Reducing hospital-acquired infections

by Jeri L. Steele, RN

Introduction

Copper is essential to the development of all forms of life and is naturally present in the earth’s crust. It is the oldest metal used by man, with the first copper coins dating from 8700 B.C. As the best electrical conductor, of all the metals, for energy generation, distribution and use, copper is at the heart of virtually all electrical and electronic devices.

Microbes were not discovered until the 19th century, but copper’s hygienic properties were well known through experience and tradition. The Egyptians used copper as a sterilization agent for drinking water and wounds. Hippocrates treated open wounds and skin irritations with copper. The Romans recorded numerous medicinal uses of copper. The Aztecs used copper to treat sore throats, while Persia and India used it to treat boils, eye infections and venereal ulcers. Today, copper is an active ingredient in many different types of antimicrobial products: fungicides, antifouling paints, antimicrobial medicines, oral hygiene products, hygienic medical devices, antiseptics and a host of other useful applications.

In February 2008, the U.S. Environmental Protection Agency (EPA) approved the registration of copper as an antimicrobial agent to reduce specific harmful bacteria linked to potentially deadly microbial infections.(EPA Registers Copper,2010) The registration is a legal U.S. federal government decision acknowledging the antimicrobial efficacy of copper-based products against the following disease causing bacteria: E. coli 0157: H7, MRSA, Staphylococcus aureus, Enterobacter aerogenes, and Psuedomonas aeruginosa, when cleaned regularly and as a supplement to routine cleaning and disinfection programs.(The Copper Advantage,2010)

There are 282 copper alloys, which can now be marketed in the United States as antimicrobial. Potential uses, that include door and furniture hardware, bed rails, intravenous (IV) poles, soap, hand sanitizer, and paper towel dispensers, faucets, sinks and workstations, could help reduce the amount of disease-causing bacteria in patient rooms and healthcare facilities in general. This can also apply to any public facility with a high risk of cross contamination such as schools, gyms, spas, or any public bathroom.

Use of Copper in the Healthcare Environment

Healthcare researchers and the copper industry are working together to answer one very important question: Can copper and copper alloys (brass and bronze) help curb the spread of bacteria that cause hospital-acquired infections?

Resistant pathogens lead to higher healthcare costs because they often require more expensive drugs and extended hospital stays. In July 2004, the Infectious Disease Society of America reported: “The pipeline of new antibiotics is drying up. Major pharmaceutical companies are losing interest in the antibiotics market because these drugs simply are not as profitable as drugs that treat chronic (long term) conditions and lifestyle issues.”(Bad Bugs, No Drugs, 2004)

If you were to be hospitalized today, you have a one in 20 chance of acquiring an infection and a one in 20 chance of dying from this infection. Hospital-acquired infections (HAI’s) kill more people than AIDS, breast cancer and car accidents combined and cost $35 billion to $45 billion a year. In the United States, HAI’s claim the lives of 100,000 people each year. Almost as many HAI’s occur annually in long-term care facilities as in hospitals. Methicillin-resistant Staphylococcus aureus (MRSA) is a major problem in nursing homes with one in four residents carrying the bacteria, as reported in a study by Queen’s University Belfast and Antrium Area Hospital published in the Journal of the American Geriatrics Society.(Baldwin,N.S.,et.al., 2009) MRSA has spread outside health-related facilities in community-acquired outbreaks reported among prison inmates, contact-sport athletes, military recruits, and children in daycare settings.

The U.S. Copper Development Association (CDA) is taking a lead role in this effort through two main initiatives: EPA registration of copper and copper alloys as antimicrobial against five disease causing bacteria (already completed) and initiation of clinical trials in three U.S. hospitals. The supporting research is being funded by the U.S. Department of Defense under the aegis of the Telemedicine and Advanced Technologies Research Center (TATRC), a section of the Army Medical Research and Material Command (USAMRMC). The U.S. studies are being conducted at Memorial Sloan-Kettering Cancer Center in New York, the Medical University of South Carolina and the Ralph H. Johnson VA Medical Center, both in Charleston, S.C. The studies are being done in the ICU’s of each hospital and represent three different patient populations.(Objects Closest to Patients, 2008) In addition to the trials in the United States, testing of copper to fight pathogens is under way in the United Kingdom, Germany, South Africa, and Japan.

The first phase of the clinical trials exploring the role of hospital high-touch surfaces in the transmission of infectious pathogens has been completed in the U.K. The first results from the trial, following sampling of three products—water faucets, push plates and toilet seats—were presented at the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) in Washington D.C., in October 2008. These results show that surfaces made from materials that contain copper kill a wide range of potentially harmful micro-organisms. Data from the three products sampled over a 10 week period showed that items made from copper had 90 percent to 100 percent fewer micro-organisms on them, compared with the same items made from standard materials (chrome-plated brass, aluminum and plastic). The U.S.’ CDA research, presented in a poster at the same conference, shows that the most heavily contaminated objects are those in closest proximity to the patient. Bed rails, call buttons, and chairs are found to have the highest levels of MRSA and Vancomycin-resistant enterococcus (VRE). These pathogens can survive for extended periods on objects, which act as reservoirs for the bacteria and are generally spread through direct contact via the hands.(Salgado, C.D., et.al.,2008)) The data presented describe the first results of a three-phase study where the bioload found on stainless steel, plastic, and aluminum objects in ICU rooms were measured. Phases two and three of the study are ongoing. During these phases, the bioload on identical objects made of microbiocidal copper are being measured to determine the effectiveness of copper at combating hospital-acquired infections.

Independent studies have shown that copper, brass, and bronze are more than 99.9 percent effective in killing potentially deadly pathogens such as MRSA and VRE, commonly found in healthcare facilities. The tests showed that 99.9 percent of the bacteria on copper alloy surfaces (with 65 percent or greater copper content) were eliminated within two hours of exposure. A research team from the University of Southampton, U.K., compared the survival rate of MRSA on stainless steel, the most commonly used metal in healthcare facilities, with those of copper alloys. They found that at room temperature, MRSA was able to persist and remain viable in dried deposits on stainless steel for periods of up to 72 hours. Copper alloys, with 99 percent and 80 percent copper content, killed all MRSA within 1.5 hours and 3.0 hours, respectively. Alloys with 55 percent copper content brought about significant reduction in 4.5 hours.(Reducing the Risk,2009) This strongly suggests that the replacement of touch surfaces with copper alloys in healthcare facilities can help to reduce the incidence of microbial infection due to contaminated surfaces. Other scientific literature cites the efficacy of copper to kill many different types of harmful microbes, including Candida albicans, Tubercle bacillus (TB), Poliovirus, Escherichia coli (E. coli), Staphylococcus Group D and in recent years, several of the most potent microbes, including: Listeria monocytogenes,  Legionella pneumophila, Salmonella enteritiditis, VRE and influenza A (H1N1).(Reducing the Risk,2009)

In a research paper on streptococcal and staphylococcal growth rates on stainless steel and brass published in 1983 Diagnostic Medicine, P Kuhn observed heavy growth on stainless steel of Gram-positive organisms and an array of Gram-negative organisms including Proteus s.p. Only sparse growth was observed on brass doorknobs. This led the author to conclude, “Brass is bacterialcidal and stainless steel is not.”(Kuhn, P. J.,1983) Other interesting points in Kuhn’s research include:

• Newly installed brushed stainless steel doorknobs and push plates were less sanitary than the tarnished brass fixtures that had been recently removed;
• Brushed surfaces on stainless steel provide a safe haven for microbes;
• For surfaces that are not bacteriostatic, such as aluminum and stainless steel, germicides must be used on a regular basis;
• Tests from the study suggest stainless steel doorknobs and push plates would have to be disinfected as often as every 15 minutes to match the protection naturally provided by bacteriostatic copper and brass.

The use of copper alloy surfaces compliments healthcare procedures and standard infection control protocol.

Conclusion

Copper is sometimes perceived as an expensive material, but is used throughout industry because it offers good value and represents a comparable capital cost to other widely used materials. Copper is 100 percent recyclable and can be recycled over, and over again, without any loss in performance. In addition to touch surfaces, the antimicrobial properties of copper go beyond the patient areas into building construction and engineering.

Works Cited

• “Bad Bugs, No Drugs Executive Summary Antibiotic-resistant Bacterial Pathogens: Why We Are Concerned.” IDSA – Infectious Disease Society. N.p., July 2004. Web. 25 Mar. 2009. <http://www.idsociety.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=5558>.
• Baldwin, N. S., et. al., “Prevalence of Methicillin-resistant Staphylococcus Aureus Colonization in Residents in Nursing Homes in Northern Ireland” Journal of the American Geriatrics Society 57.4 (2009): 620-26. Print.
• “The Copper Advantage: A Guide to Working with Copper and Copper Alloys.” pag.18, 2010. Web. 2010.
• “EPA Registers Copper-containing Alloy Products | Pesticides | US EPA.” US Environmental Protection Agency. N.p., May 2008. Web. 25 Aug. 2010. <http://www.epa.gov/pesticides/factsheets/copper-alloy-products.htm>.
• Kuhn, P. J. “Doorknobs: A Source of Nosocomial Infections?” Diagnostic Medicine (1983): Nov/Dec. Print.
• “Objects Closest to Patients Are Most Contaminated Survey Finds” Infectioncontroltoday.com (2008): n. pag. 10 Oct. 2008. Web.
• “Reducing the Risk of Healthcare- acquired Infections/ antimicrobial copper-The Scientific Evidence,” Copper Development Association, Pub. 195, March, 2009.
• Salgado, C. D., et.al.  “Microbial burden of objects in ICU rooms,” Interscience Conference for Antimicrobial Agents in Chemotherapy (ICAAC), 2008. Poster presentation.
• Wetzel, Shannon. “Bacteria Killer: Testing Has Proven Copper Kills Certain Disease-causing Bacteria” Modern Casting (2008): n. pag. Print.

With more than 34 years of hospital experience and 32 years of nursing experience, Jeri L. Steele, RN is experienced in a wide variety of clinical settings with diverse cultural and socio-economic clientele. As the nursing advisor/LEAN operations facilitator for Burt Hill, she acts as a liaison between healthcare facility employees and the design team to assist in meeting the needs of the staff to develop the best design outcome. As an experienced nurse, Jeri draws from her hands-on experience in a variety of medical fields.