’s wide-ranging coverage of the infection prevention and control world. Everything from interviews with known opinion leaders, to the news that infection preventionists and other health care professionals can use on their jobs.

Bug of the Month: I Am Hiding in the Dirt

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in health care facilities today.

Some HAI Incident Increases Continued Into Second Year of COVID-19

Device-associated HAIs were likely impacted by the continued alteration of hospital practices that occurred throughout the pandemic.

To reduce the risk of surgical-site infection, utilize evidence-based interventions and give feedback to clinicians on bacterial transmission using Staphylococcus aureus as a marker.

A Pandemic Paradigm Shift in Our Understanding of Transmission

The bugs are winning, but only because we are letting them.

Does Daily Hydrogen Peroxide Antisepsis Protect Against COVID-19?

Regardless of vaccination status, health care workers were protected with daily and regular hydrogen peroxide antisepsis.

https://www.infectioncontroltoday.com/view/does-daily-hydrogen-peroxide-antisepsis-protects-against-covid-19-

Articles

Take 5 minutes to catch up on Infection Control Today’s highlights for the week ending May 27.


Weekly Rounds: Bug of the Month: I Am Hiding in the Dirt, HAI Incident Increases, and More

.  She has been a writer and editor for over 30 years. She has an MA and BA in English Composition/Literature from the University of Akron in Akron, OH, and lives in Ohio with her fiance; her 2 tiny dogs, Sally and Doctor Danger Dog; and a big black cat, Freya. She loves reading, writing, gardening, and spending time with her loved ones.

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today. Each column explores the Bug of the Month's etiology, the infections it can cause, the modes of transmission, and ways to fight its spread. The pathogen profiles will span bacterial, viral, fungal and parasitic species. We encourage you to use Bug of the Month as a teaching tool to help educate healthcare personnel and start a dialogue about microbiology-related imperatives.

Click here to guess the June Bug of the Month

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in health care facilities today. 

Despite the increase of infection control and prevention protocols during the COVID-19 pandemic, during the first two years, several health care-acquired infections (HAIs) continued and most increased according to a study recently published, “Continued Increases in HAI Incidence During the Second Year of the COVID-19 Pandemic.”

“For most HAIs, our results are representative of most acute care hospitals in the U.S. and provide a national picture of the impact of COVID-19 on HAI incidence,” the investigators noted in the study. “Our findings describe the increases in HAIs that occurred during the 2021 COVID-19 pandemic year and underscore the continued challenges experienced in infection prevention. Resilient approaches are needed to reduce HAIs in 2022 and beyond.”

Central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), select surgical site infections (SSIs), and laboratory-identified (LabID) methicillin resistant 

 (MRSA) bacteremia increased during 2021, especially during the first and third quarters of the year. However, 

, Lindsey Lastinger, MPH, health scientist with the Centers for Disease Control and Prevention (CDC) and published by CambridgeCore, answered questions for 

). She summarizes the study, what are the practical applications for infection preventionists, and what research is coming on this topic.

): Please give a summary of the key findings and why they are important.

U.S. hospitals continued to face challenges with infection prevention and control during the second year of the pandemic. We found that the incidence of certain types of health care-associated infections (HAIs) in U.S. hospitals remained significantly higher in 2021 compared to the pre-pandemic time period. Within 2021, HAIs appeared to be highest during the first and third quarters of the year, coinciding with COVID-19 surges in the U.S. and the resulting high volume of COVID-19 hospitalizations.

: What is the practical application for the key findings for infection preventionists from this study?

 Infection preventionists should regularly review their HAI surveillance data to identify any gaps in infection prevention practices, paying particular attention to CLABSIs, VAEs, and MRSA bacteremia infections, which all appeared to have significant and substantial increases on the national-level during 2021. Health system leaders and infection prevention staff should explore building resiliency into their programs so that future efforts may better withstand public health emergencies.

 The heightened HAI incidence during 2021 is consistent with the results that were observed during 2020, the initial year of the pandemic. Unfortunately, the COVID-19 pandemic has presented numerous and unprecedented operational challenges in hospitals, particularly for those facilities experiencing high system stress as a result of an increasing caseload, the effects of which we are continuing to see during COVID-19 surges.

: What, if any, future research will there be related to this study?

 CDC will continue to monitor national HAI incidence throughout the pandemic and continue to identify new ways to improve HAI prevention efforts.

: Is there anything else that you would like to add?

 Previous efforts in health care settings to prevent HAIs were working effectively to decrease HAIs in the years prior to the onset of the COVID-19 pandemic. However, despite the utility of these efforts, our findings demonstrate the difficulty of HAI mitigation in times of severe strain on the health care system. Our report highlights this reality in the context of the COVID-19 pandemic which continues to take a significant toll on health care systems in the United States. It may also have implications for future instances of severe strain upon the health care system.

Device-associated HAIs were likely impacted by the continued alteration of hospital practices that occurred throughout the pandemic.


Franklin Dexter, MD, PhD, FASA, is a professor of anesthesia at the University of Iowa

Carver College of Medicine in Iowa City. He receives no funds personally other than his salary and allowable expense reimbursements from the University of Iowa, has tenure with no incentive program, and has no financial holdings in any company related to his work, other than indirectly through mutual funds for retirement.

Surgical-site infections invariably involve surgeons, operating room (OR) nurses, sterilization of equipment, and so forth. Anesthesiologists, nurse anesthetists, and other anesthesia practitioners also contribute substantially to the transmission of pathogens.

For context, incidences of surgical-site infections differ based on inclusion criteria and lengths of patient follow‑up.

 For example, measured incidences have been 7.7% for inpatient surgery based on 60-day follow-ups,

 5.5% for inpatient surgery based on 30-day follow-ups,

 and 3.7% for inpatient and outpatient hospital surgery using billing codes for diagnosis.

 A randomized trial showed that perioperative transmission of ESKAPE pathogens (

 species) can be reduced, which reduces surgical-site infections.

 Prospective observational study then showed the strategy can be implemented throughout a multidisciplinary surgical suite.

) are combined with feedback to clinicians about intraoperative bacterial transmission.

 as a marker. For example, investigators at Georgetown were sent boxes with swabs, tubes, etc, and once used, they were returned for culturing and analysis.

 The investigators studied the time it took to perform sampling using the kits.8 Anesthesia assistants essentially opened sterile swabs, swabbed anesthesia-machine valves, patient axilla, stopcock lumens, etc.

There were 13 sites per case, 6 at the start and 7 at the end.

Sampling was done for successive cases in the same OR on the same day (“case pairs”)

. An example of transmission within a case was from the nasopharynx of the patient at the start of the case to the anesthesiologist’s hands sometime by the end of the case.

An example of transmission between cases was from the nurse anesthetist’s hands at the start of the first case to the nasopharynx of the second patient (when sampled after induction), observed on the nurse anesthetist’s hands again at end of second case and also on the anesthesia equipment at the end of the second case.

 From the study, sampling time averaged 3.4 minutes at the start of each case and 4.4 minutes at the end of each case—the total significantly briefer than 10 minutes.8 The cases from which sampling is done generally are 3.3 to 4.8 hours long

; therefore, circulating nurses can obtain the samples. If this is done, instead, by anesthesia technicians or infection preventionists, add the time waiting for patient induction and to be present at the end of surgery.

The primary end point of the randomized trial and observational effectiveness study was 

 transmission. For the randomized trial, 19 surgeons and their patients were randomized to usual care or infection-control bundle with feedback.

 Patients with transmission had 6-fold greater risk of surgical-site infection (

= .007). Treatment reduced the incidence of transmission (incidence risk ratio [IRR], 0.56; 

 For the effectiveness study, 804 patients were observed months before and after the infection-control program, including transmission feedback.

Optimization reduced the incidence of transmission (IRR, 0.39; 

 transmission complements reporting of surgical-site infections. Although the incidence of surgical-site infection varies more than 10-fold among surgical procedures,

 consistently there are no covariates for transmission: not the procedure, not surgical duration, not a dirty wound, not patient characteristics.

 transmission is many-fold higher than resulting surgical-site infections. Both factors make feedback about transmission easier to explain (

 transmission, the first decision to make is which ORs to sample. Some fundamental characteristics of surgical suites are relevant.

 Some ORs have many more cases per week than others, principally because some rooms’ cases take much longer than other rooms’ cases.

 Also, surgical specialties are distributed unequally among ORs (eg, rooms used preferentially for one specialty versus another), and average case urgency differs among rooms, as does the American Society of Anesthesiologists’ physical status score.

 From a study of 57 ORs in a large teaching hospital, the 20% of ORs with the most surgical-site infections accounted for 44% of 

 transmission, whereas the 20% with the least infections accounted for 5% of

 The 10% of specialty and OR combinations with the most surgical-site infections accounted for 76%

 transmission, whereas 47% of operating rooms had zero observed infections.

 That latter result is important for purposes of monitoring 

 transmission within and between case pairs. Use your surgical-site infection data—not for regular feedback, but rather, to choose a few specialty-OR combinations to target for monitoring and intervention.

Pathogens likely are transmitted intraoperatively in all ORs.

 What differs are probabilities of transmission resulting in surgical-site infection.

 Many hospitals report surgical-site infections per month in control charts. With 3 years of data, when plotted by OR, there was no paired association with cases per month.

The reason: Although ORs with more overall minutes per case (ie, longer) had greater incidence of infection (

<.001), those ORs had far fewer cases per day (

In other words, the ORs with very long cases (> 4.8 hours) have the greatest incidence of surgical-site infections, yet on many days, have only one case.

 In contrast, the ORs with cases averaging 3.3 to 4.8 hours in length have cases long enough for greater risk of surgical-site infection and usually 2 or 3 cases per day.

 In general, those are the ORs to target to prevent pathogen transmission. Beneficially, when monitoring 

 transmission using the few specialty-OR combinations with the most infections, applying the bundle of infection prevention interventions (

 transmission, the next related question is how many case pairs to sample. From the randomized trial, we have a typical incidence for transmission in the usual care group and a corresponding low incidence achieved with infection prevention bundle and feedback.

 Using those 2 incidences and applying statistical power analysis, the sample size would be 25 case pairs.

 For example, suppose that the targets for infection prevention were the 3 ORs of one specialty.

 Then the cases studied could be the first and second cases of the day in each room for 2 weeks. That would potentially give 30 case pairs, but cases occasionally cancel, all sampling cannot be completed, and so forth. After implementation (

 transmission need not be as large as for the randomized trial and observational study.

 A reasonable choice for feedback is to use culture results from another 75 case pairs.

 This information on sample size helps infection preventionists have context on number of surgical cases for sampling so that they can help the anesthesiologists and nurse anesthetists (and surgeons, OR nurses, and other anesthesia practitioners) know what to change to reduce transmission of the intraoperative bacterial pathogens.

In conclusion, substantial understanding exists about how OR pathogens cause surgical-site infections. It is known that the processes involved include not only contaminated wounds and resistance to otherwise appropriate antibiotics, but also bacterial transmission including the anesthesia environment.

 Feedback to anesthesia practitioners contributes to reduced surgical-site infections because that transmission can be mitigated with basic measures (Table).

 There is considerable understanding of why and how best to use 

 transmission as a marker of transmission for the purpose of feedback.

Taylor JS, Marten CA, Potts KA, et al. What is the real rate of surgical site infection?

. 2016;12(10):e878-e883. doi:10.1200/JOP.2016.011759

Loftus RW, Dexter F, Goodheart MJ, et al. The effect of improving basic preventive measures in the perioperative arena on Staphylococcus aureus transmission and surgical site infections: a randomized clinical trial. 

. 2020;3(3):e201934. doi:10.1001/jamanetworkopen.2020.1934

Petrosyan Y, Thavorn K, Maclure M, et al. Long-term health outcomes and health system costs associated with surgical site infections: a retrospective cohort study. 

. 2021;273(5):917-923. doi:10.1097/SLA.0000000000003285

Dexter F, Epstein RH, Loftus RW. Quantifying and interpreting inequality of surgical site infections among operating rooms. 

. 2021;68(6):812-824. doi:10.1007/s12630-021-01931-5

Wall RT, Datta S, Dexter F, et al. Effectiveness and feasibility of an evidence-based intraoperative infection control program targeting improved basic measures; a post-implementation prospective case-cohort study. 

 2022;77:110632. doi:10.1016/j.jclinane.2021.110632

Dexter F, Parra MC, Brown JR, Loftus RW. Perioperative COVID-19 defense: an evidence-based approach for optimization of infection control and operating room management. 

. 2020;131(1):37-42.doi:10.1213/ANE.0000000000004829

Dexter F, Elhakim M, Loftus RW, Seering MS, Epstein RH. Strategies for daily operating room management of ambulatory surgery centers following resolution of the acute phase of the COVID-19 pandemic. 

. 2020;64:109854. doi:10.1016/j.jclinane.2020.109854

Datta S, Dexter F, Ledolter J, Wall RT, Loftus RW. Sample times for surveillance of 

 transmission to monitor effectiveness and provide feedback on intraoperative infection control. 

. 2020;21:100137. doi:10.1016/j.pcorm.2020.100137

Robinson ADM, Dexter F, Renkor V, Reddy S, Loftus RW. Operating room PathTrac analysis of current intraoperative Staphylococcus aureus transmission dynamics. 

. 2019;47(10):1240-1247. doi:10.1016/j.ajic.2019.03.028

Loftus RW, Dexter F, Robinson ADM. High-risk Staphylococcus aureus transmission in the operating room: a call for widespread improvements in perioperative hand hygiene and patient decolonization practices. 

. 2018;46(10):1134-1141. doi:10.1016/j.ajic.2018.04.211

Dexter F, Ledolter J, Epstein RH, Loftus RW. Futility of cluster designs at individual hospitals to study surgical site infections and interventions involving the installation of capital equipment in operating rooms. 

. 2020;44(4):82. doi:10.1007/s10916-020-01555-0

Dexter F, Ledolter J, Epstein RH, Loftus RW. Importance of operating room case scheduling on analyses of observed reductions in surgical site infections from the purchase and installation of capital equipment in operating rooms. 

. 2020;48(5):566-572. doi:10.1016/j.ajic.2019.08.017

Dexter F, Ledolter J, Wall RT, Datta S, Loftus RW. Sample sizes for surveillance of 

 transmission to monitor effectiveness and provide feedback on intraoperative infection control including for COVID-19. 

. 2020;20:100115. doi:10.1016/j.pcorm.2020.100115

To reduce the risk of surgical-site infection, utilize evidence-based interventions and give feedback to clinicians on bacterial transmission using Staphylococcus aureus as a marker. 


The OR: A Prime Target for Pathogens 

KEVIN KAVANAGH, MD, is the founder of the patient advocacy group Health Watch USA

The overriding mission of infection preventionists is to contain and stop the spread of disease. Modern day epidemiology has divided the spread of respiratory diseases into categories of airborne and droplet transmission. This dichotomy, along with 2 standards of prevention, persisted up to the COVID-19 pandemic.

 At the beginning of the pandemic, SARS-CoV-2, the virus that causes COVID-19, was thought to spread primarily by large droplets and environmental surfaces. These droplets should be easy to stop, and initial recommendations were made for contact precautions and wearing of surgical masks.However, surgical masks do not fit tight on one’s face. For droplet spread, they work well, but not for aerosolized particles.

Prior to COVID-19, it was believed that aerosols were composed only of small particles, less than 5 microns in size. Although SARS-CoV-2 is approximately one hundredth of a micron in size,

 the virus is primarily spread by respiratory droplets with an estimated minimal size of 9.3 microns.

 But case reports started to emerge that documented transmission over relatively large distances associated with singing in churches



In October 2020, after an extensive analysis of research, the National Academy of Sciences concluded that aerosolization can occur with particle size up to 100 microns.

 Apparently, just talking could aerosolize SARS-CoV-2. In addition, not only could larger particles aerosolize, but talking, singing, and coughing produce a wide range of particle sizes.

Infection preventionists must advocate for more effective and available PPE, better indoor ventilation, and mechanisms to decrease aerosols created by sinks and toilets, along with extensive training of new and temporary staff. 

We were not facing a dichotomy in methods of spread; we were facing a continuum. When a patient coughs or talks, some of the particles will aerosolize while others that are large droplets will splatter the environment. If a patient has tonsillitis from group B 

[MRSA]) and coughs, droplets will be propelled into the room. The size of 

 and some of the droplets can be expected to aerosolize. Thus, a surgical mask with gaping holes on the sides may not be protective.

Wu et al

 in 3 hospitals in China. The investigators isolated the bacteria in air and documented spread between wards and hospital corridors, which were at least 10 meters apart. Although many strains of 

 are commensal, the bacterium is just 1 plasmid away from transforming into the superpathogen carbapenem-resistant Enterobacteriaceae.

 One might ask, what could have aerosolized 

 Possibly toilet plumes. This mode of spread has also been postulated for SARS-CoV-2.

Unfortunately, the United States has been slow in adopting policies and standards that adequately prevent airborne spread. In the 19th century, health care and the public were highly resistant to realizing that cholera outbreaks were not primarily spread by foul air (miasma).

 In modern medicine, we are now reluctant to believe how frequently pathogens can become airborne.



The use of more effective personnel protective equipment (PPE) and upgrading ventilation systems in all public indoor venues is of paramount importance. Improvements in ventilation can be accomplished by increasing complete air exchanges with outdoor air or equivalent air exchanges with high-efficiency particulate air filtration and/or UV light sanitization.

Alondra Nelson, head of the Office of Science and Technology Policy and deputy assistant to the president, has stated that upgrading a building’s airflow to 5 air exchanges per hour reduces the risk of airborne disease transmission by 50% or more.

 For health care settings, facilities should have the equivalent of 12 or more complete air exchanges per hour.



In public venues, a proxy for determining safe levels of airflow and air exchanges is the measurement of the carbon dioxide concentration in the air.

Outside air has a carbon dioxide (CO2) concentration of less than 500 ppm. The American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) recommends a steady-state indoor CO2 concentration of 870 ppm.

 The Environmental Protection Agency (EPA) recommends a maximum indoor CO2 level of 1400 ppm.

 A study from Harvard University found large differences in cognition when CO2 levels were raised from 550 ppm to 1400 ppm. However, the Occupational Safety and Health Administration has more relaxed rules, with a maximal allowed average concentration within an 8-hour working period of 5000 ppm.

 Unfortunately, few indoor public venues in the United States meet the ASHRAE or even the EPA-recommended safe levels. Even at levels below 1000 ppm, symptoms of sick building syndrome, such as sore throat and wheezing, can occur.



The appropriate use of PPE has also become controversial, with many health care facilities still focusing on the prevention of large droplet spread. Recently, several large hospitals were removing N95 masks that patients wore into the facility and replacing them with surgical masks. This was reported by Politico to also have occurred at Massachusetts General Hospital, the previous facility of the director of the CDC.

A nonfitted N95 mask provides 4 times the protection of a surgical mask.

 Despite this, and the much greater infectivity of the Omicron variant, regulatory agencies still have not recommended N95 masks for all health care workers. One can make a strong case for wearing N95 masks when treating all patients with respiratory illnesses and relegating the use of poorly fitting surgical masks to surgery, during which the main concern is preventing secretions from the surgeon from contaminating the surgical site.

Increasing Health Care–Associated Infections



The pandemic has given us new knowledge to transform infection prevention; however, it has also created additional challenges that have exacerbated the epidemic of antibiotic-resistant bacteria.

A recent report from the CDC compared the standardized infection ratios (SIRs) of health care–associated infections from the years 2019 to 2020.

 The CDC observed significant increases in central line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections, ventilator-associated events (VAEs), and MRSA infections, but not in select surgical-site infections and 

infections. There was also a 14.2% to 36.4% decrease in the number of reporting hospitals during the pandemic.

Large increases in infections were seen in CLABSIs, VAEs, and MRSA, which experienced a 47.0%, 44.8%, and 33.8% increase, respectively. The SIR for these infections increased to a level between 0.97 and 1.39, effectively wiping out any gains achieved since the 2015 baseline that was set at 1.0.

Prevention of these infections requires trained and experienced staff, along with safe staffing levels. Unfortunately, the pandemic has placed tremendous stress on staff, resulting in extremely high turnover rates at many facilities. As pointed out by Lisa Lockerd Maragakis, MD, MPH, senior director of infection prevention at Johns Hopkins Health System, professor of medicine and epidemiology at Johns Hopkins University School of Medicine and the Johns Hopkins Bloomberg School of Public Health, and cochair of the CDC’s Healthcare Infection Control Practices Advisory Committee, during the March 24, 2022, meeting: “One of the main challenges I think that many of us are facing is an almost complete turnover in personal on some of our units.”

A primary factor that has contributed to the emergence of antibiotic-resistant bacteria is the overuse of antibiotics. Unfortunately, the use of telehealth during the pandemic may have promoted antibiotic overuse. Without a physical examination, it is very difficult to determine if an ear, sinus, or throat infection is present. Video color balance, brightness, and fogging make examinations of cavities difficult at best. In addition, testing for Group B

 along with bacterial cultures is not relatively available. Ray et al

 found that antibiotic usage for pediatric direct-to-consumer televisits occurred in 52% of the visits versus 31% for primary care–provider office visits.
 
Concern regarding bacterial coinfections also promotes antibiotic usage. In a review of the literature, Rawson et al found that 8% of patients with COVID-19 developed a bacterial/fungal coinfection compared with 11% of patients without COVID-19. Despite wide empirical administration of broad-spectrum antibiotics in patients with COVID-19, the authors stated there was a paucity of data to support their use.

There is no doubt that infection preventionists have a herculean task before them. They must advocate for more effective and available PPE, better indoor ventilation, and mechanisms to decrease aerosols created by sinks and toilets. Extensive training of new and temporary staff must be implemented regarding empirical antibiotic usage and infectious disease protocols, along with the education of patients and providers regarding the limitations of telehealth.

No one can be expected to accomplish all of this with prepandemic resources. The first step must be to educate hospital administration regarding the resources required to reverse the increasing rates of antibiotic resistance and to improve infection prevention by implementing the knowledge learned during the pandemic. Only then will an optimal safe workplace be created and the safest possible care be provided to patients.

Bouroulba L. Turbulent gas clouds and respiratory pathogen emissions: potential implications for reducing transmission of COVID-19. 

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Cuffari B. The size of SARS-CoV-2 and its implications. News Medical Life Sciences. February 15, 2021. Accessed April 18, 2022. 

https://www.news-medical.net/health/The-Size-of-SARS-CoV-2-Compared-to-Other-Things.aspx

Lee BU. Minimum sizes of respiratory particles carrying SARS-CoV-2 and the possibility of aerosol generation. 

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Hamner L, Dubbel P, Capron I, et al. High SARS-CoV-2 attack rate following exposure at a choir practice - Skagit County, Washington, March 2020. 

. 2020;15;69(19):606-610. doi:10.15585/mmwr.mm6919e6

Lu J, Gu J, Li K, et al. COVID-19 outbreak associated with air conditioning in restaurant, Guangzhou, China, 2020. 

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National Academies of Sciences, Engineering, and Medicine. Airborne
transmission of SARS-CoV-2. October 2020. Accessed April 18. 2022. 

https://www.nationalacademies.org/our-work/airborne-transmission-of-sars-cov-2-a-virtual-workshop

Diversity of structure of bacteria. Britannica. Accessed April 18, 2022. 

https://www.britannica.com/science/bacteria/Diversity-of-structure-of-bacteria

Wu B, Qi C, Wang L, Yang W, et al.Detection of microbial aerosols in hospital wards and molecular identification and dissemination of drug resistance of Escherichia coli.

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Skalova A, Chudejova K, Rotova V.AAC. 2017.Molecular characterization of OXA-48-like-producing Enterobacteriaceae in the Czech Republic and evidence for horizontal transfer of pOXA-48-like plasmids. 

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Li YY, Wang JX, Chen X. Can a toilet promote virus transmission? from a fluid dynamics perspective. 

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History: John Snow (1813 -1858). BBC. Accessed April 18, 2022. 

https://www.bbc.co.uk/history/historic_figures/snow_john.shtml

Let’s clear the air: an OSTP discussion on COVID and clean indoor air. Transcript. Let’s Clear the Air on COVID virtual event. March 29, 2022. Accessed April 18, 2022. 

https://www.whitehouse.gov/wp-content/uploads/2022/04/03-2022-Transcript-Lets-Clear-the-Air-on-COVID-An-OSTP-Discussion-on-Clean-Indoor-Air.pdf

Background C. Air. CDC. Updated July 22, 2019. Accessed April 18, 2022. 

https://www.cdc.gov/infectioncontrol/guidelines/environmental/background/air.html

Erdmann CA, Steiner KC, Apte MG. Indoor carbon dioxide concentrations and sick building syndrome symptoms in the base study revisited: analyses of the 100 building dataset. Environmental Protection Agency. Accessed April 18, 2022. 

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Allen JG, MacNaughton P, Satish U, Santanam S, Vallarino J, Spengler JD. Associations of cognitive function scores with carbon dioxide, ventilation, and volatile organic compound exposures in office workers: a controlled exposure study of green and conventional office environments. 

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Carbon dioxide. Occupational Safety and Health Administration. Updated December 21, 2020. Accessed April 18, 2022. 

Levy R. Politico. Some hospitals ask patients, visitors to remove N95s, citing CDC – Politico. March 16, 2022. Accessed April 18, 2022. 

https://www.politico.com/news/2022/03/16/hospital-mask-cdc-covid-00017556

Albarracin D, Beford T, Bollyky T, et al. Getting to and sustaining the next normal: a roadmap for living with COVID. The Rockefeller Foundation. Accessed April 18, 2022. 

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Weiner-Lastinger LM, Pattabiraman V, Konnor RY, et al. The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary of data reported to the National Healthcare Safety Network. 

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Maragakis L. Division of Healthcare Quality Promotion (DHQP) Update.Presented at CDC HICPAC Meeting.March 24, 2022; Atlanta, GA.


Ray KN, Shi Z. Gidengil CA, Poon SJ, Uscher-Pines L, Mehrotra A. Antibiotic prescribing during pediatric direct-to-consumer telemedicine visits. 

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Rawson TM, Moore LSP, Zhu N, et al. Bacterial and fungal coinfection in individuals with coronavirus: a rapid review to support COVID-19 antimicrobial prescribing. 

. 2020;71(9):2459-2468. doi:10.1093/cid/ciaa530

The bugs are winning, but only because we are letting them.


A Pandemic Paradigm Shift in Our Understanding of Transmission 

Daily and regular use of hydrogen peroxide (HP) as an antiseptic is demonstrated to give protection against COVID-19 curtails health care-acquired spread of SARS-CoV-2.

Regardless of vaccination status, health care workers were protected with daily and regular hydrogen peroxide antisepsis. 
