Disinfection

Prasant Dev
 Definitions
• Antiseptics - chemicals that kill
microorganisms on living skin or mucous
membranes.
• Bactericidal - chemical agents capable of
killing bacteria. Similarly agents that are
virucidal, fungicidal or sporicidal are agents
capable of killing these organisms.
• Bacteriostatic - Chemical agents that inhibit
the growth of bacteria but do not necessarily
kill them
• Cleaning - the physical removal of foreign
material, e.g., dust, soil, organic material such
as blood, secretions, excretions and
microorganisms.
• Decontamination: the removal of disease-
producing microorganisms to leave an item
safe for further handling.
• Disinfection: the inactivation of disease-
producing microorganisms. Disinfection does
not destroy bacterial spores. Disinfectants are
used on inanimate objects in contrast to
antiseptics, which are used on living tissue.
• Sanitation: a process that reduces
microorganisms on an inanimate object to
a level below that of infectious hazard (e.g.,
dishes and eating utensils are sanitized).
• Sterilization: the destruction of all forms
of microbial life including bacteria, viruses,
spores and fungi. Items should be cleaned
thoroughly before effective sterilization can
take place
• When chemicals are used to destroy all
forms of microbiologic life, they can be
called chemical sterilants.
• A few disinfectants will kill spores with
prolonged exposure times (3–12 hours)
• These same germicides used for shorter
exposure periods also can be part of the
disinfection process
• Factors that affect the efficacy of both
disinfection and sterilization include
– prior cleaning of the object;
– organic and inorganic load present;
– type and level of microbial contamination;
– concentration of and exposure time to the
germicide;
– physical nature of the object (e.g., crevices,
hinges, and lumens);
– presence of biofilms;
– temperature and pH of the disinfection process;
– and in some cases, relative humidity of the
sterilization process (e.g., ethylene oxide).
• At similar concentrations but with shorter
exposure periods (e.g., 20 minutes for 2%
glutaraldehyde), these same disinfectants
will kill all microorganisms except large
numbers of bacterial spores; they are
called high-level disinfectants
 High-Level Disinfection
• High level disinfection processes destroy vegetative
bacteria, mycobacteria, fungi and enveloped (lipid) and
nonenveloped (non lipid) viruses, but not necessarily
bacterial spores
• Such disinfectants are capable of sterilization when the
contact time is relatively long (e.g., 6 to 10 hours).
• As high-level disinfectants, they are used for relatively
short periods of time (e.g., 10 to 30 minutes).
• They are formulated for use on medical devices, but not
on environmental surfaces such as laboratory benches
or floors.
 Intermediate-Level Disinfection
• This procedure kills vegetative
microorganisms, including Mycobacterium
tuberculosis, all fungi, and inactivates
most viruses.
• Do not necessarily kill bacterial spores.
• They are used commonly in laboratories
for disinfection of laboratory benches and
as part of detergent germicides used for
housekeeping purposes.
 Low-Level Disinfection
• Low level disinfectants kill most vegetative
bacteria and some fungi as well as
enveloped (lipid) viruses (e.g., hepatitis B,
C, hantavirus, and HIV).
• Low level disinfectants do not kill
mycobacteria or bacterial spores.
• Low level disinfectants are typically used
to clean environmental surfaces.
 Question 1
• Which among these are the most resistant
to disinfection/sterilisation?
– CJD

– C. Difficile spores

– Acinetobacter Baumanii

– VRE
 Decreasing Order of Resistance of
Microorganisms to Disinfectants/Sterilants

Most Resistant
Prions
Bacterial spores (C. difficile)
Mycobacteria
Small, non-enveloped viruses (HPV, polio, EV-D68)
Fungal spores
Gram-negative bacilli (Acinetobacter)
Vegetative fungi and algae
Large, non-enveloped viruses
Gram-positive bacteria (MRSA, VRE)
Enveloped viruses (Ebola, MERS-CoV)
Most Susceptible
 Question 2
• How long can water-disinfectant mixture
used for mopping be used?

• 1 hour
• 2 hours
• 4 hours
• 6 hours
• Mops and reusable cleaning cloths are regularly
used to achieve low-level disinfection on
environmental surfaces. However, they often are
not adequately cleaned and disinfected, and if
the water-disinfectant mixture is not changed
regularly (e.g., after every three to four rooms, at
no longer than 60-minute intervals), the
mopping procedure actually can spread heavy
microbial contamination throughout the health-
care facility
• Standard laundering provides acceptable
decontamination of heavily contaminated
mopheads but chemical disinfection with a
phenolic is less effective.
• Frequent laundering of mops (e.g., daily),
therefore, is recommended.
• Single-use disposable towels impregnated
with a disinfectant also can be used for
low-level disinfection when spot-cleaning
of noncritical surfaces is needed
 WIPES
• Wipes-cotton, disposable, microfiber
• Wipe should have sufficient wetness to achieve the
disinfectant contact time. Discontinue use of the wipe if no
longer leaves the surface visible wet for > 1 minute.
• When the wipe is visibly soiled, flip to a clean/unused side
and continue until all sides of the wipe have been used (or
get another wipe)
• Dispose of the wipe/cloth wipe appropriately
• Do not re-dip a wipe into the clean container of pre-
saturated wipes
 DISPOSABLE WIPES
• Wetness-ideally, stays wet long enough to meet
EPA-registered contact times (e.g., bacteria-1
minute).
• Surface Coverage-premoistened wipe keeps surface
area wet for 1-2 minutes (e.g., 12”x12” wipes keep
55.5 sq ft wet for 2m; 6”x5” equipment wipe keeps
6.7 sq ft wet for 2m). Wipe size based on use from
small surfaces to large surfaces like mattress covers
• Durable substrate-will not easily tear or fall apart
• Top-keep closed or wipes dry out
 Question 3
• Ventilator tubings belong to which group?

– Critical item

– Semi Critical Item

– Non- Critical Item

 Disinfection and Sterilization
WA Rutala, DJ Weber, and HICPAC, www.cdc.gov

EH Spaulding believed that how an object will be

disinfected depended on the object’s intended use.
CRITICAL - objects which enter normally sterile tissue or
the vascular system or through which blood flows
should be sterile.
SEMICRITICAL - objects that touch mucous
membranes or skin that is not intact require a
disinfection process (high-level disinfection [HLD]) that
kills all microorganisms but high numbers of bacterial
spores.
NONCRITICAL -objects that touch only intact skin
require low-level disinfection (or non-germicidal
detergent).
 “Critical” Patient Care Objects

Classification: Critical objects enter normally sterile

tissue or vascular system, or through
which blood flows.
Object: Sterility.
Level germicidal action: Kill all microorganisms, including
bacterial spores.
Examples: Surgical instruments and devices;
cardiac catheters; implants; etc.
Method: Steam, gas, hydrogen peroxide gas
plasma, vaporized hydrogen peroxide,
ozone or chemical sterilization.
 “Semicritical”
Patient Care Objects
Classification: Semicritical objects come in contact with
mucous membranes or skin that is not
intact.
Object: Free of all microorganisms except high
numbers of bacterial spores.
Level germicidal action: Kills all microorganisms except high
numbers of bacterial spores
Examples: Respiratory therapy and anesthesia
equipment, GI endoscopes, endocavitary
probes, etc.
Method: High-level disinfection
 “Noncritical”
Patient Care Objects
Classification: Noncritical objects will not come in
contact with mucous membranes or
skin that is not intact.
Object: Can be expected to be contaminated
with some microorganisms.
Level germicidal action: Kill vegetative bacteria, fungi and lipid
viruses.
Examples: Bedpans; crutches; bed rails; EKG
leads; bedside tables; walls, floors and
furniture.
Method: Low-level disinfection (or detergent for
housekeeping surfaces)
 Question 4
• How will you disinfect a laryngoscope
used for a child with pneumonia which
turned out to be MDR pseudomonas?
 Reprocessing of Rigid Laryngoscopes
JHI 2008, 68:101; ICHE 2007, 28:504; AJIC 2007, 35: 536

• Limited guidelines for reprocessing laryngoscope’s blades and

handles
• Many hospitals consider blade as semicritical (HLD) and handle
as noncritical (LLD)
• Blades linked to HAIs; handles not directly linked to HAIs but
contamination with blood/OPIM suggest its potential and blade
and handle function together
• Ideally, clean then HLD/sterilize blades and handles (UNCHC-
blades wrapped in a tray-Sterrad; handle wrapped in tray [without
batteries]-steam); the blades and handles placed together in a
Ziploc bag. Blades and handles checked for function prior to
packaging.
Contamination of Laryngoscope Handles
J Hosp Infect 2010;74:123
• 55/64 (86%) of the handles deemed “ready for patient use”
positive for S. aureus, enterococci, Klebsiella, Acinetobacter

Anesth Analg 2009;109:479

• 30/40 (75%) samples from handles positive (CONS, Bacillus,
Streptococcus, S. aureus, Enterococcus) after cleaning

AANA J 1997;65:241
• 26/65 (40%) of the handles and 13/65 (20%) of the blades were
positive for occult blood. These blades and handles were
identified as ready for patient use.
 Laryngoscopes Blades
The Joint Commission, FAQ, October 24, 2011

• How should we process and store

laryngoscope blades?
– Processed via sterilization or HLD
– Packaged in some way
– Stored in a way that prevents recontamination.
Examples of compliant storage include, but are
not limited to, a peel pack post steam sterilization
(long-term) or wrapping in a sterile towel (short
term)
– Should not place unwrapped blades in an
anesthesia drawer
Question 5- Match the following
Compound Class of Disinfectant

• Alcohol
• Aldehydes • High
• Chlorine compounds
• Intermediate
• Iodophores
• Low
• Oxidising agents
• Phenolic compounds
• QUAT
• Alcohol  Intermediate
• Aldehydes  High to Int
• Chlorine compounds  Intermediate
• Iodophores  Inter to Low
• Oxidising agents  High to Int
• Phenolic compounds  Int to Low
• QUAT  Low
 High-Level Disinfection of “Semicritical Objects”

Exposure Time > 8m-45m, 20oC

Germicide Concentration_____
Glutaraldehyde > 2.0%
Ortho-phthalaldehyde 0.55%
Hydrogen peroxide* 7.5%
Hydrogen peroxide and peracetic acid* 1.0%/0.08%
Hydrogen peroxide and peracetic acid* 7.5%/0.23%
Hypochlorite (free chlorine)* 650-675 ppm
Accelerated hydrogen peroxide 2.0%
Peracetic acid 0.2%
Glut and isopropanol 3.4%/26%
Glut and phenol/phenate** 1.21%/1.93%___
*May cause cosmetic and functional damage; **efficacy not verified
 LOW-LEVEL DISINFECTION FOR
NONCRITICAL EQUIPMENT AND SURFACES
Exposure time > 1 min

Germicide Use Concentration

Ethyl or isopropyl alcohol 70-90%

Chlorine 100ppm (1:500 dilution)
Phenolic UD
Iodophor UD
Quaternary ammonium UD
Improved hydrogen peroxide (HP) 0.5%, 1.4%
_________________________________________________
UD=Manufacturer’s recommended use dilution
 Sterilization of “Critical Objects”
• Steam sterilization

• Hydrogen peroxide gas plasma

• Ethylene oxide

• Ozone

• Vaporized hydrogen peroxide

• Steam formaldehyde
 Question 6
• What special disinfection procedure is
required for patient care equipment
contaminated with MRSA?
• Use standard sterilization and disinfection
procedures for patient-care equipment, because
these procedures are adequate to sterilize or
disinfect instruments or devices contaminated with
blood or other body fluids from persons infected with
bloodborne pathogens or emerging pathogens, with
the exception of prions.
• No changes in these procedures for cleaning,
disinfecting, or sterilizing are necessary for removing
bloodborne and emerging pathogens other than
prions.
KEY PATHOGENS WHERE ENVIRONMENTIAL
SURFACES PLAY A ROLE IN TRANSMISSION
• MRSA
• VRE
• Acinetobacter spp.
• Clostridium difficile
• Norovirus
• Rotavirus
• SARS
ENVIRONMENTAL SURVIVAL OF KEY
PATHOGENS ON HOSPITAL
SURFACES

Pathogen Survival Time

S. aureus (including MRSA) 7 days to >12 months
Enterococcus spp. (including VRE) 5 days to >46 months
Acinetobacter spp. 3 days to 11 months
Clostridium difficile (spores) >5 months
Norovirus (and feline calicivirus) 8 hours to >2 weeks
Pseudomonas aeruginosa 6 hours to 16 months
Klebsiella spp. 2 hours to >30 months

Adapted from Hota B, et al. Clin Infect Dis 2004;39:1182-9 and

Kramer A, et al. BMC Infectious Diseases 2006;6:130
 FREQUENCY OF ACQUISITION OF MRSA ON GLOVED
HANDS AFTER CONTACT WITH SKIN AND ENVIRONMENTAL
SITES

No significant difference on contamination rates of

gloved hands after contact with skin or environmental
surfaces (40% vs 45%; p=0.59)

Stiefel U, et al. ICHE 2011;32:185-187

 RELATIVE RISK OF PATHOGEN ACQUISITION
IF PRIOR ROOM OCCUPANT INFECTED~120%

* Prior room occupant infected; ^Any room occupant in prior 2 weeks infected.
Otter , Yezli, French. ICHE. 2012;32:687-699
 Question 7
• What is the disinfection process involving
a large blood spill?

– Hydrogen Peroxide
– Sodium Hypochlorite
– Alcohol solution
– Aldehyde Solution
• If a spill involves large amounts (e.g., >10 mL)
of blood or OPIM, or involves a culture spill in
the laboratory, use a 1:10 dilution for the first
application of hypochlorite solution before
cleaning in order to reduce the risk of
infection during the cleaning process in the
event of a sharp injury.
• Follow this decontamination process with a
terminal disinfection, using a 1:100 dilution of
sodium hypochlorite.
 Question 8- Match the following

Item Bag Color

• Bag containing • Yellow

residual blood
• Red
• Discarded Linen
contaminated • Blue
• Needle • Black
• Broken/discarded • Green
Glass • White
• Catheters
• Bag containing residual blood  Yellow
• Discarded Linen contaminated  Yellow
• Needle  White
• Broken/discarded Glass  Blue
• Catheters  Red
New Updated Color Coding for Bio-Medical Waste
Management -2016
• Yellow
– Human/Animal Anatomical Waste
– Soiled Waste
– Expired/discarded Medicines
– Chemical Waste
– Discarded Linen
– Microbiological Waste
• Red
– Contaminated Waste- Recyclable
• White
– Waste Sharps
• Blue
– Glassware & Metallic body implant
 Hand Hygiene and Skin Antisepsis
• Routine Hand Hygiene
– 0.5% Chlorhexidine + 70% Ethyl Alcohol w/v or
Isopropyl Alcohol 70%
• Surgical Scrub
– Chlorhexidine 4% w/v
• Skin Antisepsis
– 10% Povidone Iodine or Chlorhexidine 2% w/v
• Peripheral Line
– 70% ethyl/Isopropyl Alcohol
• Central Line
– Chlorhexidine 2% w/v
• Chlorhexidine 2% with isopropyl alcohol 70% is the
preferred antiseptic for skin preparation before invasive
procedures on intact skin.
• Use povidone iodine 10% as an alternative skin
antiseptic when chlorhexidine 2% with alcohol 70% is
contraindicated. Povidone iodine 10% should be used:
– if patients have sensitivities or allergies to
chlorhexidine 2% with alcohol 70%;
– for mucous membranes such as the mouth and
vagina;
– on eyes and ears;
– for infants less than 2 months old; and
– in emergent trauma when there is not sufficient time
to allow chlorhexidine 2% with alcohol 70% to
completely dry before incision
 MONITORING THE EFFECTIVENESS OF CLEANING
Cooper et al. AJIC 2007;35:338

• Visual assessment-not a reliable indicator of surface

cleanliness
• ATP bioluminescence-measures organic debris (each
unit has own reading scale, <250-500 RLU)
• Microbiological methods-<2.5CFUs/cm2-pass; can be
costly and pathogen specific
• Fluorescent marker-transparent, easily cleaned,
environmentally stable marking solution that fluoresces
when exposed to an ultraviolet light
 METHODS TO IMPROVE DISINFECTION
OF ENVIRONMENTAL SURFACES

• Follow “best” practices for room cleaning and disinfection

• Follow CDC guideline for choosing disinfectant and “best” practices
• Improve training/education of environmental service workers
• Use of checklists to ensure all room surfaces are cleaned/disinfected
• Use of method (fluorescent dye, ATP) to ensure proper cleaning
• “No touch” terminal disinfection
• UV light
• Hydrogen peroxide

• Self disinfecting surfaces

• New disinfection technology

 NEW “NO TOUCH” APPROACHES TO ROOM
DECONTAMINATION
Supplement Surface Disinfection
Rutala, Weber. Infect Control Hosp Epidemiol. 2011;32:743
 How Clean Is Clean?
• AAMI and FDA trying to gain consensus
• Reached consensus on maximum levels of top three
common markers after a device is cleaned
– Less than 6.4 µg/cm2 for protein
– Less than 12 µg/cm2 for total organic compound
– Less than 2.2 µg/cm2 for hemoglobin
• Research needs to be performed to determine how
healthcare facilities should verify cleanliness (real-time
tests and meaningful analytical endpoints)
 Take home points
• Difference in susceptibility of organisms to
disinfection
• Division of health-care associated
equipment and difference in their
disinfection practices
• appreciation of contamination of items of
regular use
• Levels of disinfection
• Appreciation of Environmental
contamination
• Blood spill management
• Waste disposal guidelines
• New Developments
Thank You