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Hospital Privacy Curtains and Bed Sheets: Soft Surface Contamination and Transmission

By Kelly M. Pyrek

Ubiquitous as they are in the hospital, healthcare textiles and other soft surfaces can fly under the radar in terms of the role they may play in the transmission of infectious agents. An increasing number of experts are investigating these contaminated textiles (including privacy curtains, upholstery, apparel, etc.) as a vehicle for cross-contamination and transmission of multidrug-resistant organisms (MDROs) such as Clostridium difficile, vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA), Acinetobacter baumannii and Pseudomonas aeruginosa. Studies indicate that microorganisms shed by patients can contaminate hospital surfaces at concentrations sufficient for transmission, and that these pathogens survive and persist for extended periods despite attempts to disinfect or remove them and can be transferred to the hands of healthcare personnel. 

As Mitchell, et al. (2015) note, "…while considerable effort is placed on cleaning and disinfection of non-porous or high-touch environmental surfaces, much less effort is placed on the procedures for cleaning and decontaminating porous, soft surfaces or healthcare textiles (e.g. privacy curtains, linen, upholstery, patient furniture or room furnishings) … The complex role that these textiles play in acquisition and retention of pathogens is further complicated by varied laundering conditions and requirements, including whether the employer allows employees to launder their work-related apparel at home. While the Centers for Disease Control and Prevention (CDC) and other government agencies around the world provide guidance for laundering contaminated textiles, achieving optimal water temperature, drying time and dedicated process flow can be difficult to achieve in healthcare facilities, and nearly impossible in homes."

Suspicions about certain healthcare textiles being neglected were confirmed by DeAngelis, et al. (2013) who reported that hospitals responding to a survey indicated they only changed privacy curtains when they were visibly soiled. The researchers sent a 20-question survey to select geographic members of the Association for Professionals in Infection Control and Epidemiology (APIC), with 50 surveys submitted for analysis. Ninety-six percent of respondents (47/49) answered ‘yes’ to whether their facility uses privacy curtains in patient rooms. Fifty-five percent (21/38) had a written policy in place specifying how often privacy curtains need to be cleaned and 53 percent (19/36) had a written policy on how often privacy curtains need to be changed. With regard to how often the privacy curtains are cleaned in a standard hospital room, 37 percent (14/38) answered ‘only when visibly soiled’ as recommended by APIC Text of Infection Control and Epidemiology, 13 percent (5/38) answered ‘every month’, 13 percent (5/38) answered ‘every 3 months’ and another 13 percent (5/38) answered ‘once per year.’ Thirty-nine percent (15/38) responded ‘other.’ The researchers report that privacy curtains were most often changed or cleaned when a patient had been discharged from an isolation room for a multi-drug resistant organism. Fifty-six percent (19/34) of respondents use curtains in the ambulatory care center. Approximately 45 percent clean or change the curtains in the ambulatory care center only when visibly soiled. Eighty-six percent (24/28) of respondents felt that improvement could be made in the management of hospital curtains and 82 percent felt that hospital curtains are a potential source of transmission of health care associated infections.

Let's examine the literature for the latest studies and a review of what is currently known about healthcare textile/soft surface contamination and transmission.

Without timely intervention, privacy curtains in hospitals can become breeding grounds for resistant bacteria, posing a threat to patient safety, say Shek, et al. (2018) who conducted a longitudinal, prospective, pilot study which tracked the contamination rate of 10 freshly laundered privacy curtains in a burn unit of a Canadian hospital.

While the curtains had minimal contamination when they were first hung, the curtains that were hung in patient rooms became increasingly contaminated over time – and by day 14, 87.5 percent of the curtains tested positive for MRSA. In contrast, control curtains that were not placed in patient rooms stayed clean the entire 21 days. None of the rooms where the curtains were placed were occupied by patients with MRSA. Four curtains were placed in a four-bed room; four were placed in two double rooms; and two controls were placed in areas without direct patient or caregiver contact. Researchers took samples from areas where people hold curtains, suggesting that the increasing contamination resulted from direct contact. 

“We know that privacy curtains pose a high risk for cross-contamination because they are frequently touched but infrequently changed,” says Kevin Shek, BSc, the study’s lead author. “The high rate of contamination that we saw by the 14th day may represent an opportune time to intervene, either by cleaning or replacing the curtains.” 
By day 21, almost all curtains exceeded 2.5 CFU/cm. 

“Keeping the patient’s environment clean is a critical component in preventing healthcare-associated infections,” says 2018 APIC president Janet Haas, PhD, RN, CIC, FSHEA, FAPIC. “Because privacy curtains could be a mode of disease transmission, maintaining a schedule of regular cleaning offers another potential way to protect patients from harm while they are in our care.” 

The study authors acknowledge the small sample size of this pilot study and recommend additional research to understand the clinical consequences of contaminated curtains. They note, "To our knowledge, this is the first study to assess the trajectory of microbial contamination on curtains over time, with control curtains used for comparison. Patient curtains became increasingly contaminated despite starting at the same level as controls. Therefore, regular curtain contact that occurs in proximity to an occupied patient bed results in increasing colonization over time. Given that we sampled areas where people hold curtains, it is likely that the increasing contamination was because of direct contact. To our knowledge, no set of standards exists for assessing hospital surface hygiene. However, it has been proposed that hospitals should be at least as clean as food preparation environments. For example, the United Kingdom has specified that food processing equipment should be <2.5 CFU/cm2; by day 21, 75 percent of remaining curtains exceeded this safety threshold. The food industry also tests for the mere presence of certain high-risk organisms. Indeed, certain pathogens such as MRSA are associated with significant morbidity and mortality. By day 14, 87.5 percent of test curtains grew MRSA. Therefore, the 14-day mark may represent an important opportunity to intervene. Fourteen days were proposed in another study to be the minimum amount of time that curtains should hang before requiring intervention."

In an earlier study looking at privacy curtain contamination on a burns/plastic surgery ward for two separate occasions six months apart (23 curtains in August 2015 and 26 curtains in January 2016), Shek, et al. (2017) found curtain contamination in August 2015 was 0.7–4.7 cfu/cm2 with 22 percent testing positive for MRSA, whereas contamination on January 2016 was 0.6–13.3 cfu/cm2 with 31 percent of curtains testing positive for MRSA.

As Shek, et al. (2017) explain, "Potential for cross-contamination to and from the curtains is increased in the presence of open wounds. Burns/plastic surgery units are especially at risk due to the number and complexity of patients with open wounds." They add, " Despite a hand hygiene compliance rate of more than 80 percent on this ward, the results of this study suggest that more work needs to be done to better understand the colonization on these curtains …The current method of cleaning privacy curtains at our institution is to remove them in exchange for a cleaned curtain and send the old curtain to hospital laundry. This is a labor-intensive and time-consuming process that may also decrease how readily available a bed is for the next patient. Therefore, curtains are changed at our institution only if the patient has a known antibiotic-resistant organism or if the curtains are visibly contaminated. Since we found a high rate of bacterial curtain contamination, the pattern of contamination needs to be further evaluated to understand optimal curtain changing or cleaning schedules. This study should be interpreted in the context of its limitations. In this cross-sectional study we showed that the curtains were contaminated with large quantities of microbes. However, as the length of time that curtains were hung is not accurately recorded, we could not correlate the length of time during which curtains were hung to the degree of microbial contamination. We were also unable to comment on the directionality of contamination from curtains to patients or vice versa. Due the small numbers it is not possible to comment on whether this contamination resulted in any infections. Finally, due to the cross-sectional nature of this study, we cannot comment on the level of contamination of the curtains when they were installed, or the rate at which microbes were acquired on the curtains."

Bushey, et al. (2015) suggest increased contamination rates with higher room occupancy and that curtains should be removed, cleaned and sanitized after approximately five weeks of use. The researchers sought to determine the relationship among time to contamination, total bio-burden levels, location, and occupancy over a 12-week period. A total of 35 patient, privacy curtains were hung in several different units of the hospital. The curtains were identical in appearance and touch and were swabbed twice weekly for four weeks and then once a week for eight weeks. The hand grip area on each curtain was sampled using saline-soaked swabs and plated onto blood agar. Colony counts were plotted by time and compared to occupancy levels for each unit. In total, 582 swabs were collected during the trial. Destructive testing was conducted at the end of the trial to determine counts per area and partial speciation of the isolates.

As the researchers report, "Contamination was rapid. Twenty-eight curtains demonstrated contamination on the first swab; all curtains were contaminated by week two. Contamination levels increased substantially at week five, followed by steady increases each week thereafter. Based on destructive testing, the average Colony Forming Units per square inch (CFU/in2) for all curtains was 190. In Unit 1, where occupancy was 100 percent throughout the trial, the CFU/in2 was 395 compared to 91 to Unit 2 whose occupancy was 52 percent. Methicillin-resistant Staphylococcus aureus (MRSA) was found on 12 (34%) of the curtains (7 of 9 curtains in Unit 1). Vancomycin-resistant-enterococci (VRE) were identified on 1/12 of Unit 4 curtains. No Carbapenem-resistant Enterobacteriaceae (CRE) were detected."

Older studies have indicated similar findings. Ohl, et al. (2012) obtained swab cultures twice weekly from the leading edge of 43 curtains in 30 rooms in two intensive care units and a medical ward. Curtains were marked to determine when they were changed. The researchers found 12 of 13 curtains (92 percent) placed during the study showed contamination within one week. Forty-one of 43 curtains (95 percent) demonstrated contamination on at least 1 occasion, including 21 percent with MRSA and 42 percent with VRE. Eight curtains yielded VRE at multiple time points: three with persistence of a single isolate type and five with different types, suggesting frequent recontamination.

As Ohl, et al. (2012) observe, "Several factors make the privacy curtains that separate patient care areas in most hospitals a potentially important site of environmental contamination. First, healthcare workers and patients frequently touch privacy curtains before, during, and after care encounters. This may promote transfer of bacteria to curtains. Indeed, prior studies have found that curtains are frequently contaminated with potentially pathogenic bacteria, including VRE and MRSA. Second, available evidence suggests that bacterial pathogens on privacy curtains may travel to patients by way of health care workers’ hands. Healthcare workers are likely to touch curtains after performing hand hygiene but before patient care. Studies employing hand imprint cultures demonstrate that bacterial pathogens are readily transferred from vinyl curtains to healthcare workers’ hands. These bacteria may then transfer to the patient during the subsequent care encounter. Third, privacy curtains are difficult to disinfect and clean and are infrequently changed. In our institution, privacy curtains may hang for several weeks before changing. Because pathogens may survive on hospital surfaces for days or weeks, this makes curtains potentially important vehicles for transmission of pathogens from prior room occupants to new patients."

The researchers add, "Our findings indicate that contamination of curtains occurs rapidly after they are placed in the healthcare setting. This has implications for interventions to reduce contamination of privacy curtains. The most immediate implication of this and other studies showing substantial bacterial contamination of privacy curtains is that healthcare workers should complete hand hygiene after touching privacy curtains and before touching the patient. The finding that transfer of organisms to curtains occurs rapidly suggests that even frequent changing or cleaning of curtains may not effectively reduce contamination. There is need for strategies to inhibit curtain contamination and potential transfer of bacteria from curtains to patients on a more continuous basis. We were unable to determine whether curtain contamination arose from an infected or colonized patient at the site of the sampling, from a patient in a nearby bed, or from the hands of healthcare workers providing care for patients known to be colonized or infected with these organisms. This information may inform interventions to lower the rate of curtain contamination. Finally, estimates of curtain contamination may depend on the surface area of the curtain swabbed for culture. However, the area swabbed in this study covered the high-touch surface of curtains that were likely to be touched during routine patient care."

A Word About Soft-Surface Contamination and Hand Hygiene 
The hand carriage connection to privacy curtains was studied by Larocque, et al. (2016) who obtained imprints of healthcare workers' fingertips when participants were approached, after hand hygiene with alcohol handrub, and directly after handling curtains. Participants' hands were heavily contaminated at baseline, in some cases with potentially pathogenic species. Half of the participants (n = 30) acquired bacteria on their fingertips from handling curtains, illustrating that privacy curtains may be involved in the transmission of infection to emergency department patients.

As the researchers note, "This study suggests that baseline hand hygiene in our ED is poor, with one-third of healthcare workers growing potentially pathogenic bacteria at baseline compared with only 7 percent (n = 2) post-hand hygiene. Half of our participants acquired new strains of bacteria by handling hospital curtains; however, none were pathogenic, conflicting with previous studies.  Ohl et al. showed that direct swabbing of curtains yielded an average of 13.2 bacterial colonies per 800 cm2. Trillis, et al. reported similar results, demonstrating that small numbers of nosocomial pathogens are transferred to gloved hands after touching contaminated curtains. The discrepancy between our results and the previous study4 may be because of differences in acquisition kinetics between gloved and non-gloved hands, a difference between ED and inpatient units, or that our recently changed curtains were not heavily contaminated. This small, observational cohort study has several limitations. HCWs achieved a median 0.79 log10 colony forming unit reduction after HH, which is a lesser reduction than anticipated based on previous reports. This study was conducted in an ED setting; therefore, findings may not be generalizable to other clinical areas where curtains are cleaned or changed on different schedules or used with different frequency. Finally, curtains themselves were not swabbed; therefore, it remains unknown whether the curtains were not contaminated with pathogens or whether transmission to healthcare worker hands was not efficient."

In the Trillis, et al. (2008) study, researchers found 42 percent of curtains surrounding patients’ beds to provide privacy to be contaminated with VRE, 22 percent with MRSA and 4 percent with C. difficile. 

Sexton, et al. (2018) sampled soft surfaces at three healthcare facilities for heterotrophic plate count (HPC) bacteria, Staphylococcus spp, Streptococcus pyogenes, and Escherichia coli followed by a tracer study with a virus surrogate seeded onto volunteer hands and commonly touched surfaces. The occurrence of microbial contaminants was determined along with microbial reductions using the soft surface sanitizer. Soft surfaces were swabbed pre- and post-intervention. The researchers found that the tracer viruses were spread to 20 percent to 64 percent of surfaces in long-term care facilities and 13 percent to 41 percent of surfaces in and physicians' offices. Only one pathogen, MRSA, was recovered. The waiting room chairs had the highest concentration of HPC bacteria before disinfection and the privacy curtains had the lowest. Reductions of up to 98.5 percent were achieved with the sanitizer in healthcare settings and up to 99.99 percent under controlled laboratory conditions.

As Sexton, et al. (2018) observe, "Although soft surfaces such as linens and clothing can be laundered, other soft surfaces such as upholstered furniture must be treated on site. Fomites, such as waiting room chairs with fabric upholstery, can become sources of contamination when ill patients shed large numbers of microbes via body secretions, including blood, feces, urine, saliva, and nasal fluid. Contact with these soft surfaces may lead to direct contact with the bodily secretions and microbes aerosolized via talking, sneezing, coughing, and vomiting. Contact of unwashed hands with soft surface fomites can also lead to pathogen transmission and transfer to other points or other surfaces in the building. Performing hand hygiene after contact with soft surfaces will aid in diminishing the opportunities for microbial transfer between surfaces. This study, along with others that address the disinfection of soft and hard surfaces, demonstrates the need for proper hand hygiene and adherence to hygiene policies in healthcare settings as a primary way to decrease the amount of microbial transfer."

They add, "The composition of the soft surfaces can influence the absorption rate of the sanitizer. Various types of fabrics have different absorptive potentials allowing the sanitizer to be absorbed more quickly. In this study, the sanitizer was observed to absorb more quickly into the chair surfaces than privacy curtains, which may explain why greater log10 reductions were seen in chair samples. In a study comparing antimicrobial and plain curtains, the median amount of time for an antimicrobial curtain to become contaminated was 14 days compared with two days with plain curtains. However, after 4 weeks, 27 of the 30 antimicrobial curtains were contaminated. This demonstrates that antimicrobial materials may be helpful by increasing the amount of time for the initial contamination but may not be helpful in preventing contamination long term."

Potential Solutions
UV-C decontamination may be a feasible adjunctive measure to conventional laundering to preserve the cleanliness of healthcare textiles in ward rooms.
Smolle, et al. (2018) tested the ability of an automated ultraviolet-C (UV-C) room disinfection device to decontaminate textiles inoculated with Enterococcus faecium in a clinical setting. Contaminated polycotton (50/50 polyester/cotton) swatches were distributed to predefined locations in a ward room and exposed to UV-C light. UV-C decontamination reduced E. faecium counts by a mean log10 reduction factor of 1.37. The median time required for decontamination was 111 (range 108–165) min, and UV-C decontamination reduced the bacterial count, on average, by a log10 reduction factor of 1.37. The greatest reduction was seen in the samples placed on the floor adjoining the bed (log10 reduction factor −1.97), while the smallest reduction was seen in samples placed in the cupboard (log10 reduction factor −0.57). In all samples, the reduction was significant. 

As the researchers explain, "In this study, the greatest reduction in E. faecium viable counts was seen in samples placed on the floor adjoining the bed; this was most likely due to the fact that this sample, as well as the sample placed on the bed, was closest (approximately 1 m) to the device. In contrast to the sample on the bed, however, whose surface was parallel to the direction of the light, the sample on the floor was exposed to UV-C light in a more perpendicular fashion. This may serve as an explanation for the better decontamination of the sample on the floor. To the authors' knowledge, only one comparable study has assessed the efficacy of UV-C light for decontamination of fabrics, but that was under laboratory conditions and used a single mercury lamp placed directly over the swatches instead of the UV-C device. The test bacterium was MRSA and the bacterial load was lower (1.5 × 104 cfus) than in the present study. Conventional laundering (60°C/140°F) reduces E. faecium counts in polycotton healthcare textiles by 3–4 log10 ranks, while additional tumble drying or ironing is required for complete eradication [4]. For terminal decontamination, UV-C light is clearly less effective, although a consistent and significant reduction of bacteria can be achieved. Furthermore, one of the main limitations of the device used is the fact that it is not possible to enter the room during the decontamination process due to the potentially dangerous amount of UV-C radiation. In conclusion, UV-C decontamination is less efficient than laundering but may be a feasible adjunct to preserve the microbiological safety of healthcare textiles in place. It is important to note that UV-C decontamination does not only work on smooth surfaces in a clinical setting but also on fabrics, albeit to a lesser extent."

Rutala, et al. (2014) tested the ability of an improved hydrogen peroxide solution to decontaminate privacy curtains in inpatient and outpatient areas. The microbial contamination of the curtains was assessed before and after the curtains were sprayed with improved hydrogen peroxide. The disinfectant reduced the microbial load on the privacy curtains by 96.8% in 37 patient rooms.

The researchers also performed a wipe procedure on curtains in 10 intensive care unit (ICU) patient rooms following isolation precautions for MRSA and/or VRE. A 6.75-in × 9-in large IHP wipe was applied to the front of the curtain (i.e., the patient side) using a gloved hand placed on the back of the curtain as support. This was repeated on the opposite side but in no case were sites cultured that had just had gloved hand contact. After allowing a 2-minute contact time with the disinfectant, the post-disinfection samples were collected. The IHP was found to reduce 96.8 percent of the pathogens on the privacy curtains in 37 patient rooms. In the ICU rooms of patients subject to contact precautions, the microbial contamination of the curtains ranged from 0-341 CFU with an average of 43 MRSA and/or VRE per curtain (median, 7 MRSA and/or VRE per curtain). Post-disinfection, MRSA and VRE were completely eliminated (100% reduction). In three cases, VRE was found on the curtains of a patient subject to MRSA contact precautions and in 1 case MRSA was found on the curtain of a patient subject to contact precautions for VRE. In all 4 of these rooms, a patient with the same pathogen occupied that room during the previous 8-60 days.
Sood, et al. (2014) investigated disinfectants used on privacy curtains. The researchers inoculated curtain swatches with suspensions of clinical specimens of MRSA, VRE and Clostridium difficile before using a gloved hand to touch the inoculated curtain swatch and transfer to clean agar plates. Three different commonly used disinfectants were then sprayed onto these swatches before using a clean gloved hand to touch the swatch and transfer onto new agar plates. All plates were incubated at 35°C for 24 and 72 h. Bacterial growth before and after disinfection was assessed and compared. 3.1 percent hydrogen peroxide effectively eliminated transfer of C. difficile, MRSA and VRE from inoculated curtains.

Rinck (2010) assessed antimicrobial (AM) activity of standard versus AM curtains and to compare direct and indirect costs associated with each. Two samples of AM and one sample of standard (ST) curtain were evaluated for AM activity by placing fabric samples directly onto agar inoculated with clinical isolates or quality control organisms. Control discs were: vancomycin for Staphyloccocus aureus, coagulase-negative staphylococci and enterococci; chloramphenicol for VRE, and meropenem for gram-negative bacteria. The researcher reports that at her 634-bed academic teaching hospital privacy curtains were regularly changed at room discharge for isolation cases and when visibly soiled for non-isolation. Cost estimates of ST and AM curtains were obtained from distributor. Indirect costs of curtain washing and staff time were calculated based on the number of isolation discharges and average wage for environmental services staff. An estimate of opportunity cost of lost room availability due to time for curtain change was calculated. A total of 15 clinical and ATCC quality control organisms, including MRSA, VRE, P. aeruginosa, K. pneumoniae, E. coli, Enterobacter cloacae and A. baumannii, were tested. One of the AM fabrics exhibited broad-spectrum antibacterial activity comparable to that of an antibiotic control disc, while the other showed much less activity. No antimicrobial activity was detected with the ST sample. 475 privacy curtains are in use daily. 

A Word About Contaminated Hospital Bed Sheets
Washing contaminated hospital bedsheets in a commercial washing machine with industrial detergent at high disinfecting temperatures failed to remove all traces of Clostridium difficile (C. difficile), suggesting that linens could be a source of infection among patients and even other hospitals, according to a recent study published in Infection Control and Hospital Epidemiology. 

"The findings of this study may explain some sporadic outbreaks of C. difficile infections in hospitals from unknown sources, however, further research is required in order to establish the true burden of hospital bedsheets in such outbreaks,” says Katie Laird, PhD, head of the Infectious Disease Research Group in the School of Pharmacy at De Montfort University in the United Kingdom and lead author of the study. “Future research will assess the parameters required to remove C. difficile spores from textiles during the laundry process."

Researchers inoculated swatches of cotton sheets with C. difficile. The swatches were then laundered with sterile uncontaminated pieces of fabric using one of two different methods — either in a simulated industrial washing cycle using a washer extractor with and  without detergent or naturally contaminated linens from the beds of patients with C. difficile infection were put through a full commercial laundry where they were washed in a washer extractor (infected linen wash) with industrial detergent, pressed, dried, and finished according to current the National Health Service in the United Kingdom’s healthcare laundry policy (Health Technical Memorandum 01-04 Decontamination of Linen for Health and Social Care (2016).  Researchers measured the levels of contamination before and after washing. Both the simulated and the commercial laundering via a washer extractor process failed to meet microbiological standards of containing no disease-causing bacteria, the study found. The full process reduced C. difficile spore count by only 40 percent, and this process resulted in bacteria from the contaminated sheets being transferred to the uncontaminated sheets after washing. 

Researchers concluded that thermal disinfection conditions currently required by the UK National Health System are inadequate for the decontamination of C. difficile spores. There may be potential to spread C. difficile back into the hospital environment as linens could be a source for outbreaks at other healthcare facilities through businesses that collect, launder and redistribute rented linens to multiple hospitals and care facilities, as is the case at NHS facilities. The research team, which also includes PhD student Joanna Tarrant, is working closely with the Textiles Services Association in the UK to continue research to find which combination of laundering parameters

In an attempt to help clarify the difference in U.S. practice from that of a recent article appearing in ICHE questioning the effectiveness of the wash process to remove C. diff from hospital textiles, the Association for Linen Management (ALM) has provided a crosswalk between the two methods. The UK approach to processing healthcare linen relies primarily on thermal applications, ALM clarifies.

In the U.S., laundry processors have long relied on the recommendations from the Centers for Disease Control and Prevention (CDC):  “The antimicrobial action of the laundering process results from a combination of mechanical, thermal, and chemical factors. Dilution and agitation in water remove substantial quantities of microorganisms. Detergents and surfactants function to suspend soils, reduce water surface tension, and also exhibit some microbiocidal properties.”

ALM is offering a crosswalk document that can assist practitioners and administrators in their decision-making around healthcare textile laundering. The document can be found here: https://bit.ly/2EE1ZYo

As Fijan and Turk (2012) acknowledge, "Contaminated textiles and fabrics often contain high numbers of microorganisms from body substances, including blood, skin, stool, urine, vomitus, and other body tissues and fluids. Although contaminated textiles in healthcare facilities can be a source of substantial numbers of pathogenic microorganisms, reports of healthcare-associated diseases linked to contaminated fabrics are few, therefore the overall risk of disease transmission is very low." 

Having said that, they add, "Literature in the field of survival of microorganisms on hospital textiles after laundering is very diverse and perhaps even confusing and contradictory. Each publication states a different laundering temperature as appropriate. It is therefore important to note that a successful laundering procedure is dependent on several factors and each much be optimized. These factors with a possible synergistic effect include: duration of laundering procedure, mechanical action of laundering procedure, dosage and type of added detergents and disinfection agents, bath ratio, type of linen, filling ratio, etc. It has been reported that Clostridium difficile spores can survive temperatures and chemical treatment of typical hospital laundering cycles and that cross-contamination of Clostridium difficile spores can occur on bed linen during a wash cycle. Therefore, the persistent nature of this organism must be considered by infection control personnel when implementing programs for laundering soiled and contaminated hospital linen." 

The Healthcare Laundry Accreditation Council (HLAC) confirms that wash processes which conform to the guidelines recommended by the Centers for Disease Control and Prevention (CDC), and which are a core component of the HLAC Accreditation Standards document, sufficiently reduce the possibility of exposure of laundry workers, patients and the hospital environment to Clostridium difficile (C diff) spores.

HLAC is a nonprofit organization that inspects and accredits laundries processing textiles for hospitals, nursing homes and other healthcare facilities. HLAC's statement comes in response to concerns over a recent report published in Infection Control & Hospital Epidemiology (October 2018) that concluded that C diff spores were able to survive laundering processes used by the United Kingdom National Healthcare System (UK NHS). The UK study found that conventional NHS laundering methods for hospital bed sheets left significant C diff spores behind, increasing the risk of contamination. 

"Since the UK study was published, we've received a number of queries from our accredited laundries about the effectiveness of HLAC's standards in reducing the burden of C diff," says HLAC board member and healthcare epidemiologist Carol M. McLay, DrPH, MPH, RN, CIC, FAPIC. "Operators want to know if the UK findings were cause for concern in the US and Canada. We're reassuring them that following CDC guidelines sufficiently removes C diff spores from textiles."

McLay noted that there are major differences between HLAC processing standards and how the UK process healthcare textiles, including temperature levels, durations of processing time and chemical concentrations.

HLAC's comments echo the review and published document by the Association for Linen Management (ALM) that noted "a close look at this study reveals the UK approach to processing healthcare linen relies primarily on thermal applications."

According to the ALM review, "In the U.S., laundry processors have long relied on the recommendations from the Centers for Disease Control and Prevention (CDC)." ALM said those recommendations state, "The antimicrobial action of the laundering process results from a combination of mechanical, thermal, and chemical factors. Dilution and agitation in water remove substantial quantities of microorganisms. Detergents and surfactants function to suspend soils, reduce water surface tension, and also exhibit some microbiocidal properties." 

For additional information, HLAC is also recommending an earlier article "Healthcare Laundry and Textiles in the United States: Review and Commentary on Contemporary Infection Prevention Issues" (June 2015), in which Lynne M. Sehulster, PhD, M(ASCP), CMIP(AHE) noted that, "Outbreaks of infectious diseases associated with laundered HCTs are extremely rare; only 12 such outbreaks have been reported worldwide in the past 43 years." In her article, Sehulster, a former HLAC board member, said, "Current infection prevention strategies and textile management during patient use appear to be adequate in preventing HAIs, provided that every step is taken to maintain the hygienic quality of HCTs before use." 
 
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Ohl M, et al. Hospital privacy curtains are frequently and rapidly contaminated with potentially pathogenic bacteria. Am J Infect Control. Vol. 40, No. 10. Pages 904-906. December 2012.
Rinck G. Comparison of Antimicrobial and Standard Privacy Curtains: Efficacy and Cost Analysis. Am J Infect Control. Vol. 38, No. 5. Page e14. June 2010.
Rutala WA, Gergen MF, et al.  Effectiveness of improved hydrogen peroxide in decontaminating privacy curtains contaminated with multidrug-resistant pathogens. Am J Infect Control. Vol. 42, No. 4. Pages 426-428. April 2014.
Sexton JD, Wilson AM, Sassi HP, and Reynolds KA. Tracking and controlling soft surface contamination in healthcare settings. Am J Infect Control. Vol. 46, No. 1. Pages 39-43. January 2018.  
Shek K, Patidar R, Kohja Z, Liu S, Gawaziuk JP, Gawthrop M, Kumar A, and Logsetty S, Rate of contamination of hospital privacy curtains in a burns/plastics ward: A longitudinal study. Am J Infect Control. Vol. 46, No. 9. September 2018. 
Shek K, Patidar R, Kohja Z, et al. Rate of contamination of hospital privacy curtains on a burns and plastic surgery ward: a cross-sectional study. J Hosp Infect, 96. 2017.
Smolle C, Huss F, et al. Effectiveness of automated ultraviolet-C light for decontamination of textiles inoculated with Enterococcus faecium. J Hosp Infection. Vol. 98, No. 1. Pages 102-104. January 2018.
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