—James Pile, MD, FACP, SFHM, vice chair, department of hospital medicine, Cleveland Clinic
Hospital-acquired infections (HAIs) are on the rise despite efforts to decrease them. HAIs cause an estimated 100,000 deaths annually and account for up to $45 billion in health-care costs. Adding fuel to the fire, bacteria increasingly are becoming resistant to last-resort drugs. Despite this gloomy outlook, a recent study in Infection Control and Hospital Epidemiology shows that a material known for its antimicrobial properties for more than 4,000 years—copper—might be a light at the end of this darkening tunnel.1
Ancient Indians stored water in copper pots to prevent illness, says lead study author Cassandra D. Salgado, MD, associate professor of medicine, hospital epidemiologist, and medical director for infection prevention at the Medical University of South Carolina (MUSC) in Charleston. But copper rarely is used in that manner today because molded plastics and stainless steel are less expensive and easier to mass-produce.
Dr. Salgado explains that the antimicrobial effect of copper-alloy surfaces is a result of the metal stealing electrons from the bacteria when they come into contact with each other. “Once the bacteria donate the electrons to the copper metal, this places the organism into a state of electrical-charge deficit,” she says. “As a consequence, free radicals are generated inside the cell, which ultimately leads to the cell’s death.”
Copper-alloy surfaces kill 99.9% of bacteria in less than two hours, says Harold T. Michels, PhD, PE, senior vice president of technology and technical services for Copper Development Association Inc. in New York, who was a study author. On other surfaces, bacteria may live for multiple days or even months.
Unlike current methods used to decrease HAIs (i.e. hand-washing and sanitizing surfaces), copper components don’t require human intervention or compliance to be effective.
“It supplements what these other things can do; it’s in the background and it’s always working,” Michels says.
—Cassandra D. Salgado, MD, associate professor of medicine, hospital epidemiologist, medical director for infection prevention, Medical University of South Carolina, Charleston
To conduct the study, copper prototypes of items touched most frequently by patients, health-care providers, and visitors were made and placed in patient rooms located within ICUs. “We placed the copper around the patient [much like a defensive perimeter] to reduce the likelihood that the health-care worker or visitor would introduce the infectious agent to the patient,” says the study’s lead investigator, Michael Schmidt, PhD, a professor and vice chair of MUSC’s department of microbiology and immunology.
Then, bacterial loads were measured on each object. For every study room, there was a control room without copper objects. Researchers were most interested in methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). For a period of time, bacterial burdens were measured in both copper rooms and control rooms.
Results exceeded the researchers’ expectations. Although only 7% of the touch surfaces in each ICU were replaced with copper components, there were 58% fewer HAI cases. The rate of HAI and/or MRSA or VRE colonization in ICU rooms with copper-alloy surfaces was significantly lower than that in standard ICU rooms (0.071 versus 0.123). For HAIs only, the rate was reduced to 0.034 from 0.081.3
“We were pleasantly surprised with the reductions,” Dr. Salgado says. “We consistently saw a more than 50% reduction in HAIs in all study sites.”
Archelle Georgiou, MD, president of Georgiou Consulting LLC in Minneapolis and an advisor to the Copper Development Association, is an advocate for making the health-care system simpler and safer for consumers. She says copper is a “game-changer.”
“It’s a brand-new way of thinking about decreasing the number of HAIs,” she says.
In light of the study’s encouraging findings, hospitalist and infectious-disease specialist James Pile, MD, FACP, SFHM, vice chair of the Department of Hospital Medicine at Cleveland Clinic, says that although study results appear valid, “it didn’t provide any final answers.”
“It would be premature for a hospital to install copper based on this study,” he says, adding he didn’t find the study results surprising, because copper is known to have antimicrobial properties.
But, Dr. Pile says, the study did provide proof of concept and opens the door for larger, more definitive studies that will show if installing copper in hospital rooms is worthwhile.
“If future studies confirm earlier results, then hospitals should seriously consider copper installations,” he says.
Barriers to Implementation
Despite the promising outlook for copper in dramatically reducing HAIs, implantation of copper components is off to a slow start.
Negotiations with the Environmental Protection Agency, the federal agency with jurisdiction over public-health claims for antimicrobial surfaces, started in 2004. Testing started in 2005. Although federal registration was completed in February 2008, it wasn’t until late 2011 that all regulatory issues were resolved for manufacturers.
“The regulatory process created delays in educating hospitals and the public about copper’s effectiveness in killing certain bacteria,” Dr. Georgiou explains. “As a result, American manufacturers with the ability to make copper components weren’t developing products because they couldn’t sell them.”
Now that the regulatory issues have been resolved, U.S. manufacturers are beginning to make copper components. The first wave of commercial products came on the market in late 2011. Meanwhile, European countries have not been delayed and are well ahead of U.S. hospitals in implementing copper components.
Presently, nine U.S. hospitals have installed some form of copper components, including door hardware, cabinet pulls, sinks, stretchers, and IV poles, Michels reports.
Despite these advances, hospitals may be slow to incorporate copper components due to a variety of reasons:
Cost. Dr. Pile believes that cost will be the major barrier. “Installing copper surfaces won’t be cheap,” he says. “But, then again, HAIs are very costly. I think it will be more difficult to justify their existence if they can be prevented. If copper is effective in preventing HAIs, it would prove to be cost-effective over time.”
Dr. Salgado concurs. “A study needs to be done on the cost-effectiveness of copper surfaces,” she says. “Health economists estimate that if copper surfaces were incorporated into ICUs, after three to six months, those surfaces would pay for themselves. That is not a long time period. Hospitals need to understand that there will be upfront costs but that they will realize benefits downstream.”
The Center for Medicare & Medicaid Services (CMS) has reported that one infection adds $43,000 in patient costs.4 A typical U.S. hospital room contains $100,000 worth of goods and equipment.
“When you do the math using the amount of copper in our study, the cost would be between $1 and $10 per patient,” Dr. Schmidt says. “It’s also important to note that an infection adds 19 days to a patient’s hospital stay.”
Aesthetics. For some, appearance may be a concern. “Copper is actually an appealing material that is offered in an array of colors and surface finishes,” Dr. Michels says. Because a copper-and-brass combination is more prone to tarnishing, a copper-nickel alloy may be more desirable.
Availability. Copper components are not produced and marketed to U.S. hospitals; however, they are available. “We are hoping with our study and future studies that some medical-device companies, as well as hospital-furniture manufacturers, will jump on board to look at ways to mass-produce items,” Dr. Salgado says.
Acceptance. The study published in Infection Control and Hospital Epidemiology validated the effectiveness of copper in decreasing HAIs. This pilot study, however, was not blinded.3
“It was pretty apparent to providers where copper surfaces were located, which tends to result in some bias. Future studies will, hopefully, try to answer questions regarding healthcare providers’ behaviors with different surfaces,” says Dr. Salgado, noting researchers in California and Chile also are studying the effects of copper surfaces in hospitals.
Possible loss of efficacy. Even if a surface is effective initially, Dr. Pile points out that it’s possible for that to change. “I have a theoretical concern that, over time, bacterial pathogens may develop a tolerance to copper,” he says. “Bacterial adversaries have been able to overcome any type of treatment that we have devised for them thus far. But this remains to be seen.”
This has been an issue with other surfaces; once microbes establish a foothold, it is hard to eliminate them. But Dr. Schmidt says because bacteria are killed so quickly on copper surfaces and cleaning is only required once daily, the ability to establish a foothold is greatly reduced, if not completely eliminated.
—Harold T. Michels, PhD, PE, senior vice president of technology and technical services, Copper Development Association Inc.
Champion Proven Strategies
Dr. Pile sees antimicrobial stewardship as a great opportunity for hospitalists as a specialty. In fact, the Centers for Disease Control and Prevention is partnering with HM groups on piloting multiple antimicrobial stewardship initiatives at several sites.
Dr. Pile suggests that leaders spearhead formal quality-improvement efforts, be involved with patient-safety efforts, and serve as physician champions.
“No one is better positioned to do this than hospitalists, because we own the hospital environment,” he says. “We have an incredible stake in making sure that our inpatient environment provides safe and high-value care.”
As a result of the published study, Dr. Salgado says discussions are underway with hospital leaders at MUSC to determine if copper surfaces will be used in its ICUs and, if so, how changes will be implemented.
Karen Appold is a freelance writer in Pennsylvania.
- Klevens RM, Edwards JR, Richards CL, et al. Estimating healthcare-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122:160-166.
- Scott RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Atlanta: Centers for Disease Control and Prevention, 2009.
- Salgado CD, Sepkowitz KA, John JF, et al. Copper Surfaces Reduce the Rate of Healthcare-Acquired Infections in the Intensive Care Unit. Infect Control Hosp Epidemiol. 2013;34(5):479-486.
- Healthcare Cost and Utilization Project. Statistical Brief No. 94. Agency for Healthcare Research and Quality. Aug. 2010. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb94.pdf. Accessed Aug. 6, 2013.