Transcript Slide 1

Infection Transmission Is A
Contact Sport
 Environmental Disinfection
 Making the Right Choice
Cindy Winfrey MSN, RN, CIC
7/18/2015
© 2008 Professional Disposables International, Inc.
Program Objectives
 Understand EPA regulations and requirements for
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surface disinfectants
Comprehend disinfectant label claims
Identify Influencing factors for disinfection efficacy
Describe recommendations for special pathogens.
Discuss factors to consider when choosing
disinfectants
© 2008 Professional Disposables International, Inc.
Is Infection Transmission A Contact
Sport?
• Patient contact with contaminated surfaces or medical
equipment
• Contamination of the environment & poor hand hygiene
contribute to the spread of resistant pathogens such as
MRSA, VRE and other significant pathogens
• Hands of healthcare workers come in contact with
a contaminated surface and patients
• Environmental surfaces/inanimate objects
(fomites) serve as reservoirs
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The Dirty Dozen
1. Kitchen Sink >500,000
bacteria per sq.in. drain
2. Airplane bathrooms
3. Wet laundry
4. Public drinking fountains
5. Shopping cart handles
6. ATM buttons
7. Women’s purses
(makeup;bottom)
8. Playgrounds
9. Health club
(mats/machines)
10. Your bathtub
11. Your office telephone
12. Hotel Room Remote
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Healthcare Environmental Hygiene
Study Group
 23 Acute Care Hospitals (16 East; 7 West)
 106 to 709 Beds (mean 252 beds)
 Evaluated terminal cleaning of rooms using a solution
that fluoresces brightly when exposed to ultraviolet
light
 Targeted ICUs and regular units
 Highest Risk Objects: sinks; toilet seats, toilet hand
bars, bedside tables, tray tables, doorknobs, BR light
switches, etc.
Carling P.C. et al. Identifying Opportunities to Enhance Environmental Cleaning
In 23 Acute Care Hospitals, ICHE, January 2008.
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Figure 1. Overall percentage of high risk objects determined to have been cleaned in each of the 23 acute care hospitals
From Infection Control and Hospital Epidemiology 29(1):1–7.
© 2007 by The Society for Healthcare Epidemiology of America..
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UNDERSTANDING
REGULATIONS
What does this mean to You?
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Rules & Regulations for
Surface Disinfectants
 Environmental Protection Agency (EPA)
 Classifies public health antimicrobials into categories
that depend on the stringency of tests the product
has passed
 EPA Categories:
-Disinfectants
-Sanitizers
-Sterilants
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Terminology – EPA Categories
• Sterilant: An agent that destroys or eliminates all
forms of microbial life in the inanimate
environment, including all forms of vegetative
bacteria, bacterial spores, fungi, fungal spores,
and viruses
• Non-liquid chemical sterilants (e.g., ethylene
oxide) and liquid chemical sterilants used on
surfaces or objects that are not critical or semicritical devices (e.g. veterinary equip.) FDA
regulates liquid chemical sterilants for medical
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Terminology – EPA Categories
• Disinfectant: an agent that destroys or
irreversibly inactivates infectious or other
undesirable bacteria, pathogenic, or viruses,
but not necessarily bacterial spores, on
surfaces or inanimate objects
• EPA registers three types of disinfectant
products (based upon submitted and
reviewed efficacy data)
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Limited Disinfectant
• Agent limited to either gram-positive or
gram-negative microorganisms
• Example: some pine oil toilet bowel
products are only effective against gramnegative bacteria
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General or Broad-spectrum
Disinfectant
• An agent that is effective against both grampositive and gram-negative bacteria
• Most household disinfectants fall in this
group
• Major uses for general disinfectants are
swimming pools and water purifiers
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Hospital Disinfectant
• Agent effective against : Gram negative and Gram
positive organisms (Staphylococcus aureus;
Salmonella choleraesuis) plus Pseudomonas
aeruginosa
• Used in hospitals, clinics, dental offices, and other
healthcare facilities
• A registrant that wants to market a hospital
disinfectant as a virucide must provide data to EPA
showing the product is effective against specific virus
the company wishes to list on label
• Same for tuberculocide – product effective against a
Mycobacterium that EPA accepts as a surrogate for
the actual tuberculosis bacterium
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Terminology – EPA Categories
• Sanitizer: Agent that reduces, but does not necessarily
eliminate, the microorganisms in the inanimate
environment to levels considered safe by public health
codes or other regulations
• EPA registers many sanitizers i.e., non food contact
surfaces, food contact surfaces
• Performance standard for food contact surfaces is
99.999% (5-log reduction) within 30 sec; for non-food
use sanitizer the standard is 99.9% (3-log) reduction in
5 min.
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LOG REDUCTION
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1 Log reduction = 90%
2 Log reduction = 99.0%
3 Log reduction = 99.9 %
4 Log reduction = 99.99%
5 log reduction = 99.999%
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Magnitude of Log Reduction
• 1 log10 = reduced by 90% (90% of 100,000
organisms = 90,000 killed, leaves 10,000 on skin)
• 2 log10 = reduced by 99%(1,000 left)
• 3 log10 = reduced by 99.9% (100 left)
• 4 log10 = reduced by 99.99% (10 left)
© 2008 Professional Disposables International, Inc.
Key Information to Look for on
Disinfectant Labels
• Germicidal as
Bacterialcidal,
Tuberculocidal,
Virucidal (May list
pathogens)
• Active ingredients
• Cautions
• Areas of Use
• Directions for Use
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Contact time
Special Instructions
Disposal, Storage
Precautionary/Safety
statements
• First Aid
• EPA registration
number
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Kill Claims vs. Contact Times
• Kill Claim is defined when a disinfectant
product is tested to have 100% efficacy
against a specific organism at a determined
contact time; and the testing data has been
accepted by the EPA
• Bridging of Data for Label Claims – What
does this mean?
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Kill Claims vs. Contact Times continued
• Contact Time is the time needed for the germicide
solution to remain wet on the surface to achieve
disinfection of the stated kill claims on the
manufacturer’s label
• For general directions for use, manufacturers are
required to put the highest contact time in those
directions.
• There is usually a different shorter contact time in
the “Special Instructions for Bloodborne
Pathogens” directions for use section of the
product label
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Contact Time
“ Disinfect noncritical surfaces 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.
However, many 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 of EPA-registered products label, the user
assumes liability for any injuries resulting from off-label
use and is potentially subject to enforcement action under
FIFRA”
Rutala, W. Disinfection, Sterilization and Antisepsis Principles, Practices, Current
Issues and New Research. APIC Conference Proceedings, 2006. Page 103.
© 2008 Professional Disposables International, Inc.
Influencing Factors for Disinfection
Efficacy
• Cleaning of object (clean vs. disinfect)
• Remove Bioburden (organic or inorganic
load present)
• Type and level of contamination
• Concentration of and exposure time
• Nature of object
• Temperature and relative humidity
© 2008 Professional Disposables International, Inc.
Disinfectants Used in Healthcare*
(Intermediate-Low level)
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Phenolics
Quaternary ammonium compounds
Iodophors
Alcohols
Chlorine and chlorine compounds
Combination e.g., Alc/Quat
Disinfectants are not interchangeable. Select an
appropriate disinfectant for any item and use.
Cautions with some disinfectant use causing
breathing problems e.g. chlorines.
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Approach to Disinfection and
Sterilization
• Spaulding’s Classification - >30 yrs old
• Critical Items – High risk of infection –
sterile tissue
• Semicritical items – Contact with mucous
membranes or nonintact skin
• Noncritical items – Contact with intact skin
(environmental disinfection; inanimate
objects)
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Levels of Disinfection
• Sterilization
• High-level disinfection (expected to destroy all
microorganisms except high numbers of bacterial
spores)
• Intermediate-level disinfection (inactivates
Mycobacterium tuberculosis, vegetative bacteria,
most viruses, most fungi)
• Low-level disinfection (can kill most bacteria,
some viruses, and some fungi, but cannot be
relied on to kill resistant microorganisms such as
tubercle bacilli or bacterial spores)
© 2008 Professional Disposables International, Inc.
BACTERIALSPORES
MYCOBACTERIUM
NON LIPID VIRUSES
FUNGI
VEGATIVE BACTERIA
LIPID VIRUSES
Descending Order of Resistance to Germicidal Chemicals.
Rutala, W. APIC Guideline for Selection & Use of Disinfectants-1996
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Pathogens of Concern
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Viruses
Non-enveloped (non lipid)
• Generally transmitted
by fecal-oral route and
contaminated fomites
• Sturdy
• Can withstand drying,
the effects of
detergents, and
extremes of pH and
temperature
• Can withstand acid
environment of
stomach
Enveloped (lipid)
• Fragile (they require an
intact envelop for
infectivity)
• Must remain wet and
are spread in: (1)
Respiratory droplets,
blood, mucus, saliva,
and semen (2) injection
(3) organ transplants)
Murphy, Rosenthal, Pfaller. Medical Microbiology 5th Ed Chapter 29,
pp. 499-500. 2005.© 2008 Professional Disposables International, Inc.
Viruses
Non-enveloped (non
lipid)
• Norwalk Virus
(Caliciviridae)
• Parvovirus
• Enterovirus
• Rhinovirus
• Rotavirus
• Hep A
Enveloped (lipid)
 Herpes Simplex
 HIV
 CMG
 Influenza
 Coronavirus
 Hep B, C
 RSV
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Vegetative Bacteria
• MRSA
• VRE
• ESBL producing E. Coli; Klebsiella
pneumoniae
• Carbapenem-Resistant Enterobacteriaceae
(CRE)
• Acinetobacter baumanii ; A. calcoaceticus;
A. lwoffii
• Pseudomonas aeruginosa
• E. Coli 0157:H7
© 2008 Professional Disposables International, Inc.
Rutala’s Computer Keyboard
Study
ICHE – April, 2006
• Increase use of computers in patient care
areas has led to contamination of keyboards
as reservoirs of pathogens
• Study examined the efficacy of different
disinfectants on the keyboard
• Determined if there was cosmetic (key
lettering removed) or functional changes
after 300 wipes
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Rutala’s Computer Keyboard
Study
ICHE – 2006; 27:372
• All tested products were effective in
removing or inactivating test pathogens
MRSA, P. aeruginosa, VRE
• Contact time with disinfectant: 5 sec wipe
and air dry
• Quats demonstrated excellent sustained
activity against VRE and antimicrobial
activity was maintained over the 48hr test
period
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Transmission of A. baumannii
AJIC - 2008
• Argentina Study: Barbolla et. al. Molecular
epidemiology of Acinetobacter baumannii spread
in an adult intensive care unit under an endemic
setting. AJIC. August, 2008.
• 1042 Screening samples – 159 positive Ab (Clone
“If” found in all types of samples : 56.9% patients,
66.7% staff hands and 84.1 environment samples)
• 30.8% Surfaces of handrub antiseptic dispenser;
39% Bed Rails; 12% Surfaces of mechanical vent
equip
• Frequently touched surfaces close to contaminated
patients seemed to have role in transmission
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Clostridia difficile
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Inactivation of C. difficile
• C. difficile spores are more resistant than vegetative
cells to commonly used surface disinfectants
• Environment may be an important source of C.
difficile spores
• Two EPA-registered products specific for
inactivating C. difficile spores
• Recommendations: Use of diluted sodium
hypochlorite (1:10 dilution of bleach) in units with
high endemic rates and outbreaks1
1Rutala,
W. Disinfection, Sterilization and Antisepsis Principles, Practices, Current
Issues and New Research. APIC Conference Proceedings, 2006. Page 98.
© 2008 Professional Disposables International, Inc.
Clostridia difficile
continued
2008 EPA Mandates
• EPA has determined all pesticide products that are
registered for use against C. difficile must
demonstrate efficacious performance against the
spore form
• EPA believes claims of efficacy against the
vegetative form is not the organism of concern for
infection control processes
• Efficacy testing performed on the vegetative form
of the organism will not support a claim for C.
difficile spores
• Manufacturers with vegetative label claims were
notified by letter to remove these claims
• EPA has developed guidelines to address label
claims for C. difficile spores
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CDC Recommendations
• Clean noncritical medical equipment
surfaces with a detergent/disinfectant. This
may be followed by an application of an
EPA-registered hospital disinfectant with or
without a tuberculocidal claim (depending
on the nature of the surface and the degree
of contamination), in accordance with
germicide label instructions
© 2008 Professional Disposables International, Inc.
36
CDC Recommendations Cont.
• Do not use alcohol to disinfect large
environmental surfaces
• Clean and disinfect high-touch surfaces (e.g.,
doorknobs, bed rails, light switches, and
surfaces in and around toilets in patients'
rooms) on a more frequent schedule than
minimal- touch housekeeping surfaces.
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CDC Recommendations for
Special Organisms
• Thoroughly clean and disinfect
environmental and medical equipment
surfaces on a regular basis by using EPAregistered disinfectants in accordance with
manufacturers' instructions
• Do not use high-level disinfectants (i.e.,
liquid chemical sterilants) on environmental
surfaces; such use is inconsistent with label
instructions because of the toxicity of the
chemicals
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Special Organisms Cont.
• Use standard cleaning and disinfection
protocols to control environmental
contamination with antibiotic-resistant, grampositive cocci (e.g MRSA, VRE)
• In units with high rates of endemic Clostridium
difficile infection or in an outbreak setting, use
dilute solutions of 5.25%–6.15% sodium
hypochlorite (e.g., 1:10 dilution of household
bleach) for routine environmental disinfection.
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ASHES 2008 Practice Guidelines
• Establish cleaning checklists
• Prefer pour spouts not spays (cotton decreases
efficacy of Quats)
• Never re-immerse cloth (cloth & bucket systems)
• Training
• Establish who cleans what
• Understand which products are compatible with
equipment
• Clean and disinfect as usual for C. diff and then
wipe high touch areas with bleach.
http://www.ashes.org
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Selecting the Right Disinfectant
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Current Disinfectants
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Quaternary ammonium compounds
Quat/Alcohol formulations
Sodium hypochlorite formulations (bleach)
Phenolics
New Technology: Accelerated Hydrogen
Peroxide; Silver
© 2008 Professional Disposables International, Inc.
Selecting Disinfectants
• A dilemma for Facilities
- Many types of equipment and end users
- Confusion about regulatory compliance (CMS, TJC)
- IC involvement in product / equipment selection?
• Focus on Practice or Product or Both?
- Monitor Practices
- Education of staff and their involvement in prevention
initiatives
- Who is responsible for cleaning/disinfecting
environmental surfaces and equipment?
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Selecting Disinfectants continued
• Should one disinfectant be used hospitalwide?
• Medical equipment specifying specific
product to use e.g., IV pumps, Patient
Monitoring Equipment
• Consider safety and precautionary factors
• Consider stability and shelf life of product
• Consider convenience and ease of use
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Going Green?
• Hospitals moving toward green initiatives
- building materials
- lighting
- water usage (more efficient toilets, faucets)
• Insuring “green” initiatives don’t inadvertently
place infection control and prevention efforts at
risk
• Green cleaners are “cleaners”, but don’t disinfect
• Summer 2008 Prevention Strategist (APIC),
“Finding a Balance”.
© 2008 Professional Disposables International, Inc.
Summary
• The environment and fomites play a role in
infection transmission thus a “contact
sport”.
• Understanding the rules and regulations for
surface disinfectants, kill claims, contact
times and product labels is key to making
good choices in selecting disinfectants.
• In dealing with problem pathogens,
understand that it is important to focus on
practices & products.
© 2008 Professional Disposables International, Inc.
Questions??????
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THANK YOU
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References
• CDC Guideline for disinfection and sterilization in healthcare
facilities., 2008 . Available at:
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfectio
n_Nov_2008.pdf
• CDC Guidelines for environmental infection control in
healthcare facilities. MMWR 2003:52(RR 10):1-42. Available
at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.ht
m
• Murphy, Rosenthal, Pfaller. Medical Microbiology 5th Ed
Chapter 29, pp. 499-500. 2005.
• Rutala, W. APIC Guideline for Selection & Use of Disinfectants1996
• Spaulding EH. Chemical disinfection of medical and surgical
materials. In: Lawrence C, Block S S, eds. Disinfection,
Sterilization and Preservation. Philadelphia: Lea & Febiger,
1968:517-531.
© 2008 Professional Disposables International, Inc.
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