A BETR (Benefits of Enhanced Terminal Room Disinfection) Way to Clean Hospital Rooms

Jane Conyers, Mercer University College of Pharmacy

Methicillin-resistant Staphylococcus aureus (MRSA) can survive for up to a year in accumulated hospital dust. Its presence creates an increased risk of infection for patients and healthcare providers. [1]

The Centers for Disease Control and Prevention (CDC) acknowledged that effective contact time for disinfectants was often too long to be adhered to in practice, and that aerosol spray disinfectants produced unsatisfactory results. [2]

Patients may be at increased risk of acquiring MRSA, vancomycin resistant enterococcus (VRE), or Acinetobacter baumanii if admitted to rooms previously occupied by individuals infected or colonized with these organisms.  The pathogens can be acquired from objects and sites contaminated by the prior occupant when the room is not adequately cleaned after discharge. [3]

Additionally, spores can survive and be transmitted when a gloved hand comes into contact with a contaminated surface; [4] however, there is some evidence that ultraviolet (UV) light is effective in killing these spores. [5]

Enhanced Terminal Room Disinfection and Acquisition and Infection Caused by Multidrug-Resistant Organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): A Cluster-Randomised, Multicentre, Crossover Study [6]
Design A multicenter, cluster-randomized, crossover trial; N= 11,859
Objective To assess four strategies for terminal room disinfection on acquisition of multidrug-resistant organisms and Clostridium difficile infection (CDI)
Study Groups Ammonia (n= 4,916); ultraviolet (UV) (n= 5,178); bleach (n= 5,438); bleach + UV (n= 5,863)
Methods In the reference group, all rooms were disinfected with a quaternary ammonium-containing (ammonia) disinfectant, except rooms of patients with CDI.  In patients with CDI, rooms were disinfected with a hypochlorite-containing disinfectant (bleach).  Ultraviolet C (UV) devices were used in addition to either ammonia or bleach in those study groups.
Seed rooms contained a patient with microbiologically proven history of or current infection or colonization with one or more target organisms: MRSA, VRE, C. difficile, or multidrug-resistant (MDR) Acinetobacter.  The next patient admitted to the seed room was an exposed patient.  Incidence rate was calculated as the number of qualifying incident cases per 10,000 exposure days.  Exposure days were calculated as the number of days the exposed patient spent in the seed room.
Duration April 2012 to July 2014
Primary Outcome Measure Incidence of target organisms among patients exposed to seed rooms
Baseline Characteristics
Ammonia UV Bleach Bleach + UV
Mean age, years 57.9 58.5 58.6 57.7
Race, n (%)
 White 3042 (63) 3228 (65) 3416 (64) 3747 (64)
African – American 1418 (30) 1411 (28) 1591 (30) 1655 (28)
Other 345 (7) 330 (7) 344 (7) 440 (8)
Male, n (%) 2475 (51) 2518 (51) 2768 (52) 3017 (52)
Organism Ammonia UV Bleach Bleach + UV
C. difficile
Incidents, n (%) 36 (1.4) 30 (1.8)
Exposure days 11,385 8,015
Rate per 10,000 exposure days 31.6 37.4

(95% CI)


(0.68 – 2.17)

p-value 0.511
Incidents, n (%) 73 (2.2) 28 (1.5) 74 (2.0) 63 (2.6)
Exposure days 14,525 7,934 15,343 10,681
Rate per 10,000 exposure days 50.3 35.3 48.2 59.0

(95% CI)


(0.48 – 0.94)


(0.82 – 1.21)


(0.85 – 1.39)

p-value 0.019 0.967 0.503
Incidents, n (%) 37 (3.5) 13 (2.0) 24 (1.6) 24 (2.1)
Exposure days 5,838 3,265 7,522 6,237
Rate per 10,000 exposure days 63.4 29.4 31.9 39.0

(95% CI)


(0.21 – 1.50)


(0.16 – 0.78)


(0.22 – 0.77)

p-value 0.248 0.010 0.006
MDR Acinetobacter
Incidents, n (%) 0 0 1 (3.6) 0
Adverse Events Common Adverse Events: N/A
Serious Adverse Events: N/A
Percentage that Discontinued due to Adverse Events: N/A
Study Author Conclusions There was a decrease in acquisition and infection with resistant pathogens following the use of enhanced room disinfection strategies.  The largest risk reduction occurred when a UV-C device was added to the standard disinfectant strategy.  Only one patient acquired MDR Acinetobacter, so no comparisons or models were constructed.


The cleaning protocol was standardized and evaluated on a per protocol basis that reflected a best case scenario.  Wait times for patients admitted from the emergency department did not increase even with the additional measures for enhanced cleaning, which is an important finding for hospital administration and patient satisfaction.  However, despite consistent cleaning techniques, not all of the hospitals showed reduced incidence of infection.  One possible reason for this is that hand hygiene protocols were not standardized across all participants, resulting in low adherence rates among one hospital’s staff.  This potentially direct transmission of pathogens to patients limits the usefulness of any intervention performed on an inanimate object.

Standard room cleaning with ammonia was not enough to control VRE organisms and hospitals could benefit from changing their protocols to include bleach in these rooms.  The finding that the addition of UV light did not reduce C. difficile incidence casts doubt on its sporicidal reliability.



  1. Dancer SJ. Importance of the environment in meticillin-resistant Staphylococcus aureus acquisition: the case for hospital cleaning. Lancet Infect Dis. 2008;8(2):101-13.
  2. Rutala W, Weber D, Weinstein R, et al. Centers for Disease Control. Guideline for disinfection and sterilization in healthcare facilities. 2008. https://www.cdc.gov/hicpac/Disinfection_Sterilization/3_4surfaceDisinfection.html. Accessed February 1, 2017.
  3. Carling PC, Parry MM, Rupp ME, et al. Improving cleaning of the environment surrounding patients in 36 acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(11):1035-41.
  4. Guerrero DM, Nerandzic MM, Jury LA, Jinno S, Chang S, Donskey CJ. Acquisition of spores on gloved hands after contact with the skin of patients with Clostridium difficile infection and with environmental surfaces in their rooms. Am J Infect Control. 2012;40(6):556-8.
  5. Pegues DA, Han J, Gilmar C, Mcdonnell B, Gaynes S. Impact of Ultraviolet Germicidal Irradiation for No-Touch Terminal Room Disinfection on Clostridium difficile Infection Incidence Among Hematology-Oncology Patients. Infect Control Hosp Epidemiol. 2017;38(1):39-44.
  6. Anderson DJ, Chen LF, Weber DJ, et al. Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study. Lancet. 2017; doi: 10.1016/S0140-6736(16)31588-4.



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