title: Cleaning the grey zones of hospitals: A prospective, crossover, interventional study.
abstract: Environmental cleaning is a fundamental principle of infection prevention in hospitals, but its role in reducing transmission of health care-acquired pathogens has been difficult to prove experimentally. In this study we analyze the influence of cleaning previously uncleaned patient care items, grey zones (GZ), on health care-acquired transmission rates.
  
  
  
  The intervention consisted of specific GZ cleaning by an extra cleaner (in addition to routine cleaning) on 2 structurally different acute care medical wards for a period of 6 months each, in a crossover design. Data on health care-acquired transmissions of vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus, and Clostridium difficile were collected during both periods. Adjusted incidence rate ratios (IRRs) using Poisson regression were calculated to compare transmission of pathogens between both periods on both wards.
  
  
  
  During the intervention VRE transmission was significantly decreased (2-fold) on the ward where patients had fewer roommates; cleaning of GZ did not have any effect on the ward with multiple-occupancy rooms. There was no impact on methicillin-resistant S aureus transmission and only a nonsignificant decrease in transmission of C difficile.
  
  
  
  Our data provide evidence that targeted cleaning interventions can reduce VRE transmission when rooming conditions are optimized; such interventions can be cost-effective when the burden of VRE is significant. Enhanced cleaning interventions are less beneficial in the context of room sharing where many other factors contribute to transmission of pathogens.
authors.affiliation: McGill University, Montreal, Quebec, Canada; St Mary's Hospital Centre, Montreal, Quebec, Canada. Electronic address: makeda.semret@mcgill.ca.
authors.forename: Makeda
authors.initials: M
authors.lastname: Semret
authors.affiliation: St Mary's Hospital Centre, Montreal, Quebec, Canada.
authors.forename: Alina
authors.initials: A
authors.lastname: Dyachenko
authors.affiliation: St Mary's Hospital Centre, Montreal, Quebec, Canada.
authors.forename: Leila
authors.initials: L
authors.lastname: Ramman-Haddad
authors.affiliation: St Mary's Hospital Centre, Montreal, Quebec, Canada.
authors.forename: Eric
authors.initials: E
authors.lastname: Belzile
authors.affiliation: St Mary's Hospital Centre, Montreal, Quebec, Canada.
authors.forename: Jane
authors.initials: J
authors.lastname: McCusker
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016360:Clostridioides difficile / Q000302:isolation & purification; D003428:Cross Infection / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control* / Q000635:transmission; D018592:Cross-Over Studies; D004203:Disinfection / Q000379:methods*; D006761:Hospitals; D006797:Housekeeping, Hospital / Q000379:methods*; D006801:Humans; D008297:Male; D055624:Methicillin-Resistant Staphylococcus aureus / Q000302:isolation & purification; D008875:Middle Aged; D011446:Prospective Studies; D065507:Vancomycin-Resistant Enterococci / Q000302:isolation & purification
keywords: Clostridium difficile; Environmental cleaning; MRSA; VRE