Nosocomial Infection ----Prevention and control

1. Nosocomial Infection----Prevention and control Wang kefang（王克芳） wangkf@sdu.edu.cn

2. 2 Cleaning, Disinfection and Sterilization 下列物品或情形该怎样处理？ • 体温计需要消毒吗？该怎样处理？ • 你发现手上扎了一根小刺，同学找来缝衣针要给你挑出来，这根缝衣针可以直接用吗？ • 你从商店里买来一件T恤衫，你穿之前处理吗？ • 有个亲戚在你家吃住2天，他走后你想消毒一下餐具和被褥，如何做？

3. Concepts Cleaning（清洁） Disinfection（消毒） Sterilization（灭菌）

4. Concepts Cleaning • Cleaning is toremove the dirt from item surface by the use of water, detergents and mechanical actions. • Will remove most organisms from a surface. Remove not kill！！！

5. Concepts Cleaning Disinfection • A process that eliminates/kills almost all pathogens on objects, except of bacterial spores, to decrease the number of them to a harmless level.

6. Concepts Cleaning Disinfection Sterilization • Aprocess that destroys all forms of microorganisms, including bacterial spores

7. Decontamination Steps

8. Levels of disinfection and sterilization Low-level disinfection (LLD) ,Intermediate-level disinfection (ILD),High-level disinfection (HLD)

9. How to select disinfection and sterilization • Items’ risk to patients • High risk(critical) items • Intermediate risk (semi-critical) items • Low risk (noncritical) items

10. How to select disinfection and sterilization • Items’ risk to patients • High risk(critical) items • Items that reach the sterile tissues or organs( such as body cavities and the vascular system). • Items: Surgical instruments, syringes • Items should be sterilized before using

11. How to select disinfection and sterilization • Items’ risk to patients • High risk(critical) items • Intermediate risk (semi-critical) items • Items that do not enter sterile areas of the body but contact with mucous membranes or skin closely. • Items: thermometer, ventilator tube • HLD/ILD, Sterilization is preferred.

12. How to select disinfection and sterilization • Items’ risk to patients • High risk(critical) items • Intermediate risk (semi-critical) items • Low risk (noncritical) items • Items that contact with intact skin, not mucous membranes • Items: gown, sheet, blood pressure cuff • LLD (in some cases, cleaning is acceptable)

13. How to select disinfection and sterilization • Items’ risk to patients • Characters of contaminated microorganisms 种类、数量、对消毒因子的敏感性 • 致病性芽胞、真菌孢子—灭菌、高水平消毒 • 致病性细菌、真菌、亲水病毒、支原体、衣原体—中水平以上消毒 • 一般细菌和亲脂病毒—中水平和低水平消毒

14. How to select disinfection and sterilization • Items’ risk to patients • Characters of contaminated microorganisms • Characters of items • 耐热、耐湿物品和器材，应首选压力蒸汽灭菌法 • 耐高温的玻璃器材、油剂类和干粉类可选用干热灭菌 • 怕热、忌湿和贵重物品，可选择甲醛或环氧乙烷气体 • 金属器械的浸泡灭菌，应选择腐蚀性小的灭菌剂 • 在进行物品表面消毒时，应考虑到表面性质 表面光滑—紫外线；多孔材料—喷雾

15. Methods of Disinfection and Sterilization Heat Microwave Ionizing radiation Radiation Mechanical removing microorganisms burning、toasting Dry heat： Moist heat: Boiling Steam Disinfection Low Temperature Steam Disinfection High-Pressure Steam Sterilization • Physical Methods • Chemical Methods: Sunshine Ultraviolet light ozone Immersion; Rubbing; Nebulization; Fumigation

16. Physical Methods High-Pressure Steam Sterilization • the most common and effective method • Advantages: • Highly effective; • Rapid heating and rapid penetration of items; • Nontoxic; • Inexpensive; • 用途: • 常用于: 耐高温、耐高压、耐潮湿物品的灭菌 • ----金属、玻璃、橡胶、搪瓷、敷料等 • 不能用于凡士林等油剂、滑石粉等粉剂的灭菌 Sterilization

17. Physical Methods High-Pressure Steam Sterilization Sterilization parameters Sterilization

18. Notes: • Clean and dry items • Package size：下排气式30 ×30 × 25cm；预真空式 30 ×30 × 50cm • Arrange all packages in a way that allows the steam to circulate freely. • Timing until the autoclave reaches the required temperature and pressure. • Follow the instruction for operating the autoclave. • Packs should NOT be pick out of the autoclave until dry. • Label accurately with contents, date of processing and expiration and store in storage cabinet. • Monitor the effectiveness of sterilization Sterilization

19. Monitoring the Effectiveness Mechanical indicators Chemical indicators Biological indicators Indicatiors

20. Mechanical Indicators • These indicators, which are part of the autoclave or dry-heat oven itself, record and allow you to observe time, temperature, and/or pressure readings during the sterilization cycle. Indicators

21. Chemical Indicators • Each pack must have external chemical indicators. • Indicator strips will change color when temperature, time, and pressure has been achieved. Indicators

22. Biological Indicators • 非致病性嗜热脂肪肝菌芽孢. • If the bacterial spores have been killed after sterilization, you can assume that all microorganisms have been killed as well. • Advantages: • It directly measures the effectiveness of sterilization. • Disadvantages: • This indicator is not immediate. Bacterial culture results are needed before sterilization effectiveness can be determined. Indicators

23. Physical Methods Toasting Sterilization (Hot Air Oven) • 用途: • 适用于在高温下不变形、不损坏、不蒸发的物品：glass, metal instruments, oil, ointments and powders • 不适用于纤维织物、塑料制品等的灭菌。 • 灭菌参数： • 160 ºC, 2 hours; • 170 ºC, 1 hour; • 180 ºC, 0.5 hour. Sterilization

24. Notes: • Clean and dry all items to be sterilized. • Package size：10cm×10cm×20cm. • Organic items：temperature no more than 170℃ Sterilization

25. Other Physical Methods • Disinfection by Boiling • Ultraviolet Light Radiation • Microwave Disinfection High Level Disinfection

26. Boiling For items which are resistant to moisture and high temperature, such as mental, glass, rubber. • Notes: • Clean • Open all hinged instruments and other items. Catheter should be filled with water. Make sure that all items are completely submerged because water must touch all surfaces. • Once the water is in a rolling boil, start timing for 5-15 minute. From this point on do not add or remove any water or items. High Level Disinfection

27. Notes: • A 1-2% solution of sodium bicarbonate(碳酸氢钠) rises the boiled temperature to 105℃ and helps to prevent corrosion of the instruments. • The boiling point of water is affected by air pressure. Generally, every 300 meters is added, disinfection time should be prolonged for 2 minutes. • Never leave boiled items in water that has stopped boiling; they can become contaminated as the water cools. High Level Disinfection

28. Ultraviolet (UV) Light Radiation The best anti-bacterial effect: 250-270nm. • Air disinfection • A 30W UV light for every 10 m2 • The effective distance：≤ 2 meters • The radiation time： 30-60 min. • Object surface disinfection • The effective distance: 25-60 cm • The radiation time： 20-30min. • Fluid disinfection • The fluid depth : ≤ 2 cm High Level Disinfection

29. Notes: • Keep UV light clean: alcohol cotton twice a week. • Effective condition: • Temperature: 20-40 ºC Humidity: 40-60% • Record radiation time after the UV light has been on for 5-7 minutes. • When turned off, the light should be cooled off for 3-4 minutes before being turned on again • Regularly check the output of the UV light • Intensity≤ 70µW/cm2 , change the light. • Time ≥ 1000 hours, change the light. • Keep people off the room; cover eyes and skin if people couldn’t leave. High Level Disinfection

30. Microwave disinfection Uses: food, tableware, medication and some heat-tolerant non-metal instruments. • Notes: • Microwave is harmful to health, so avoid long term contact in small dose or large dose. • Microwave can not penetrate metal, do not put objects in metal container. • Water is a strong microwave absorbing medium, so wet wrapped item or put a glass of water in the microwave oven can enhance disinfection efficacy. High Level Disinfection

31. Methods of Disinfection and Sterilization Heat Microwave Ionizing radiation Irradiation Mechanical removing microorganisms Dry heat：burning、toasting Moist heat: Boiling Steam Disinfection Low Temperature Steam Disinfection High-Pressure Steam Sterilization • Physical Methods • Chemical Methods:Immersion; Rubbing; Nebulization; Fumigation Sunshine Ultraviolet light ozone

32. Chemical Methods Sterilant • A chemical agent that can destroys all forms of microorganisms to achieve sterilization. Disinfectant • A chemical agent that destroys most pathogens but may not kill bacterial spores.

33. Disinfectant/Sterilant 消毒灭菌水平、用法及浓度、注意事项 • Glutaraldehyde（戊二醛） • Chlorine disinfectant(含氯消毒剂) • Alcohol（乙醇） • Iodophor（碘伏） • Iodine tincture(碘酊) Textbook p73 表4-4

34. Levels of disinfection and sterilization

35. Principles for Chemical Sterilization/Disinfection • Before deciding to use a chemical method, consider whether a more appropriate physical method is available. • Select appropriate disinfectant and method according to the characteristics of items and microorganisms • Pay attention to the effective concentration of disinfectant and contact time • Make sure the solution is still effective when you use a previously prepared solution or a new solution. • Put it in a sterile container with a lid and mark the container with the preparation date and expiration date. • Do not put gauze, cotton in disinfectant.

36. 妇儿医院手术切口分枝杆菌感染暴发（广东深圳，1998）妇儿医院手术切口分枝杆菌感染暴发（广东深圳，1998） • 表现： 1998年4月1日～5月31日共手术292例，4月22日～7月14日发生切口感染166例。 • 调查：20份切口分泌物标本培养出分支杆菌（脓肿亚型）。使用中和未启用的戊二醛半小时不能杀灭金葡菌、1小时不能杀灭分支杆菌，测浓度为0.137%。 • 结论：戊二醛浓度错配导致手术器械分支杆菌污染，从而引起切口感染

37. Principles for Chemical Sterilization/Disinfection • Before deciding to use a chemical method, consider whether a more appropriate physical method is available. • Select appropriate disinfectant and method according to the characteristics of items and microorganisms • Pay attention to the effective concentration of disinfectant and contact time • Clean, and dry all items to be sterilized /disinfected. • Maintain enough contact time for items with disinfectant solution • Rinse thoroughly with sterile/clean saline to remove the residue that is left on items. This residue is toxic to skin and to tissues.

38. Common methods • 浸泡法（immersion） • 擦拭法(rubbing) • 喷雾法(nebulization) • 熏蒸法(fumigation)

39. Immersion • Open all hinged instruments and other items. • Place all items in the solution so that they are completely submerged. • 应用范围 • 耐湿不耐热的器械物品 • 如锐利器械（刀剪）、贵重仪器（导管、胃镜等）、塑料尼龙制品等

40. Rubbing • 应用范围 • 擦拭被污染物体的表面或皮肤、黏膜 • 选用： • 易溶于水、穿透力强、无显著刺激的消毒剂 • 如用含氯消毒剂擦拭墙壁、地面

41. Nebulization • 用喷雾器将消毒剂均匀地喷洒于空气或物品表面进行消毒的方法。 • 常用于地面、墙壁、空气等的消毒。

42. Fumigation • 将消毒剂加热或加入氧化剂，使其产生气体进行消毒的方法。如手术室、换药室、病房的空气消毒。在消毒间或密闭的容器内，也可用熏蒸法对被污染的物品进行消毒灭菌。 • 常用的有甲醛气体和环氧乙烷气体。

43. Daily Cleaning, Disinfection and Sterilization in Hospital • Hospital environment • Preventive disinfection and disinfection of epidemic focus • Textiles and laundry • Skin and mucous membrane • Equipment, instruments/devices • Waste and sewage

44. Environmental： Air Disinfection

45. Environmental： Surface Disinfection • Floor: • If no obvious contamination, Wet cleaning. • If contaminated by pathogenic microorganisms, use chemical disinfectants to mop or spay the floor. • Wall: • Do not need regular disinfection; • if contaminated, use chemical disinfectants to spay or rub the wall. • Object surfaces: • Use clean cloth or cloth with disinfection solution to rub the surfaces • bed, bedside tables, chair, doorknob, windows, door and urinal. • If contaminated, use chemical disinfectant to spay or rub them, or use ultraviolet light.

46. Preventive Disinfection andDisinfection of Epidemic Focus • Preventive disinfection • Disinfection of epidemic focus • Concurrent disinfection • Terminal disinfection

47. Textiles and Laundry • The textiles and laundry used by patients are sterilized by ethylene oxide, then washed and prepared for use. • If there is no ethylene oxide sterilization room, use the following methods: • wash and then disinfect patients’ cloth and sheet by high temperature; • use ultraviolet light to disinfect blankets, pillows, bed mattress; • wash and disinfect contagious patients’ and other patients’ textiles and laundry separately; • wash and disinfect health care workers’ and patients’ textiles and laundry separately.

48. Skin and Mucous Membrane • Skin and mucous membrane provide protective barrier to microorganisms. • choose appropriate antiseptics according to patients’ skin and mucous membrane site, pathogenic microorganisms. • Use 2% iodine tincture to disinfect skin, after dry deiodinize it with 75% alcohol. • Use 0.5%-2% iodophor.

49. Surveillance • Environmental air, object surfaces and HCW’s hands • Equipment, instruments/devices • Disinfection solution • High pressure sterilization and ultraviolet light • Dishware and eating utensils • Sanitary utensils • Drink water • Textiles and laundry, medical waste • Waste

50. 教学内容 清洁消毒灭菌概念 消毒灭菌的方法 医院清洁、消毒、灭菌工作 教学目标 解释术语：清洁、消毒、灭菌 掌握常用物理消毒灭菌法的方法和注意事项 掌握常用化学消毒剂的名称、浓度、使用注意事项 2 清洁、消毒、灭菌