The long-awaited BETR-D study has finally been published, in the Lancet. The huge cluster randomised controlled trial proves that UV-C is effective in reducing the rate of acquisition of VRE and MRSA, and argues strongly for the adoption of UV-C to improve patient safety.
This is a very impressive study. It’s a huge two year cluster-randomised controlled trial (RCT) spanning nine US hospitals, which is the absolute gold standard for a study of an infection control intervention. The hospitals implemented a randomised sequence for four different terminal disinfection approaches: QAC, QAC+UV, bleach, bleach+UV. There was a statistically significant 31% reduction in the acquisition of target organisms (MRSA, VRE and C. difficile) for patients admitted into rooms disinfected using QAC+UV compared with QAC alone. The effect on VRE was bigger than on MRSA. When C. difficile patients were removed from the analysis, there was a statistically significant 28% reduction in the acquisition of target organisms (MRSA and VRE) for patients admitted into rooms disinfected using bleach + UV compared with bleach alone. It is worth noting that the QAC + UV arm was not inferior to the bleach + UV arm, suggesting that bleach cleaning prior to UV isn’t necessary. Environmental sampling showed trends that matched the clinical reductions (UV pretty much eliminated MRSA and VRE, but didn’t reduce the level of C. difficile contamination. The study was exceptionally well controlled, with rates of hand hygiene, compliance with standard cleaning, and colonisation pressure all meticulously measured and shown not to change. UV disinfection added only 10 minutes to room turnaround time.
There was no clinical impact on C. difficile in this study, in contrast to a number of other studies, which have showed that UV-C reduces the acquisition of C. difficile. Could it be that the levels of reduction in spores that UV-C systems are able to achieve are not high enough to reduce significantly the acquisition rate of C. difficile? Or perhaps there was something about the way that UV-C was applied in this study that explains this apparent discrepancy? In this study, the UV-C system was staged at a single point in the patient room, and a separate cycle was not performed in the bathroom (which isn’t our recommended use of the Clinell UV-360!). It would be interesting to see whether altered device staging and multiple cycles improve the clinical impact of UV-C against C. difficile.
Overall though, this is a powerful study, which argues strongly for the adoption of UV-C into a hospital’s disinfection strategy for the terminal disinfection of rooms vacated by patients with MRSA / VRE, and perhaps C. difficile as well.