker of becoming the target of infection. In order to estimate the risk of cross contamination, Kramer et al. [64, 65] have published a systematic review on persistence of pathogens on surfaces. 2 Survival of Microorganisms on Inanimate Surfaces 11 The following findings are based on this review; however, knowledge on persistence of microorganisms on inanimate surfaces is now expanded by addi- tional findings published after 2005/2006. 2.3.1 Persistence of Bacteria In most reports, persistence was studied on dry surfaces using artificial contamina- tion of a standardized type of surface in a laboratory. Bacteria were prepared in broth, water or saline. Most Gram-positive bacteria, such as Enterococcus spp. including VRE, S. aureus including MRSA, or Streptococcus pyogenes survive for months on dry surfaces (Table 2.2). In general, there is no observable difference in survival between multi-resistant and susceptible strains of S. aureus and Enterococcus spp. [78]. Only in one study [118] a difference of survival time between antibiotic resistant and susceptible bacteria was suggested, yet, the susceptible strains dem- onstrated only a non-significant shorter survival time on surfaces. The factors why the same bacteria may persist more or less on a surface (i.e. from hours to days as detailed in Table 2.2) will be discussed later in Sect. 2.3.5. Many Gram-negative species, such as Acinetobacter spp., Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, Serratia marcescens,or Shigella spp. can survive on inanimate surfaces even for months (Table 2.2). These species are found among the most frequent isolates from patients with HAI [64, 65]. However, a few others Gram-negative bacteria, such as Bordetella pertussis, Haemophilus influenzae, Proteus vulgaris,or Vibrio cholera persist only for days (Table 2.2). Mycobacteria, including Mycobacterium tuberculosis, and spore-forming bac- teria, such as C. difficile, can survive for many months on surfaces (Table 2.2). Because paper still is omnipresent in healthcare settings worldwide today, Hu¨bner et al. [56] have analysed the persistence of various Gram-positive and Gram-negative bacteria including E. coli, S. aureus, P. aeruginosa, and Enterococ- cus hirae on office paper after contamination with standardised inocula of bacterial suspensions in the range of 2.8 10 cfu/mL. Opposite to E. coli, all other organ- isms were more stabile at room conditions and were reduced on paper only by 3 log after 7 days, whereas E. coli was reduced by 5 log within 10 10 24 h. Furthermore, the transmissibility of bacteria from hands to paper and back could be demonstrated for all bacteria strains. Similar investigations showed that paper money notes could harbour and transmit pathogens [62, 111, 115]. 2.3.2 Persistence of Viruses In order to estimate the persistence of viruses on inanimate surfaces, usually cell culture media are prepared [64, 65]. Most viruses from the respiratory tract such as Corona-, Coxsackie-, or Influenza virus, SARS, or rhinovirus can persist on surfaces 12 A. Kramer and O. Assadian Table 2.2 Published data on survival of nosocomial and community acquired pathogens on various inanimate surfaces Range of survival Organism (environment) Reference Acinetobacter spp. 3 days to 1 year (in-vitro) Wagenvoort and Joosten [117], Espinal et al. [36] 36 days within biofilm vs. 15 days for non-biofilm-forming strains Bordetella pertussis 3to >10 days; in pernasal Hunter [57], Walther and Ewald swabs: >4 days [121] Campylobacter jejuni >6 days, in water Gonza´lez and Ha¨nninen [44] >60 days Clostridium difficile 5 months Weber et al. [123] spores C. difficile, vegetative 15 min (dry surface) form 6 h (moist surface) Chlamydia pneumoniae 96 h Fukumoto et al. [40], Haider et al. [51], Matsuo et al. [70] C. trachomatis <1 week Chlamydia psittaci 15 days to months Wendel [125] (environment) Corynebacterium 7 days to 6 months Walther and Ewald [121] diphtheriae Corynebacterium 1–8 days, up to several Yeruham et al. [129] , pseudotuberculosis weeks (environment) Dorella et al. [31] Enterococcus spp. 5 days up to 30 months Robine et al. [97], Wagenvoort including VRE et al. [116] Escherichia coli 1.5 h to 16 months Guan and Holley [46], Erickson et al. [35], Chauret [19] , E. coli O157:H7 27 days on spinach leaves, Duffitt et al. [33] 179 days in soil, 98 days in water Haemophilus influenzae 12 days Helicobacter pylori 90 min; in water: 2–30 West et al. [124], Percival and days Thomas [89] Klebsiella spp. 2hto >30 months, 144 h Beadle and Verran [6] in detergent solution Listeria spp. 1 day–months, 141 days in Budzin´ska et al. [13] water Mycobacterium bovis >2 months Mycobacterium 1 day up to 4 months Walther and Ewald [121] tuberculosis Neisseria gonorrhoeae 1–3 days Neisseria meningitidis 72 h Tzeng et al. [110] Parachlamydia <4 weeks, in presence of Fukumoto et al. [40] acanthamoebae blood <7 weeks Proteus vulgaris 1–2 days Pseudomonas 6 h up to 16 months; on Clifton et al. [21] aeruginosa dry floor: 5 weeks; in aerosol: few hours Salmonella typhi 6 h up to 4 weeks Salmonella typhimurium 10 days up to 4.2 years (continued) 2 Survival of Microorganisms on Inanimate Surfaces 13 Table 2.2 (continued) Range of survival Organism (environment) Reference Salmonella spp. 1 day non typhoid Salmonella 336 days Morita et al. [76] spp. Salmonella enteritidis 1 year Davies and Wray [27] (broiler farms) Salmonella enteritica 30 days (dried in Aviles et al. [1] sv. Tennessie desiccated milk powder) Serratia marcescens 3 days up to 2 months; on dry floor: 5 weeks Shigella spp. 2 days up to 5 months Ghosh and Sehgal [42] 3–11 days in water Staphylococcus aureus 7 days up to 1 year Oie and Kamiya [81], Wagenvoort including MRSA (in-vitro) and Penders [118], Huang and MSSA et al. [54, 55], Noyce 9–12 days (plastic et al. [80], Tolba et al. [108], surfaces) Petti et al. [90] 72 h (stainless steel) 6 h (copper) 28 days (dry mops) 14 days (in water) Streptococcus 1 day up to 30 month Walsh and Camilli [120] pneumoniae Streptococcus pyogenes 3 days up to 6.5 months Wagenvoort et al. [119] Vibrio cholerae 1–7 days Yersinia enterocolitica Up to 64 weeks (in water) Guan and Holley [46] Yersinia pestis Up to 5 days Rose et al. [98] Additional references in Kramer et al. [64, 65] only for a few days [18]. Herpes viruses such as Cytomegalie virus or Herpes simplex virus type 1 and 2 have been shown to persist from only a few hours up to 7 days. Viruses from the gastrointestinal tract, such as Astrovirus, Hepatitis A virus, Polio- and Rotavirus persist significantly longer for approximately 2 months. Blood-borne viruses, such as Hepatitis B virus or Human Immunodeficiency virus can persist for more than 1 week (Table 2.3). 2.3.3 Persistence of Fungi Candida albicans, the most important nosocomial yeast, can survive up to 4 months on surfaces. Persistence of other yeasts was described to be similar (Torulopsis glabrata: 5 months) or shorter (Candida parapsilosis: 14 days) (Table 2.4). The survival of fungi in the environment, however, is strongly influenced by physical factors in nature, such as temperature and relative humidity (see Sect. 2.3.5). 14 A. Kramer and O. Assadian Table 2.3 Survival of clinically relevant viruses on dry inanimate surfaces Organisms Range of survival (environment) Reference Adenovirus <6 h up to 3 months (type Hara et al. [48], Rigotto dependent), 301 days et al. [95] (in water) Astrovirus 7–90 days Avian ~48 h up to 6 days Tiwari et al. [107] metapneumonovirus SARS Coronavirus <5 min up to 24 h (on paper) Lai et al. [66], Rabenau et al. [93], Guionie 5–28 days (at room temp.) et al. [47] 28 days (at 4 C) Coxsackievirus 7–10 days, up to >2 weeks Wong et al. [127] Cytomegalovirus 1–8 h Faix [37], Stowell et al. [102] Echovirus Up to 7 days Hepatitis A virus 2 h up to 60 days Hepatitis B virus 1 week Human immunodefi- Up to 7 days, 7 days Van Bueren et al. [113], ciency virus (in peritoneal dialysis efflu- Farzadegan et al. [38] ent), 48 h (on peritoneal dial- ysis exchange and tubing), 4–8 weeks (on glass cover slides) Herpes simplex virus, <2 h up to 8 weeks Larson and Bryson [67], Type 1 & 2 Bardell [2], Rabenau et al. [93] Influenza virus 1–28 days (strain dependent) Edward and Derrick [34], Walther and Ewald 1–3 days (on banknotes), up to [121], Tiwari 8 days (admixed in mucous) et al. [107] , Thomas et al. [106] Marburg virus (strain 4–5 days Belanov et al. [7] Popp) Para-influenza virus 10 h Brady et al. [11] Norovirus, Feline calici 8 h up to 7 days, MNV> 40 days Cannon et al. [14], Lee virus (FCV), Murine (in diapers and gauze) et al. [69] norovirus (MNV) Papillomavirus 16 7 days Hsueh [53] Papovavirus 8 days Parvovirus >1 year Poliovirus type 1 4 h to <8 days Poliovirus type 2 1 day up to 8 weeks Pseudorabies virus 7 days, <1 h (in aerosol infec- Schoenbaum et al. [100] tivity decreases by 50 % per hour) Respiratory syncytial up to 6 h virus Rhinovirus 2 h up to 7 days Rotavirus 30 min, 6–60 days Keswick et al. [61] Vacciniavirus 3 weeks up to >20 weeks Additional references in Kramer et al. [64, 65] 2 Survival of Microorganisms on Inanimate Surfaces 15 Table 2.4 Survival of clinically relevant fungi on dry inanimate surfaces Organisms Range of survival (environment) Reference Aspergillus spp. >30 days Neely and Orloff [79] Candida 1 up to 120 days, 24 weeks (in soil-water Neely and Orloff [79], The´raud albicans mixture) et al. [105] Candida >30 days Neely and Orloff [79] parapsilosis Candida krusei 11 days Cryptococcus 24 weeks (in soil-water mixture) The´raud et al. [105] spp. Fusarium spp. >30 days Neely and Orloff [79] Mucor spp. >30 days Paecilomyces 11 days spp. Torulopsis 102–150 days Kane et al. [59] glabrata Additional references in Kramer et al. [64, 65] Moulds are ubiquitous in nature, thermo-tolerant, and can survive in house dust for long time. Indoor airborne mould measurements underline the survival for several months [4, 5]. 2.3.4 Persistence of Other Pathogenic Microorganisms Cryptosporidium spp. can induce water-born infection. Their oocysts can survive for months in surface water [96, 20, 75, 15], and up to 120 days in soil [60]. Acanthamoeba are one of the most common protozoa in soil, and frequently found in fresh water and other environmental habitats. An important habitat and vector for infection are hydrogel contact lenses, resulting in contact lens associated keratitis caused by acanthamoeba and fusarium [87], particularly since the contact lenses’ moist condition supports survival protozoa. 2.3.5 Factors Influencing the Survival of Microorganisms in the Environment 2.3.5.1 Relative Humidity (RH) Generally, viruses with lipid envelops, such as most respiratory viruses including Influenza virus, Para-Influenza virus, Corona virus, Respiratory syncytial virus, Herpes simplex virus, Measles virus, Rubella virus, and Varicella zoster virus will tend to survive longer at lower relative humidity (20–30 % RH) [103]. However, 16 A. Kramer and O. Assadian Cytomegalie virus makes an exception, as it was more likely isolated from moist surfaces [102]. Conversely to enveloped viruses, non-lipid enveloped viruses such as Adenovi- rus, Enterovirus, and Rhinoviruses tend to survive longer at higher relative humid- ity (70–90 % RH) [103]. For Rotavirus and Poliovirus conflicting results were reported [64, 65]. S. aureus can persist longer at low humidity [74]. However, for Enterococcus faecalis the survival kinetic is decreased at 25 % RH compared to 0 % RH [97]. The survival of aerosolized Gram-negative bacteria including Pseudomonas spp., Enterobacter spp. and Klebsiella spp. improved at higher relative humidity and low temperature [103]. Studies on airborne Gram-negative bacteria such as S. marcescens, E. coli, Salmonella pullorum, Salmonella derby, and Proteus vulgaris showed decreased survival at intermediate (approx. 50–70 % RH) to high (approx. 70–90 % RH) relative humidity. For some airborne Gram-positive bacteria, such as Staphylococcus epidermidis, Streptococcus haemolyticus, Bacillus subtilis, and Streptococcus pneumoniae, their survival rate also decreased at inter- mediate relative humidity ranging at 50–70 % RH [103]. Gram-positive cocci were most prevalent in indoor air, followed by Gram-positive rods (e.g. Bacillus spp. and Actinomycetes spp.), Gram-negative rods and Gram-negative cocci [103]. The reason for this bacterial behaviour is the design of bacterial cell wall, which allows Gram-positive organisms to tolerate dry conditions better than Gram-negative organisms. Because of a lipid double-layer structure with a thin peptidoglycan (Murein) layer consisting of alternating residues of β-(1,4) N-acetylglucosamine and N-acetylmuramic acid, the later are not so well protected against physical stress and need higher RH in order to survive. 2.3.5.2 Temperature The viral genome (viral DNA or RNA) is sensitive to the surrounding temperature. Indeed, temperature is an important factor influencing the survival of a number of viruses. Higher temperatures impact viral proteins and enzymes, as well as the viral genome. In general, DNA viruses are more stable than RNA viruses; yet, high temperature also will affect DNA integrity. For most viruses, such as Astrovirus, Adenovirus, Poliovirus, Herpes simplex virus, and Hepatitis A virus, low temperature is associated with a longer persistence [64, 65]. Constant temperatures >24 C appear universally to decrease airborne bacterial survival [103]. 2.3.5.3 Biofilm Biofilm is the predominate form of life for microorganisms in a nutrient-sufficient ecosystem. Adhesion triggers the expression of a sigma factor that depresses a large number of genes so that bacteria within the biofilm are at least 500 times more 2 Survival of Microorganisms on Inanimate Surfaces 17 tolerable against antimicrobial agents [23] as well as against physical cold plasma [71, 72]. The reason for the unspecific increased tolerance is the production of extracellular substances like polysaccharides, proteins and DNA after attachment to surfaces. A precondition for biofilm formation is the presence of certain amounts of humidity. The biofilm matrix restrains water and nutrients and protects the micro- organisms against environmental influences [28, 39]. Because of that, once formed biofilms are an important factor of persistence of microorganisms on surfaces in nature as well as in industrial or medical areas [22, 29, 12]. The persistence on inanimate surfaces is prolonged and depends of the environmental conditions, especially the humidity. Also on hospital surfaces biofilms were demonstrated on a number of objects and surfaces, such as sterile supply buckets, opaque plastic doors, venetian blind cords, and sink rubbers, and it was possible to cultivate viable bacteria. Currently, there is not enough research to elucidate whether presence or absence of biofilm affect the risk of transmission or possibility for cross- transmission. However, multi-drug resistant bacteria may not only be protected within biofilms, which may be the mechanism why they persist within the hospital environment [114], but may also exchange virulence factors among their own species or to other species present in biofilms as well [29, 43, 109]. 2.3.5.4 Other Factors A number of other factors may influence the survival of microorganisms on surfaces. Clearly, the material character of a surface itself may play in important role. However, inconsistent results are reported for the influence of type of mate- rials on microbial survival. Some authors described that the type of material did not affect the persistence of Echovirus, Adenovirus, Para-Influenza virus, Rotavirus, Respiratory syncytial virus, Poliovirus, or Norovirus. Other investigators found that persistence was favoured on non-porous surfaces for Influenza virus on formica and gloves for Respiratory syncytial virus, and on hand pieces of telephones for Feline calicivirus [64, 65]. Other factors for a longer persistence of viruses include the presence of faecal suspension and a higher bio-inoculum [66, 64, 65]. Interestingly and by nature, Urease activity enhances the survival of Haemophilus influenzae at a reduced pH [77]. 2.3.6 Limitations on the Knowledge of Microbial Survival on Inanimate Surfaces Laboratory studies to determine the survival and persistence do not reflect the clinical situation, in which surfaces can be simultaneously contaminated with various nosocomial pathogens, different types of bodily and other fluids, secretions, 18 A. Kramer and O. Assadian and antimicrobial residues, i.e. from the last surfaces disinfection. However, little dispute exists that beside the hands of healthcare workers surfaces in the close vicinity of patients may play a key role for the transfer of nosocomial pathogens. 2.4 Mechanisms of Transmission from Inanimate Surfaces to Susceptible Patients and Consequences Thereof The main route of transmission of HAI is via transiently contaminated hands of healthcare workers, but contaminated surfaces may serve as important vectors for cross transmission after hand contact as well (Fig. 2.1). A single hand contact with a contaminated surface results in a variable degree of pathogen transfer. Transmission from surfaces to hands was most successful with E. coli, Salmonella spp., S. aureus (all 100 %), C. albicans (90 %), Rhinovirus (61 %), Hepatitis A virus (22–33 %), and Rotavirus (16 %) [64, 65]. Other transfer rates were calculated for Echovirus, Poliovirus, and Rotavirus with 50 % transmis- sibility, and for Salmonella enteritidis, Shigella spp., and E. coli O157:H7 with 33 % [104]. Contaminated hands can transfer viruses to 5 more surfaces or 14 other subjects. Contaminated hands can also be the source of re-contamination of the surface, as demonstrated with Hepatitis A virus [64, 65]. Because of this, it is critical to note that healthcare workers’ compliance with hand hygiene varies between 13 % and 94 % with a median of less than 50 % [91]. Moreover hand hygiene is performed less frequently after contact with the environment than with the patient [94]. Both facts underline the necessity to perform additional surface decontamination procedures to interrupt the transmis- sion of nosocomial pathogens. Due to the overwhelming evidence of low compli- ance of hand disinfection, the risk from contaminated surfaces cannot be overlooked and must not be down played by hospital administrations. Fig. 2.1 Transmission routes for nosocomial pathogens 2 Survival of Microorganisms on Inanimate Surfaces 19 During outbreaks, the role of the patients’ environment is particularly evident, as suggested by observed evidence for Acinetobacter baumannii, C. difficile, MRSA, P. aeruginosa, VRE, Adenovirus, SARS virus, Rotavirus, and Norovirus [64, 65, 54, 55, 99, 9, 123, 83, 58]. The role of contaminated surfaces is also underlined by the observation that after environmental disinfection, significant decrease of trans- missions and HAI have been shown, i.e. for C. difficile [73, 126], for VRE [50], for MRSA [32], for multidrug-resistant A. baumanii [84], for S. marcescens [3], and for other multidrug-resistant Gram-negative rods [86]. If performed correctly, also the burden of microbial airborne transmission can be significantly decreased by surface disinfection. This again may have an impact on healthcare organisations, resulting in i.e. higher clean room class of drug manufacturing areas [8] by elimination of critical bacterial and fungal contamina- tion [63]. As consequence for the successful interruption of cross contamination and infections a multi-barrier approach is required with the key points of hand hygiene and surface disinfection, appropriate used of antisepsis, barrier nursing, and safe reprocessing of contaminated medical devices. Within such multi-barrier strategy, environmental disinfection policies should be based on risk assessments for surfaces with different risks for cross contamination such as high- and low-touched surfaces with appropriate standards for adequate disinfection mea- sures. Generally, surface disinfection is indicated in the following situations: – Frequently touched surfaces adjacent to patients – Surfaces with assumed or visible contamination – Terminal disinfection in rooms or areas where infected or colonized patients with easily transferable nosocomial pathogens are cared for, and – in outbreak situations. The purpose of preventive or targeted disinfection on inanimate surfaces is the killing or irreversible inactivation of pathogens to an extent which prevents subse- quent infection transmission [41]. In order to ensure the success of environmental disinfection, education, training [52], and targeted microbiological control are impor- tant measures and have been shown to improve both, cleaning performance and infection prevention [50]. Increasingly, novel technologies are introduced, which may be used additionally to cleaning. 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Food Environ Microbiol 3:1–30 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Use of Biocidal Surfaces for Reduction of Healthcare Acquired Infections Pubmed Central

Survival of Microorganisms on Inanimate Surfaces

Use of Biocidal Surfaces for Reduction of Healthcare Acquired InfectionsJul 12, 2014

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© Springer International Publishing Switzerland 2014
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Abstract

Chapter 2 Survival of Microorganisms on Inanimate Surfaces Axel Kramer and Ojan Assadian Contents 2.1 Introduction ................................................................................. 8 2.2 The Role of Surfaces in the Transmission of Pathogenic Microorganisms Causing Healthcare-Acquired Infections (HAI) ..................................................... 9 2.3 Persistence of Microorganisms on Inanimate Surfaces ................................... 10 2.3.1 Persistence of Bacteria ............................................................. 11 2.3.2 Persistence of Viruses .............................................................. 11 2.3.3 Persistence of Fungi ................................................................ 13 2.3.4 Persistence of Other Pathogenic Microorganisms ................................. 15 2.3.5 Factors Influencing the Survival of Microorganisms in the Environment ....... 15 2.3.6 Limitations on the Knowledge of Microbial Survival on Inanimate Surfaces . . . 17 2.4 Mechanisms of Transmission from Inanimate Surfaces to Susceptible Patients and Consequences Thereof ................................................................. 18 References ........................................................................................ 19 Abstract In healthcare settings microbial contaminated surfaces play an important role in indirect transmission of infection. Especially surfaces close to the patients’ environment may be touched at high frequencies, allowing transmission from animated sources to others via contaminated inanimate surfaces. Therefore, the knowledge on the survival of bacteria, fungi, viruses and protozoa on surfaces, and hence, in a broader sense, in the human environment, is important for implementing tactics for prevention of Healthcare-acquired Infections (HAI). A. Kramer, M.D., Ph.D. Institute of Hygiene and Environmental Medicine, Universita¨tsmedizin Greifswald, Ernst-Moritz-Arndt University Greifswald, Walther-Rathenau-Str. 49A, 17485 Greifswald, Germany e-mail: kramer@uni-greifswald.de O. Assadian, M.D., DTMH (*) Department for Hospital Hygiene and Infection Control, Medical University of Vienna, Wa¨hringer Guertel 18-20, 1090 Vienna, Austria e-mail: ojan.assadian@meduniwien.ac.at G. Borkow (ed.), Use of Biocidal Surfaces for Reduction of Healthcare 7 Acquired Infections, DOI 10.1007/978-3-319-08057-4_2, © Springer International Publishing Switzerland 2014 8 A. Kramer and O. Assadian This chapter will elaborate the role of surfaces in the transmission of pathogens. Particular emphasis is laid on the current knowledge of the survival time and conditions favouring survival of the pathogens. Finally, mechanisms of transmis- sion from inanimate surfaces to patients are highlighted. Within the multi-barrier strategy of the prevention of HAI, environmental disinfection policies should be based on risk assessments for surfaces with different risks for cross contamination such as high- and low-touched surfaces with appro- priate standards for adequate disinfection measures under consideration of the persistence and infectious dose of the pathogens. As a result, surface disinfection is indicated in the following situations: – Frequently touched surfaces adjacent to patients – Surfaces with assumed or visible contamination – Terminal disinfection in rooms or areas where infected or colonized patients with easily transferable nosocomial pathogens are cared for, and – in outbreak situations. Furthermore, the knowledge of the persistence of pathogens will also support ensuring the biosafety in microbiological and biomedical laboratories, food- handling settings, and for hygienic behaviour in the everyday life to prevent transmission of infectious diseases. Keywords Persistence • Bacteria • Fungi • Viruses • Protozoa transmission mechanisms • Surface disinfection List of Abbreviations HAI Healthcare-acquired infections MRSA Methicillin-resistant Staphylococcus aureus MSSA Methicillin-sensible Staphylococcus aureus RH Relative humidity SARS Severe acute respiratory syndrome VRE Vancomycin-resistant enterococci 2.1 Introduction Microorganisms may be transmitted from animated sources to inanimate environ- mental sources, which may become secondary reservoirs if they meet the needs of transmitted pathogens to survive and to multiply. In healthcare settings, however, contaminated surfaces, which may not always be optimal for microbial survival and multiplication, still may play a role in the chain of infection, since surfaces close to the patients’ environment may be touched at high frequencies, allowing transmis- sion from animated sources to others via contaminated inanimate surfaces. 2 Survival of Microorganisms on Inanimate Surfaces 9 Because of this, the knowledge on the survival of bacteria, fungi, viruses and protozoa on surfaces, and hence, in a broader sense, in the human environment, is important for planning and implementing tactics for prevention of Healthcare-acquired Infections (HAI). Furthermore, such knowledge will also assist ensuring the biosafety in microbiological and biomedical laboratories, food-handling settings, and for hygienic behaviour in the everyday life to prevent transmission of infectious diseases. One example of microorganisms with relatively short ability of persisting in the environment is the severe acute respiratory syndrome (SARS) coronavirus (CoV), which became pandemic within months in China in 2002. This virus retains infectivity on different substrates up to 9 days, as compared to the influenza virus, which demonstrates a relatively long persistence in the environment up to 4 weeks [112]. Both viruses are airborne transmitted infectious agents, however, they may also be transmitted via hand-surface contacts, supporting the relevance of hand hygiene and personal protection against infection. Because of a number of microorganisms’ ability to persist and survive for long- term periods on surfaces, particularly in healthcare settings, the usage of antimicrobially impregnated surfaces is increasingly discussed [82]. However, because of the required long contact times of microorganisms on antimicrobial surfaces [64, 65, 25, 45], such technologies may be useful for surfaces with low frequency of hand contacts. 2.2 The Role of Surfaces in the Transmission of Pathogenic Microorganisms Causing Healthcare-Acquired Infections (HAI) In healthcare settings, bacteria, bacterial spores, viruses and yeasts are mainly transmitted from infected and/or colonized patients, but also from staff, and in some situations from visitors to the inanimate hospital environment, particularly to areas adjacent to patients and frequently touched surfaces by hands (“high-touch surfaces”). Potential pathogenic microbial flora of the respiratory tract and of the vestibulum nasi, such as methicillin- sensible (MSSA) or resistant Staphylococcus aureus (MRSA), is correlated with a higher risk of contamination of surrounding surfaces through direct or indirect contact with hands [81]. Intestinal infections caused i.e. by Clostridium difficile and Norovirus, or enteral colonization with nosocomial pathogens such as vancomycin-resistant enterococci (VRE) may also be associated with a risk of widespread environmental contamination [30]. Compared with the large number of published literature on environmental contamination with MRSA, VRE, and C. difficile, there are relatively few published studies on environ- mental contamination by Gram-negative bacteria [64, 65]. Aside of a possible publication bias in the past, one reason for this is the different ability of Gram- positive and Gram-negative bacteria to survive in the inanimate environment. The level of microbial bio-burden on surface in healthcare settings is low compared to the numbers on patients’ skin or in faeces. However, even at low particle numbers 10 A. Kramer and O. Assadian Table 2.1 Infectious doses for selected pathogens Infectious dose Organisms Reference (1)-10–100 Norovirus, Rotavirus, EHEC, Ward et al. [122], Paton and Paton [88], Pang viable ETEC, C. difficile, Enterococci et al. [85], Lawley et al. [68], Porter particles incl. VRE et al. [92], Yezli and Otter [130], Robine et al. [97] 1 viable Oocysts of cryptosporidia Chappell et al. [17] particle in water >10 viable Salmonella enteritidis Craven et al. [24] particles there is a risk of transmission (Table 2.1). In immuno-compromised patients, the required numbers of microorganisms for causing infectious diseases is even lower, increasing the risk of HAI in these populations. Inanimate surfaces have been described as source for HAI-outbreaks. Hayden et al. [49] demonstrated that touching the environment contaminated with relatively low pathogen concentrations in a room occupied by a patient colonized with VRE is associated with approximately the same risk of VRE acquisition on hands as touching an affected patient directly. Evidence of the importance of environmental transmission is further provided by studies showing an increased risk of infection in patients admitted to the same rooms previously occupied by other infected/colonised cases. This has been shown for C. difficile [101], VRE and MRSA ([54, 55], and also own observations). Environmental Norovirus contamination has been repeatedly found to be correlated with continuing outbreaks [128], although the significance of this pathway has not been fully elucidated. The importance of surface contamination is also shown by reduction in the rate of HAI when effective measures of environmental disinfection are implemented [50, 10, 26]. A recent observational study showed a significant reduction in C. difficile infection rates following the introduction of sporicidal wipes in an environmental cleaning regimen in an acute London trust [16]. However, not all studies have shown a direct link between surface disinfection and reduction in infection rates, probably because of the complex interactions and transmission routes in the clinical practice. Yet, in summary it is undisputed that contaminated surfaces may contribute to the transmission of pathogens and may thus pose a critical element in the chain of transmission of microorganisms [41]. 2.3 Persistence of Microorganisms on Inanimate Surfaces The risk for transmission of HAI depends of the persistence of nosocomial pathogens on surfaces. The longer a microorganism may persist on a surface, the longer the contaminated surface may be a source of transmission and thus endanger a susceptible patient or healthcare worker of becoming the target of infection. In order to estimate the risk of cross contamination, Kramer et al. [64, 65] have published a systematic review on persistence of pathogens on surfaces. 2 Survival of Microorganisms on Inanimate Surfaces 11 The following findings are based on this review; however, knowledge on persistence of microorganisms on inanimate surfaces is now expanded by addi- tional findings published after 2005/2006. 2.3.1 Persistence of Bacteria In most reports, persistence was studied on dry surfaces using artificial contamina- tion of a standardized type of surface in a laboratory. Bacteria were prepared in broth, water or saline. Most Gram-positive bacteria, such as Enterococcus spp. including VRE, S. aureus including MRSA, or Streptococcus pyogenes survive for months on dry surfaces (Table 2.2). In general, there is no observable difference in survival between multi-resistant and susceptible strains of S. aureus and Enterococcus spp. [78]. Only in one study [118] a difference of survival time between antibiotic resistant and susceptible bacteria was suggested, yet, the susceptible strains dem- onstrated only a non-significant shorter survival time on surfaces. The factors why the same bacteria may persist more or less on a surface (i.e. from hours to days as detailed in Table 2.2) will be discussed later in Sect. 2.3.5. Many Gram-negative species, such as Acinetobacter spp., Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, Serratia marcescens,or Shigella spp. can survive on inanimate surfaces even for months (Table 2.2). These species are found among the most frequent isolates from patients with HAI [64, 65]. However, a few others Gram-negative bacteria, such as Bordetella pertussis, Haemophilus influenzae, Proteus vulgaris,or Vibrio cholera persist only for days (Table 2.2). Mycobacteria, including Mycobacterium tuberculosis, and spore-forming bac- teria, such as C. difficile, can survive for many months on surfaces (Table 2.2). Because paper still is omnipresent in healthcare settings worldwide today, Hu¨bner et al. [56] have analysed the persistence of various Gram-positive and Gram-negative bacteria including E. coli, S. aureus, P. aeruginosa, and Enterococ- cus hirae on office paper after contamination with standardised inocula of bacterial suspensions in the range of 2.8 10 cfu/mL. Opposite to E. coli, all other organ- isms were more stabile at room conditions and were reduced on paper only by 3 log after 7 days, whereas E. coli was reduced by 5 log within 10 10 24 h. Furthermore, the transmissibility of bacteria from hands to paper and back could be demonstrated for all bacteria strains. Similar investigations showed that paper money notes could harbour and transmit pathogens [62, 111, 115]. 2.3.2 Persistence of Viruses In order to estimate the persistence of viruses on inanimate surfaces, usually cell culture media are prepared [64, 65]. Most viruses from the respiratory tract such as Corona-, Coxsackie-, or Influenza virus, SARS, or rhinovirus can persist on surfaces 12 A. Kramer and O. Assadian Table 2.2 Published data on survival of nosocomial and community acquired pathogens on various inanimate surfaces Range of survival Organism (environment) Reference Acinetobacter spp. 3 days to 1 year (in-vitro) Wagenvoort and Joosten [117], Espinal et al. [36] 36 days within biofilm vs. 15 days for non-biofilm-forming strains Bordetella pertussis 3to >10 days; in pernasal Hunter [57], Walther and Ewald swabs: >4 days [121] Campylobacter jejuni >6 days, in water Gonza´lez and Ha¨nninen [44] >60 days Clostridium difficile 5 months Weber et al. [123] spores C. difficile, vegetative 15 min (dry surface) form 6 h (moist surface) Chlamydia pneumoniae 96 h Fukumoto et al. [40], Haider et al. [51], Matsuo et al. [70] C. trachomatis <1 week Chlamydia psittaci 15 days to months Wendel [125] (environment) Corynebacterium 7 days to 6 months Walther and Ewald [121] diphtheriae Corynebacterium 1–8 days, up to several Yeruham et al. [129] , pseudotuberculosis weeks (environment) Dorella et al. [31] Enterococcus spp. 5 days up to 30 months Robine et al. [97], Wagenvoort including VRE et al. [116] Escherichia coli 1.5 h to 16 months Guan and Holley [46], Erickson et al. [35], Chauret [19] , E. coli O157:H7 27 days on spinach leaves, Duffitt et al. [33] 179 days in soil, 98 days in water Haemophilus influenzae 12 days Helicobacter pylori 90 min; in water: 2–30 West et al. [124], Percival and days Thomas [89] Klebsiella spp. 2hto >30 months, 144 h Beadle and Verran [6] in detergent solution Listeria spp. 1 day–months, 141 days in Budzin´ska et al. [13] water Mycobacterium bovis >2 months Mycobacterium 1 day up to 4 months Walther and Ewald [121] tuberculosis Neisseria gonorrhoeae 1–3 days Neisseria meningitidis 72 h Tzeng et al. [110] Parachlamydia <4 weeks, in presence of Fukumoto et al. [40] acanthamoebae blood <7 weeks Proteus vulgaris 1–2 days Pseudomonas 6 h up to 16 months; on Clifton et al. [21] aeruginosa dry floor: 5 weeks; in aerosol: few hours Salmonella typhi 6 h up to 4 weeks Salmonella typhimurium 10 days up to 4.2 years (continued) 2 Survival of Microorganisms on Inanimate Surfaces 13 Table 2.2 (continued) Range of survival Organism (environment) Reference Salmonella spp. 1 day non typhoid Salmonella 336 days Morita et al. [76] spp. Salmonella enteritidis 1 year Davies and Wray [27] (broiler farms) Salmonella enteritica 30 days (dried in Aviles et al. [1] sv. Tennessie desiccated milk powder) Serratia marcescens 3 days up to 2 months; on dry floor: 5 weeks Shigella spp. 2 days up to 5 months Ghosh and Sehgal [42] 3–11 days in water Staphylococcus aureus 7 days up to 1 year Oie and Kamiya [81], Wagenvoort including MRSA (in-vitro) and Penders [118], Huang and MSSA et al. [54, 55], Noyce 9–12 days (plastic et al. [80], Tolba et al. [108], surfaces) Petti et al. [90] 72 h (stainless steel) 6 h (copper) 28 days (dry mops) 14 days (in water) Streptococcus 1 day up to 30 month Walsh and Camilli [120] pneumoniae Streptococcus pyogenes 3 days up to 6.5 months Wagenvoort et al. [119] Vibrio cholerae 1–7 days Yersinia enterocolitica Up to 64 weeks (in water) Guan and Holley [46] Yersinia pestis Up to 5 days Rose et al. [98] Additional references in Kramer et al. [64, 65] only for a few days [18]. Herpes viruses such as Cytomegalie virus or Herpes simplex virus type 1 and 2 have been shown to persist from only a few hours up to 7 days. Viruses from the gastrointestinal tract, such as Astrovirus, Hepatitis A virus, Polio- and Rotavirus persist significantly longer for approximately 2 months. Blood-borne viruses, such as Hepatitis B virus or Human Immunodeficiency virus can persist for more than 1 week (Table 2.3). 2.3.3 Persistence of Fungi Candida albicans, the most important nosocomial yeast, can survive up to 4 months on surfaces. Persistence of other yeasts was described to be similar (Torulopsis glabrata: 5 months) or shorter (Candida parapsilosis: 14 days) (Table 2.4). The survival of fungi in the environment, however, is strongly influenced by physical factors in nature, such as temperature and relative humidity (see Sect. 2.3.5). 14 A. Kramer and O. Assadian Table 2.3 Survival of clinically relevant viruses on dry inanimate surfaces Organisms Range of survival (environment) Reference Adenovirus <6 h up to 3 months (type Hara et al. [48], Rigotto dependent), 301 days et al. [95] (in water) Astrovirus 7–90 days Avian ~48 h up to 6 days Tiwari et al. [107] metapneumonovirus SARS Coronavirus <5 min up to 24 h (on paper) Lai et al. [66], Rabenau et al. [93], Guionie 5–28 days (at room temp.) et al. [47] 28 days (at 4 C) Coxsackievirus 7–10 days, up to >2 weeks Wong et al. [127] Cytomegalovirus 1–8 h Faix [37], Stowell et al. [102] Echovirus Up to 7 days Hepatitis A virus 2 h up to 60 days Hepatitis B virus 1 week Human immunodefi- Up to 7 days, 7 days Van Bueren et al. [113], ciency virus (in peritoneal dialysis efflu- Farzadegan et al. [38] ent), 48 h (on peritoneal dial- ysis exchange and tubing), 4–8 weeks (on glass cover slides) Herpes simplex virus, <2 h up to 8 weeks Larson and Bryson [67], Type 1 & 2 Bardell [2], Rabenau et al. [93] Influenza virus 1–28 days (strain dependent) Edward and Derrick [34], Walther and Ewald 1–3 days (on banknotes), up to [121], Tiwari 8 days (admixed in mucous) et al. [107] , Thomas et al. [106] Marburg virus (strain 4–5 days Belanov et al. [7] Popp) Para-influenza virus 10 h Brady et al. [11] Norovirus, Feline calici 8 h up to 7 days, MNV> 40 days Cannon et al. [14], Lee virus (FCV), Murine (in diapers and gauze) et al. [69] norovirus (MNV) Papillomavirus 16 7 days Hsueh [53] Papovavirus 8 days Parvovirus >1 year Poliovirus type 1 4 h to <8 days Poliovirus type 2 1 day up to 8 weeks Pseudorabies virus 7 days, <1 h (in aerosol infec- Schoenbaum et al. [100] tivity decreases by 50 % per hour) Respiratory syncytial up to 6 h virus Rhinovirus 2 h up to 7 days Rotavirus 30 min, 6–60 days Keswick et al. [61] Vacciniavirus 3 weeks up to >20 weeks Additional references in Kramer et al. [64, 65] 2 Survival of Microorganisms on Inanimate Surfaces 15 Table 2.4 Survival of clinically relevant fungi on dry inanimate surfaces Organisms Range of survival (environment) Reference Aspergillus spp. >30 days Neely and Orloff [79] Candida 1 up to 120 days, 24 weeks (in soil-water Neely and Orloff [79], The´raud albicans mixture) et al. [105] Candida >30 days Neely and Orloff [79] parapsilosis Candida krusei 11 days Cryptococcus 24 weeks (in soil-water mixture) The´raud et al. [105] spp. Fusarium spp. >30 days Neely and Orloff [79] Mucor spp. >30 days Paecilomyces 11 days spp. Torulopsis 102–150 days Kane et al. [59] glabrata Additional references in Kramer et al. [64, 65] Moulds are ubiquitous in nature, thermo-tolerant, and can survive in house dust for long time. Indoor airborne mould measurements underline the survival for several months [4, 5]. 2.3.4 Persistence of Other Pathogenic Microorganisms Cryptosporidium spp. can induce water-born infection. Their oocysts can survive for months in surface water [96, 20, 75, 15], and up to 120 days in soil [60]. Acanthamoeba are one of the most common protozoa in soil, and frequently found in fresh water and other environmental habitats. An important habitat and vector for infection are hydrogel contact lenses, resulting in contact lens associated keratitis caused by acanthamoeba and fusarium [87], particularly since the contact lenses’ moist condition supports survival protozoa. 2.3.5 Factors Influencing the Survival of Microorganisms in the Environment 2.3.5.1 Relative Humidity (RH) Generally, viruses with lipid envelops, such as most respiratory viruses including Influenza virus, Para-Influenza virus, Corona virus, Respiratory syncytial virus, Herpes simplex virus, Measles virus, Rubella virus, and Varicella zoster virus will tend to survive longer at lower relative humidity (20–30 % RH) [103]. However, 16 A. Kramer and O. Assadian Cytomegalie virus makes an exception, as it was more likely isolated from moist surfaces [102]. Conversely to enveloped viruses, non-lipid enveloped viruses such as Adenovi- rus, Enterovirus, and Rhinoviruses tend to survive longer at higher relative humid- ity (70–90 % RH) [103]. For Rotavirus and Poliovirus conflicting results were reported [64, 65]. S. aureus can persist longer at low humidity [74]. However, for Enterococcus faecalis the survival kinetic is decreased at 25 % RH compared to 0 % RH [97]. The survival of aerosolized Gram-negative bacteria including Pseudomonas spp., Enterobacter spp. and Klebsiella spp. improved at higher relative humidity and low temperature [103]. Studies on airborne Gram-negative bacteria such as S. marcescens, E. coli, Salmonella pullorum, Salmonella derby, and Proteus vulgaris showed decreased survival at intermediate (approx. 50–70 % RH) to high (approx. 70–90 % RH) relative humidity. For some airborne Gram-positive bacteria, such as Staphylococcus epidermidis, Streptococcus haemolyticus, Bacillus subtilis, and Streptococcus pneumoniae, their survival rate also decreased at inter- mediate relative humidity ranging at 50–70 % RH [103]. Gram-positive cocci were most prevalent in indoor air, followed by Gram-positive rods (e.g. Bacillus spp. and Actinomycetes spp.), Gram-negative rods and Gram-negative cocci [103]. The reason for this bacterial behaviour is the design of bacterial cell wall, which allows Gram-positive organisms to tolerate dry conditions better than Gram-negative organisms. Because of a lipid double-layer structure with a thin peptidoglycan (Murein) layer consisting of alternating residues of β-(1,4) N-acetylglucosamine and N-acetylmuramic acid, the later are not so well protected against physical stress and need higher RH in order to survive. 2.3.5.2 Temperature The viral genome (viral DNA or RNA) is sensitive to the surrounding temperature. Indeed, temperature is an important factor influencing the survival of a number of viruses. Higher temperatures impact viral proteins and enzymes, as well as the viral genome. In general, DNA viruses are more stable than RNA viruses; yet, high temperature also will affect DNA integrity. For most viruses, such as Astrovirus, Adenovirus, Poliovirus, Herpes simplex virus, and Hepatitis A virus, low temperature is associated with a longer persistence [64, 65]. Constant temperatures >24 C appear universally to decrease airborne bacterial survival [103]. 2.3.5.3 Biofilm Biofilm is the predominate form of life for microorganisms in a nutrient-sufficient ecosystem. Adhesion triggers the expression of a sigma factor that depresses a large number of genes so that bacteria within the biofilm are at least 500 times more 2 Survival of Microorganisms on Inanimate Surfaces 17 tolerable against antimicrobial agents [23] as well as against physical cold plasma [71, 72]. The reason for the unspecific increased tolerance is the production of extracellular substances like polysaccharides, proteins and DNA after attachment to surfaces. A precondition for biofilm formation is the presence of certain amounts of humidity. The biofilm matrix restrains water and nutrients and protects the micro- organisms against environmental influences [28, 39]. Because of that, once formed biofilms are an important factor of persistence of microorganisms on surfaces in nature as well as in industrial or medical areas [22, 29, 12]. The persistence on inanimate surfaces is prolonged and depends of the environmental conditions, especially the humidity. Also on hospital surfaces biofilms were demonstrated on a number of objects and surfaces, such as sterile supply buckets, opaque plastic doors, venetian blind cords, and sink rubbers, and it was possible to cultivate viable bacteria. Currently, there is not enough research to elucidate whether presence or absence of biofilm affect the risk of transmission or possibility for cross- transmission. However, multi-drug resistant bacteria may not only be protected within biofilms, which may be the mechanism why they persist within the hospital environment [114], but may also exchange virulence factors among their own species or to other species present in biofilms as well [29, 43, 109]. 2.3.5.4 Other Factors A number of other factors may influence the survival of microorganisms on surfaces. Clearly, the material character of a surface itself may play in important role. However, inconsistent results are reported for the influence of type of mate- rials on microbial survival. Some authors described that the type of material did not affect the persistence of Echovirus, Adenovirus, Para-Influenza virus, Rotavirus, Respiratory syncytial virus, Poliovirus, or Norovirus. Other investigators found that persistence was favoured on non-porous surfaces for Influenza virus on formica and gloves for Respiratory syncytial virus, and on hand pieces of telephones for Feline calicivirus [64, 65]. Other factors for a longer persistence of viruses include the presence of faecal suspension and a higher bio-inoculum [66, 64, 65]. Interestingly and by nature, Urease activity enhances the survival of Haemophilus influenzae at a reduced pH [77]. 2.3.6 Limitations on the Knowledge of Microbial Survival on Inanimate Surfaces Laboratory studies to determine the survival and persistence do not reflect the clinical situation, in which surfaces can be simultaneously contaminated with various nosocomial pathogens, different types of bodily and other fluids, secretions, 18 A. Kramer and O. Assadian and antimicrobial residues, i.e. from the last surfaces disinfection. However, little dispute exists that beside the hands of healthcare workers surfaces in the close vicinity of patients may play a key role for the transfer of nosocomial pathogens. 2.4 Mechanisms of Transmission from Inanimate Surfaces to Susceptible Patients and Consequences Thereof The main route of transmission of HAI is via transiently contaminated hands of healthcare workers, but contaminated surfaces may serve as important vectors for cross transmission after hand contact as well (Fig. 2.1). A single hand contact with a contaminated surface results in a variable degree of pathogen transfer. Transmission from surfaces to hands was most successful with E. coli, Salmonella spp., S. aureus (all 100 %), C. albicans (90 %), Rhinovirus (61 %), Hepatitis A virus (22–33 %), and Rotavirus (16 %) [64, 65]. Other transfer rates were calculated for Echovirus, Poliovirus, and Rotavirus with 50 % transmis- sibility, and for Salmonella enteritidis, Shigella spp., and E. coli O157:H7 with 33 % [104]. Contaminated hands can transfer viruses to 5 more surfaces or 14 other subjects. Contaminated hands can also be the source of re-contamination of the surface, as demonstrated with Hepatitis A virus [64, 65]. Because of this, it is critical to note that healthcare workers’ compliance with hand hygiene varies between 13 % and 94 % with a median of less than 50 % [91]. Moreover hand hygiene is performed less frequently after contact with the environment than with the patient [94]. Both facts underline the necessity to perform additional surface decontamination procedures to interrupt the transmis- sion of nosocomial pathogens. Due to the overwhelming evidence of low compli- ance of hand disinfection, the risk from contaminated surfaces cannot be overlooked and must not be down played by hospital administrations. Fig. 2.1 Transmission routes for nosocomial pathogens 2 Survival of Microorganisms on Inanimate Surfaces 19 During outbreaks, the role of the patients’ environment is particularly evident, as suggested by observed evidence for Acinetobacter baumannii, C. difficile, MRSA, P. aeruginosa, VRE, Adenovirus, SARS virus, Rotavirus, and Norovirus [64, 65, 54, 55, 99, 9, 123, 83, 58]. The role of contaminated surfaces is also underlined by the observation that after environmental disinfection, significant decrease of trans- missions and HAI have been shown, i.e. for C. difficile [73, 126], for VRE [50], for MRSA [32], for multidrug-resistant A. baumanii [84], for S. marcescens [3], and for other multidrug-resistant Gram-negative rods [86]. If performed correctly, also the burden of microbial airborne transmission can be significantly decreased by surface disinfection. This again may have an impact on healthcare organisations, resulting in i.e. higher clean room class of drug manufacturing areas [8] by elimination of critical bacterial and fungal contamina- tion [63]. As consequence for the successful interruption of cross contamination and infections a multi-barrier approach is required with the key points of hand hygiene and surface disinfection, appropriate used of antisepsis, barrier nursing, and safe reprocessing of contaminated medical devices. Within such multi-barrier strategy, environmental disinfection policies should be based on risk assessments for surfaces with different risks for cross contamination such as high- and low-touched surfaces with appropriate standards for adequate disinfection mea- sures. Generally, surface disinfection is indicated in the following situations: – Frequently touched surfaces adjacent to patients – Surfaces with assumed or visible contamination – Terminal disinfection in rooms or areas where infected or colonized patients with easily transferable nosocomial pathogens are cared for, and – in outbreak situations. The purpose of preventive or targeted disinfection on inanimate surfaces is the killing or irreversible inactivation of pathogens to an extent which prevents subse- quent infection transmission [41]. In order to ensure the success of environmental disinfection, education, training [52], and targeted microbiological control are impor- tant measures and have been shown to improve both, cleaning performance and infection prevention [50]. Increasingly, novel technologies are introduced, which may be used additionally to cleaning. 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