Tray tables, bed rails, light switches, and toilets: All are common vectors for swapping germs between patients and health care workers. While a new systematic overview in this week’s Annals of Internal Medicine points to several promising cleaning tactics of these “high-touch surfaces,” there’s a lack of evidence as to which is the most effective at reducing healthcare-associated infections (HAIs). Few studies measured patient outcomes or focused on newer technologies, and even less compared cleaning tactics against one another — important gaps to fill as the U.S. health care system works to reduce the 75,000 HAI-related deaths that occur annually.

The systematic overview was led by Craig A. Umscheid, MD, MSCE, an assistant professor of Medicine and Epidemiology in the Perelman School of Medicine at the University of Pennsylvania, and Senior Associate Director at the ECRI Institute-Penn Medicine Agency for Healthcare Research and Quality (AHRQ)-funded Evidence-Based Practice Center (EPC), Jennifer Han, MD, MSCE, an assistant professor of Medicine and Epidemiology, and Brian Leas, MS, MA, and Nancy Sullivan, research analysts in the ECRI-Penn AHRQ EPC, and revealed major gaps in existing evidence for the best practices for cleaning hospital room surfaces to prevent HAIs, including Clostridium difficile, MRSA, andVRE.  

“The cleaning of hard surfaces in hospital rooms is critical for reducing healthcare-associated infections,” said Han, the study’s lead author. “We found that the research to date does provide a good overall picture of the before and after results of particular cleaning agents and approaches to monitoring cleanliness. Researchers now need to take the next step and compare the various ways of cleaning these surfaces and monitoring their cleanliness in order to determine which are the most effective in driving down the rate of hospital-acquired infections.”

While studies examining HAIs have increased over the last 15 years, infections acquired in the hospital remain a leading cause of death and morbidity. In 2011, there were over 721,000 HAIs in the U.S., according to the most recently available data from the U.S. Centers for Disease Control and Prevention (CDC). What’s more, many experts believe that only 50 percent of surfaces are typically disinfected during cleaning of a patient’s room. 

Examining 80 studies published between 1998 and 2014, the research team found that comparative effectiveness studies were uncommon. Such studies would have directly compared different ways of cleaning, disinfecting, and monitoring the cleanliness of hard surfaces in order to determine which were most effective. There were also relatively few studies that focused on measuring outcomes of most interest to patients, such as changes in HAI rates or the presence of pathogens on patients. Only five of the studies were randomized controlled trials.

Instead, the existing studies were largely before and after experiments, comparing the magnitude of surface contamination after cleaning with a particular agent to the magnitude of contamination before cleaning.  Over 65 percent of the studies assessed surface contamination, such as bacterial burden and colony counts, as the primary outcome.  Less than 35 percent reported on patient-centered outcomes, such as HAI rates or acquisition of a specific organism in the body, known as colonization.

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