Cleaning Disinfectant Sterlization PDF

Basics of Cleaning, Disinfection & Sterilization for Health Care
Dr. Lynne Sehulster, CDC

A Webber Training Teleclass
Disclaimer
Basic Principles of The findings and conclusions in this presentation are those of the author and her
information resources and do not necessarily represent any determination or
Cleaning, Disinfection, and Sterilization policy of the Centers for Disease Control and Prevention (CDC).
in Health Care
Lynne Sehulster, PhD, M(ASCP)

Division of Healthcare Quality Promotion
Centers for Disease Control and Prevention
Hosted by Paul Webber

paul@webbertraining.com
www.webbertraining.com
Bluebonnets in Central Texas
Topics for Today Chain of Infection

 Basic infection control considerations Virulent pathogen
 Levels of disinfection
Sufficient number of the pathogen
 Introduction to the Spaulding (infectious dose)
Classification
 Sterilization Susceptible host
 Cleaning and disinfection of Mode of transmission
environmental surfaces
Correct portal of entry
From Point A to Point B So Why All the Fuss About

Medical/Dental Instruments Hand Hygiene?
and Accessories
 Most common mode
of transferral of
Physicians, pathogens is via the
Patient A Nurses, and Patient B hands!
Assistants
 Infections acquired in
healthcare
Medical Equipment,  Spread of resistant
Environmental Surfaces,
Frequently Touched
microorganisms
Surfaces
Hosted by Paul Webber paul@webertraining.com

1
Evidence of Relationship
Between Hand Hygiene and Cleaning
Healthcare-Associated Infections
A process that:
 Substantial evidence that hand hygiene  Renders a surface or device safe to handle
reduces the incidence of infections
 Reduces the natural bioburden on devices
 Historical study: Semmelweis and environmental surfaces
 More recent studies: rates lower when  Removes organic / inorganic contaminants
antiseptic handwashing was performed  Reduces the challenge load posed to a

sterilizing or disinfecting process
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002;
vol. 51, no. RR-16.
Disinfection Low-Level Disinfection

 By definition, disinfection differs from  Kills most vegetative bacteria, some
sterilization by its lack of sporicidal power viruses, and some fungi, but NOT
 Levels of disinfection: mycobacteria
– High – Hospital-type germicides used
primarily for housekeeping
– Intermediate
• quaternary ammonium compounds
– Low (“quats”)
 Environmental surfaces need only low- to • some phenolics
intermediate level disinfection • some iodophors
Intermediate-Level
Disinfection High-Level Disinfection
 Kills resistant mycobacteria (MTB var.  Kills all microorganisms except HIGH
bovis or M. terrae) and all other vegetative numbers of bacterial spores
bacteria, fungi, and most viruses – Liquid chemical sterilizing agents
– “Tuberculocidal” chemicals (sporicides), minimum 10-20 minutes
• phenolics exposure time
• iodophors • aldehydes
• chlorine compounds • hydrogen peroxide
• alcohols • peracetic acid

2
What is Sterility? Sterilization

 Kills all microorganisms, including HIGH
 Sterile – free from living microorganisms
numbers of bacterial spores
 In practical terms, this is expressed as a – Heat (moist or dry)
probability function, such as the probability – Chemical gas or vapor
of a surviving microorganism on an item as – Radiation
being 1 in 1 million – Liquid chemical sterilizing agents
 Sterility Assurance Level (SAL) – the (sporicides); 6-10 hours exposure time
predictor of the efficacy of the sterilization • aldehydes
process • hydrogen peroxide
• peracetic acid
Relative Microbial Resistance and Germicide Levels*

Sterilization*
Bacterial Spores
B. subtilis HLD*
Cl. sporogenes
Mycobacteria ILD*
MTB var. bovis
Nonlipid Viruses
Spaulding Classification
and
polio -
rhino - LLD*
Fungi
Cryptococcus sp.
Candida sp. Instrument Reprocessing
Vegetative Bacteria
Pseudomonas sp.
Salmonella sp.
Staphylococcus sp.
Lipid Viruses
HSV
CMV
HBV
HIV
Spaulding Classification of Critical Instruments

Instruments and Devices
 Critical – penetrates mucous
 Medical instruments and devices: membranes; makes contact with bone,
– Critical the bloodstream, or other normally
sterile tissues
– Semicritical
– Noncritical
 Examples:
 CDC modification; Environmental – Surgical instruments, scalpel blades
– Housekeeping – Surgical dental burs
– Frequently touched, clinical touch – Orthopedic drill bits, saws

3
Semicritical Instruments Noncritical Instruments

and Devices
 Semicritical – contacts mucous
membranes, but does not not make contact  Noncritical – contacts intact skin
with the bloodstream, bone, normally
sterile tissues, or penetrate soft tissue
 Examples:
 Examples:
– Blood pressure cuff
– Dental mouth mirror
– Stethoscope
– Speculum
– Pulse oximeter
– Ultrasonic probe tips
The most important step in

Levels of Reprocessing instrument reprocessing or
surface management is….
 Critical – sterilization
 Semicritical – sterilization, high-level
disinfection
 Noncritical – low- to intermediate-level
disinfection (depending on the type and
degree of contamination)
 Environmental – low- to intermediate-level
disinfection (depending on the type and
degree of contamination)
Decontamination and Reusable Medical Devices:

Cleaning Effect of Cleaning on Bioburden
(1) Nyström - instrument washer
 Decontamination or cleaning helps to – >78% of the instruments had <101 CFU/device
ensure the success of the terminal
– 96% had <102; 100% had <103
reprocessing step (e.g., sterilization)
(2) Rutala - standard cleaning procedure
 Manual scrubbing or automated process – 72% of the instruments had <101 CFU/device
 Keep instrument surfaces moist to prevent – 86% had <102; 94% had <3 x 102
organic matter from drying (3) McAllister, et al. - standard cleaning procedure
 DO NOT USE HIGH-LEVEL – 88% of the instruments had <102 CFU/device
DISINFECTANTS AS HOLDING – 100% had <103
SOLUTIONS!! (1) J. Hosp. Infect. 1981, 2: 363-368 (2) Amer. J. Infect. Cont. 1997. 25: 185.
(3) Amer. J. Infect. Cont. 1997. 25: 156.

4
Flexible Fiberoptic Endoscopes: Factors Affecting

Effect Cleaning on Bioburden Sterilization or Disinfection
(1) Colonoscope insertion tube:
 AMOUNT OF ORGANIC MATERIAL
– After clinical use - 1.3 x 107 - 2.0 x 1010
 Number of microorganisms
cfu/device
 Type of microorganisms (resistance levels)
– After manual cleaning - 1.3 x 105 - 4.5 x
105 cfu/device  Type of germicidal agent
(2) Five studies showed that cleaning alone  Concentration of germicidal agent
provided a mean 4.0 log10 reduction in microbial  Exposure time to germicidal agent
contamination
 Temperature of exposure
(1) Chu, NS er al. 1997. Am. J. Infect. Cont. 25: 186.  pH of solution
(2) Rutala, WA & DJ Weber. 1995. Infect. Cont. Hosp. Epidemiol. 16: 231-235.
 Presence or absence of moisture
Instrument Factors
 Lumens
 Mated surfaces
Sterilization 

Acute angles
Absorbent surfaces
Springs / valves
 Rough / pitted surfaces
 Inaccessible areas
 Heat-sensitive materials
 Faulty “cleaning” devices
Attributes of the Ideal Attributes of the Ideal

Sterilant*
Sterilant*  Non-toxic
 Highly efficacious – Poses no health hazards to the operator, patient, or
– Bacteriocidal, sporicidal, tuberculocidal, the environment
 Organic material resistance
fungicidal, virucidal
 Rapid activity
– Withstands reasonable organic challenge without
loss of efficacy
– Achieves sterilization quickly  Adaptability
 Strong permeability  Monitoring capability
– Penetrates packaging materials and device – Physical, chemical, or biological indicators
lumens  Cost effective
 Materials compatibility
* Source: Schneider, PM. Low-temperature sterilization in the 1990’s.
– Negligible changes in either appearance or 1994. Tappi Journal 77: 115-121.
function of processed items

5
Effective Sterilization:
Controlled Conditions
Moist Heat Sterilization
 For all physical processes:  All moist heat sterilization processes
– Time, temperature, relative humidity consist of four phases in their cycles:
– Heating phase
 For liquid chemical processes:
– Sterilization phase
– Time, temperature, pH, concentration
– Evacuation and cooling phase
 For gas or plasma processes: – Drying phase
– Time, temperature, gas concentration,
relative humidity, wrapping
Sterilization via Saturated Steam: “Flash” Sterilization

Air Removal Mechanisms
 Air interferes with the ability of steam to make  In hospitals, unwrapped item(s) are run
contact with items to be sterilized. Air is through a sterilization cycle using a higher
removed by: temperature and a shorter exposure time
 Gravity displacement: incoming steam forces  Items used immediately after cool-down
air to the bottom of the chamber for removal  Do not use flash sterilization for implanted
 Pre-vacuum (porous load): air is pumped out devices
of the chamber mechanically in one or  Avoid using flash sterilization if possible
multiple cycles before steam enters  Have adequate instrument inventory
Flash Sterilization Liquid Chemical Sterilants

 None of the new processes are approved for
and Low-Temperature
flash sterilization Processes
 Items must be thoroughly cleaned
 AAMI, AORN recommendations:  Use of liquid chemical sterilants or low-
– Non-porous loads, unwrapped: 3 minutes temperature sterilization processes is
>132ºC in either gravity-displacement or intended for the reprocessing of heat-
prevacuum units sensitive instruments and devices
– Porous loads: at >132ºC , 10 minutes in gravity-  NOTE: The vast majority of instruments
displacement units, or 4 minutes in prevacuum in medicine and dentistry are heat-
units stable

6
Liquid Chemical Sterilants and Advice From an Indoor

Low-Temperature Processes Environmental Microbiologist
 Liquid chemical sterilants
– Powerful, toxic chemical used for immersion “The proper method of reprocessing a
– Safety concerns; follow instructions carefully heat-stable device is to
– Use of these chemicals is discouraged AUTOCLAVE it! You COOK it!
 Low-temperature sterilization processes You don’t gas it, you don’t dunk it,
– Ethylene oxide (EO) YOU COOK IT!!!”
– Gas-plasma (e.g., hydrogen peroxide
W.W. Bond, MS
plasma) CDC Microbiologist (Retired)
– Chemical systems
Biological Indicators Types of Biological Indicators
 A standardized preparation of bacterial  Bacillus stearothermophilis

spores on or in a carrier – Moist-heat systems
 Serves to demonstrate whether sterilizing – Geobacillus stearothermophilis
conditions have been met  Bacillus subtilis
 BI must be placed in the most difficult site – EO, dry heat systems
for sterilant penetration – Bacillus atropheus
 A positive BI indicates a process failure  Bacillus pumilus
– Radiation-based systems
Chemical Indicators Physical Indicators

 Measure key parameters of the sterilization  Equipment monitors that are engineered
process to detect any of these parameters:
 Visual change when the desired parameter – Temperature, time
has been achieved (e.g., color change with – Pressure, gas concentration
temperature) – Relative humidity
 Single parameter indicators, multi- – Steam purity
parameter indicators – Delivered dose of sterilant

7
General Points to Consider

 Cleaning:
– Was this done, automated or manual, what cleaning
chemical, use conditions
 Rinsing:
Disinfection
– Use of tap water, removal of residuals, water quality
 Sterilization/disinfection:
– Label instructions, contact time, factors affecting the
operation of equipment, water quality, inappropriate
use/misuse of disinfectants, drying of the instrument
 Equipment use during medical procedures:
– Use of tap water, reuse of single-use devices, multi-
dose vials, examine all instruments/devices available for
use
 Documentation:
– Instrument identification noted in charts, processes
used, instrument trace back
Environmentally
The Inanimate Environment Can Transmitted Infections
Facilitate Transmission  Healthcare workers and patients can be
X represents VRE culture positive sites infected directly or indirectly from
environmental sources
– Sources can be air, fomites, instruments, or
aerosols
 Environmental surfaces (e.g., walls, floors) are
not directly involved in infectious disease
transmission
~ Contaminated surfaces increase cross-transmission ~ Fomite: An inanimate object or substance capable of carrying
Abstract: The Risk of Hand and Glove Contamination after Contact with a infectious organisms and hence transferring them from one
VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL. individual to another
Choosing a Disinfectant Choosing a Disinfectant

Procedure
 Clean first!
 Nature and use of the item to be disinfected  Nature of the item to be disinfected
 Disinfection level  Concentration of microorganisms present
 Sufficient potency for disinfection  Innate resistance of those microorganisms
 Intrinsic resistance of microbes  Amount of organic soil
 Chemical class of disinfectant, use conditions  Type and concentration of germicide used
 Materials compatibility  Duration and temperature of germicide
 Safety concerns: hazards with use? contact
 Aerosols, residuals, chemical sensitivities  Other factors if using a proprietary product

8
EPA Lists of Registered What is a “Hospital

Germicides Disinfectant?”
 List A – sterilants  An EPA category for disinfectants
 List B – tuberculocides
 Demonstrated potency against:
 List C – HIV-1
 List D – HIV-1, hepatitis B virus (HBV) – Pseudomonas aeruginosa
 List E – HIV-1, HBV, and Mycobacterium – Staphylococcus aureus
tuberculosis – Salmonella choleraesuis
 List F – hepatitis C virus (HCV)
 Low-level disinfectant
 List G – norovirus
 List H – MRSA, VRE (E. faecalis or E. faecium)  Intermediate-level disinfectant if the
 List J – medical waste treatment chemical is tuberculocidal
“Tuberculocidal” Germicides
Do NOT use high-level
 Use of these products will NOT prevent the disinfectants/chemical sterilants
spread of TB because TB is not acquired (e.g., glutaraldehyde,
from environmental surfaces
 Measure of potency
formaldehyde) to disinfect
 Mycobacteria have the highest intrinsic medical equipment surfaces or
level of resistance among the vegetative housekeeping surfaces!!
bacteria, viruses, and fungi
 Broad spectrum antimicrobial capability
Cleaning and Disinfecting of Cleaning and Disinfecting of

Medical Equipment the Housekeeping Surfaces
 FOLLOW THE MANUFACTURER’S  Clean on a regular basis to remove soil and
INSTRUCTIONS!!! dust
 In the absence of instructions, clean and  Physical removal of microorganisms and
organic soil is as important as the
follow with low- to intermediate-level antimicrobial effect of the disinfecting agent
disinfection depending on the degree of  Surfaces not touched frequently by hand (i.e.,
contamination floors) in general care areas are cleaned and
 Consider covering those surfaces that are disinfected
 This is controversial – routine disinfection of
frequently touched during delivery of care floors is not supported by epidemiology; lack
of consensus among infection control staff
and hospital epidemiologists

9
Microorganism Removal with Microfiber Cleaning and Disinfecting of

Cleaning Solution Cleaning System
Dry Time
(mins)
Mean % Reduction CFU + SD the Housekeeping Surfaces
Cotton string mop/standard
QUAT 2:48 94.84 + 4.8
bucket with wringer
 Follow manufacturer’s
QUAT
Microfiber mop/standard
bucket with wringer
2:13 87.94 + 17.2 instructions if using
Microfiber mop/microfiber
proprietary cleaners or
QUAT
bucket
7:04 95.31 + 5.7
disinfectants
Detergent
Cotton string mop/standard
bucket with wringer
2:48 67.75 + 31.6  Use conditions (e.g.,
concentration, contact time)
Microfiber mop/standard
Detergent
bucket with wringer
2:23 79.74 + 24.8
 Clean and disinfect surfaces
Detergent
Microfiber mop/microfiber
8:03 94.50 + 4.6 that are touched by hand on
bucket
a frequent and regular basis
 QUAT = 1:128 dilution of product containing 5.15% didecyl dimethyl ammonium chloride, 3.43%  Door knobs, light switches,
dimethyl benzyl ammonium chloride. Detergent was a neutral cleaner with no germicidal properties bed rails
 RODAC plates with D/E Neutralizing agar; CFU compared before and after cleaning
 Surfaces around the toilet
Source: Rutala WA, Gergen MF, Weber DJ. Microbiologic evaluation of microfiber mops for surface disinfection. Am J Infect
Control 2007; 35: 569-73.
Minimize Glove “Misuse” Environmental Cleaning Study:

VRE in RUMC MICU
 Failure to remove or change contaminated gloves
 18.3% (4/22) samples showed potential transferral of  4 periods of time over 9 months:
 Period 1: baseline, current procedures
microorganisms [a = from patient, b = from gloves]  Period 2: enhanced environmental cleaning
 Virex (cleaner / quat disinfectant)
Source: Girou E, Chai SHT, Oppein F, et al. J Hosp Infect 2004; 57: 162-9  20 – 25 mins/room, 2X per day
 “Bucket method for the floors, 8 – 12 cloths for touched surfaces
 Period 3: “washout” (no continued emphasis)
Glove Cultures Environmental Cultures
 Period 4: hand hygiene campaign
No. of Contacts Bacterial Bacterial  Rectal swabs for patients; environmental swabs; hand cultures for HCWs
Pathogenic Sampled Pathogenic
Before Counts
Bacteria Surfaces
Counts
Bacteria
 VRE acquisition rates:
Sampling (CFU) (CFU)  Period 1: 33.47 cases per 1000 patient-days at risk
P. aeruginosa (a), P. aeruginosa,  Period 2: 16.84
6 4,500 Serratia Bed barrier (rail) 85 Serratia  Period 3: 12.09
marcescens (a) marcescens (a, b)
 Period 4: 10.40
10 >30,000 P. aeruginosa Bedside table 2 P. aeruginosa
 Limitations to the study and unanswered questions:
 No reported use of neutralizer for the disinfectant
 Little or no details on the housekeeping procedures
10 >30,000 P. aeruginosa Bedside table >300 P. Aeruginosa (a)
 Hayden MK, Bonten MJM, Blom DW, Lyle EA, van de Vijver DAMC, Weinstein RA. Reduction in acquisition of vancomycin-resistant
Weighing Enterococcus after enforcement of routine environmental cleaning measures Clin Infect Dis 2006; 42: 1552-60
17 >30,000 P. aeruginosa 169 P. aeruginosa (b)
machine
An Example on Why Should Environmental

Instructions are so Important Sampling Be Done?
 EPA-registered products labeled as  NO, not routinely
“cleaner/disinfectants:”  Environmental sampling may be useful:
– Label clearly distinguishes between use of  To verify the effectiveness of a new cleaning
the product as a cleaner OR as a and disinfecting process
disinfectant
 To identify environmental reservoirs during
– Level of soil, precleaned surface outbreak situations
– Contact time  Coordinate sampling with the laboratory
– Surface is to remain WET for the full
contact time

10
Cleaning in the ICU: Environmental Infection

The Most and the Least
Control: Bacterial Spores
 Anthrax spore abatement; management of
Clostridium difficile outbreaks
 The Big Dilemma!
– HLDs are not routinely recommended for use
on environmental surfaces
– ILDs are not EPA-registered as sporicides
– Safe, yet effective decontamination of
A = Sink B = Tray Table C = Toilet Seat D = Bedside Table affected areas
E = Room Door Knobs F = Bathroom Door Knobs G = Bedpan Cleaner
H = Bathroom Light Switch
Adapted From: Carling PC, et al. J Hosp Infect 2008; 68: 39-44
Hydrogen Peroxide Vapor

 Vapor-phase hydrogen peroxide VHP has been shown to
be sporicidal at concentrations ranging from 0.5 <
10mg/L; optimal range of 2.4 mg/L with a contact time of
1 hr
 Break down products are non toxic (water and oxygen)
 Can adsorb to some plastics
 Requires low RH < 30%
 Two commercial companies slightly different technologies
 Has been used for laboratories, Building
Decontamination following Anthrax releases from
intentionally contaminated mail, glove boxes, aerosol
chambers, patient wards and rooms in healthcare
facilities
How to Determine if Cleaning Products Are

Hazardous or Contain Hazardous
Impact on Staff and Patients Substances
Review ingredients on material safety data sheet (MSDS). You can check
 Staff: products or ingredients against the following databases or lists.
– Irritant and allergic
contact dermatitis on  IARC – International Agency for Research on Cancer: www.iarc.fr
hands and forearms  NTP – National Toxicology Program; http://ntp-server.niehs.nih.gov
– Occupational asthma  OSHA – Occupational Safety and Health Administration: www.osha.gov
on the increase  IRIS – EPA Integrated Risk Information System: www.epa.gov/iris
 NIOSH – National Institute of Occupational Health and Safety: www.cdc.gov/niosh
– 20% are eye and skin ACGIH – American Conference of Governmental Industrial Hygienists: www.acgih.org
 Patients:

burns (chemical  CleanGredients Database – Green Blue Institute: www.greenblue.org
exposures) - Many exposed  Green Seal: www.greenseal.org
to chemicals 24/7  EPA DfE - EPA Design for the Environment: www.epa.gov/dfe/pubs/projects/formulat/index.htm
– Muscular/skeletal - Chemical IRCHS - Indiana Relative Chemical Hazard Score: www.ecn.purdue.edu/CMTI/IRCHS/
injuries (ergonomics) 
sensitivities  TURI – Toxic Use Reduction Institute: www.cleanersolutions.org

11
Safety Assessment of Cleaning and

Strategies to Enhance the Safety and Disinfectant Products
Efficacy of Cleaning and Disinfecting
 How is the product diluted and how frequently is it being used?
 Be familiar with the product’s MSDS and  What is the product’s intended use?
instructions for proper and safe
What is the likelihood it will be misused?
application 
 Look for opportunities to prevent surface  What is the experience level of users?
contamination from occurring  What are the hazard ratings for the product?
 Look for opportunities to reduce the
 What does the MSDS say about the product safety?
amounts of chemicals used
 Does the product present an acceptable level of risk?
 What do others report about the product safety?
EPA and FDA Information

 EPA information about registered
germicides:
http://www.epa.gov/oppad001/chemregindex
.htm
 FDA information about LCS/HLD:
http://www.fda.gov/cdrh/ode/germlab.html
 FDA MAUDE database:
http://www.accessdata.fda.gov/cdrh/cfdocs/c
fMAUDE/search.CFM
Source: U.S. Dept. of the Interior, National Park Service: Grand Teton National Park
Thank You! Bonus Material

Division of Healthcare Quality Promotion
Use and Interpretation of
Sterilizer BI Indicators
Centers for Disease Control and Prevention
“Protect patients, protect health-care

Biological Spill Management
personnel, and promote safety, quality, and
value in the health-care delivery system” Emerging Pathogens,
Antimicrobial Resistance

12
Use and Interpretation of Use and Interpretation of

Indicators Indicators
 Use on each sterilizer periodically (e.g., at
least weekly)  Check the mechanical parametric readings
 Use on each load of implantable devices (e.g., time, pressure) and internal/external
chemical indicators (e.g., temperature) first
 Use control BI’s (not processed) for
comparison purposes  When these suggest that the sterilizer is
functioning properly, a single positive BI may
 In-office culture services vs. mail-in services:
not indicate process failure
– No significant influence on results if delayed
during mailing  Take sterilizer out of service, review process
of operation to determine possible error
Use and Interpretation of Basic Principles of Biological

Indicators Spill Management
 Repeat BI testing with controls on three  Know and understand the Chain of Infection
consecutive sterilization cycles, empty chamber  Aerosol production and control
 If all processed BI’s are negative, return the unit
– Is the agent an airborne organism?
to service
 If any of the processed BI’s are positive: – Does the spill management activity produce
– Recall the processed items from that unit, aerosols?
rewrap, and re-sterilize these items  Low- to intermediate-level disinfection
– Have the equipment repaired and repeat the BI  Do not let the pathogenicity of the agent
challenge series override the science of its inactivation!
Biological Spill Management Sodium Hypochlorite

Solutions
 Contain the spill’s organic material with  Intermediate-level germicide, tuberculocidal
disinfectant-soaked absorbent toweling properties
 Intermediate-level disinfectant  When using generic or reagent grade
– Hospital disinfectant with tuberculocidal formulations: 5000-6000 ppm or 500-600
property ppm working solutions
– Sodium hypochlorite solutions  Manufacturer’s instructions for proprietary,
 Remove organic material, clean EPA-registered formulations
 Apply fresh disinfectant at proper use
conditions

13
Antimicrobial Resistance
More About Spill Management
And Emerging Pathogens
 DO NOT use liquid sterilants to disinfect  Newly discovered pathogens or organisms
environmental surfaces! that acquire antimicrobial resistance are
– Not cleared for this purpose; respiratory usually erroneously assigned extraordinary
hazard resistance to commonly used disinfection and
 DO NOT use environmental surface sterilization procedures
disinfectants to wash exposed skin!  Examples: SARsCo-V, HIV, HBV, Ebola
– Use antiseptic solutions for this purpose virus, Hantavirus, MDR-Tb, VRE, MRSA,
 DO NOT use alcohol to “neutralize” chlorine VRSA
residuals on surfaces!
Antimicrobial Resistance Drug Resistant Pathogens
 In general, antibiotic resistance is a trait  No correlation to drug resistance and

independent of an organism’s innate resistance to disinfection
susceptibility or resistance to a  Some organisms may develop tolerance at
disinfectant’s properties. concentrations hundreds to thousand folds
 Environmental infection control of major below use dilution
antibiotic-resistant bacteria (e.g., MRSA,  Current protocols do not have to be altered;
VRSA, VRE) is similar to that for antibiotic- use products per manufacturer’s label or per
sensitive organisms laboratory protocols
Antibiotic-Resistant Gram-
Antimicrobial Resistance Positive Cocci: MRSA, VRE
 Resistance may be apparently  Antibiotic resistance does not confer increased resistance to
“increased” because of physical chemical germicides
 Hand transferral is considered to be the primary means of spreading
factors these bacteria to patients, workers, and other surfaces
Control measures:
– Thicker cell walls 
 HANDWASHING!
– Biofilms  Follow the hands – what is touched with gloved hands during
care?
– Release into the environment as a  Appropriate barrier precautions
cell-associated agent  Patient isolation measures
 Standard cleaning and disinfection of surfaces
– Other organic matter  Terminal cleaning and disinfection of the patient’s room may be
intensified if environmental reservoirs of the MDRO persist

14
Staphylococcus aureus and MDROs and Environmental Infection

MRSA: Infection Control Issues Control
 V.A.6. Environmental Measures
 People are the source:  a. Clean and disinfect surfaces and equipment that may
– Carriage, infection be contaminated, including those in close proximity to the
– Shed into the general environment patient and frequently touched surfaces in the patient
– Transmit to other people care environment on a more frequent schedule compared
to that for minimal touch surfaces. Category IB
 Small numbers of staph can initiate infection  b. Dedicate noncritical medical items when patients are
 Staph contaminates the environment known to be infected or colonized with MDROs.
– Person to environment to person Category IB
– Staph can survive for long periods of time  c. Prioritize room cleaning of patients on Contact
 Cleaning can reduce staph and MRSA in the Precautions. Focus on cleaning and disinfecting
environment frequently touched surfaces and equipment in the
immediate vicinity of the patient. Category IB
 Cleaning can reduce staph / MRSA infection rates
Management of Multi-Drug Resistant Organisms in Healthcare Settings, 2006. HICPAC
guideline available at: www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf
Adapted from: Dancer SJ. The Lancet Infectious Disease; epub 10/31/07
Environmental Sites Positive for

MRSA in Endemic and Outbreak MDROs: When All Else Fails…
Situations
 V.B.8 Enhanced Environmental Measures
Item or Surface Mean % Range %  a. Use patient-dedicated or single-use noncritical
Floor 34.5 9.0 – 60.0 equipment and devices. Category IB
Patient Gown 40.5 34.0 – 53.0  b. Intensify training of environmental staff to achieve
Bed Rails 27.0 1.0 – 60.0 consistency of proper environmental cleaning and
Bed Linens 41.0 34.0 – 54.0 disinfection services. Category IB
Overbed Table 40.0 18.0 – 67.0  c. Monitor cleaning performance to ensure consistent
Bathroom Door Knob 14.0 8.0 – 24.0 cleaning and disinfection of surfaces in close proximity
Room Door Knob 21.5 4.0 – 59.0 to the patient and those likely to be touched by the
Furniture 27.0 11.0 – 59.0 patient and HCP
Flat Surfaces 21.5 7.0 – 38.0
Sink Taps 23.5 14.0 – 33.0 Management of Multi-Drug Resistant Organisms in Healthcare Settings, 2006. HICPAC
Infusion Pump Button 19.0 7.0 – 30.0 guideline available at: www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf
Adapted from: Dancer SJ. The Lancet Infectious Diseases: epub 10/31/07
MDROs: When All Else Fails… Environmental Control of

Avian Influenza Virus
 V.B.8 Enhanced Environmental Measures
 d. Obtain environmental cultures when there is  Basic biophysical and biochemical properties of
epidemiologic evidence that an environmental avian influenza virus have not changed
source is associated with ongoing transmission.  Sensitivity to disinfectants predicted to be
Category IB equivalent to that for human influenza viruses
 e. Vacate units for environmental assessment  Infection control strategy for environmental
and intensive cleaning when previous efforts to surfaces will be similar to current protocols (e.g.,
eliminate environmental reservoirs have failed. focus on clinical touch surfaces, LLD)
Category II
Management of Multi-Drug Resistant Organisms in Healthcare Settings, 2006. HICPAC
guideline available at: www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf

15
March is Novice Month

March 6
Basic Microbiology, with Jim Gauthier
March 13
Basics of Cleaning, Disinfection and
Sterilization, with Dr. Lynne Sehulster
March 20
Basics of Outbreak Management
with Dr. Bill Jarvis
March 27
Surveillance 101, with Mary
Andrus
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Cleaning Disinfectant Sterlization PDF

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Basics of Cleaning, Disinfection & Sterilization for Health Care

Dr. Lynne Sehulster, CDC

Lynne Sehulster, PhD, M(ASCP)

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Topics for Today Chain of Infection

From Point A to Point B So Why All the Fuss About

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antiseptic handwashing was performed  Reduces the challenge load posed to a

Disinfection Low-Level Disinfection

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What is Sterility? Sterilization

Relative Microbial Resistance and Germicide Levels*

Spaulding Classification of Critical Instruments

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Semicritical Instruments Noncritical Instruments

The most important step in

Decontamination and Reusable Medical Devices:

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Flexible Fiberoptic Endoscopes: Factors Affecting

Attributes of the Ideal Attributes of the Ideal

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Sterilization via Saturated Steam: “Flash” Sterilization

Flash Sterilization Liquid Chemical Sterilants

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Liquid Chemical Sterilants and Advice From an Indoor

Biological Indicators Types of Biological Indicators

 A standardized preparation of bacterial  Bacillus stearothermophilis

Chemical Indicators Physical Indicators

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General Points to Consider

Choosing a Disinfectant Choosing a Disinfectant

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EPA Lists of Registered What is a “Hospital

Cleaning and Disinfecting of Cleaning and Disinfecting of

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Microorganism Removal with Microfiber Cleaning and Disinfecting of

Minimize Glove “Misuse” Environmental Cleaning Study:

An Example on Why Should Environmental

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Cleaning in the ICU: Environmental Infection

Hydrogen Peroxide Vapor

How to Determine if Cleaning Products Are

sensitivities  TURI – Toxic Use Reduction Institute: www.cleanersolutions.org

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Safety Assessment of Cleaning and

 What do others report about the product safety?

EPA and FDA Information

Thank You! Bonus Material

“Protect patients, protect health-care

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Use and Interpretation of Use and Interpretation of

Use and Interpretation of Basic Principles of Biological

Biological Spill Management Sodium Hypochlorite

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Antimicrobial Resistance Drug Resistant Pathogens

 In general, antibiotic resistance is a trait  No correlation to drug resistance and

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Staphylococcus aureus and MDROs and Environmental Infection

Environmental Sites Positive for

MDROs: When All Else Fails… Environmental Control of

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March is Novice Month

www.webbertraining.com or e-mail info@webbertraining.com