ARTICLE IN PRESS American Journal of Infection Control ■■ (2016) ■■-■■
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Letters to the editor
Response to Russotto et al To the Editor: We welcome the comments regarding our recent article.1 The study showed a number of interesting findings that built on our earlier article2 where we proposed a new, synergistic approach to monitoring cleanliness within health care settings. The use of rapid adenosine triphosphate (ATP) testing is a single component of the monitoring approach we trialed. We strongly agree that there are limitations to using rapid ATP testing.3 We have previously discussed both the failure risks and also the precision limitations of ATP testing.2,4 The results obtained during our bad bugs pilot study could be easily overstated, as we indicated in the first sentence of the Discussion. The statistical significance demonstrated through a pilot study such as ours (with acknowledged small sample numbers) should be considered very carefully, dare we say conservatively. In our study the use of ATP testing in combination with targeted microbiologic sampling was compared against the use of targeted microbial sampling without the aid of ATP testing. The immediacy of feedback from the ATP testing was the advantage indicated. There is no suggestion that the use of ATP testing correlates with the presence of multidrug-resistant organisms (MDROs). The presence of MDROs on various surfaces within clinical environments, particularly when contained within biofilms, poses an important transmission risk.5 The pilot study indicated that the benefits of a selected monitoring approach can be used to complement the weaknesses of other monitoring systems. When used together the synergistic monitoring approach assisted in identifying those surfaces that had higher ATP readings and that were coincidentally occupied by MDROs. We do not endorse the use of ATP testing in isolation, and would be guarded over its use even in verification of a cleaning process without a carefully considered sampling methodology.6 An international manufacturer of ATP testing equipment previously commented that “ATP testing is not a substitute for microbiology testing.”7 Again we are in strong agreement. This discussion on cleanliness monitoring highlights the importance of allowing the science in this area to develop and be subjected to peer review, critique, and confirmation testing, and to have a dynamic dialogue.8 Our research program using an integrated cleanliness monitoring approach is being extended with a series of larger studies to qualify the initial results. More work is required to determine the best and most scientifically defensible methods of cleanliness and cleaning monitoring. In addition to the importance of cleanliness, we also heartily endorse the conclusion of the letter, which states that we should all be reminded to clean our hands. The research suggests that of the 5 Moments of Hand Hygiene, Moments 1 and 5 may be crucial infection intervention points between the patient zone and the clinical workspace, particularly in intensive care units when cleaning is inadequate.
References 1. Whiteley GS, Knight JL, Derry CW, Jensen SO, Vickery K, Gosbell IB. A pilot study into finding the bad bugs in a busy intensive care unit. Am J Infect Control 2015;43:1270-5. 2. Whiteley GS, Derry C, Glasbey T. Failure analysis in the identification of synergies between cleaning monitoring methods. Am J Infect Control 2015; 43:147-53. 3. Shama G, Malik DJ. The uses and abuses of rapid bioluminescence-based ATP assays. Int. J Hyg. Environ. Health 2013;216:115-25. 4. Whiteley GS, Derry C, Glasbey T, Fahey P. The perennial problem of variability in Adenosine Triphosphate (ATP) tests for hygiene monitoring within healthcare settings. Infect Control Hosp Epidemiol 2015;36:658-63. 5. Hu H, Johani K, Gosbell IB, Jacombs ASW, Almatroudi A, Whiteley GS, et al. Intensive care unit environmental surfaces are contaminated by multidrugresistant bacteria in biofilms: combined results of conventional culture, pyrosequencing, scanning electron microscopy, and confocal laser microscopy. J Hosp Infect 2015;91:35-44. 6. Whiteley GS, Derry C, Glasbey T. Sampling plans for use of rapid Adenosine Triphosphate (ATP) monitoring must overcome variability or suffer statistical invalidity. Infect Control Epidemiol 2015;36:236-7. 7. Roady L. Abundant research in support of ATP cleaning verification’s applicability in healthcare. Infect Control Hosp Epidemiol 2015;36:1367. 8. Dancer J. Hospital cleanliness: establishing a new science. J Hosp Infect 2012;80:354-6. Conflicts of Interest: None to report.
Greg S. Whiteley, MSafetySc, Dip AICD, BAppSc* School of Science and Health, University of Western Sydney, Richmond, NSW, Australia Whiteley Corporation Pty Ltd, North Sydney, NSW, Australia Jessica L. Knight, DipSc, BSc(Hons) School of Medicine, University of Western Sydney, Campbelltown, NSW, Australia Antibiotic Resistance and Mobile Elements Group, Molecular Medicine Research Group, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia Chris W. Derry, PhD, MSc(Med), BSc(Med)Hons School of Science and Health, University of Western Sydney, Richmond, NSW, Australia Slade O. Jensen, PhD, BSc(Hons) School of Medicine, University of Western Sydney, Campbelltown, NSW, Australia Antibiotic Resistance and Mobile Elements Group, Molecular Medicine Research Group, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia Karen Vickery, PhD, MSc, BVSc(Hons) Surgical Infection Research Group, Faculty of Medicine and Health Sciences, Macquarie University, North Ryde, NSW, Australia
0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
ARTICLE IN PRESS 2
Letter to the Editor / American Journal of Infection Control ■■ (2016) ■■-■■
Iain B. Gosbell, MD, MBBS, FRACP School of Medicine, University of Western Sydney, Campbelltown, NSW, Australia Antibiotic Resistance and Mobile Elements Group, Molecular Medicine Research Group, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia Department of Microbiology and Infectious Diseases, Sydney South West Pathology Service, Liverpool, NSW, Australia
* Address correspondence to Greg S. Whiteley, MSafetySc, Dip AICD, BAppSc, Whiteley Corporation Pty Ltd, PO Box 1076, North Sydney, NSW 2096, Australia. E-mail address:
[email protected] (G.S. Whiteley). http://dx.doi.org/10.1016/j.ajic.2016.01.034
