Infection Control Facts: How to Select an Ideal Disinfectant

Lee Nesbitt, BMSc Manager, Professional & Technical Services Virox Technologies Inc Phone: 1-800-387-7578 x115 Email: lnesbitt@virox.com

2003: CDN Hospitals notified >900 patients that improper sterilization of equipment may have exposed them to HIV, Hepatitis and other diseases. $150M class action lawsuit filed alleging negligence in failing to meet adequate sterilization standards. Government ordered a province-wide audit of hospital infection-control practices

Healthcare Quarterly Vol. 8, Special Issue October 2005

Canadian law clearly establishes a positive duty on care providers to inform patients of errors that occur during their care When care providers realize that patients may have been exposed to infection from equipment, other patients or healthcare workers, a legal obligation may arise to contact patients to warn them of the risk and provide advice regarding appropriate follow-up testing and care.

The removal of adherent visible soil, blood, protein substances (tissue) and other debris from surfaces by mechanical or manual process Generally accomplished with water and detergents Removes or eliminates the reservoirs of potential pathogenic organisms

Viruses (enveloped) Bacteria (Gram +ve & Gram -ve) Fungi Viruses (non-enveloped) Mycobacteria Protozoa Bacterial Spores

Most Susceptible

Least Susceptible

Consider the Device Classification

(According to Spaulding)

Once the device has been defined determine the Disinfection Process

Choose the CORRECT Product

Critical Devices*

Sterilization High Level Disinfection

Semi-Critical Devices

Intermediate Level Disinfection

Low Level Disinfection

Non-Critical Devices

*Foot Care Instruments defined as critical according to CCDR Vol. 23S8 (Dec 1997) Infection Control Guidelines: Foot Care by Health Care Providers

 refers

to the level of disinfection required when processing noncritical items or some environmental surfaces and kills most vegetative bacteria and some fungi as well as enveloped viruses but not mycobacteria or bacterial spores.

refers to disinfectant that kills vegetative bacteria, most viruses and most fungi but not resistant bacterial spores.

refers to a process which destroys vegetative bacteria, mycobacteria, fungi, enveloped and non-enveloped viruses, but not necessarily bacterial spores

refers to the chemical disinfection process that destroys all forms of microbial life including bacteria, viruses, spores and fungi.

LLD Enveloped Viruses Vegetative Bacteria Fungi Non-Enveloped Viruses Mycobacteria Spores 3 Log / 99.9% 6 Log / 99.9999% 5 Log / 99.999% 3 Log / 99.9%

ILD 3 Log / 99.9% 6 Log / 99.9999% 5 Log / 99.999% 3 Log / 99.9% 4 Log / 99.99%

HLD

Chemical Sterilants

5 Log / 99.999%

5 Log / 99.999%

6 Log / 99.9999% 6 Log / 99.9999%

6 Log / 99.9999% 6 Log / 99.9999%

Whats in your bottle?

Disinfectants are the backbone of Environmental Infection Control >8000 Products registered in the U.S. & Canada 50% of which are used for Healthcare Infection Control There are 300 different active chemistries 14 are in 95% of the disinfectant products 6 are the most common

Detergency properties for cleaning Not Readily Neutralized in Organic or Inorganic Matter Microorganism Resistance will not develop Broad-Spectrum & Fast Acting Germicidal Activity

Alcohols
Must have good cleaning ability to remove organic soil load on surface. Alcohols are not effective cleaners as they do not contain detergency Properties

Chlorine
Chlorine can be inactivated by a soil load and do not contain detergency Properties

Phenolics
Phenolics are ineffective cleaners

QUATs
Quaternary Ammonia Compounds are not effective cleaners

AHP
AHP contains a combination of superior surfactants that are proven effective cleaners in synergy with H2O2

Is effective in a soil load.

Testing is done with no soil load.

Neutralized by soil.

Testing is done with a soil load

Testing is generally done without a soil load. Leaves active ingredient residual on surface

Testing is done with a soil load.

Will not lead to development of resistant organisms

Active ingredient evaporates

Active ingredient evaporates

Leaves active ingredient residual on surface

Active ingredient hydrogen peroxide evaporates from surface

Alcohols
Vegetative Bacteria Enveloped Viruses Fungi YES 3 min to 10 min YES 3 min to 10 min YES 3 min to 10 min NO

Chlorine
YES 10 min YES 10 min YES 10 min YES 10 min

Phenolics
YES 5 min to 10 min YES 3 min to 10 min YES 3 min to 10 min YES / NO Product Specific Review label 3 min to 10 min YES 3 min to 10 min

QUATs
YES 3min to 10 min YES 3 min to 10 min YES 3 min to 10 min NO

AHP
YES 30 sec to 20 min YES 1 min to 5 min YES 3 min to 5 min YES 1 min to 5 min

NonEnveloped Viruses

Mycobacteria

YES 3 min to 10 min

YES 10 min

ONLY WITH SOLVENT OR ALCOHOL 3 min 10 min NO

YES 1 min to 5 min

Bacterial Spores

NO

YES 10 min

NO

YES 10 min

OPA
Fungi YES 10 min YES 10 min YES 32 hours

Gluteraldehyde
YES 20 min 45 min YES 20 min 45 min YES 8 12 hours

AHP
YES 5 min 20 min YES 5 min 20 min YES 20 min 6 hours

Mycobacteria

Bacterial Spores

Safe to Transport & Easy to Store

Improper storage of disinfectants may lead to explosions or fires

Long

Shelf Life & Material Compatible

Improper or prolonged storage of disinfectants may lead to growth of bacteria in them Using the wrong type or level of disinfectant may cause corrosion or other damage to expensive items such as flexible endoscopes

Non-Corrosive

Alcohols
Does not have storage limitations Flammable

Chlorine
Highly reactive with other chemicals creating toxic by-products

Phenolics
Toxicity poses risk for water and food contamination. Cannot be used around children Relatively stable in both concentration and Use Dilution

QUATs
Caution with products that contain solvents or alcohols

AHP
Nonflammable or combustible

Realistic Shelf life and stabilty

Readily evaporates decreasing concentration

Readily degrades once open, diluted product must be made fresh daily Concerns with stainless steel and fabric materials

Relatively stable in both concentration and Use Dilution

Stable in concentrate and Use Dilution

Compatible with a wide variety of surfaces and materials

Concerns with plastics and glues

Concerns with residue build up on vinyl

Concerns with residue build up or Quat burn on some flooring and vinyl

Concerns with prolonged exposure to copper and brass

OPA
Does not have storage limitations Non-flammable or combustible

Gluteraldehyde
Do not store at elevated temperatures and keep away from ignition sources.

AHP
Non-flammable or combustible

Realistic Shelf life and stability

Shelf life decreases to 75 days once bottle is opened

Once activated shelf life rapidly decreases

Shelf life does not decrease once opened

Compatible with a wide variety of surfaces and materials

Concerns with plastics and glues

Concerns with residue build up on vinyl

Concerns with prolonged exposure to copper and brass

Non-Toxic to humans & animals Non-Allergenic & non-sensitizing Non-Hormone disruption

Certain microbicidal chemicals or their

Safe for the User and Patient

breakdown products can disrupt hormone function in humans & animals

Exposure to cleaner & disinfectant vapours may

cause respiratory sensitization Improperly rinsed endoscopes or other devices may release residues of disinfectants into body cavity

Alcohols
Indoor Air Quality (VOCs) Contains high levels of VOCs which contribute to poor indoor air quality
Does not contain APEs / NPEs

Chlorine
Creates high levels of VOCs through reactions with surface and soil load
Highly reactive creating toxic / carcinogenic by-products Active ingredient evaporates

Phenolics
Contain VOCs; Toxicity poses risk for water and food contamination

QUATs
Contain VOCs;

AHP
Contains no VOCs

Does not contain hormone disrupting or carcinogenic chemicals Will not lead to development of resistant organisms

Phenolic Compounds have been found to be carcinogenic

Many formulations contain APEs / NPEs

Does not contain APEs/NPEs ; is not carcinogenic

Active ingredient evaporates

Leaves active ingredient residual on surface

Leaves active ingredient residual on surface

Active ingredient hydrogen peroxide evaporates from surface

OPA
Indoor Air Quality (VOCs) Contains high levels of VOCs which contribute to poor indoor air quality

Gluteraldehyde
Contain VOCs; Requires special ventilation

AHP
Contains no VOCs

Adverse Reactions to Residues left on surfaces after reprocessing

Residues have lead to anaphylactic reactions

Anaphylactic reactions to both vapours and residues

No Active Residue left on surface

Will not lead to development of resistant organisms

Leaves active ingredient residual on surface

Leaves active ingredient residual on surface

Active ingredient hydrogen peroxide evaporates from surface

Environmentally sound (Biodegradable)

Environmentally-stable sanitizers & disinfectants

can contaminate food or water (groundwater & surface water)

No Active Residual Chemistry Good Air Quality

Free of any pungent smell No Volatile Organic Compounds (VOCs)

Use of gaseous or volatile products may

negatively affect indoor air quality Fragrance Free

Alcohols
Positive environmental profile including indoor air quality. Contains high levels of VOCs which contribute to poor indoor air quality Active ingredient evaporates

Chlorine
Creates high levels of VOCs through reactions with surface and soil load Active ingredient evaporates

Phenolics
Contain VOCs; Toxicity poses risk for water and food contamination

QUATs
Contain VOCs; often contain hormone disruptors

AHP
Contains no VOCs and no hormone disruptors

Will not lead to development of resistant organisms

Leaves active ingredient residual on surface

Leaves active ingredient residual on surface

Active ingredient hydrogen peroxide evaporates from surface Received certifications by EcoLogo and Green Seal

Carries EcoLogo or Green Seal Certification

Does not meet certification criteria

Does not meet certification criteria

Does not meet certification criteria

Only1 product meets Canadas EcoLogo criteria

OPA
Positive environmental profile including indoor air quality. Contains high levels of VOCs which contribute to poor indoor air quality

Gluteraldehyde
Contain VOCs; requires special ventilation

AHP
Contains no VOCs; does not require special ventilation

Restrictions to Disposal

Restrictions in disposal

Restrictions in disposal

Can be disposed into municipal waste water

Clearly outlines the requirements of what must be included on a label

Name of Product & Manufacturer

DIN must be on the main panel

Active Ingredients Intended Use Net contents Lot Number & Expiry Date Precautionary symbols and cautionary

statements

 Label

Claims Area or Site of Use Directions for Use

requirements continued:

Specific directions for preparing in-use dilution including ratios or metric units Reference to level of hardness of product diluent at time of testing Pre-cleaning or cleaning requirements Contact Times Temperature Stability of diluted or in-use product

Label requirements continued:

Rinse procedures Directions for Use for intended use against

bloodborne pathogens Reference to PPE Directions for disposal of infectious waste

Remember: Match Product with Protocol Surfaces vs

Instruments

Cleaning = 1st step Disinfection = 2nd step Contact Time is MANDATORY!

 Infection

Control Guidelines: Hand Washing, Cleaning, Disinfection and Sterilization in Health Care, Health Canada. Dec 1998, Vol 24S8 Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care, Health Canada. July 1999, Vol 25S4 Guidelines for Environmental Infection Control in Healthcare Facilities, CDC. MMWR June 2003, Vol 52, No RR-10 Best Practices for Cleaning, Disinfection and Sterilization in All Health Care Settings, PIDAC, May 2006

 Block

S. Disinfection. Sterilization, and Preservation, 5th Ed. 2001 Mayhall CG. Hospital Epidemiology and Infection Control, 3rd Ed. Philadelphia. Lippincott Williams & Wilkins, 2004:1473-1522 Cokendolpher JC & Haukos JF. The Practical Applications of Disinfection and Sterilization in Health Care Facilities, Chicago. American Hospital Association, 1996: 47-59 Rutala WA. APIC Guideline for Selection and Use of Disinfectants AJIC 1990:17(2) 99-117

 Bessems

E. The effect of practical conditions on the efficacy of disinfectants. Int Biodeter & Biodeg 1998:177-183 Crawford L et al. A Comparison of Commonly Used Surface Disinfectants: Alcohol-, Phenol-, Chlorine- and Quat Disinfectants. www.infectioncontroltoday.com/articles/0b1fe at2.html Russel AD. Glutaraldehyde: Current Status and Uses. Inf Con & Hosp Epi 1994;15 (11) 724-733 Rutala WA. Sporicidal Activity of Chemical Sterilants Used in Hospitals. Inf Con & Hosp Epi 1993; 14(12) 713-718

 Rutala

WA & Weber DJ. The benefits of surface disinfection. AJIC 2004;32(4) 226-229 Woldkoff P et al. Risk in cleaning: chemical and physical exposure. Sci of Total Env 1995:215:135-156 Sattar SA. Current issues in testing, selection and use of microbicides in infection control: a critical review. AICJ 2004;9(3):84-100 Health Canada. Therapeutic Products Programme Guidelines: Disinfectant Drugs. Fall 1999

Degussa, Hydrogen Peroxide: Properties, Handling and Application Hugo, Inhibition and destruction of the microbial cell Ascenzi, Handbook of disinfectants and antiseptics CCDR Supplement, Vol 23S8 (Dec 1997), Infection Control Guidelines: Foot Care by Health Care Providers. http://www.phacaspc.gc.ca/publicat/ccdrrmtc/97vol23/23s8/fcindexe.html