Disinfection and Sterilization: Current Issues and New Technologies William A. Rutala, PhD, MPH 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 School of Medicine, Chapel Hill, NC Disclosure: Clorox

Disinfection and Sterilization: Current Issues and New Technologies Current Issues and New Technologies Sterilization of critical items  Cleaning, washer disinfectors, biological indicators High-level disinfection for semi-critical items  New HLDs, prostate probes, cystoscopes, laryngoscopes Low-level disinfection of non-critical items  Role of the environment, curtain decontamination, room decontamination, thoroughness of cleaning D/S and Emerging Pathogens  MERS-CoV, Enterovirus D68, Ebola

Disinfection and Sterilization: Current Issues and New Technologies Current Issues and New Technologies Sterilization of critical items  Cleaning, washer disinfectors, biological indicators High-level disinfection for semi-critical items  New HLDs, prostate probes, cystoscopes, laryngoscopes Low-level disinfection of non-critical items  Role of the environment, curtain decontamination, room decontamination, thoroughness of cleaning D/S and Emerging Pathogens  MERS-CoV, Enterovirus D68, Ebola

DISINFECTION AND STERILIZATION WA Rutala, DJ Weber, and HICPAC, 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 except for low numbers of bacterial spores NONCRITICAL - objects that touch only intact skin require low- level disinfection

Sterilization of “Critical Objects” Steam sterilization-1970s Hydrogen peroxide gas plasma-1993 Ethylene oxide-1970s Vaporized hydrogen peroxide-2011

Some Potential Future Low-Temperature Sterilization Technologies Rutala WA, Weber WA. Infect Control Hosp Epidemiol 2015, In press Ozone plus hydrogen peroxide vapor Nitrogen dioxide Supercritical CO 2 Peracetic acid vapor

Cleaning Purpose: remove all adherent debris from an item and to reduce the number of particulates, microorganisms, and pyrogens. Removes debris such as blood, mucus, oil, salts or other foreign matter interferes with the sterilization process Reduces the bioburden and enhances the probability of sterilization

Bioburden on Surgical Devices Bioburden on instruments used in surgery (Nystrom, 1981) 62% contaminated with < % contaminated with < % contaminated with <10 3 Bioburden on surgical instruments (Rutala, 1997) 72% contained < % contained <10 2 Bioburden on surgical instruments (50) submitted to CP (Rutala, 2014) 58% contained <10 20% contained < % contained <5x10 2 6% contained <10 3

Washer/Disinfector Rutala et al. Infect Control Hosp Epidemiol : Five Chambers Pre-wash: water/enzymatic is circulated over the load for 1 min Wash: detergent wash solution (150 o F) is sprayed over load for 4 min Ultrasonic cleaning: basket is lowered into ultrasonic cleaning tank with detergent for 4 min Thermal and lubricant rinse: hot water (180 o F) is sprayed over load for 1 min; instrument milk lubricant is added to the water and is sprayed over the load Drying: blower starts for 4 min and temperature in drying chamber 180F

Washer/Disinfector Removal/Inactivation of Inoculum (Exposed) on Instruments Rutala et al. Infect Control Hosp Epidemiol : WD Conditions OrganismInoculum Log Reduction Positives RoutineMRSA2.6x10 7 Complete 0/8 RoutineVRE2.6x10 7 Complete 0/8 Routine P aeruginosa 2.1x10 7 Complete 0/8 Routine M terrae 1.4x /8 RoutineGS spores5.3x /14 No Enz/DetVRE2.5x10 7 Complete 0/10 No Enz/DetGS spores8.3x /10

Bioburden on surgical instruments is low Washer/disinfectors are very effective (>7 log 10 reduction) in removing/inactivating microorganisms from instruments Huge margin of safety

Rapid Readout BIs for Steam Now Require a 1- 3h Readout Compared to 24-48h

Super Rapid Readout Biological Indicators Commercially available 1491 BI (blue cap) Monitors 270°F and 275°F gravity –displacement steam sterilization cycles 30 minute result (from 1 hour) 1492V BI (brown cap) Monitors 270°F and 275°F dynamic-air-removal (pre-vacuum) steam sterilization cycles 1 hour result (from 3 hours)

Disinfection and Sterilization: Current Issues and New Technologies Current Issues and New Technologies Sterilization of critical items  Cleaning, washer disinfectors, biological indicators High-level disinfection for semi-critical items  New HLDs, prostate probes, cystoscopes, laryngoscopes Low-level disinfection of non-critical items  Role of the environment, curtain decontamination, room decontamination, thoroughness of cleaning D/S and Emerging Pathogens  MERS-CoV, Enterovirus D68, Ebola

DISINFECTION AND STERILIZATION WA Rutala, DJ Weber, and HICPAC, 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 except for low numbers of bacterial spores NONCRITICAL - objects that touch only intact skin require low- level disinfection

High-Level Disinfection of “Semicritical Objects” Exposure Time > 8m-45m (US), 20 o C Germicide Concentration_____ Glutaraldehyde > 2.0% Ortho-phthalaldehyde 0.55% Hydrogen peroxide* 7.5% Hydrogen peroxide and peracetic acid* 1.0%/0.08% Hydrogen peroxide and peracetic acid* 7.5%/0.23% Hypochlorite (free chlorine)* ppm Accelerated hydrogen peroxide 2.0% Peracetic acid 0.2% Glut and isopropanol 3.4%/26% Glut and phenol/phenate** 1.21%/1.93%___ * May cause cosmetic and functional damage; **efficacy not verified

Resert TM HLD l High Level Disinfectant - Chemosterilant l 2% hydrogen peroxide, in formulation pH stabilizers Chelating agents Corrosion inhibitors l Efficacy (claims need verification) Sporicidal, virucidal, bactericidal, tuberculocidal, fungicidal l HLD: 8 mins at 20 o C l Odorless, non-staining, ready-to-use l No special shipping or venting requirements l Manual or automated applications l 12-month shelf life, 21 days reuse l Material compatibility/organic material resistance (Fe, Cu)? * The Accelerated Hydrogen Peroxide technology and logo are the property of Virox Technologies, Inc. Modified from G MacDonald. AJIC 2006;34:571

Reprocessing Semicritical Items New Developments in Reprocessing Endoscopes Cystoscopes, ureteroscopes, hysteroscopes Prostate biopsy probes Laryngoscopes

Reprocessing Channeled Endoscopes Cystoscopes, Ureteroscopes, Hysteroscopes

Reprocessing Channeled Endoscopes Rutala, Gergen, Bringhurst, Weber, 2015 Exposure Method VRE Contamination Before HLD (glutaraldehyde) VRE Contamination After HLD Passive HLD (immersed, not perfused) 3.6x x x x x x10 7 Active HLD (HLD perfused with syringe) 8.4x x x CFU 0 l Pathogens must have exposure to HLD for inactivation l Immerse channeled flexible scope into HLD will not inactivate channel pathogens l Completely immerse the endoscope in HLD and ensure all channels are perfused, complete inactivation l Air pressure in channel stronger than fluid pressure at fluid-air interface

Reprocessing Semicritical Items New Developments in Reprocessing Endoscopes Cystoscopes, ureteroscopes, hysteroscopes Prostate biopsy probes Laryngoscopes

Prostate Biopsy Probe Rutala, Gergen, Weber. ICHE. 2007;28:916 Evaluated effectiveness of HLD when assembled (needle biopsy holder in probe) and unassembled. Inoculated ( P.aeruginosa ): internal lumen/outside surface of needle biopsy holder; internal lumen of probe with and without needle biopsy holder in place Conclusion: HLD achieved when unassembled but not when assembled

Disinfection of Prostate Probe Rutala, Gergen, Weber. ICHE. 2007;28:916 Needle guide must be removed from the probe for disinfection

Disinfection of Prostate Probe Rutala, Gergen, Weber. ICHE; 2007;28:916

Do Not Reuse Single Use Devices l Federal judge convicted a urologist who reused needle guides meant or single use during prostate procedures (Sept 2014) l Criminal prosecution (conspiracy to commit adulteration)

Reprocessing Semicritical Items New Developments in Reprocessing Endoscopes Cystoscopes, ureteroscopes, hysteroscopes Prostate biopsy probes Laryngoscopes

Reprocessing of Rigid Laryngoscopes JHI 2008, 68:101; ICHE 2007, 28:504; AJIC 2007, 35: 536 Limited guidelines for reprocessing laryngoscope’s blades and handles Many hospitals consider blade as semicritical (HLD) and handle as noncritical (LLD) Blades linked to HAIs; handles not directly linked to HAIs but contamination with blood/OPIM suggest its potential and blade and handle function together Ideally, clean then HLD/sterilize blades and handles (UNCHC-blades wrapped in a tray-Sterrad; handle wrapped in tray [without batteries]- steam); the blades and handles placed together in a Ziploc bag. Blades and handles checked for function prior to packaging.

Contamination of Laryngoscope Handles J Hosp Infect 2010;74:123 55/64 (86%) of the handles deemed “ready for patient use” positive for S. aureus, enterococci, Klebsiella, Acinetobacter Anesth Analg 2009;109:479 30/40 (75%) samples from handles positive (CONS, Bacillus, Streptococcus, S. aureus, Enterococcus) after cleaning AANA J 1997;65:241 26/65 (40%) of the handles and 13/65 (20%) of the blades were positive for occult blood. These blades and handles were identified as ready for patient use.

Laryngoscopes Blades The Joint Commission, FAQ, October 24, 2011 How should we process and store laryngoscope blades? Processed via sterilization or HLD Packaged in some way Stored in a way that prevents recontamination. Examples of compliant storage include, but are not limited to, a peel pack post steam sterilization (long-term) or wrapping in a sterile towel (short term) Should not place unwrapped blades in an anesthesia drawer

Disinfection and Sterilization: Current Issues and New Technologies Current Issues and New Technologies Sterilization of critical items  Cleaning, washer disinfectors, biological indicators High-level disinfection for semi-critical items  New HLDs, prostate probes, cystoscopes, laryngoscopes Low-level disinfection of non-critical items  Role of the environment, curtain decontamination, room decontamination, thoroughness of cleaning D/S and Emerging Pathogens  MERS-CoV, Enterovirus D68, Ebola

DISINFECTION AND STERILIZATION 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 except for low numbers of bacterial spores NONCRITICAL - objects that touch only intact skin require low- level disinfection

LOW-LEVEL DISINFECTION FOR NONCRITICAL EQUIPMENT AND SURFACES Exposure time > 1 min Germicide Use Concentration Ethyl or isopropyl alcohol70-90% Chlorine100ppm (1:500 dilution) Phenolic UD Iodophor UD Quaternary ammonium UD Improved hydrogen peroxide (HP) 0.5%, 1.4% ____________________________________________________ UD=Manufacturer’s recommended use dilution

ENVIRONMENTAL CONTAMINATION LEADS TO HAIs 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

KEY PATHOGENS WHERE ENVIRONMENTIAL SURFACES PLAY A ROLE IN TRANSMISSION Weber, Rutala et al. AJIC :S25-33 MRSA VRE Acinetobacter spp. Clostridium difficile Norovirus Rotavirus SARS

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

ENVIRONMENTAL SURVIVAL OF KEY PATHOGENS ON HOSPITAL SURFACES PathogenSurvival Time S. aureus (including MRSA) 7 days to >12 months Enterococcus spp. (including VRE) 5 days to >46 months Acinetobacter spp. 3 days to 11 months Clostridium difficile (spores) >5 months Norovirus (and feline calicivirus)8 hours to >2 weeks Pseudomonas aeruginosa 6 hours to 16 months Klebsiella spp. 2 hours to >30 months Adapted from Hota B, et al. Clin Infect Dis 2004;39: and Kramer A, et al. BMC Infectious Diseases 2006;6:130

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:

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

EVALUATION OF HOSPITAL ROOM ASSIGNMENT AND ACQUISITION OF CDI l Study design: Retrospective cohort analysis, l Setting: Medical ICU at a tertiary care hospital l Methods: All patients evaluated for diagnosis of CDI 48 hours after ICU admission and within 30 days after ICU discharge l 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:

RELATIVE RISK OF PATHOGEN ACQUISITION IF PRIOR ROOM OCCUPANT INFECTED~120% * Prior room occupant infected; ^Any room occupant in prior 2 weeks infected. Otter, Yezli, French. ICHE. 2012;32:

ACQUISITION OF MRSA ON HANDS AFTER CONTACT WITH ENVIRONMENTAL SITES

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

Effective Surface Decontamination Product and Practice = Perfection

LOW-LEVEL DISINFECTION FOR NONCRITICAL EQUIPMENT AND SURFACES Exposure time > 1 min Germicide Use Concentration Ethyl or isopropyl alcohol70-90% Chlorine100ppm (1:500 dilution) Phenolic UD Iodophor UD Quaternary ammonium UD Improved hydrogen peroxide 0.5%, 1.4% ____________________________________________________ UD=Manufacturer’s recommended use dilution

Daily Disinfection of High-Touch Surfaces Kundrapu et al. ICHE 2012;33:1039 Daily disinfection of high-touch surfaces (vs cleaned when soiled) with sporicidal disinfectant (PA) in rooms of patients with CDI and MRSA reduced acquisition of pathogens on hands after contact with surfaces and of hands caring for the patient

Alfa et al. AJIC 2015;43:

Use of a Daily Disinfectant Cleaner Instead of a Daily Cleaner Reduced HAI Rates Alfa et al. AJIC : Method: Improved hydrogen peroxide disposable wipe was used once per day for all high-touch surfaces to replace cleaner Result: When cleaning compliance was ≥ 80%, there was a significant reduction in cases/10,000 patient days for MRSA, VRE and C. difficile Conclusion: Daily use of disinfectant applied to environmental surfaces with a 80% compliance was superior to a cleaner because it resulted in significantly reduced rates of HAIs caused by C. difficile, MRSA, VRE

Key Considerations for Selecting the Ideal Disinfectant for Your Facility Rutala, Weber. Infect Control Hosp Epidemiol. 2014;35: ConsiderationQuestion to Ask Score (1-10) Kill ClaimsDoes the product kill the most prevalent healthcare pathogens Kill Times and Wet-Contact Times How quickly does the product kill the prevalent healthcare pathogens. Ideally, contact time greater than or equal to the kill claim. SafetyDoes the product have an acceptable toxicity rating, flammability rating Ease-of-UseOdor acceptable, shelf-life, in convenient forms (wipes, spray), water soluble, works in organic matter, one-step (cleans/disinfects) Other factorsSupplier offer comprehensive training/education, 24-7 customer support, overall cost acceptable (product capabilities, cost per compliant use, help standardize disinfectants in facility) Note: Consider the 5 components shown, give each product a score (1 is worst and 10 is best) in each of the 5 categories, and select the product with the highest score as the optimal choice (maximum score is 50).

Effective Surface Decontamination Product and Practice = Perfection

SURFACE DISINFECTION Effectiveness of Different Methods Technique (with cotton)MRSA Log 10 Reduction (QUAT) Saturated cloth4.41 Spray (10s) and wipe4.41 Spray, wipe, spray (1m), wipe4.41 Spray4.41 Spray, wipe, spray (until dry)4.41 Disposable wipe with QUAT4.55 Control: detergent2.88 Rutala, Gergen, Weber. Unpublished data.

Wipes Cotton, Disposable, Microfiber, Cellulose-Based, Nonwoven Spunlace

WIPES Rutala, Weber. Infect Control Hosp Epidemiol. 2014;35: Wipes-cotton, disposable, microfiber Wipe should have sufficient wetness to achieve the disinfectant contact time. Discontinue use of the wipe if no longer leaves the surface visible wet for > 1 minute. When the wipe is visibly soiled, flip to a clean/unused side and continue until all sides of the wipe have been used (or get another wipe) Dispose of the wipe/cloth wipe appropriately Do not re-dip a wipe into the clean container of pre-saturated wipes

WIPES Rutala, Weber. Infect Control Hosp Epidemiol. 2014;35: Wipes-cotton, disposable, microfiber Wipe should have sufficient wetness to achieve the disinfectant contact time. Discontinue use of the wipe if no longer leaves the surface visible wet for > 1 minute. When the wipe is visibly soiled, flip to a clean/unused side and continue until all sides of the wipe have been used (or get another wipe) Dispose of the wipe/cloth wipe appropriately Do not re-dip a wipe into the clean container of pre-saturated wipes

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.

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

MICROBIAL BURDEN ON ROOM SURFACES AS A FUNCTION OF FREQUENCY OF TOUCHING Huslage K, Rutala WA, Weber DJ. ICHE. 2013;34: SurfacePrior to Cleaning Mean CFU/RODAC (95% CI) Post Cleaning (mean) Mean CFU/RODAC (95% CI) High71.9 ( )9.6 Medium44.2 ( )9.3 Low56.7 ( )5.7 l The level of microbial contamination of room surfaces is similar regardless of how often they are touched both before and after cleaning l Therefore, all surfaces that are touched must be cleaned and disinfected

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

ENVIRONMENTAL CONTAMINATION LEADS TO HAIs 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

MONITORING THE EFFECTIVENESS OF CLEANING Cooper 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, < RLU) Microbiological methods-<2.5CFUs/cm 2 -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)

DAZO Solution (AKA – Goo)

Target Enhanced

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:

Cleaning/Disinfection ES and nursing need to agree on who is responsible for cleaning what (especially equipment) ES needs to know Which disinfectant/detergent to use What concentration would be used (and verified) What contact times are recommended (bactericidal) How often to change cleaning cloths/mop heads How important their job is to infection prevention

Percentage of Surfaces Clean by Different Measurement Methods Rutala, Gergen, Sickbert-Bennett, Huslage, Weber Fluorescent marker is a useful tool in determining how thoroughly a surface is wiped and mimics the microbiological data better than ATP

Touch (Wiping) vs No-Touch (Mechanical) No Touch (supplements but do not replace surface cleaning/disinfection)

NEW “NO TOUCH” APPROACHES TO ROOM DECONTAMINATION Supplement Surface Disinfection Rutala, Weber. Infect Control Hosp Epidemiol. 2011;32:743

EFFECTIVENESS OF UV-C FOR ROOM DECONTAMINATION (Inoculated Surfaces) PathogensDose*Mean log 10 Reduction Line of Sight Mean log 10 Reduction Shadow TimeReference MRSA, VRE, MDR-A12, ~15 minRutala W, et al. 1 C. difficile 36, ~50 minRutala W, et al. 1 MRSA, VRE12,000>2-3NA~20 minNerandzic M, et al. 2 C. difficile 22,000>2-3NA~45 minNerandzic M, et al. 2 C. difficle 22, overall67.8 minBoyce J, et al. 3 MRSA, VRE, MDR-A, Asp 12, > > minMahida N, et al. 4 MRSA, VRE, MDR-A, Asp 22,000>4.0* minMahida N, et al. 4 C. difficile, G. stear spore 22, overall73 minHavill N et al 5 VRE, MRSA, MDR-A12, minAnderson et al 6 1 ICHE 2010;31:1025; 2 BMC 2010;10:197; 3 ICHE 2011;32:737; 4 JHI 2013;84:323l 5 ICHE 2012;33: ICHE 2013;34:466 *  Ws/cm 2 ; min = minutes; NA = not available

HP for Decontamination of the Hospital Environment Falagas et al. J Hosp Infect. 2011;78:171 Author, YearHP SystemPathogenBefore HPVAfter HPV% Reduction French, 2004VHPMRSA61/85-72%1/85-1% 98 Bates, 2005VHP Serratia 2/42-5%0/24-0%100 Jeanes, 2005VHPMRSA10/28-36%0/50-0%100 Hardy, 2007VHPMRSA7/29-24%0/29-0%100 Dryden, 2007VHPMRSA8/29-28%1/29-3% 88 Otter, 2007VHPMRSA18/30-60%1/30-3% 95 Boyce, 2008VHP C. difficile 11/43-26%0/37-0%100 Bartels, 2008HP dry mistMRSA4/14-29%0/14-0%100 Shapey, 2008HP dry mist C. difficile 48/203-24%; 77/203-3%; Barbut, 2009HP dry mist C. difficile 34/180-19%4/180-2% 88 Otter, 2010VHPGNR10/21-48%0/63-0%100

USE OF HPV TO REDUCE RISK OF ACQUISITION OF MDROs Design: 30 mo prospective cohort study with hydrogen peroxide vapor (HPV) intervention to assess risks of colonization or infection with MDROs Methods: 12 mo pre-intervention phase followed by HPV use on 3 units for terminal disinfection Results Prior room occupant colonized or infected with MDRO in 22% of cases Patients admitted to HPV decontaminated rooms 64% less likely to acquire any MDRO (95% CI, ) and 80% less likely to acquire VRE (95% CI, ) Risk of C. difficile, MRSA and MDR-GNRs individually reduced but not significantly Proportion of rooms environmentally contaminated with MDROs significantly reduced (RR, 0.65, P=0.03) Conclusion-HPV reduced the risk of acquiring MDROs compared to standard cleaning Passaretti CL, et al. Clin Infect Dis 2013;56:27-35

A Four-Arm Prospective, Multicenter Study to Assess Efficacy, Effectiveness and Feasibility of Enhanced Room Disinfection with Chlorine and UV Light Using Clinical and Microbiologic Outcomes Anderson, Sexton, Chen, Moehring, Knelson, Rutala, Weber, et al. 2014

LOW-LEVEL DISINFECTION FOR NONCRITICAL EQUIPMENT AND SURFACES Exposure time > 1 min Germicide Use Concentration Ethyl or isopropyl alcohol70-90% Chlorine100ppm (1:500 dilution) Phenolic UD Iodophor UD Quaternary ammonium UD Improved hydrogen peroxide (HP) 0.5%, 1.4% ____________________________________________________ UD=Manufacturer’s recommended use dilution

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)

Decontamination of Curtains with Activated HP (1.4%) Rutala, Gergen, Weber. Am J Infect Control. 2014;42: CP for:Before Disinfection CFU/5 Rodacs (#Path) After Disinfection CFU/5 Rodacs (#Path) % Reduction MRSA330 (10 MRSA)21*(0 MRSA)93.6% MRSA186 (24 VRE)4* (0 VRE)97.9% MRSA108 (10 VRE)2* (0 VRE)98.2% VRE 75 (4 VRE)0 (0 VRE)100% VRE68 (2 MRSA)2* (0 MRSA)97.1% VRE98 (40 VRE)1* (0 VRE)99.0% MRSA618 (341 MRSA)1* (0 MRSA)99.8% MRSA55 (1 VRE)0 (0 MRSA)100% MRSA, VRE320 (0 MRSA, 0 VRE)1* (0 MRSA, 0 VRE)99.7% MRSA288 (0 MRSA)1* (0 MRSA)99.7% Mean2146/10=215 (432/10=44)33*/10=3 (0)98.5% * All isolates after disinfection were Bacillus sp; now treat CP patient curtains at discharge with IHP

TERMINAL CLEANING PRACTICE Some hospitals change curtains after Contact Precaution patients At UNC Health Care, privacy curtains are changed routinely every 3 months or when visible soiled In all discharge rooms, frequently touched surfaces of the curtains are sprayed with approved disinfectant (e.g., improved HP) Vinyl shower curtains are cleaned when visibly soiled or replaced as needed

Disinfection and Sterilization: Current Issues and New Technologies Current Issues and New Technologies Sterilization of critical items  Cleaning, washer disinfectors, biological indicators High-level disinfection for semi-critical items  New HLDs, prostate probes, cystoscopes, laryngoscopes Low-level disinfection of non-critical items  Role of the environment, curtain decontamination, room decontamination, thoroughness of cleaning D/S and Emerging Pathogens  MERS-CoV, Enterovirus D68, Ebola

Decreasing Order of Resistance of Microorganisms to Disinfectants/Sterilants Prions Bacterial spores (C. difficile) Mycobacteria Small, non-enveloped viruses (HPV, polio, EV-D68) Fungal spores Gram-negative bacilli (Acinetobacter) Vegetative fungi and algae Large, non-enveloped viruses Gram-positive bacteria (MRSA, VRE) Enveloped viruses (Ebola, MERS-CoV) Most Resistant Most Susceptible

New and Emerging Pathogens MERS-CoV, Ebola, Enterovirus D68 Will likely not have an EPA-registered disinfectant on the market to kill it Manufacturers may not make claims about emerging pathogens without EPA approval, which may take months for new pathogens Until an EPA-approved claim is available, users may refer to the hierarchy of microbial susceptibility to select the appropriate disinfectant For example, use EPA-registered disinfectant suitable for non-enveloped viruses (norovirus, rotavirus, adenovirus, poliovirus) to disinfectant surfaces for Ebola

Disinfection and Sterilization: Current Issues and New Technologies Current Issues and New Technologies Sterilization of critical items  Cleaning, washer disinfectors, biological indicators High-level disinfection for semi-critical items  New HLDs, prostate probes, cystoscopes, laryngoscopes Low-level disinfection of non-critical items  Role of the environment, curtain decontamination, room decontamination, thoroughness of cleaning D/S and Emerging Pathogens  MERS-CoV, Enterovirus D68, Ebola

Disinfection and Sterilization: Current Issues and New Technologies Disinfection and sterilization technologies and practices reduce risk of infection associated with medical devices and surfaces. Washer-disinfector extremely effective in removing/inactivating pathogens All channeled endoscopes must be perfused with HLD to inactivate pathogens. Do not reuse single-use medical devices The contaminated surface environment in hospital rooms is important in the transmission of healthcare-associated pathogens (MRSA, VRE, C. difficile, Acinetobacter ). Thoroughness of cleaning should be monitored (e.g., fluorescence). No-touch technologies (UV, VHP) kill pathogens and may reduce HAIs. Emerging pathogens, such as Ebola, are susceptible to currently available disinfectants.

Quality Control Provide comprehensive and intensive training for all staff assigned to reprocess medical/surgical instruments To achieve and maintain competency, staff should: hands-on training all work supervised until competency is documented competency testing should be conducted at commencement of employment and regularly review written reprocessing instructions to ensure compliance