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Selection of an Ideal Disinfectant

Selection of an Ideal Disinfectant. William A. Rutala, Ph.D., M.P.H.

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Selection of an Ideal Disinfectant

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  1. Selection of an Ideal Disinfectant William A. Rutala, Ph.D., M.P.H. Director, Hospital Epidemiology, Occupational Health and Safety, UNC Health Care; Research Professor of Medicine and Director, Statewide Program for Infection Control and Epidemiology, University of North Carolina at Chapel Hill, NC, USA Disclosure: Clorox

  2. LECTURE OBJECTIVES • Review the role of the environment in transmission of nosocomial pathogens • Review the properties of an ideal disinfectant • Review the key considerations for selecting the ideal disinfectant • Kill Claims • Kill and wet-contact time • Safety • Ease of use • Other factors

  3. DISINFECTION AND STERLIZATION • 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-leveldisinfection.

  4. Processing “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

  5. Low-Level Disinfection for “Noncritical” Objects 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

  6. LECTURE OBJECTIVES • Review the role of the environment in transmission of nosocomial pathogens • Review the properties of an ideal disinfectant • Review the key considerations for selecting the ideal disinfectant • Kill Claims • Kill and wet-contact time • Safety • Ease of use • Other factors

  7. There is increasing evidence to support the contribution of the environment to disease transmission This supports comprehensive disinfecting regimens (goal is not sterilization) to reduce the risk of acquiring a pathogen from the healthcare environment/equipment ENVIRONMENTAL CONTAMINATION LEADS TO HAIs

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

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

  10. 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

  11. Thoroughness of Environmental CleaningCarling et al. Am J Infect Control. 2013;41:S20-S25 >110,000 Objects Mean = 32%

  12. Mean proportion of surfaces disinfected at terminal cleaning is ~30%

  13. 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

  14. 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.

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

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

  17. 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

  18. Increased Risk of Acquisition of HA Pathogen from Prior Room Occupant~120% * Prior room occupant infected; ^Any room occupant in prior 2 weeks infected

  19. 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.

  20. FREQUENCY (mean) OF HCP CONTACT FOR SURFACES IN AN ICU (N=28) AND WARD (N=24) ICU WARD Huslage K, Rutala WA, Sickbert-Bennett E, Weber DJ. ICHE 2010;31:850-853

  21. 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

  22. Thoroughness of Environmental CleaningCarling et al. Am J Infect Control. 2013;41:S20-S25 >110,000 Objects Mean = 32%

  23. ENVIRONMENTAL CONTAMINATION LEADS TO HAIsSuboptimal Cleaning • There is increasing evidence to support the contribution of the environment to disease transmission • This supports comprehensive disinfecting regimens (goal is not sterilization) to reduce the risk of acquiring a pathogen from the healthcare environment

  24. Quality Improvement

  25. MONITORING THE EFFECTIVENESS OF CLEANINGCooper 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

  26. SURFACE EVALUATION USING ATP BIOLUMINESCENCE Swab surface luciferace tagging of ATP Hand held luminometer Used in the commercial food preparation industry to evaluate surface cleaning before reuse and as an educational tool for more than 30 years.

  27. 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 (applied by IP unbeknown to EVS, after EVS cleaning, markings are reassessed) MONITORING THE EFFECTIVENESS OF CLEANINGCooper et al. AJIC 2007;35:338

  28. Fluorescent Marking Solution

  29. Target After Marking

  30. Target Enhanced

  31. TERMINAL ROOM CLEANING: DEMONSTRATION OF IMPROVED CLEANING • Evaluated cleaning before and after an intervention to improve cleaning • 36 US acute care hospitals • Assessed cleaning using a fluorescent dye • Interventions • Increased education of environmental service workers • Feedback to environmental service workers †Regularly change “dotted” items to prevent targeting objects Carling PC, et al. ICHE 2008;29:1035-41

  32. LECTURE OBJECTIVES • Review the role of the environment in transmission of nosocomial pathogens • Review the properties of an ideal disinfectant • Review the key considerations for selecting the ideal disinfectant • Kill Claims • Kill and wet-contact time • Safety • Ease of use • Other factors

  33. PROPERTIES OF AN IDEALSURFACE DISINFECTANT • Broad spectrum • Fast acting • Remains wet • Not affected by environmental factors • Nontoxic • Surface compatibility • Persistence • Easy to use • Acceptable odor • Economical • Solubility • Stability • Cleaner • Nonflammable Rutala WA, Weber DJ. Infect Control Hosp Epidemiol 2014;35:855-865

  34. PROPERTIES OF AN IDEALSURFACE DISINFECTANT • Broad spectrum • Should have a wide antimicrobial spectrum, including kill claims for all pathogens that are common causes of HAIs and outbreaks • Fast acting • Should have a rapid kill and short kill/contact time listed on the label • Remains wet • Should keep surfaces wet long enough to meet listed kill/contact times with a single application or meet wet times recommended by evidence-based guidelines (60 seconds) Rutala WA, Weber DJ. Infect Control Hosp Epidemiol 2014;35:855-865

  35. PROPERTIES OF AN IDEALSURFACE DISINFECTANT • Not affected by environmental factors • Should be active in the presence of organic matter (e.g., blood, sputum, feces) and compatible with soaps, detergents, and other chemicals encountered in use • Nontoxic • Should not irritating to the user, visitors, and patients. Should not induce allergic symptoms (especially asthma and dermatitis). The toxicity ratings for disinfectants are danger, warning, caution, and none. Ideally choose products with the lowest toxicity rating. • Surface compatibility • Should be proven compatible with common healthcare surfaces and devices Rutala WA, Weber DJ. Infect Control Hosp Epidemiol 2014;35:855-865

  36. PROPERTIES OF AN IDEALSURFACE DISINFECTANT • Persistence • Should have sustained antimicrobial activity or residual antimicrobial effect on the treated surface • Easy to use • Should be available in multiple forms, such as wipes (large and small), sprays, pull tops, and refills; directions for use should be simple and contain information about personal protective equipment as required • Acceptable odor • Should have an odor deemed acceptable by users and patients • Solubility • Should be soluble in water Rutala WA, Weber DJ. Infect Control Hosp Epidemiol 2014;35:855-865

  37. PROPERTIES OF AN IDEALSURFACE DISINFECTANT • Economical • Costs should not be prohibitively high but when considering the costs of a disinfectant one should also consider product capabilities, cost per compliant use, etc. • Stability • Should be stable in concentrate and use dilution • Cleaner • Should have good cleaning properties • Nonflammable • Should have a flash point above 150oF Rutala WA, Weber DJ. Infect Control Hosp Epidemiol 2014;35:855-865

  38. 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

  39. 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

  40. BACTERICIDAL ACTIVITY OF DISINFECTANTS (log10 reduction) WITH A CONTACT TIME OF 1m WITH/WITHOUT FCS. Rutala et al. ICHE. 2012; 33:1159-61 Improved hydrogen peroxide is significantly superior to standard HP at same concentration and superior or similar to the QUAT tested

  41. Hospital Privacy Curtains(pre- and post-intervention study; sampled curtain, sprayed “grab area” 3x from 6-8” with 1.4% IHP and allowed 2 minute contact; sampled curtain)

  42. Decontamination of Curtains with Activated HP (1.4%)Rutala, Gergen, Weber. Am J Infect Control. 2014;42:426-428 * All isolates after disinfection were Bacillus sp; now treat CP patient curtains at discharge with IHP

  43. How About “Green” Products? • Today, the definition of green is unregulated • It can mean: • Sustainable resources/plant-based ingredients • Free of petrochemicals • Biodegradable • No animal testing • Minimal carbon footprint • Traded fairly • It can, but does not always mean “safer”

  44. Efficacy of “Green” Products to Inactivate MDR PathogensRutala, Gergen, Weber. Unpublished results. 2013 • No measurable activity against A. baumannii, A. xyloxidans, Burkholderia cenocepacia, K. pneumoniae, MRSA and P. aeruginosa, VRE, Stenotrophomonas maltophilia

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

  46. 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

  47. 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

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