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Emerging Technology in Infection Prevention
Healthcare-acquired infections (HAI) can occur in all health care settings, including hospitals, medical centers, surgical centers, ambulatory clinics, long-term care facilities and continue to be prevalent, affecting about 1 in 25 patients in the United States.1
The World Health Organization (WHO) has hypothesized that by the year 2050 there will be 10 million annual deaths due to multi-drug resistant infections, costing hundreds of trillions of dollars each year.1 Of these infections, Clostridium difficile was the most commonly reported infection followed by medical device associated infections.2 It has been estimated that there were about 721,800 HAI in United States hospitals in 2011 and more recently it has been reported that approximately 725,000 people die annually as a result of their HAI.2 These infections not only negatively affect health outcomes of patients, but place a significant economic burden on the health care system, especially given concerns regarding the increased global prevalence of multi-drug resistant bacteria.
To assist with infection prevention and control in the podiatric medical setting, the American Podiatric Medical Association (APMA), Centers for Disease Control and Prevention (CDC) and other agencies have published guidelines that address standard precautions including use of personal protective equipment (PPE), disinfection and sterilization of reusable patient-care instruments, hand hygiene, and environmental inflectional control. Recent advancements have also resulted in emerging technologies to help further combat the prevalence and spread of microorganisms in the health care setting. Several technologies are being developed to maximize infection prevention through various measures such as antimicrobial surfaces and textiles, long-lasting alcohol-free hand and surface sanitizers, and through electronic tools (e-tools) and artificial intelligence.
The transmission of infectious microorganisms requires three components: a source (reservoir) of infectious agents, a susceptible host to transfer the microorganisms, and a mode of transport.3 The importance of the prevention of the spread of infection and use of PPE was amplified during the COVID-19 pandemic. Sources of infectious agents could be derived from both human sources as well as fomites such as hospital bedding, examination tables, garments in the hospital and outpatient settings, curtains, and furniture, among others. The most common method of transmitting infectious agents in the health care setting is through contact transmission, which can be either direct or indirect. Direct transmission would be defined as an infected individual directly transmitting infectious material to another person. Indirect transmission entails transmitting infectious agents through a contaminated intermediate source, and much research and effort has been expended to attempt to reduce these modes of transmission.3
How Hand Hygiene and Surface Sanitizers Help
The cleaning and disinfection of environmental surfaces—especially those most likely to become contaminated, such as patient chairs, tabletops and other surfaces on which procedures are performed—are important parts of the infection prevention policies and procedures in all health care settings.4 Hand hygiene, either via washing with soap and water or sanitizing with an alcohol-based hand rub, is considered critical to help reduce the risk of spreading infections. The CDC recommends the use of an alcohol-based hand rub as the primary mode of hand hygiene in health care settings due to its activity against a broad spectrum of pathogens and because the use of alcohol-based hand rub requires less time to facilitate hand hygiene at the point of care.4 Most hand and surface sanitizers that are currently available are alcohol based—they are corrosive in nature and are neither user- nor eco-friendly.14 The alcohol is flammable and is irritating both to the eyes and skin, which can affect the health and safety of an individual.
However, the greatest drawback of using an alcohol-based sanitizer is its reduced duration of protective antimicrobial properties. This happens because once the alcohol in the sanitizer evaporates, the sanitization is effective for only 15 seconds to 2 minutes.14 After this period of time, an individual or space that was previously sanitized is vulnerable to infection and further transmission.
The US Food and Drug Administration (FDA) proposed 60–95% alcohol as safe and effective for hand sanitizers whereas the WHO recommended 80% ethyl alcohol or 75% isopropyl alcohol. A newer formulation that was demonstrated in a 2022 study is a choline and geranic acid–containing eutectic solvent. This formulation contains safer materials such as choline and geranic acid that provide a long-term skin protection against infectious disease. The study assessed the duration of protection that saline, alcohol-based products, and the new choline and geranic acid–containing eutectic solvent provides. The results in this study demonstrated that alcohol-based products and saline both provide the same level of protection at 30 minutes; however, the choline and geranic acid–containing eutectic solvent provided a longer protection from infectious pathogens for up to 4 hours.14
Along with alcohol-free products, several forthcoming measures in preventative medicine have been studied and enhanced with the use of nanotechnology. Nanotechnology has been defined as a branch of science and technology that deals with research and development conducted at dimensions of less than 100 nanometers (nm).12 Materials <100 nm are termed nanomaterials, and these materials possess enhanced physical and chemical properties allowing a wide range of applications. Some examples of nanomaterials that are currently being utilized to inhibit various viruses include graphene oxide, carbon nanoparticles, and metal nanoparticles amongst many. For example, metal nanoparticle-based disinfecting agents rely on the antibacterial and antiviral properties of metals such as silver, copper, and titanium. These are environment- and user-friendly compared to alcohol-based products because they are non-flammable and non-volatile.
Microcapsules containing salicylic acid are also currently being researched for use in marine antifouling. A 2022 study investigated the effectiveness of salicylic acid in polyurea-formaldehyde microcapsules. The study demonstrated that the salicylic acid microcapsules have excellent long-term antibacterial and anticorrosive properties.7 The microcapsule structure allows for control release of core materials whereas the salicylic acid induces reactive oxygen species, which provides bactericidal effects against microbes such as Staphylococcus aureus and Pseudomonas aeruginosa. An extrapolation from the results of the study can be used in developing hand and surface sanitizers that provide long-lasting protection.
A Closer Look at Clinic/Hospital Attire, PPE, and High-Touch Surfaces
Hospital garments, laboratory coats, PPE, and other fomites have been implicated as potential sources of the spread of infectious agents such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and Clostridium difficile.8–10 Due to the high prevalence of HAI and the modes of transmission, antimicrobial surfaces and textiles have been implemented in an effort to curtail the spread of infectious microorganisms.
The cleanliness of high-touch surfaces (HTS) in the hospital or clinical setting is critical to diminish the prevalence of and transmission of HAI. Current methods to decrease infection transmission from fomites are directed towards using disinfectants. Unfortunately, the surfaces can be contaminated shortly after being cleansed, and the process of disinfecting a clinic or hospital surface can be labor intensive. Further, inadequate room disinfection is common, and studies have suggested that less than 50% of room surfaces are appropriately disinfected following the discharge of a patient.11,12 This often leaves behind multidrug-resistant organisms that can either spread directly to patients or through health care providers as vectors.
The Antimicrobial Scrub Contamination and Transmission Trial (ASCOT) was conducted at Duke University Hospital to assess the efficacy of antimicrobial-coated hospital scrubs in preventing health care provider contamination.13 This study assessed hospital scrubs embedded with a silver alloy and scrubs with an organosilane-based quaternary ammonium and hydrophobic fluoroacrylate copolymer emulsion as compared to standard cotton-polymer surgical scrubs (control). In this study, the antimicrobial coated surgical scrubs did not effectively reduce the contamination of health care providers.
Another study assessed the effectiveness of zinc nanoparticles impregnated into textiles through a specialized process.14 In this study, the zinc textiles demonstrated a microbial reduction of 99.99% on common gram-positive, gram-negative bacteria as well as fungi. This study also demonstrated that the specialized process of infusing zinc into textiles increased the durability of the antimicrobial textiles, remaining intact after 100 laundry cycles, which would be favorable for repeat use in a health care setting.
Zinc also has been investigated as an antimicrobial coating of titanium alloys used in orthopedic surgery. It has been estimated that about 1% of patients develop a postoperative infection following prosthetic joint implant surgery, which can lead to significant morbidly and increased cost of care.15 Bacteria can cause a biofilm to develop on implanted orthopedic hardware, rendering the host immune system and systemic antibiotics ineffective at eradicating the biofilm bacteria. This has led to an increased interest in antimicrobial coated implants to reduce the incidence of postoperative hardware infection. A study published in Bioactive Materials in 2021 demonstrated that multilayer antimicrobial coating of orthopedic hardware with calcium phosphate (CaP) and zinc coating would inhibit bacterial infection and biofilm formation for many months after implantation of the hardware.5 These efforts towards minimizing postoperative infections could not only improve patient outcomes, but also contribute positively towards antibiotic stewardship.
Finally, silver has been studied as an option to create antimicrobial textiles. Silver nanoparticles have been used widely for many years in health care due to their broad antimicrobial activity. Numerous different methods of attaching silver nanoparticles to cotton fabrics have been performed, including ultraviolet irradiation, plasma, sol-gel processing among others.16
However, silver nanoparticles have been difficult to remain adherent to cotton materials over time.16,17 Another technique, via binders and cross-linkers, has been developed to help the silver adhere to the textiles, specially through the use of L-cysteine-covered nanoparticles. L-cysteine silver nanoparticles coating cotton fibers not only has demonstrated activity against common bacteria such as Escherichia coli and Staphylococcus aureus, but it appears more durable as well, sustaining its antimicrobial activity over a longer period of time.16
The Role of Artificial Intelligence in Infection Prevention
Recent advancements in artificial intelligence have been created to prevent the spread of infection through the use of game technology, automatic video auditing, infrared and pressure sensors, and automated interpretation of blood culture Gram stains. Studies utilized the WHO’s multifaceted “five moments for hand hygiene strategy” in their implementation.18–20 One study created a real time hand washing notification system with infrared and pressure sensors in order to evaluate the patterns of when the clinician is washing their hands prior to first patient contact in an outpatient setting. A pressure plate was placed on the patient’s chair as well as on the physician’s chair, with the infrared sensor in between the physician’s chair and the dispenser trackers in the hand washing station. The processor was able to determine both visual and auditory notifications. If the physician did not complete the hand hygiene, a beeping sound was used to notify them prior to patient contact. The mean adherence with hand hygiene at baseline was 53.8% and 100% after the intervention.21
Another study implemented a training program using an automated gaming technology training and audit tool to educate staff on hand hygiene technique. This study utilized a time-series quasi-experimental design to measure adherence with an adenosine triphosphate (ATP) monitoring system to monitor hand washing technique. When ATP is brought into contact with the testing device, light is emitted in direct proportion to the amount of ATP present. The more ATP present after hand hygiene, the higher the contamination present. Another hand hygiene training technology trial utilized an automated auditing and training unit that was deployed to each department for two weeks during the study. Then random audits were performed and ATP values were documented after the training was completed during the study period. Twelve months prior to the implementation of the technology, the adherence rate of hand hygiene was 42% at baseline and increased to 84% in the 12 months following implementation with statistical significance P < .0001.19
A similar study utilized an automatic video auditing (AVA) system with real-time feedback on the quality and quantity of hand wash events in the hospital setting. Eight AVA units were placed in an active surgical unit with the screen showing each step to follow with red and green traffic light symbols with individualized real-time feedback on technique. The study was divided into four phases over a four-month period to provide feedback on hand hygiene quality and quantity. There was an increase in the average number of hand hygiene events per patient day from 0.91 at baseline to 2.25 (P < .0001). Moreover, the average percentage of handwashing events meeting the quality standard increased from 15.7% at baseline to 46% (P < .0001).20
A further area of development is with the automated interpretation of blood culture Gram stains via the use of a deep convolutional neural network since microscopic interpretation of stained smears is one of the most labor-, time-intensive, and operator-dependent activities in the clinical microbiology laboratory. One study investigated the application of an automated image acquisition and convolutional neural network-based approach for automated gram stain classification. The investigators scanned over 25,000 Gram stain images and the system achieved 94.9% classification accuracy on a test set of images. This algorithm was able to identify and classify crops that would accelerate smear review and could be extended to all Gram stain interpretive activities to help enhance capabilities of clinical laboratories.21
In Conclusion
Health care acquired infections constitute a major source of adverse health care outcomes and impose an economic burden on health care systems. Infection prevention is a priority for all health care providers, including podiatric physicians, in all settings in which care is delivered. Guidelines that address standard precautions have been published by the CDC, APMA, and other agencies. To help further combat the prevalence and spread of microorganisms in the health care setting, antimicrobial textiles, coated surfaces and artificial intelligence technologies have been researched to determine their efficacy in infection prevention. The implementation of alcohol-free products such as choline and geranic acid–containing eutectic solvent, nanotechnology, microcapsules containing salicylic acid and antimicrobial textiles composed of zinc or silver could provide a significant decrease in postoperative infections and increase the duration of protection from infectious pathogens. Educating health care professionals using gaming technology or artificial intelligence has also shown a significant increase in hand hygiene compliance and can help reduce the rate of HAIs.
The continued research, development and implementation of infection prevention can assist our efforts in decreasing healthcare-acquired infections and its associated complications.
Priya M. Thakkar, BS is completing her fourth year of studies at the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science and will be starting residency training at the Saint Joseph Health System in Mishawaka, IN.
Aashi Modi, BS, is a Dr. Scholl Scholar who is starting her fourth year of studies at the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University.
Leland Jaffe, DPM, FACFAS, CWSP is Associate Professor in the Department of Podiatric Medicine and Surgery, and the Associate Dean of Clerkship and Residency Placement at the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University.
Dr. Wu is the Dean, Professor of Surgery, and Professor of Stem Cell and Regenerative Medicine at Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science.
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