Download Taking the Mystery out of Chemical Disinfection

SASKPIC
Taking the Mystery out of
Chemical Disinfection
Nicole Kenny, BSc, Assoc Chem
Director of Professional & Technical Services
Virox Technologies Inc
Phone: 1-800-387-7578 x118
Email: [email protected]
Basic Facts
¾ Disinfectants are the backbone of Infection
Control
Products registered in the U.S. &
Canada
¾ 50% of which are used for Healthcare
Infection Control
¾ There are 300 different active chemistries
¾ >8000
z
z
14 are in 95% of the disinfectant products
6 are the most common
Effects of Germicides on
Microorganisms
¾ HCWs take for granted the action of
disinfectants without fully understanding
mechanism of action
¾ Differences in the action of antimicrobial
ingredients
¾ Differences depending on concentration of
chemical used
Infection Control Today
Cleaning & Disinfecting: The Effects of Germicides on Microorganisms
Microorganisms
Feb 2004
Chicago Tribune (2000)
¾ 75% of an estimated 103 000 patient
deaths linked to HAIs
¾ Due to unsanitary facilities, unwashed
hands & dirty instruments
¾ Found that hospital cleaning staff were
inadequately trained & cuts cleaning
budgets
Computer Keyboards May
Harbor Harmful Bacteria
¾
¾
¾
¾
Harmful bacteria can survive for prolonged periods
on keyboards & keyboard covers (VRE & MRSA: 24
hrs, PSAE: 1hr)
More contact with contaminated keyboard increase
likelihood of transmitting bacteria to hands (MRSA:
42% - 92%, VRE: 22% to 50%, PSAE: 9% to 18%)
Hand Hygiene important helps cut down on
transmission
Cleaning & Disinfection of keyboards & keyboard
covers helps decrease contamination
Infection Control Today
Computer Keyboards May Harbor Harmful Bacteria;
Experts Advise to Use Disinfectant and Wash Your Hands
April 2005
On the Same Page
Terminology, Definitions,
Common Words
Major Groups Of Microbes
Most
Susceptible
¾ Viruses (enveloped)
¾ Bacteria (Gram
(Gram +ve
+ve
& Gram -ve)
ve)
¾ Fungi
¾ Viruses (non(non-enveloped)
¾ Mycobacteria
¾ Protozoa
¾ Bacterial
Spores
Least
Susceptible
Typically, the more resistant the pathogen, the
more toxic the disinfectant needs to be…
be…
BACTERIA WITH SPORES
(Bacillus subtilis, Clostridiu,
tetani, C. difficile C. botulinum)
High Toxicity
MYCOBACTERIA
(Mycobacterium tuberculosis
M. avium-intracellulare, M.
chelonae
Hard
NON-ENVELOPED VIRUSES
(coxsackieviruses, polio
viruses, rhinoviruses,
rotaviruses, Norwalk virus,
hepatitis A virus
Intermediate
&High Level
FUNGI
(Candida species, cryptococcus
species, Aspergillus species,
Dermatophytes)
Kill
VEGETATIVE BACTERIA
(Staphylococcus aureus,
Salmonella typhi, Pseudomonas
aeruginosa, coliforms)
Low Level Disinfection
ENVELOPED VIRUSES
(Herpes simplex, varicella-zoster
virus, cytomegalovirus, EpsteinBarr virus, Measles virus, Mumps
virus, Rubella virus, Influenza
virus, Respiratory syncytial virus,
Hepatitis B and C viruses,
Hantaviruses, and Human
immunodeficiency virus)
Easy
•Glutaraldehyde
•Ethylene oxide
•Phenolics
•Alcohol Blends
•Iodine
•Bleach/Chlorine
•Quat/phenol Blends
•Quat/Alcohol Blends
•Quat as active
•Peracids
AHP
Chemical Sterilant
PROTOZOA WITH CYSTS
(Giardia lamblia,
Cryptosporidium parvum)
Low Toxicity
Process for Choosing a Disinfectant
Consider the Device/Surface Classification
(According to Spaulding)
Once the device has been defined
determine the Disinfection Process
Choose the CORRECT
Product
Process for Choosing a Disinfectant
Critical Devices
Semi-Critical
Devices
Sterilization
High Level
Disinfection
Intermediate
Level Disinfection
Low Level
Disinfection
Sanitizing
Non-Critical
Devices
Environmental
Surfaces
Cleaning
¾
¾
¾
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
Criteria for Sanitizing
¾
A process that reduces microorganisms on
surfaces to a safe level
z
z
¾
Food Contact Surfaces: reduction of surrogate
bacterial strains by more than 55-log10 in the presence
of 5% bovine serum
NonNon-Food Contact Surfaces: reduction of surrogate
bacterial strains by more than 33-log10
Vegetative Bacteria such as E. coli,
Staphylococcus, Pseudomonas and other
common food borne bacteria can be used
Criteria for Low Level Disinfection
¾
Bactericidal: effective against Vegetative bacteria:
> 6 Log10 reduction
z
¾
¾
¾
Staphylococcus aureus, Pseudomonas aeruginosa,
Salmonella cholerasius
General Virucide: effective against the Sabin strain
of Polio virus Type 1 (Hydrophilic virus), criterion is
> 3 Log10 reduction
Virucidal: effective against targeted viruses
(enveloped or nonnon-enveloped), criterion is > 3
Log10 reduction
Fungicidal: effective against criterion is > 5 Log10
z
Trichophyton mentagrophytes
Criteria for Intermediate Level
Disinfection
¾ Bactericidal: criterion is > 6
Log10 reduction
¾ General Virucide: criterion is > 3 Log10
reduction against Polio
¾ Virucidal: criterion is > 3 Log10 reduction
against specific viruses
¾ Fungicidal: effective against Trichophyton
mentagrophytes,
mentagrophytes, criterion is > 5 Log10
¾ Tuberculocidal: effective against
Mycobacteria terrae,
terrae, criterion is > 4 Log10
Criteria for High Level Disinfection
& Sterilization
¾ Fungicidal: effective against
Trichophyton
mentagrophytes,
mentagrophytes, criterion is > 5 Log10
¾ Tuberculocidal: effective against
Mycobacteria terrae,
terrae, criterion is > 6 Log10
¾ Sporicidal: effective against Bacillus
subtilis & Clostridium sporogenes,
sporogenes, criterion
is > 6 Log10
Disinfectants:
Desired Traits & Limiting
Factors
What’s in your bottle?
Marketplace overview
¾
Existing Technologies “FAIL”
FAIL” in one or
more of the key decision making criteria
when selecting a cleaner/disinfectant.
z
z
z
z
Cleaning Efficacy
Disinfection Capability
Personal Health & Safety
Environmental Responsibility
Positive Changes
¾ “It is cheaper & more effective to prevent
environmental & health damage than to
attempt to manage or cure it. Prevention
requires examining the entire life cycle of
products. It encourages the exploration
of safer alternatives and the
development of cleaner products,
technologies & workplaces.”
workplaces.”
-
Preventing Occupational & Environmental Cancer
- A strategy for Toronto
Registration
¾ Government registered by
Health
Canada (DIN)
¾ Easy to Use with clear label instructions
Microbiological
¾ BroadBroad-Spectrum Germicidal Activity
¾ Fast
Acting
¾ Not Readily Neutralized in Organic or
Inorganic Matter
¾ Microorganism Resistance will not develop
Chemical
¾
¾
Safe to Transport
Long Shelf Life
z
¾
Safe & Easy to Store
z
¾
Improper or prolonged storage of disinfectants may
lead to growth of bacteria in them
Improper storage of disinfectants may lead to
explosions or fires
NonNon-Corrosive & Material Compatible
z
Using the wrong type or level of disinfectant may
cause corrosion or other damage to expensive items
such as flexible endoscopes
Toxicological
¾
¾
¾
NonNon-Toxic to humans & animals
NonNon-Allergenic & nonnon-sensitizing
NonNon-Hormone disruption
z
¾
Certain microbicidal chemicals or their breakdown
products can disrupt hormone function in humans &
animals
Safe for the User and Patient
z
z
Exposure to cleaner & disinfectant vapours may
cause respiratory sensitization
Improperly rinsed endoscopes or other devices may
release residues of disinfectants into body cavity
Environmental
¾
Environmentally sound (Biodegradable)
z
¾
¾
EnvironmentallyEnvironmentally-stable sanitizers & disinfectants can
contaminate food or water (groundwater & surface
water)
No Active Residual Chemistry
Good Air Quality
z
z
z
z
Free of any pungent smell
No Volatile Organic Compounds (VOCs)
Use of gaseous or volatile products may negatively
affect indoor air quality
Fragrance Free
Purchasing & Training
¾
Cost Effective
z
z
z
¾
Consider the ShelfShelf-life of product once diluted
(i.e. 24hrs vs 30 days)
Consider cost at Use Dilution ($/L of product)
Decisions on purchasing disinfectants may be made
entirely based on cost which can lead to choosing an
inappropriate product
Training Support
z
Personnel responsible for using disinfectants may not
receive any training or inadequate instruction in the
preparation, use, storage and disposal of the
formulation in use
Factors Affecting Disinfectants
¾
Prior cleaning of a surface or device
z
z
z
¾
Cleaning MUST precede disinfection & sterilization
procedures
Cleaning residues can interfere with the activity of
some disinfectants
Chemical sterilants can be relied on to produce
sterility only if adequate cleaning occurs
Organic load on the surface or device
z
z
Soil can provide a protection barrier for microbes
Soil can neutralize many of the disinfectant
chemistries
Factors Affecting Disinfectants
¾
Type & level of microbial load on the surface or
device
z
¾
Water Quality
z
¾
Mechanism of action differs for each chemistry
(surface actives, cell components)
Many chemistries can be neutralized when diluted
with hard water
Concentration of the chemical
z
Improper dilution can lead to a false sense of security
Factors Affecting Disinfectants
¾ Exposure time of the surface or device to
the chemical
z
z
Contact time must be adhered to in order to
achieve desired level of disinfection
Surface or device must remain wet
¾ Physical configuration of the object
(crevices, hinges etc)
z
Difficult to remove debris or ensure
disinfectant comes in contact with all areas of
a surface or device
Factors Affecting Disinfectants
¾
Temperature
z
z
¾
pH
z
z
¾
Effectiveness is enhanced or hindered by various
temperature levels
Higher temperatures can accelerate the evaporation
of volatiles which can reduce the concentration &
effectiveness
Some products need to be activated prior to use
Changes to pH can decrease (neutralize) some
chemistries
Storage & ShelfShelf-life
z
z
Must consider how products are stored (too cold or
hot)
Efficacy of product decreases once diluted
The Chemistries
NAME THAT CHEMISTRY!?!
What Do the following chemicals have in common?
¾N-Alkyl (40% C12, 50% C14, 10% C16) dimethyl
benzyl ammonium chloride
¾3-(trimethoxysilyl) propyldimethyloctadecyl
ammonium chloride
¾N-Alkyl (68% C12, 32% C14) dimethyl ethylbenzyl
ammonium chloride
¾Benzalkonium chloride
They are all QUATERNARY AMMONIUM
COMPOUNDS!
Next Slide
Quaternary Ammonium
Compounds
Advantages:
¾
¾
¾
¾
¾
¾
Bactericidal, Fungicidal, Virucidal (enveloped) with
a minimum contact time of 10 minutes
Generally non-irritating to hands & non-corrosive to
surfaces
Usually has detergent properties
Low Toxicity profile
Stable in concentrate and use dilution
Newer generations are relatively stable in the
presence of organic matter
Quaternary Ammonium
Compounds
Disadvantages:
¾ Not sporicidal, generally not tuberculocidal
or virucidal against non-enveloped viruses
¾ Not effective against Biofilms
¾ DO NOT use to disinfect Instruments
¾ Leaves Residual Active Chemistry on
Environmental Surfaces
Quaternary Ammonium
Compounds
Disadvantages:
¾ Repeated uses increase residue build up on
surfaces which may lead to increase
resistance to susceptibility to antimicrobials
inside health settings
¾ Formulations may contain APEs or NPEs
(hormone disrupting chemicals)
¾ Non-Biodegradable
NAME THAT CHEMISTRY!?!
What do the following chemicals have in common?
¾Ethanol
¾Isopropanol
¾Methanol
¾Alcohol Anhydrous
They are all ALCOHOLS
Next Slide
Alcohols
Advantages:
¾ Broad-spectrum effectiveness:
bactericidal, tuberculocidal, fungicidal and
virucidal
¾ Contact time for Ethanol is1 to 3 minutes
¾ Contact time for Isopropanol is 5 to 10
minutes (generally added to Quats)
¾ No Active Chemical Residue
¾ Non Staining
Alcohols
Disadvantages:
¾ Evaporation may diminish concentration
therefore contact time is difficult to achieve
unless items are immersed
¾ Inactivated by organic material
¾ Poor cleaners, not appropriate for use on
Environmental Surfaces
¾ Not sporicidal
Alcohols
Disadvantages:
¾ Volatile, flammable and must be stored in
well-ventilated area
¾ Use in the OR is contraindicated
¾ Prolonged exposure may cause dry skin &
skin irritation
¾ Compatibility issues with glues & plastics
¾ May affect indoor air quality due to VOCs
Quat-Alcohol Blends
¾ Surface products on the market that
contain a combination of Quats & Alcohol
(IPA)
¾ Addition of IPA allows for efficacy against
Mycobacteria (TB Claim)
¾ These products have the same
Advantages & Disadvantages for both
Quats and Alcohols
NAME THAT CHEMISTRY!?!
What do the following chemicals have in common?
¾Chlorophene
¾Chloroxylenol
¾P-terttert-amylphenol Potassium salt
¾O-phenylphenol
¾O-benzylbenzyl-p-chlorophenol
They are all PHENOLS / PHENOLICS
Next Slide
Phenols & Phenolics
Advantages:
¾
¾
¾
¾
¾
Commercially available with added detergents to
provide cleaning & disinfecting
Broad-Spectrum antimicrobial (bactericidal,
tuberculocidal, fungicidal & virucidal) with a 5 to
10 minute contact time
Stable in both concentrate and use dilutions
Tolerance for organic load and hard water will
depend on formulation
Generally regarded as biodegradable
Phenols & Phenolics
Disadvantages:
¾ Poor cleaning efficacy
¾ Not Sporicidal
¾ Contraindicated for use around children
¾ Not recommended for use on Food
Contact Surfaces
¾ Residual disinfectant may cause tissue
irritation
¾ Pungent Odour (Volatile)
Phenols & Phenolics
Disadvantages:
¾ High Toxicity (listed on the Canadian Toxic
Substance List & the EPA National Priority Lists)
¾ Phenols have limited use in Educational & Food
Preparation settings because of their restrictions
due to the toxicity
¾ Potential toxicity (skin, brain, kidneys, liver &
lungs) from o-phenylphenol (listed as a
carcinogen), o-benzyl-p-chlorophenol & ethylene
glycol (anti-freeze, listed as a teratogen)
NAME THAT CHEMISTRY!?!
What do the following chemicals have in common?
¾Calcium Hypochlorite
¾Sodium Hypochlorite
¾Chlorine Dioxide
¾Sodium Chlorite
They are all CHLORINE COMPOUNDS!
Next Slide
Chlorine & Chlorine Compounds
Advantages:
¾
¾
¾
¾
¾
¾
Low cost, readily available, Multi-purpose
Relatively Fast Acting (average contact time of
10 minutes)
Broad-Spectrum Antimicrobial (bacteria, viruses,
fungi, protozoa, spores)
Effective in removing biofilms (does not kill)
Readily available in liquid or solid
Use for disinfection Environmental surfaces,
toys, sports equipment
Chlorine & Chlorine Compounds
Disadvantages:
¾ Unstable, Corrosive & pH dependant
¾ Inactivated (neutralized) by Organic Matter
¾ No detergent properties
¾ Irritant to skin & mucous membranes
¾ Compatibility issue with metals, rubber &
fabric materials
Chlorine & Chlorine Compounds
Disadvantages:
¾ Use in well-ventilated areas
¾ High Toxicity, especially on aquatic life
¾ Chlorine disinfection by-products cause
adverse developmental & reproductive
effects including spontaneous abortion
NAME THAT CHEMISTRY!?!
What do the following chemicals have in
common?
¾Dihydrogen dioxide
¾Hydrogen dioxide
¾Dioxidane
They are all synonymous for Hydrogen Peroxide!
Next Slide
Hydrogen Peroxide
Advantages:
¾ Environmentally safe
¾ Broad-spectrum antimicrobial (bacteria,
viruses, mycobacteria, fungi, spores)
¾ Effective against biofilms
¾ Stable in presence of organic matter
¾ Non-staining
¾ No Active Chemical Residue
Hydrogen Peroxide
Disadvantages:
¾ Can be corrosive to soft metals aluminum,
copper, brass, zinc, mild & galvanized steel
¾ High concentration has strong pungent odour
(>20%)
¾ High concentration may cause chemical burns
(>20%)
¾ Can be explosive at high concentrations (>20%)
Accelerated Hydrogen Peroxide
Advantages:
¾ Fast acting broad-spectrum antimicrobial
(bacteria, viruses, mycobacteria, fungi,
spores) for environmental surfaces and
instruments
¾ Contact times ranging from 30 seconds to 20
minutes depending on level of disinfection
¾ Effective against biofilms
¾ Excellent cleaning efficacy
¾ Excellent Health & Safety profile
Accelerated Hydrogen Peroxide
Advantages:
¾ Stable in presence of organic matter
¾ No active chemical residuals
¾ Low foam & non-staining
¾ Stable in concentrate form
¾ VOC free
¾ Environmentally friendly (EcoLogo and
Green Seal Approved formulas)
¾ Not manufactured using APEs (ie NPEs)
Accelerated Hydrogen Peroxide
Disadvantages:
¾ Not recommended for use on soft metals
aluminum, copper, brass, zinc, anodized
aluminum and carbon steel
¾ Surface disinfectants do not contain
solvents
NAME THAT CHEMISTRY!?!
What do the following chemicals have in common?
¾Glutaral
¾1,51,5-pentanedial
¾OrthoOrtho-phthalaldehyde
¾Formalin
They are all ALDEHYDES!
Next Slide
Ortho-phthalaldehyde
Advantages:
¾ High level disinfectant in 5 - 12 mins
¾ No activation required
¾ Non-corrosive to metals
¾ Non-flammable
¾ Excellent material compatibility, can be
used on lensed instruments and flexible
endoscopes
Ortho-phthalaldehyde
Disadvantages:
¾ Slow sporicidal activity
¾ Stains skin, mucous membranes, clothing
and environmental surfaces
¾ Eye irritation with contact
¾ Not enough information on Toxicity
¾ Potential material incompatibility (anodize
aluminum coating dulls)
Ortho-phthalaldehyde
Disadvantages:
¾ Restrictions to disposal (dependant on
municipality)
¾ Instruments must be well rinsed to ensure
removal of all chemical residues
¾ Contraindication for use on urological
instruments due to anaphylaxis
Glutaraldehydes
Advantages:
¾ Chemical sterilants in 6 - 12 hrs
¾ High level disinfectant in 10 - 60 mins
¾ Non-corrosive to metals
¾ Non-flammable
¾ Active in presence of Organic Matter
¾ Excellent material compatibility, can be
used on lensed instruments and flexible
endoscopes
Glutaraldehydes
Disadvantages:
¾ Not suitable or safe for use as a surface
disinfectant
¾ Pre-cleaning is essential (fixative)
¾ May corrode or stain high-carbon steel &
leave residues on metals
¾ Germicidal activity is affected by pH &
dilution
¾ Questionable ability to kill / remove
Biofilms
Glutaraldehydes
Disadvantages:
¾ Extremely irritating to skin & mucous
membranes (pungent odour)
¾ Special ventilation is required
¾ Liquid & vapour are recognized as toxic
can cause dermatitis (skin), conjunctivitis
(eyes), rhinitis & sinusitis (lungs)
¾ Gluteraldehyde is a suspected mutagen &
carcinogen
Conclusions
Disinfectant Selection
Consider:
¾ Efficacy
¾ Spectrum
¾ Versatility
¾ Ease of use
¾ Safety profile
¾ Cost
What’s in your bottle?
Disinfectant Selection
pe
Ty
Iodine
Alcohols
Phenolics
Chlorine
Quats
AHP
Ac
de
ic
i
m
er
G
S
u
m
m
a
r
y
t
Vo ive
l R
To ital esi
xi e O du
Su c / rg als
b Ir a
Po str rita nic
o at n C
E n r C e Im t o m
po
v le p
Na ir o an ac
un
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rr nm ing t
O ow en
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S
a
Re ani pe l is
s t c N c tr s u
r ic e u e
ti o u tr m s
n s a li G e
In z a t r m i
Us ion cid
e
e
Remember:
¾ Match Product with
Protocol
z Surfaces vs Instruments
¾ Cleaning = 1st step
¾ Disinfection = 2nd step
¾ Contact Time is
MANDITORY!
Ac
V o ti ve
R
T o lita l e s
x e id
S u ic / O rg u a
ls
P o b str Irrit a n i c
a a
E n o r C te I n t C o
m
l m
po
N a v ir o ea n p a
un
n m in ct
r
r
Or ow e g
d
ga -S nt a
Re n p l
s t ic N e c t is s
ric e ru u e
tio u tr m s
n s a li G e
In z a t rm
U s io ici
de
e
pe
Ty
de
ic i
rm
Ge
S
u
m
m
a
r
y
Peracetic Acid
OPA
Glutaraldehyde
AHP
Virox Technologies
Inc.
Engineering
Revolutionary
Disinfectants for the
War Against
Microbes
References
¾
¾
¾
¾
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 RRRR-10
Best Practices for Cleaning, Disinfection and
Sterilization in All Health Care Settings, PIDAC,
March 2006
References
¾
¾
¾
¾
Block S. Disinfection. Sterilization, and
Preservation, 5th Ed. 2001
Mayhall CG. Hospital Epidemiology and
Infection Control, 3rd Ed. Philadelphia. Lippincott
Williams & Wilkins, 2004:14732004:1473-1522
Cokendolpher JC & Haukos JF. The Practical
Applications of Disinfection and Sterilization in
Health Care Facilities, Chicago. American
Hospital Association, 1996: 4747-59
Rutala WA. APIC Guideline for Selection and
Use of Disinfectants AJIC 1990:17(2) 9999-117
References
¾
¾
¾
¾
Bessems E. The effect of practical conditions on
the efficacy of disinfectants. Int Biodeter &
Biodeg 1998:1771998:177-183
Crawford L et al. A Comparison of Commonly
Used Surface Disinfectants: AlcoholAlcohol-, PhenolPhenol-,
ChlorineChlorine- and Quat Disinfectants.
www.infectioncontroltoday.com/articles/0b1feat2
.html
Russel AD. Glutaraldehyde: Current Status and
Uses. Inf Con & Hosp Epi 1994;15 (11) 724724-733
Rutala WA. Sporicidal Activity of Chemical
Sterilants Used in Hospitals. Inf Con & Hosp Epi
1993; 14(12) 713713-718
References
¾
¾
¾
¾
Rutala WA & Weber DJ. The benefits of surface
disinfection. AJIC 2004;32(4) 226226-229
Woldkoff P et al. Risk in cleaning: chemical and
physical exposure. Sci of Total Env
1995:215:1351995:215:135-156
Sattar SA. Current issues in testing, selection
and use of microbicides in infection control: a
critical review. AICJ 2004;9(3):842004;9(3):84-100
Health Canada. Therapeutic Products
Programme Guidelines: Disinfectant Drugs. Fall
1999
References
¾ Degussa, Hydrogen Peroxide: Properties,
Handling and Application
¾ Hugo, Inhibition and destruction of the
microbial cell
¾ Ascenzi, Handbook of disinfectants and
antiseptics