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Can Copper-Coated Surfaces Prevent Healthcare-Associated Infections?

(See the article by Souli et al, on pages 765–771.) Despite dramatic decreases in the incidence of healthcareassociated infections (HAIs) in recent years, a large prevalence study of US acute-care hospitals estimated that ~722,000 HAIs occurred in 2011, resulting in ~75,000 deaths. Several decades ago, Weinstein theorized that pathogens causing HAIs in the intensive care unit (ICU) had several sources: the patients’ endogenous flora (40%–60%), cross-infection via the hands of healthcare personnel (HCP; 20%–40%), antibiotic-driven changes in flora (20%–25%), and other causes (including contamination of the environment; 20%). More recently, accumulating scientific evidence has indicated that contamination of environmental surfaces in hospital rooms plays an important role in the transmission of several key healthcareassociated pathogens, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp (VRE), Clostridium difficile, Acinetobacter spp, and norovirus. In general, all of these pathogens share the following characteristics: ability to survive for prolonged periods of time on environmental surfaces, ability to remain virulent after environmental exposure, frequent contamination of the hospital environment, ability to colonize patients, ability to contaminate or transiently colonize the hands of HCP, and transmission via the contaminated hands of HCP. Evidence supporting the role of contaminated surfaces in the transmission of key healthcareassociated pathogens includes the following observations. (1) The surfaces in rooms of colonized or infected patients are frequently contaminated with the pathogen. (2) Contact with hospital-room surfaces ormedical equipment byHCP frequently leads to contamination of hands and/or gloves. (3) The patient admitted to a room previously occupied by a patient colonized or infected with a pathogen (eg, MRSA, VRE, C. difficile, Acinetobacter) has a substantially increased likelihood (ie, 39%– 353%) of developing colonization or infection with that pathogen. (4) Improved terminal cleaning of rooms decreases environmental pathogens and the rate of individual patient colonization and/or infections; it also leads to a decreased facility-wide rate of colonization and/or infection. Unfortunately, inadequate terminal room disinfection is common. In fact, studies have demonstrated that <50% of room surfaces are cleaned. Therefore, and not surprisingly, many room surfaces remain contaminated with a multidrugresistant organisms (MDROs) following terminal room disinfection. Although enhanced education of environmental service staff with feedback regarding cleaning effectiveness (eg, fluorescent dye) improves cleaning effectiveness, overall cleaning remains suboptimal. For this reason, “no-touch” methods of terminal room disinfection have been developed. No-touch methods that use ultraviolet (UV) light devices or hydrogen peroxide systems for terminal room disinfection when the occupant has been colonized or infected with a MDRO have been demonstrated to reduce the risk of the subsequent room occupant developing colonization and/ or an HAI. Importantly, some studies have demonstrated a facility-wide reduction of HAIs; furthermore, these reductions were not related to improved hand hygiene or to environmental cleaning compliance. One of the limitations of currently available UV devices or hydrogen peroxide systems is that they can only be used for terminal disinfection because patients and HCP must evacuate the room prior to use. Because daily room disinfection has been shown to reduce contamination of HCP hands and gloves, there has been interest in developing “no-touch” methods for decreasing MDRO surface contamination on a continuous basis. Such methods have been reviewed and include self-disinfecting surfaces using heavy metals, lightactivated photosensitizers, high-intensity narrow-spectrum light, low-dose continuous hydrogen peroxide, photocatalytic disinfection, bacteriophage-modified surfaces, and altered surface topography. Of these potential methods, the best studied is the use of heavy metals (eg, silver, copper) with copper-coated or impregnated surfaces; it is the only method that has been assessed in clinical trials. The studies assessing the effectiveness of no-touch methods including self-disinfecting surfaces for disinfection of room surfaces in hospitals can be divided into 3 general approaches.