Well, they certainly do in the National Health Service in England!
There has been significant coverage recently of some new research suggesting “Wet wipes could be spreading bacteria in homes and hospitals” (Daily Telegraph), “Hospital bugs ‘spread by use of wet wipes to clean wards’ according to first study of its kind” (Daily Fail) and “Diana killed with wet wipes by dole scrounger immigrant fundamentalists” (Daily Express).
But just for once the headlines were pretty accurate.
The reporting under those headlines was long on sensation and short on facts (so no great surprises there, then) and – naturally – none of the journalists bothered to read the source material preferring to simply regurgitate the press release adding whatever fact-free spin suited their purposes.
So, dear readers, I have picked over the detail in the original paper. Which is a good study by a highly-respected team published in a high-impact journal. Let’s start with what the paper actually said:
- Detergent wipes widely used in the NHS (and elsewhere) are rubbish at removing dangerous microorganisms from surfaces
- They are rather good at spreading microorganisms about the place to cause trouble elsewhere, however.
Let’s quickly remind ourselves how detergent wipes are claimed to work:
- To first ensure the efficient removal of bioburden and microorganisms from a surface
- Secondly, to retain the captured microorganisms on the wipe, thus preventing cross-contamination by the transfer of pathogens.
This is important because the majority of infection control policies over here are based on the NHS Hygiene Code and parrot its advocacy of detergent and water (or microfibre cloth and plain water) for cleaning soiled / contaminated surfaces, because disinfectants should not be routinely used. Yes, you did read that correctly. Disinfectants should not be routinely used.
Let’s look at the logic of that. As we rapidly approach a post-antibiotic era it’s no longer as simple as a clinician prescribing your aged mother an antimicrobial drug when the poor, senile old bat picks up an entirely preventable infection from a filthy ward or – more likely – no-one washing their damn hands.
Quite simply, we can’t rely on a convenient antibiotic being instantly available any more to deal with any given infection. So we need to do all we can to prevent infections being passed on. Like cleaning hospitals with stuff that kills bugs stone dead instantly rather than spreading them around the place.
But never let it be said the NHS does things by halves:
“Let’s make sure when the ward gets cleaned every other month, we use something that doesn’t kill bugs. Because bugs develop resistance to antibiotics. And lab experiments have shown if we try really hard we can elicit resistance to low-concentration on-skin biocides like Triclosan as well.
Therefore bugs will become resistant to cleaning chemicals like caustic soda too. Because even though that kills a bug stone dead by turning its cell wall to soap, bacteria can still develop resistance to. Because dead things mutate, innit.”
This Food Babe-like antipathy to disinfectants is a principal reason for the increasing use of detergent wipes for environmental cleaning in health and social care. They are seen as a convenient, ready to-use, disposable solution and a key intervention in infection prevention and control. And, of course, they work. Because the guidelines say detergent good, disinfectant bad.
And despite infection prevention and control not being the natural home of evidence-based practice (because outbreaks don’t lend themselves to double-blind, placebo-controlled randomised trials, the guidance must be evidence-based, right?
Why the Current Advice Is So Dense Light Bends Around It
The ability of microorganisms such as MRSA, vancomycin-resistant enterococci, Clostridium difficile and many significant others to persist on inanimate surfaces for prolonged periods is well recognized. And I see paper after paper reporting study after study showing common healthcare-associated pathogens repeatedly being isolated from ‘high-touch’ points in close proximity to patients.
While proper hand hygiene will always be the key intervention in effective infection prevention and control, the body of evidence showing the significance of environmental contamination in the transmission of clinically-relevant pathogens grows constantly – yet the advice is still that disinfectants or combined sanitiser / detergent products should not be used and general-purpose detergents or detergent wipes are ‘best practice’.
This advice has always flown in the face of the most basic tenets of microbiology and is a classic example of the informal logical fallacy of argumentum ad ignorantum – essentially asserting a proposition (in this case that detergents are perfectly adequate) must be true because no-one has proved otherwise.
The paper recently published in the American Journal of Infection Control Pathogen transfer and high variability in pathogen removal by detergent wipes hasn’t just driven a rather large coach and horses through the wipe nonsense it also suggests – shock! – that perhaps it might be an idea to use products actually kill bugs, given detergent wipes just send them on a nice little holiday to somewhere else in the hospital.
And this is no half-arsed study in some fly-by-night publication; AJIC is what’s known in the biz as a ‘high-impact’ (i.e. high-quality, highly respected) academic journal, as is the leader of the group who conducted the study, Jean-Yves Maillard. He and his group are highly regarded in infection control research so if Jean-Yves says ‘detergent wipes are bad‘ people will listen.
Perhaps even the NHS…
What Happens Now?
So, non-ionic detergent wipes are rubbish at picking up and hanging on to bacteria. Water is wet. Fire is hot. Bears defecate in woodland areas. That bacteria are negatively charged may well play a part in this – but that’s my opinion, not something in the paper and my view may well not be shared by the authors, their successors and assigns, responsible adults anywhere, yo’ mama and certainly not the NHS or those nice folks at PHE Colindale.
What is true is wipes impregnated with a cationic (positively charged) surfactant do not suffer this problem and work very well – but if you put a cationic on a wipe it won’t just clean effectively, it will kill bacteria – and so fall foul of the Hygiene Code.
And then where would we be?
We might reduce the one million NHS bed nights per year taken up by patients with infections they picked up in hospital (the equivalent of 2,700 hospital beds every day) or reduce the number of deaths caused by preventable infections. Or save the £10m per annum the NHS pays out in compensation in addition to the cost of all those hospital stays. And let’s not forget the human cost of all those preventable infections too.
It would seem to be a no-brainer that the NHS do as suggested – follow the recommendations of some of the most respected people in the business and re-evaluate its position. A position which is, frankly, barking mad to any sane observer or even dangerous seditionists like me.
But flogging these wipes to the NHS is a huge industry and if you want to elicit a sea change in an organisation like the NHS that is – paradoxically – incredibly monolithic and incredibly tribal at the same time you probably have more chance of taking a shit in the Queen’s handbag.
Another embarrassing and inconvenient fact is that hospital-acquired (sorry, we’re supposed to call them ‘healthcare-associated’ now) infection rates are far lower in countries such as Iran, Latvia, Mongolia or Ghana than in NHS hospitals.
If the WHO publishing the epidemiological data that backs up that last statement didn’t shame the NHS into change I’m not convinced slam-dunk scientific data will. And we can already see the nay-sayers lining their ducks up:
Granted, like all science this needs to be (and will be) replicated by others. But none of the above arguments sink the findings of this paper and are what’s known as ‘special pleading’ – which is a polite scientific term for ‘clutching at straws’.
Incidentally, this is different to research conducted by companies – where experimental design tends towards “how can we prove our widget is best” whereas a scientist has a different starting point: “I wonder how I can find out which of these widgets is best?” – it’s a big difference.
The Bottom Line
What one cannot escape is this is a well-designed study, conducted by a highly-respected group with no conflicts of interest and their principle findings are simple – detergent wipes are largely ineffective at removing potentially life-threatening microorganisms from surfaces but are pretty damn good at moving potentially life-threatening microorganisms from one surface to another.
This doesn’t just show detergent wipes have no role to play in infection control; as the authors note it’s time to re-evaluate whether using cleaning products that actually kill bugs might be appropriate (and I’m sure you can guess my views on that).
This may seem simple but it’s not. There’s a whole other post brewing about evidence-based practice – which seems like a Good Thing until you get basic scientific plausibility sacrificed on the EBP altar as soon as some shitty study is published.
Or, as in this case, the argument from ignorance prevails – this is from National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England:
Whilst subsequent studies may have demonstrated a link between disinfection and reduced environmental contamination, and sometimes the acquisition of HCAI, the study designs are weak with no control groups or randomisation of intervention, and /or the introduction of multiple interventions at the same time.
This makes it difficult to draw definitive conclusions about the specific effect of disinfection or cleaning.
How the fuckitty fuckitty fuck are you supposed to conduct a randomised, controlled trial of an infection control intervention during an outbreak?
And even if you could design one how the fuck would it ever pass ethical review? See what I mean about basic scientific plausibility or just basic common sense being ignored because you can’t run a fucking RCT? Let’s try to predict the Dept of Health’s position:
My challenge is I just can’t see any change happening in an organisation led by a health secretary who believes interventions such as homeopathy – entirely based on magic rather than science – is a legitimate use of the public purse.
Which – if you think about it – is a bit like having a transport secretary that believes in broomsticks…