Executive Summary
Manufacturers of healthcare furnishingsi have been
developing new products with antimicrobial properties
to protect materials from degradation, for aesthetic
reasons, and to reduce microbial burdens on product
surfaces, anticipating that this may help reduce the risk of
healthcare-associated infections (HAIs). Industry experts
predict hospitals will continue to increase purchases of
products containing antimicrobials. Antimicrobial use
in other consumer products, including items for food
production and storage, personal care, clothing, household
goods, and building materials, is also increasing. These
uses collectively add to the potential for general population
and environmental exposures. Unfortunately, data on the
safety and efficacy of this growing practice are scarce, and
potential unintended consequences have not been fully
explored.
Healthcare-associated infections have always been a
formidable challenge in hospitals and are major causes
of morbidity and mortality today. Healthcare-associated
infections can prolong the length of hospital stays,
result in readmission after discharge, and increase costs
to individuals, families, and communities. Moreover,
under provisions of the Affordable Care Act, preventable
readmissions can result in a financial penalty in
reimbursement for all Medicare patients at that hospital.
This has driven an interest in developing new strategies to
reduce HAIs.
Although some antimicrobials clearly reduce the microbial
load on textiles and other environmental surfaces in
laboratory settings, they have rarely been evaluated in
well-designed clinical studies for their effectiveness in
contributing to HAI reduction. While antimicrobials in
hospital furnishings may ultimately prove to be efficacious,
currently the benefits, risks, tradeoffs, and costs associated
with their use are largely unknown.
Beyond their potential impact on HAIs, life cycle safety
concerns associated with the manufacture, use, and
disposal of antimicrobials need careful consideration.
Releases into the indoor and outdoor environments can
result in unwanted exposures to humans, wildlife, and
ecosystems with adverse and sometimes unanticipated
consequences. Historically, failure to examine life cycle
benefits and risks of other chemical agents have resulted
in nearly ubiquitous exposures with adverse human health
and environmental effects discovered years later, after
irreparable damage is done.
The growing use of products containing antimicrobials
can also further increase the risk of antibiotic resistance,
engender a false sense of security with reduced attention
to cleaning and disinfection, and increase costs of products
and materials.
Evaluation of the benefits at the point of use, life cycle
risks, tradeoffs, and financial implications of adding
antimicrobials to products in hospitals will help product
designers, purchasers, infection preventionists, and
environmental services personnel make informed
decisions. Until then, design and purchasing decisions will
be based mostly on unverified assumptions rather than
objective data.
Healthcare administrators and staff, clinicians, and
product manufacturers each have opportunities to help
generate the data necessary to justify the growing use of
antimicrobial agents in hospital furnishings. Demonstrated
efficacy of added antimicrobials with reduction in HAIs as
part of a comprehensive infection control program and life
cycle safety evaluations are essential. Until then, we make
the following recommendations.
Recommendations
The benefits, risks, tradeoffs, and cost implications of
adding antimicrobials to furnishings are active areas of
research. These recommendations are based on a current
evaluation of the state of the science with the expectation
that more objective data will aid in making informed
design and purchasing decisions.
For health care
These recommendations are offered as a complement
to comprehensive integrated infection surveillance and
control programs.
Executive Summary
i Here the term “furnishings” includes surfaces (tables, desks,
countertops, etc.), built-in and modular casework, seating, beds,
bedding, cubicle curtains, window coverings, panels and partitions,
storage and shelving.
Antimicrobials in Hospital Furnishings 4
• Do not specify antimicrobials in furnishings unless
they have undergone U.S. Environmental Protection
Agency (EPA) evaluation and registration under the
Federal Insecticide, Fungicide, and Rodenticide Act
(FIFRA) and have been shown to help reduce HAIs in a
clinical setting as part of an integrated infection control
program.
• Ask suppliers to disclose any antimicrobials added to
materials and products, even if they are used for the
purpose of material preservation, the control of odor,
or some other aesthetic reason.
• Take the lead or collaborate in the design and
execution of a research agenda intended to address
data gaps related to efficacy and risks associated with
adding antimicrobials to furnishings.
• Examine antibiotic stewardship programs in your
institution for opportunities to reduce the risk of
generating antimicrobial resistance.
• Examine antibiotic stewardship programs in your
community for opportunities to reduce the risk of
generating antimicrobial resistance, including in
animal agriculture. Help make the case that antibiotic
stewardship to address the growing problem of
antimicrobial resistance is a community-wide
responsibility.
For furnishings manufacturers
• Do not make antimicrobials the standard option for
any products, with the exception of antimicrobials that
are used solely for product protection. Antimicrobials
should be a “must select” option in order to make
the decision clear, as well as to track the demand for
products containing antimicrobials.
• Use only antimicrobials that have undergone EPA
evaluation and registration under FIFRA and have
been shown to reduce the risk of HAIs in a clinical
setting unless using them is in the context of a
research program to examine their efficacy.
• Take the lead or collaborate in the design or execution
of a research agenda intended to fill data gaps
related to efficacy and risks associated with adding
antimicrobials to furnishings.
• Require full toxicity testing, studies of potential
leaching, and evaluations of potential human or
environmental exposure to any antimicrobials used in
products.
• Align sales and marketing claims with EPA FIFRA
labeling requirements.
• Investigate and make publicly available information
about the presence of all antimicrobials in products,
including antimicrobials that are exempt from FIFRA
registration because of the Treated Articles Exemption.
For manufacturers of antimicrobials
• Conduct full toxicity testing, including environmental
toxicity, fate, and transport, as well as life cycle
assessment of any antimicrobials, including
antimicrobials used for purposes of preserving the
product, and make results publicly available.
• Collaborate to develop clinically-relevant testing
methods to determine efficacy in the clinical setting.
• Align sales and marketing claims with EPA FIFRA
labeling requirements.
• Commit to transparency in toxicity and efficacy testing
for all antimicrobials.
For the research community
• Prioritize research to determine efficacy, risks
throughout the life cycle, tradeoffs, and cost
implications of the use of antimicrobials in furnishings
in clinical settings.
• Research hazard profiles and potential human and
environmental exposures to antimicrobials used for
purposes of preserving the product.
• Research whether the addition of antimicrobials in
products changes the microbial ecology (microbiome)
of a building or spaces within a building and
whether those changes have clinical or public health
significance.
For more information, please refer to the attached file.
