1. Selecting the Ideal Disinfectant One Size does not Fit All
Jim Gauthier, MLT, CIC
Senior Clinical Advisor
Infection Prevention

2. Objectives Review the characteristics of the ‘ideal’ disinfectant
Highlight important characteristics for disinfection selection
Review procedures and validation that make up effective disinfection

3. Rutala WA, et al. ICHE 2014;35(7):855-65

4. Criteria of an Ideal Disinfectant
Broad spectrum – kills Healthcare pathogens of concern
Fast acting – short contact times (for pathogens of concern)
Remains wet – must keep surfaces wet for entire contact time in single application
Unaffected by environmental factors – not affected by organic soil or hard water
Non-toxic and non-irritating to the user – should have lowest possible safety risk to user
Compatible with surfaces – should be proven compatible with common Healthcare surfaces and equipment
Persistence – should have a residual effect on surfaces

5. Criteria of an Ideal Disinfectant
Easy to use – available in multiple forms to align with highest convenience for users
Acceptable odor – should have an acceptable odor for patients and staff
Economical – should not be cost prohibitive for facility
Soluble in water – so will not cause issues when it contacts water
Stable - in concentrate and end use dilution
Cleaner - good cleaning ability
Nonflammable – should have a flash point over 150°F

6. The Environment Plays a Role in the Risk of Transmission
Contaminated Environmental Surfaces
Susceptible Patient
Hands of Healthcare Providers
Environmental Hygiene
Hand Hygiene
Direct Transmission

7. Healthcare Associated Infections
HAI(p) = PA + HH + ASP + CP + FWM + ED
Where:
HAI(p) = Healthcare Associated Infection Prevention
PA = Patient Acuity
HH = Hand Hygiene
ASP = Antibiotic Stewardship Program
CP = Clinical Practices
FWM = Fecal Waste Management
ED = Environmental Disinfection
Introduction of components of equation

8. Healthcare Associated Infections
HAI(p) = PAvent+PApoe+PAold+PAabtic+PAco-m+ HHprod+HHplace+HHaudit+HHmom+HHchamp+HHpat+HHfam/vis + ASPdrug+ASProute+ASPduration+ASPdose+ASPrestriction CPskinprep+CPdecol+CPprophy+CPbundle+ FWMcontainer+FWMppe+FWMno rinse+FWMprotocol + EDevs+ EDaudit+ EDnurse+ EDother+ EDfamily+ EDprod+ EDppe+ EDcontact+ EDdilute + EDcompat + EDresource

9. Effective Disinfection: 3 Key Elements
The use of an effective disinfectant cleaner
A clearly defined protocol with education
Compliance monitoring with staff feedback

11. Key Considerations for Selecting the Optimal Disinfectant for Your Facility
Rutala 2014(2)

12. Criteria of Ideal Disinfectant: 5 Considerations
Do they list safety for assets as one of the criteria?

13. Kill Claims
Does the product kill the most prevalent healthcare pathogens, including those that:
Cause most HAIs*?
Cause most outbreaks?
Are of concern in your facility?

14. +
~27%
~53%
79% (without Yeasts)
Rutala 2014

15. Magill 2014

16. 65%

17. Most common causes of outbreaks and ward closures by causative pathogen, which are relatively hard to kill
Clostridium difficile spores
Norovirus
Aspergillus
Rotavirus
Adenovirus

18. Viral Pathogens Enveloped Viruses (Easy to Kill) Colds Influenza
Respiratory Syncytial Virus (RSV)
Parainfluenza virus
Human Metapneumovirus
Hepatitis B and C
HIV
Colds

19. Viral Pathogens Non-Enveloped Viruses (Not Easy to kill) Norovirus
Rhinovirus
Enterovirus
Hepatitis A
*Adenovirus (larger – easier to kill)

20. Effect of Disinfectants on Microorganisms
Type
Examples
Bacterial Spores
Spore
Bacillus anthracis, Clostridium difficile
Mycobacteria
Bacteria
M. tuberculosis
Small non-enveloped virus
Virus
Poliovirus, Norovirus
Fungal spores
Fungus
Aspergillus, Penicillium, Trichophyton
Gram negative bacteria
E. coli, Klebsiella including CRE, Pseudomonas, Acinetobacter
Fungi (Vegetative)
Candida
Large Virus (non-enveloped)
Adenovirus, Rotavirus
Gram positive bacteria
Staphylococcus including MRSA
Enterococcus including VRE
Virus (enveloped)
HIV, HBV, HCV, Influenza R^
Low Level S*
^Resistant
* Sensitive
Adapted from Rutala et al. ICHE 2014;35(7):862

21. Task Oriented vs. Daily Use
C. Diff isolation

22. Criteria of an Ideal Disinfectant: 5 Considerations
Do they list safety for assets as one of the criteria?

23. Kill Times and Wet-Contact Time
How quickly does the product kill the prevalent healthcare pathogens?
Does the product keep surfaces visibly wet for the kill times listed on its label?

24. Dry Time vs. Label Contact Time
IHP (0.5% Hydrogen peroxide)
Omidbakhsh 2010

25. Criteria of an Ideal Disinfectant: 5 Considerations
Do they list safety for assets as one of the criteria?

26. Safety Does the product have an acceptable toxicity rating?
Does the product have an acceptable flammability rating?
Is a minimum level of Personal Protective Equipment (PPE) required?
Is the product compatible with the common surfaces in your facility?

29. Sporicidal Everywhere?
“Effectiveness of an environmental cleaning management plan implemented by the quality department” Change Management Plan – Interventions:
Stakeholder meetings
Education
Cleaning carts and checklists
Daily duties distributed to staff
Switched to sporicidal for daily cleaning
Mahmutoglu D, Haque J, Graham Munoz-Price LS. Division of Infectious Diseases, Medical College of WI – SHEA 2016 Poster

30. High Touch Surfaces

31. Different Units

32. Conclusions
A quality-driven change management plan was unsuccessful to improve environmental cleaning Both daily and terminal cleaning were found suboptimal before and after the implementation of interventions Cleaning of bedrails was found significantly less after the implementation of interventions New sporicidal daily cleaning solutions which have a strong and irritating odor might be playing a major role in this decrease

33. Criteria of an Ideal Disinfectant: 5 Considerations
Do they list safety for assets as one of the criteria?

34. Ease of Use Is the product odor considered acceptable?
Does the product have an acceptable shelf-life?
Does the product come in convenient forms to meet your facility’s needs (e.g. liquids, sprays, refills, and multiple wipe sizes, etc.)?

35. Ease of Use Does the product work in the presence of organic matter?
Is the product water soluble?
Does the product clean and disinfect in a single step?
Are the directions for use simple and clear?

36. Disposable Disinfectant Wipes
Study Demonstrated
Disinfectant wipes increased compliance and improved speed.
Disinfectant wipes yielded a cost savings over traditional towel and bucket method
Point out here that
The right products/procedure
Can improve compliance
and reduce labor costs
We studied the value of ready-to-use cleaning and disinfection wipes
compared with the traditional towel and bucket method. When using ready-to-use wipes, we found
compliance to be significantly higher, a more rapid cleaning and disinfection process, and potential cost
savings. Facilities should consider these products when making environmental services product
selections.
Wiemken et al. AJIC 2014;42:329-30

37. Microfiber vs. Disposable Wipes

38. Quat Binding
Some cleaning tool fabrics, such as cotton and microfiber, are known to bind with quaternary ammonium compounds (“quats”). This is known as “quat binding”
Active ingredients (quat) have a tendency to become attracted to, and absorbed into, microfiber and cotton fabrics
Cotton fabrics and most microfibers are negatively charged or anionic
Nicole / Carolyn

39. Quat Binding
Quats are positively charged, or cationic, and are attracted to the negatively charged fabric surfaces
Some non-woven disposable wipes have no charge, and do not demonstrate binding with quats or other disinfectants
CONSEQUENCE: A portion of the quat actives become unavailable to disinfect hard surfaces making the disinfection process ineffective!

40. Quat Binding
Microfiber wipers, cotton towels, and 1 of 2 types of disposable wipes soaked in a Quat disinfectant revealed significant binding of the disinfectant.
Boyce 2016

41. Dispensers – 33 Stations Number of Dispensers Issue 7 <200 ppm 176
ppm 2
No Concentrate 1
Inoperative

42. Other Factors
Does the supplier offer comprehensive t­raining and ongoing education, both in-person and virtual?
Does the supplier offer 24-7 customer support?
Is the overall cost of the product acceptable (considering product capabilities, costs of infections that may be prevented and costs per compliant use)?
Can the product help standardize disinfectants used in your facility?

43. Total Score? Consideration Score (1-10) Kill Claims
Kill Times and Wet Contact Time
Safety
Ease of Use
Other Factors

45. Procedures
Integrating safe, and effective products and tools, into cleaning processes to deliver better outcomes
Understand current cleaning methods
Integrating the products, tools, and equipment to drive improved results and operational efficiency
Finding the comprehensive bundle for the specified needs
The next step is to select an integrated offering of products, services and cleaning methods to help the facility best achieve its goals.
Since Diversey can provide cleaners, disinfectants, cleaning tools, equipment and services, we look across the system to determine which products work best together and can be integrated to deliver improved results and operational efficiency.

46. Roles and Responsibilities
Define…
Who?
When?
What?
Where?
How?

48. Cleaning and Disinfection
What surfaces/equipment need to be cleaned, how often, what product should be used, what cleaning tool, what dilution, amount needed, contact time?
Is there product available where/when needed?
Is the product being used properly, PPE donned correctly (if needed), right technique used, contact time achieved, feedback provided?

49. Cleaning and Disinfection
Assess the adequacy of room cleaning
If room cleaning and disinfection practices are deemed to be inadequate, focus on reviewing and improving cleaning and disinfection techniques
Create a unit-specific checklist based on cleaning protocols and perform observations to monitor cleaning practice
Consider environmental decontamination with sodium hypochlorite or EPA-approved sporicidal agent if room cleaning and disinfection is deemed to be adequate but there is ongoing CDI transmission
b. Important issues to address include proper dilution of cleaning products, adequacy of cleaning and disinfection technique, cleaning high-touch surfaces frequency of changing rags/mop water, and moving from clean areas to dirty areas.
Use of fluorescent markers to monitor thoroughness of cleaning or adenosine triphosphate (ATP) bioluminescence to measure organic material on surfaces has been shown to be effective in improving cleaning and disinfection performance. However, these methods may not result in a reliable reduction in C. difficile spores from the environment.
Use an EPA-approved sporicidal disinfectant or diluted sodium hypochlorite for environmental cleaning and disinfection. Implement a system to coordinate with environmental services if it is determined that sodium hpochlorite is needed for environmental disinfection (quality of evidence: III).
(Dubberke 2014

50. Elbow grease does the job
Efficacy of Different Cleaning and Disinfection Methods against Clostridium difficile Spores: Importance of Physical Removal versus Sporicidal Inactivation
Tested the removal of C. difficile spores from environmental surfaces using various cleaners, disinfectants and wipes. Wipes with a non-sporicidal agent showed 2.9 log10 reductions of C. difficile spores. Wiping with a sporicidal agent increased the removal efficacy by 1 log10 (3.9 log10).
Results: Just wiping the surface (physical removal) resulted in a ~3 log10 reduction in C. difficile spores
Rutala 2012

51. C. difficile Eradication from Toilets
Few alternatives to bleach for non-outbreak conditions have been evaluated in controlled healthcare studies.
METHODS:
This study was a prospective clinical comparison during non-outbreak conditions of the efficacy of an improved hydrogen peroxide cleaner (0.5%) with respect to spore removal from toilets in a tertiary care facility.
CONCLUSION:
IHP formulation evaluated that has some sporicidal activity and provides a one-step process that significantly lowers the C. difficile spore level in toilets during non-outbreak conditions without the workplace safety concerns associated with 5000 ppm bleach. 2-3 Log10 kill after 1 minute
Alfa 2010
The toilets used by patients who had diarrhea with and without C. difficile associated disease (CDAD) were cultured for C. difficile and were monitored using an ultraviolet mark (UVM) to assess cleaning compliance on a daily basis 5 days per week. A total of 243 patients and 714 samples were analysed. The culture results were included in the analysis only if the UVM audit from the same day confirmed that the toilet had been cleaned.

52. All rates reduced by > 20%
Proven Solution to Reduce HAI
First Clinical study to show that improved compliance with environmental surface disinfection using IHP reduced HAI rates for VRE, MRSA and C. difficile
3 key components to ensure reduction of HAI:
All rates reduced by > 20%
The use of an effective disinfectant cleaner
A clearly defined protocol with education
Compliance monitoring with staff feedback
Cost avoidance of $668,000/year due to HAI rate reduction
Use of a daily disinfectant cleaner instead of a daily cleaner reduced hospital-acquired infection rates
Alfa 2015

53. Quat Binding
Dr. Alfa’s study would be very applicable in this case!

54. A New Study with Improved Hydrogen peroxide (IHP) Presented at APIC 2016
John M. Boyce, MD
AJIC 2016;44(6)Suppl:S16

55. Study Design
12-month prospective trial with cross-over design conducted on two campuses of a university-affiliated hospital
On each campus, 2 wards were randomized to have EVS perform routine daily cleaning/disinfection of surfaces:
IHP disinfectant wipes containing 0.5% IHP
Quat disinfectant currently used in the hospital , applied using a disposable wipe made of meltblown polypropylene (same material as disposable wipe above)

56. Study Design The 4 study wards included:
An MICU and its step-down unit on one campus
Two general medical wards on the other campus
After the initial 6 months, ward assignments were changed

57. Two Facilities – Two Technologies
One: Quat-based disinfectant cleaner/meltblown polypropylene disposable wipes for daily cleaning; addition of bleach wipes for C. diff rooms (EVS and Clinical)
Two: Improved hydrogen peroxide (0.5%IHP) for all cleaning; all quat and bleach wipes removed from the wards
Hand hygiene compliance rates comparable on study wards

58. Methods
Analysis included data for months when wipe rates on study wards were > 80%
IHP wards – 16 months (10,741 patient-days)
Quat wards – 17 months (11,490 patient-days)

59. Results Mean ACC/surface after cleaning:
On IHP wards (14.0 CFUs/surface)
On Quat wards (22.2 CFUs/surface)
(p = 0.003)
Mean ACC/surface after cleaning:
–On IHP wards (14.0 CFUs/surface)
–On Quat wards (22.2 CFUs/surface)
–(p = 0.003)
•Logistic regression analysis revealed that the proportion of surfaces yielding no growth after cleaning
–On IHP wards (240/501 [47.9%])
–On Quat wards (182/517 [35.2%])
–(p < )
•Both microbiological outcomes favor IHP over Quat
Copyright

60. Both microbiological outcomes favored IHP over Quat
Results
Logistic regression analysis revealed that the proportion of surfaces yielding no growth after cleaning
On IHP wards (240/501 [47.9%])
On Quat wards (182/517 [35.2%])
(p < )
Both microbiological outcomes favored IHP over Quat

61. 23% fewer cases/1000 Pt-days on IHP wards
Results
23% fewer cases/1000 Pt-days on IHP wards
Antibiotic usage: Non-C. difficile agent use was 10.8% higher on IHP wards which would be expected to lead to more VRE, MRSA and CDI outcomes, not fewer as observed

62. Training & Tools Drives Competence
Facilitate best practice adoption
Support tools that demonstrate the proper workflow and procedures
Training content delivery in multiple languages and formats to support needs
Bringing optimized procedures to life – adapting to individual facilities needs
Example
Example
These are examples of a daily patient room cleaning check list and wall charts which can be customized for your facility. We provide tools in various easy-to-understand formats, including pictograms, that walk your staff through the work flow process – step by step. This helps provide role clarity and improves adoption of change and best practices.

63. Are we missing anything?

64. The Patient’s Environment
EVS cleans 1x per day
What happens the other 23.5 hrs?

65. Patient Room Entries (Cohen)
Between 5 AM and 8 PM, (ICU and Med/Surg Unit)
Number of room entries = 5.5/hour (28 max)
Number of different staff entering room = 3.5/hour (18 max)
Number of people in room during waking hours
= 15 hrs * 5.5 /hr = 82.5 people

66. Who came in room?
45% = Nursing staff 23% = Personal visitors 17% = Medical staff 8% = Nonclinical staff 4% = Other clinical staff

67. What do they touch while in the room?
33.5% = contact with the environment only
Most common level of touch
27.1% = patient’s intact skin
17.8% = blood or body fluids
16.0% = the person touched nothing in the room
Cohen, et. al., “Frequency of patient contact with health care personnel and visitors: implications for infection prevention”, Jt Comm J Qual Patient Safety, 2012; 38 (12):

68. What do they touch while in the room?
Staff frequently enter a room and either touch nothing or only touch the environment. This may help explain low hand hygiene rates.
Cohen, et. al., “Frequency of patient contact with health care personnel and visitors: implications for infection prevention”, Jt Comm J Qual Patient Safety, 2012; 38 (12):

69. Surface Contact
Huslage and Rutala (2010) studied HTS in an ICU and a general med-surg unit.
In the ICU (contacts per interaction):
Bedrails = 7.8
Bed surface = 6
Supply cart = 4

70. Surface Contact In the Med-Surg unit (contact per interaction)
Bedrails = 3.1
Over-bed table = 1.6
IV pump = 1.4
Bed surface = 1.3
Average surfaces per interaction:
ICU = 44, Med-Surg = 15

71. More Math! Room entries per hour = 5.5
Bedrail contacts per hour = 17.1 (5.5 x 3.1)
Bedrail contacts per 15 hour patient ‘awake’ day = 256
Number of times per day bedrail is disinfected by EVS = 1
Probability of EVS disinfecting the bedrail = 50%

72. ?255?

73. Math!
Number of times per day bedrail is disinfected by the clinical staff = ? (probably zero)
Probability of Clinical staff performing hand hygiene = 40%
We should not be surprised that surfaces in the patient zone contribute to infection risk given the frequency of contact and the limited disinfection

74. Environmental Disinfection (ED)
Recognize that high touch surfaces are done every 24 hours
Subsets may be done 2x per day
Point of Care Prevention
Certain procedures need disinfection of surfaces

75. Point of Care Disinfection
It is everyone’s job to disinfect, but it is not everyone’s job to disinfect everything
Training cards for:
Clinician – workstation on wheels, bed rails
Food servers – over bed table, sanitize patient hands
CNAs – bedrails, other bed controls
Blood lab tech – bedrail, bed controls
Respiratory therapists – bedrail, bed controls

76. 6 Moments of Surface Disinfection
Before placing a food tray on an over-bed table
After any procedure involving feces (or body fluids) within the patient bed space
After any wound dressing change
After patient bathing (within bed space)
After assistance with productive cough or vomiting
Any time surfaces are visibly soiled

77. Point of Care Disinfection
Disinfectant at point of care! 0/0/0 HMIS – can’t be flammable, can’t be caustic Fast contact time

78. Dispose in the regular garbage
Suggestion
Family and Visitors
Feel free to use our disinfectant wipe on hard surfaces around the patient (not a “baby wipe”)
Dispose in the regular garbage
Please do not flush!

80. Validation Are you Confident? The Job has been completed?
All areas are in compliance?
All surfaces are cleaned?
Procedures are followed?

81. CDC Guidance
Based on strong evidence that transmission of HAPs is related to contamination of near patient surfaces and equipment
CDC issued a guidance document “Options for Evaluating Environmental Cleaning,” December 2010
Recommends that all hospitals develop programs to optimize the thoroughness of high-touch surface cleaning as part of terminal room cleaning
CDC thought this was strong enough evidence to launch a recommendation for environmental cleaning

82. Cleaning and Disinfection
Routinely assess adherence to protocols and adequacy of cleaning and disinfection
Assess the adequacy of cleaning and disinfection practices before changing to a new cleaning product (e.g. bleach)
Protocols for disinfection of equipment and the environment.
Assess adherence to protocols.
Assess practices before changing to a new cleaning product (eg, bleach).
If not adequate, address this before changing products.
Ensure patient care and electronic equipment that remain in the patient room are cleaned and disinfected.
Educate environmental service personnel.
Dedicate noncritical patient care items, such as blood pressure cuffs, stethoscopes, and thermometers, to a single patient with C. difficile.
When this is not possible, ensure adequate cleaning and disinfection of shared items between patient encounters
Dubberke 2014

83. Cleaning and Disinfection
Consider sporicidal if:
Cleaning and disinfection are deemed adequate, but still ongoing CDI transmission
For disinfection of the environment in outbreak or hyperendemic settings in conjunction with other IPC measures

84. Environmental Cleaning Evaluation Program – Level I Program
Cleaning responsibilities and frequencies clearly defined
Structured education of staff
Implementation of a monitoring system that measures staff competency and incorporates patient satisfaction survey results
Continuous monitoring of the program
Interventions to improve the quality of cleaning and disinfection
Consideration and documentation of feasibility of moving to a Level II program

85. Environmental Cleaning Evaluation Program – Level II
Everything in Level I AND
Implementation of a monitoring system that covertly assesses terminal room thoroughness of surface disinfection cleaning using one or more generally accepted methods
The learning from the monitoring of surfaces should be used to improve processes and overall cleaning outcomes
Accepted Methods
Direct Observation
Fluorescence
- ATP
- Culturing
Not recommended
- Post Cleaning Inspections

86. Establishing a Baseline for Cleaning Evaluation Program
The program requires a baseline to be established
10-15% of rooms should be included in the baseline calculation - or 15 rooms if the facility has less than 150 rooms
This is referred to as the pre-intervention thoroughness of disinfectant cleaning (TDC score)
TDC Score = # of objects cleaned/total number of objects evaluated X 100
The baseline learning should be used to optimize programmatic interventions

87. Cleaning Evaluation Program
Ongoing measurement of high touch surfaces is recommended at least 3 times/year
The ongoing measurement should be compared to the baseline to determine if cleaning practices are improving or deteriorating

88. Validation Monitoring and ongoing feedback are key
Deploy for Compliance Monitoring and Improvement
Measure
Analyze
Activate
Improve
Florescent Marker, Light & Audit Tool
Simple web-based data entry and analysis
On-line, Real-time Reporting
The final step is where the VeriClean System comes in to play. The VeriClean System allows you to objectively measure your cleaning results. The software analyzes and reports out actionable data showing where you can focus to drive improvement. The system itself incorporates a fluorescent spray, a black light and software that provides reports based on multiple data collection methods.
Since germs are invisible, it is important to put an objective measurement system in place – such as a fluorescent marking tool and black light to show what surfaces were properly cleaned and where gaps exist. The system provides reports by room, surface, and ES staff member. These reports are available 24/7 on a web-based, password protected platform.
The system is a low cost, turn key program that enables facilities to meet the CDCs Options for Evaluating Environmental Cleaning recommendation.
We have found that it is important to measure what matters, and this enables you to measure the effectiveness of your cleaning and disinfection program which is the key driver to improve patient safety and outcomes.
Monitoring and ongoing feedback are key

89. Summary

90. Sporicide vs. Effective Cleaning and Disinfection
Most of our pathogens are easy to kill
If you have transmission of MRSA, VRE, ESBL or CRE – moving to a sporicide will not help!
Find your ideal disinfectant
Review the moments for environmental disinfection!

91. Example
Products that staff can use confidently and efficiently. Fast-acting disinfectant cleaners kill tough pathogens in as little as one minute, but are gentle on staff and surfaces.
Procedures that standardize processes and help ensure consistent performance. Training programs and best-practice protocols enhance cleaning and disinfection efficiency and effectiveness.
Validation system that provides actionable intelligence that can be used to provide feedback to employees, improve the cleaning and disinfection of high touch surfaces and empower employees to drive continuous improvement.

92. Procedures
Validation
Products

93. Questions?

94. References
Alfa MJ et al. Improved eradication of Clostridium difficile spores from toilets of hospitalized patients using an accelerated hydrogen peroxide as the cleaning agent. BMC Infect Dis 2010:10: Alfa MJ, et al. Use of a daily disinfectant cleaner instead of a daily cleaner reduced hospital-acquired infection rates. AJIC 2015;43:141-6 Boyce JM, et al. Quaternary Ammonium Disinfectant Issues Encountered in an Environmental Services Department. ICHE 2016;37(3):340-2

95. References
Cohen, et. al., “Frequency of patient contact with health care personnel and visitors: implications for infection prevention”, Jt Comm J Qual Patient Safety, 2012; 38 (12): Dubberke ER, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 Update. ICHE 2014;35(6): Hawley B, et al. Respiratory symptoms and skin irritation amoung hospital workers using a new disinfection product – Pennsylvania, MMWR 2005;65(10):400-1 Huslage K et al. A Quantitative approach to defining “high‐touch” surfaces in hospitals. ICHE 2010;31(8):850-3

96. References
Kundrapu S, et al. Daily disinfection of high-touch surfaces in isolation rooms to reduce contamination of healthcare workers’ hands. ICHE 2012;33(10): Magill SS, et al. Multistate point-prevalence survey of health care–associated infections. N Engl J Med 2014;370: Omidbakhsh N. Theoretical and experimental aspects of microbicidal activities of hard surface disinfectants: are their label claims based on testing under field conditions? J AOAC Inter 2010;93(6):1-8 Rutala WA, et al. Efficacy of different cleaning and disinfection methods against spores: Clostridium difficile: importance of physical removal versus sporicidal inactivation ICHE 2012;33(12):1255-8

97. References
Rutala WA, et al. Selection of the ideal disinfectant. ICHE 2014;35(7): Rutala 2014(2). Selection of the ideal disinfectant. Accessed from: Disinfectionandsterilization.org Wiemken TL, et al. The value of ready-to-use disinfectant wipes: compliance, employee time, and costs. AJIC 2014;42:329-30

98. james.gauthier@sealedair.com kimberly.dwyer@sealedair.com