Efficacy, Selection and Use of Disinfectants and Detergents in Environmental Cleaning/Disinfection

1. Efficacy, Selection and Use of Disinfectants and Detergents in Environmental Cleaning/Disinfection William A. Rutala, PhD, MPH Director, Hospital Epidemiology, Occupational Health and Safety; Professor of Medicine and Director, Statewide Program for Infection Control and Epidemiology University of North Carolina at Chapel Hill and UNC Health Care, Chapel Hill, NC

2. DISCLOSURES • Consultation and Honoraria • ASP (Advanced Sterilization Products), Clorox • Honoraria • 3M • Grants • CDC, CMS

3. Efficacy, Selection and Use of Disinfectants and Detergents in Environmental Cleaning/Disinfection • Role of the environment in disease transmission • Factors that affect disinfection • Advantages/disadvantages of disinfectants used on environmental surfaces and non-critical patient equipment • Efficacy of disinfectants • Selection and use of disinfectants

4. Efficacy, Selection and Use of Disinfectants and Detergents in Environmental Cleaning/Disinfection • Role of the environment in disease transmission • Factors that affect disinfection • Advantages/disadvantages of disinfectants used on environmental surfaces and non-critical patient equipment • Efficacy of disinfectants • Selection and use of disinfectants

5. DISINFECTION AND STERILIZATIONRutala, Weber, HIPAC. www.cdc.gov, 2008 • 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 except for high numbers of bacterial spores • NONCRITICAL - objects that touch only intact skin require low-level disinfection

6. DISINFECTION AND STERILIZATION • 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 except for high numbers of bacterial spores • NONCRITICAL - objects that touch only intact skin require low-level disinfection

8. KEY PATHOGENS WHERE ENVIRONMENTIAL SURFACES PLAY A ROLE IN TRANSMISSION • MRSA • VRE • Acinetobacter spp. • Clostridium difficile • Norovirus • Rotavirus • SARS

9. ENVIRONMENTAL CONTAMINATION LEADS TO HAIsWeber, Rutala, Miller et al. AJIC 2010;38:S25 • Frequent environmental contamination • Microbial persistence in the environment • HCW hand contamination with the environment • Prior room occupant with MRSA, VRE, CDI is a significant risk for acquisition of these pathogens. • Improved surface disinfection removes pathogens and reduce HAIs

10. ENVIRONMENTAL CONTAMINATION ENDEMIC AND EPIDEMIC MRSA Dancer SJ et al. Lancet ID 2008;8(2):101-13

11. ENVIRONMENTAL SURVIVAL OF KEY PATHOGENS ON HOSPITAL SURFACES Adapted from Hota B, et al. Clin Infect Dis 2004;39:1182-9 and Kramer A, et al. BMC Infectious Diseases 2006;6:130

12. 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

13. RELATIVE RISK OF PATHOGEN ACQUISITIONIF PRIOR ROOM OCCUPANT INFECTED * Prior room occupant infected, 120% increased risk; ^Any room occupant in prior 2 weeks infected. Otter , Yezli, French. ICHE. 2012;32:687-699

14. EVALUATION OF HOSPITAL ROOM ASSIGNMENT AND ACQUISITION OF CDI • Study design: Retrospective cohort analysis, 2005-2006 • Setting: Medical ICU at a tertiary care hospital • Methods: All patients evaluated for diagnosis of CDI 48 hours after ICU admission and within 30 days after ICU discharge • Results (acquisition of CDI) • Admission to room previously occupied by CDI = 11.0% • Admission to room not previously occupied by CDI = 4.6% (p=0.002) Shaughnessy MK, et al. ICHE 2011;32:201-206

15. TRANSMISSION MECHANISMS INVOLVING THE SURFACE ENVIRONMENT Rutala WA, Weber DJ. In:”SHEA Practical Healthcare Epidemiology” (Lautenbach E, Woeltje KF, Malani PN, eds), 3rd ed, 2010.

16. ACQUISITION OF MRSA ON HANDS AFTER CONTACT WITH ENVIRONMENTAL SITES

17. ACQUISITION OF MRSA ON HANDS/GLOVES AFTER CONTACT WITH CONTAMINATED EQUIPMENT

18. TRANSFER OF MRSA FROM PATIENT OR ENVIRONMENT TO IV DEVICE AND TRANSMISSON OF PATHOGEN

19. TRANSMISSION MECHANISMS INVOLVING THE SURFACE ENVIRONMENT Rutala WA, Weber DJ. In:”SHEA Practical Healthcare Epidemiology” (Lautenbach E, Woeltje KF, Malani PN, eds), 3rd ed, 2010.

20. ACQUISITION OF C. difficile ON PATIENT HANDS AFTER CONTACT WITH ENVIRONMENTAL SITES AND THEN INOCULATION OF MOUTH

21. Donskey CJ. Am J Infect Control 2013;41:S12

22. Disinfectant Product SubstitutionsDonskey CJ. AJIC. May 2013

23. Improve Effectiveness of Cleaning/DisinfectionDonskey AJIC. May 2013

24. Automated Disinfection Devices Donskey CJ. AJIC. May 2013

25. Does Improving Surface Cleaning and Disinfection Reduce Healthcare-Associated Infections?Donskey CJ. AJIC. 2013;41:S12-S19 “As reviewed here, during the past decade a growing body of evidence has accumulated suggesting that improvements in environmental disinfection may prevent transmission of pathogens and reduce HAIs.Although, the quality of much of the evidence remains suboptimal, a number of high-quality investigations now support environmental disinfection as a control strategy”

26. Efficacy, Selection and Use of Disinfectants and Detergents in Environmental Cleaning/Disinfection • Role of the environment in disease transmission • Factors that affect disinfection • Advantages/disadvantages of disinfectants used on environmental surfaces and non-critical patient equipment • Efficacy of disinfectants • Selection and use of disinfectants

27. Efficacy of Disinfection Influencing Factors Rutala, Weber, HIPAC. www.cdc.gov. 2008 • Organic load present-interfere by protect microbe from exposure or alters the disinfectant making it less antimicrobial • Type of microbial contamination-intrinsic resistance varies • Level of microbial contamination-larger the number of microorganisms, the more time needed to inactivate them • Concentration of disinfectant-the more concentrated the disinfectant, the greater its efficacy and the shorter the time to achieve kill. Use manufacturer’s recommended use-dilution.

28. Efficacy of DisinfectionInfluencing Factors • Temperature-activity increases as temperature increases • pH-increase in pH improves the antimicrobial activity of some disinfectants (e.g., Quat) but decreases the activity of others (e.g., hypochlorites) • Duration of exposure-must be exposed to disinfectant for kill time • Water hardness-high concentrations can reduce the rate of kill because cations in water interact with disinfectant to form insoluble precipitates

29. Efficacy, Selection and Use of Disinfectants and Detergents in Environmental Cleaning/Disinfection • Role of the environment in disease transmission • Factors that affect disinfection • Advantages/disadvantages of disinfectants used on environmental surfaces and non-critical patient equipment • Efficacy of disinfectants • Selection and use of disinfectants

30. PROPERTIES OF AN IDEAL DISINFECTANT Rutala and Weber. Infect Control Hosp Epidemiol. In press • Broad spectrum-wide antimicrobial spectrum • Fast acting-should produce a rapid kill • Remains Wet-meet listed kill/contact times with a single application • Not affected by environmental factors-active in the presence of organic matter • Nontoxic-not irritating to user • Surface compatibility-should not corrode instruments and metallic surfaces • Persistence-should have sustained antimicrobial activity • Easy to use • Acceptable odor • Economical-cost should not be prohibitively high • Soluble (in water) and stable (in concentrate and use dilution) • Cleaner (good cleaning properties) and nonflammable

31. 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 0.5%, 1.4% ____________________________________________________ UD=Manufacturer’s recommended use dilution

32. Quaternary ammonium compounds (e.g., didecyl dimethyl ammonium bromide, dioctyl dimethyl ammonium bromide)Rutala, Weber. Am J Infect Control 2013;41:S36-S41 Advantages Disadvantages Not sporicidal In general, not tuberculocidal and virucidal against non-enveloped viruses High water hardness and cotton/gauze can make less microbicidal A few reports documented asthma as result of exposure to benzalkonium chloride Affected by organic matter Multiple outbreaks ascribed to contaminated benzalkonium chloride • Bactericidal, fungicidal, virucidal against enveloped viruses (e.g., HIV) • Good cleaning agents • EPA registered • Surface compatible • Persistent antimicrobial activity when undisturbed • Inexpensive (in dilutable form) • Not flammable

33. Sodium HypochloriteRutala, Weber. Am J Infect Control 2013;41:S36-S41 Advantages Disadvantages Reaction hazard with acids and ammonias Leaves salt residue Corrosive to metals (some ready-to-use products may be formulated with corrosion inhibitors) Unstable active (some ready-to-use products may be formulated with stabilizers to achieve longer shelf life) Affected by organic matter Discolors/stains fabrics Potential hazard is production of trihalomethane Odor (some ready-to-use products may be formulated with odor inhibitors). Irritating at high concentrations. • Bactericidal, tuberculocidal, fungicidal, virucidal • Sporicidal • Fast acting • Inexpensive (in dilutable form) • Not flammable • Unaffected by water hardness • Reduces biofilms on surfaces • Relatively stable (e.g., 50% reduction in chlorine concentration in 30 days) • Used as the disinfectant in water treatment • EPA registered

34. Improved Hydrogen PeroxideRutala, Weber. Am J Infect Control 2013;41:S36-S41 Advantages Disadvantages More expensive than most other disinfecting actives Not sporicidal at low concentrations • Bactericidal, tuberculocidal, fungicidal, virucidal • Fast efficacy • Easy compliance with wet-contact times • Safe for workers (lowest EPA toxicity category, IV) • Benign for the environment • Surface compatible • Non-staining • EPA registered • Not flammable

35. AlcoholRutala, Weber. Am J Infect Control 2013;41:S36-S41 Advantages Disadvantages Not sporicidal Affected by organic matter Slow acting against non-enveloped viruses (e.g., norovirus) No detergent or cleaning properties Not EPA registered Damage some instruments (e.g., harden rubber, deteriorate glue) Flammable (large amounts require special storage) Evaporates rapidly making contact time compliance difficult Not recommended for use on large surfaces Outbreaks ascribed to contaminated alcohol • Bactericidal, tuberculocidal, fungicidal, virucidal • Fast acting • Non-corrosive • Non-staining • Used to disinfect small surfaces such as rubber stoppers on medication vials • No toxic residue

36. PhenolicsRutala, Weber. Am J Infect Control 2013;41:S36-S41 Advantages Disadvantages Not sporicidal Absorbed by porous materials and irritate tissue Depigmentation of skin caused by certain phenolics Hyperbilirubinemia in infants when phenolic not prepared as recommended • Bactericidal, tuberculocidal, fungicidal, virucidal • Inexpensive (in dilutable form) • Non-staining • Not flammable • EPA registered

37. Efficacy, Selection and Use of Disinfectants and Detergents in Environmental Cleaning/Disinfection • Role of the environment in disease transmission • Factors that affect disinfection • Advantages/disadvantages of disinfectants used on environmental surfaces and non-critical patient equipment • Efficacy of disinfectants • Selection and use of disinfectants

38. Most Prevalent Pathogens Causing Healthcare-Associated InfectionsRutala, Weber. Infect Control Hosp Epidemiol. In press • Staphylococcus aureus (15.6%) • E coli (11.5%) • Coagulase-negative Staphylococcus (CoNS) (11.4%) • Klebsiella (8.0%) • Pseudomonas aeruginosa (7.5%) • Enterococcus faecalis (6.8%) • Candida albicans (5.3%) • Enterobacter spp.(4.7%) • Other Candida spp.(4.2%) • Enterococcus faecium (4.1%) • Enterococcus spp. (3.0%) • Proteus spp. (2.5%) • Serratia spp. (2.1%) • Acinetobacter baumanii (1.8%) Modify Disinfectant Used • C. difficile spores-over the past decade, incidence of C. difficile increasing and now most common in some hospitals • Norovirus

39. DECREASING ORDER OF RESISTANCE OF MICROORGANISMS TO DISINFECTANTS/STERILANTS Prions Spores (C. difficile) Mycobacteria Non-Enveloped Viruses (norovirus) Fungi Bacteria (MRSA, VRE, Acinetobacter) Enveloped Viruses Most Resistant Most Susceptible

40. EFFECTIVENESS OF DISINFECTANTS AGAINST MRSA AND VRE Rutala WA, et al. Infect Control Hosp Epidemiol 2000;21:33-38.

41. Tuberculocidal Activity of DisinfectantsRutala et al. Am J Med 1991;91:267S • A modified AOAC tuberculocidal activity test was used to assess 14 hospital disinfectants • Effective-2% glut, 0.8%HP plus 0.06% PA, 1000ppm chlorine • Not effective-QUATs, 100ppm chlorine, and 0.13% glut not effective

42. C. difficile spores

43. DISINFECTANTS AND ANTISEPSISC. difficile spores at 20 min, Rutala et al, 2006 • No measurable activity (1 C. difficile strain, J9) • CHG • Phenolic • 70% isopropyl alcohol • 95% ethanol • 3% hydrogen peroxide • Disinfecting spray (65% ethanol, 0.6% QUAT) • Disinfecting spray (79% ethanol, 0.1% QUAT) • 0.06% QUAT; QUAT may increase sporulation capacity- Lancet 2000;356:1324 • 10% povidone iodine • 0.5% hydrogen peroxide

44. DISINFECTANTS AND ANTISEPSISC. difficile spores at 10 and 20 min, Rutala et al, 2006 • ~4 log10 reduction (3 C. difficile strains including BI-9) • Bleach, 1:10, ~6,000 ppm chlorine (but not 1:50) • Chlorine, ~19,100 ppm chlorine • Chlorine, ~25,000 ppm chlorine • 0.35% peracetic acid • 2.4% glutaraldehyde • OPA, 0.55% OPA • 2.65% glutaraldehyde • 3.4% glutaraldehyde and 26% alcohol

45. Product + Practice

46. ALL “TOUCHABLE” (HAND CONTACT) SURFACES SHOULD BE WIPED WITH DISINFECTANT “High touch” objects only recently defined (no significant differences in microbial contamination of different surfaces) and “high risk” objects not epidemiologically defined.

47. MICROBIAL BURDEN ON ROOM SURFACES AS A FUNCTION OF FREQUENCY OF TOUCHING • The level of microbial contamination of room surfaces is similar regardless of how often they are touched both before and after cleaning • Therefore, all surfaces that are touched must be cleaned and disinfected Huslage K, Rutala WA, Weber DJ. ICHE. 2013;34:211-212

48. Surface Disinfection • Wipe all “touchable” or “hand contact” surfaces with sufficient wetness to achieve the disinfectant contact time (> 1 minute). • Daily disinfection of surfaces (vs cleaned when soiled) in rooms of patients with CDI and MRSA reduced acquisition of pathogens on hands after contact with surfaces and on hands caring for the patient

49. Efficacy, Selection and Use of Disinfectants and Detergents in Environmental Cleaning/Disinfection • Role of the environment in disease transmission • Factors that affect disinfection • Advantages/disadvantages of disinfectants used on environmental surfaces and non-critical patient equipment • Efficacy of disinfectants • Selection and use of disinfectants

50. Key Considerations for Selecting the Optimal Disinfectant for Your FacilityRutala, Weber. Infect Control Hosp Epidemiol. In press