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Disinfectants, Detergents and Microfiber: Current and Future Issues

This lecture examines emerging knowledge and controversies surrounding disinfectants, detergents, and microfiber cleaning products in healthcare settings. Topics include disinfection and sterilization practices, the use of disinfectants for non-critical surfaces, and the effectiveness of disinfectants against antibiotic-resistant pathogens.

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Disinfectants, Detergents and Microfiber: Current and Future Issues

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  1. Disinfectants, Detergents and Microfiber:Current and Future Issues 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 • Grants • CDC, CMS

  3. Disinfectants, Detergents and MicrofiberObjective Describe emerging knowledge and controversies related to disinfectants, detergents and microfiber cleaning products

  4. 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

  5. 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

  6. Disinfectants • Disinfectants are recommended for noncritical patient care objects (CDC, 2008) • Disinfectants are recommended for Precaution/Isolation patients (CDC, 2007) • Disinfectants are recommended for blood/OPIM (OSHA, 1991) • Disinfectants (or detergents) are recommended for other noncritical environmental surfaces (CDC, 2002 and 2008)

  7. LECTURE OBJECTIVES • Disinfectants • Knowledge and controversies • Detergents • Knowledge and controversies • Microfiber • Knowledge and controversies

  8. CLEANING AND DISINFECTING ENVIRONMENTAL SURFACES Cleaning (removes soil) and disinfecting is one-step with disinfectant-detergent. No pre-cleaning necessary unless spill or gross contamination.

  9. 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

  10. DISINFECTION OF NONCRITICAL PATIENT-CARE DEVICESRutala, Weber, HICPAC. 2008 www.cdc.gov • Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label’s safety precautions and use directions. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes but multiple scientific studies have demonstrated the efficacy of hospital disinfectants against pathogens with a contact time of at least 1 minute. By law, the user must follow all applicable label instructions on EPA-registered products. If the user selects exposure conditions that differ from those on the EPA-registered product label, the user assumes liability for any injuries resulting from the off-label use and is potentially subject to enforcement action under FIFRA. (II, IC)

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

  12. CONTACT TIMES FOR SURFACE DISINFECTION • Follow the EPA-registered contact times, ideally • Some products have achievable contact times for bacteria/viruses (30 seconds-2 minutes) • Other products have non-achievable contact times • If use a product with non-achievable contact time • Use >1 minute based on CDC guideline and scientific literature • Prepare a risk assessment http://www.unc.edu/depts/spice/dis/SurfDisRiskAssess2011.pdf

  13. Disinfectants • Disinfectants are recommended for noncritical patient care objects (CDC, 2008) • Disinfectants are recommended for Precaution/Isolation patients (CDC, 2007) • Disinfectants are recommended for blood/OPIM (OSHA, 1991) • Disinfectants (or detergents) are recommended for other noncritical environmental surfaces (CDC, 2002 and 2008)

  14. Surface Disinfection:Should We Do It? The use of disinfectants for non-critical items in health care is controversial (especially in some parts of the world)

  15. Justification for Using a Disinfectant for Non-Critical Surfaces • Surfaces may contribute to transmission of epidemiologically-important pathogens such as MRSA, VRE, C. difficile, MDR-Acinetobacter • Disinfectants prevent HAIs • Disinfectants are more effective than detergents in reducing contamination on surfaces • Detergents become contaminated and result in seeding the patient’s environment with bacteria • Disinfection of non-critical patient care items and equipment is recommended for patients on isolation • Disinfectants may have persistent antimicrobial activity

  16. Justification for Using a Disinfectant for Non-Critical Surfaces • Surfaces may contribute to transmission of epidemiologically-important pathogens such as MRSA, VRE, C. difficile, MDR-Acinetobacter • Disinfectants prevent HAIs • Disinfectants are more effective than detergents in reducing contamination on surfaces • Detergents become contaminated and result in seeding the patient’s environment with bacteria • Disinfection of non-critical patient care items and equipment is recommended for patients on isolation • Disinfectants may have persistent antimicrobial activity

  17. ENVIRONMENTAL CONTAMINATION LEADS TO HAIs • Microbial persistence in the environment • In vitro studies and environmental samples • MRSA, VRE, Ab, Cd • Frequent environmental contamination • MRSA, VRE, Ab, Cd • HCW hand contamination • MRSA, VRE, Ab, Cd • Relationship between level of environmental contamination and hand contamination • Cd

  18. ENVIRONMENTAL CONTAMINATION LEADS TO HAIS • Person-to-person transmission • Molecular link • MRSA, VRE, Ab, Cd • Housing in a room previously occupied by a patient with the pathogen of interest is a risk factor for disease • MRSA, VRE, Cd, Ab • Improved surface cleaning/disinfection reduces disease incidence • MRSA, VRE, Cd

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

  20. 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

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

  22. 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.

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

  24. 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

  25. 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

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

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

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

  29. 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.

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

  31. Justification for Using a Disinfectant for Non-Critical Surfaces • Surfaces may contribute to transmission of epidemiologically-important pathogens such as MRSA, VRE, C. difficile, MDR-Acinetobacter, others • Disinfectants prevent HAIs • Disinfectants are more effective than detergents in reducing contamination on surfaces • Detergents become contaminated and result in seeding the patient’s environment with bacteria • Disinfection of non-critical patient care items and equipment is recommended for patients on isolation • Disinfectants may have persistent antimicrobial activity

  32. Disinfectant Product SubsitutionsDonskey CJ. AJIC. May 2013

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

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

  35. Does Improving Surface Cleaning and Disinfection Reduce Healthcare-Associated Infections?Donskey CJ. AJIC. May 2013 “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”

  36. Justification for Using a Disinfectant for Non-Critical Surfaces • Surfaces may contribute to transmission of epidemiologically-important pathogens such as MRSA, VRE, C. difficile, MDR-Acinetobacter, others • Disinfectants prevent HAIs • Disinfectants are more effective than detergents in reducing contamination on surfaces • Detergents become contaminated and result in seeding the patient’s environment with bacteria • Disinfection of non-critical patient care items and equipment is recommended for patients on isolation • Disinfectants may have persistent antimicrobial activity

  37. Surface DisinfectionEffectiveness of Different MethodsRutala, Gergen, Weber. 2013, Unpublished Resutls

  38. It appears that not only is disinfectant use important but how often is important Daily disinfection vs clean when soiled

  39. Daily Disinfection of High-Touch SurfacesKundrapu et al. ICHE 2012;33:1039 Daily disinfection of high-touch surfaces (vs cleaned when soiled) with sporicidal disinfectant (PA) in rooms of patients with CDI and MRSA reduced acquisition of pathogens on hands after contact with surfaces and of hands caring for the patient

  40. Justification for Using a Disinfectant for Non-Critical Surfaces • Surfaces may contribute to transmission of epidemiologically-important pathogens such as MRSA, VRE, C. difficile, MDR-Acinetobacter, others • Disinfectants prevent HAIs • Disinfectants are more effective than detergents in reducing contamination on surfaces • Detergents become contaminated and result in seeding the patient’s environment with bacteria • Disinfection of non-critical patient care items and equipment is recommended for patients on isolation • Disinfectants may have persistent antimicrobial activity

  41. Transfer of C. difficile Spores by Nonsporicidal WipesCadnum et al. ICHE 2013;34:441-2 • Detergent/nonsporicidal wipes transfer or spread microbes/spores to adjacent surfaces; disinfectants inactivate microbes

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

  43. Bacterial Contamination of Water With and Without a Disinfectant • Detergent become contaminated and result in seeding the patient’s environment with HA pathogens. Ayliffe et al. Brit Med J. 1966;2:442-5

  44. Justification for Using a Disinfectant for Non-Critical Surfaces • Surfaces may contribute to transmission of epidemiologically-important pathogens such as MRSA, VRE, C. difficile, MDR-Acinetobacter, others • Disinfectants prevent HAIs • Disinfectants are more effective than detergents in reducing contamination on surfaces • Detergents become contaminated and result in seeding the patient’s environment with bacteria • Disinfection of non-critical patient care items and equipment is recommended for patients on isolation-CDC 2007 and OSHA 1991 • Disinfectants may have persistent antimicrobial activity

  45. QUATS AS SURFACE DISINFECTANTSWITH PERSISTENT ACTIVITY • Study of computer keyboards: Challenge with VRE or P. aeruginosa • Keys wiped with alcohol or quats (CaviWipes, Clorox Disinfecting Wipes, or Sani-Cloth Plus) • Persistent activity when not removed Rutala WA, White MS, Gergen MF, Weber DJ. ICHE 2006;27:372-77.

  46. Justification for Using a Disinfectant for Non-Critical Surfaces • Surfaces may contribute to transmission of epidemiologically-important pathogens such as MRSA, VRE, C. difficile, MDR-Acinetobacter, others • Disinfectants prevent HAIs • Disinfectants are more effective than detergents in reducing contamination on surfaces • Detergents become contaminated and result in seeding the patient’s environment with bacteria • Disinfection of non-critical patient care items and equipment is recommended for patients on isolation • Disinfectants may have persistent antimicrobial activity

  47. LECTURE OBJECTIVES • Disinfectants • Knowledge and controversies • Detergents • Knowledge and controversies • Microfiber • Knowledge and controversies

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