1. Disinfection, Sterilization and Antisepsis İ. Çağatay Acuner M.D., Clinical Microbiologist, Associate Professor Department of Microbiology Faculty of Medicine, Yeditepe University

2. References and Recommended Further Readings 1.Medical Microbiology, 6th Ed. Murray P.R., Rosenthal K.S., Pfaller M.A. 2009, Mosby. 2.Mim’s Medical Microbiology, 4th Ed. Goering R.V., et al. 2008, Mosby. 3.Sherris Medical Microbiology, 5th Ed. Ryan K.J., et al. 2010, McGraw Hill. 4.Manual of Clinical Microbiology, 9th Ed. Murray P.R., et al. 2007, ASM Press.

3. Purpose and definitions of Antisepsis, Disinfection and Sterilization A strategy to control infections: Antisepsis, disinfection and sterilization are among the strategies to control the presence of microorganisms. Antisepsis, disinfection and sterilization are basic components of any infection control program.

4. Definitions of Sterilization, Disinfection, Decontamination, and Antisepsis

5. Definitions of germicide, sterilant (chemical-), high-level disinfectant, intermediate-level disinfectant, low- level disinfectant, minimum effective concentration, cleaning (or precleaning)

6. Microorganisms’ resistance to disinfectants

7. Classification of medical devices

8. Spaulding classification of clinical (medical) devices

9. Methods of Sterilization Sterilization; – can be achieved by employing different methods and techniques.

10. Sterilization is the destruction of all microbes, including the more resilient forms such as bacterial spores, mycobacteria, non-enveloped (non-lipid) viruses, and fungi. – can be done by using physical, gas vapor, or chemical sterilants. – selected for their safety and efficacy Physical sterilants; – Moist – Dry heat most common sterilizing methods used in hospitals indicated for most materials exceptions are; – heat sensitive materials or – toxic or volatile chemicals – Filtration useful for removing bacteria and fungi from; – air (with high-efficiency particulate air [HEPA] filters) or – solutions unable to remove viruses and some small bacteria – Ultraviolet or ionizing radiation (e.g., microwave or gamma rays) also common limitation of U.V. radiation is that direct exposure is required Sterilization

11. Gas vapor sterilants; – Ethylene oxide most commonly used highly efficient strict regulations limit its use; flammable, explosive, and carcinogenic to lab animals – Formaldehyde limited because carcinogenic restricted primarily to sterilization of HEPA filters – Hydrogen peroxide effective because of the oxidizing nature of the gas used for the sterilization of instruments – Plasma gas sterilization A variation of sterilization with hydrogen peroxide » hydrogen peroxide is vaporized, and » then reactive free radicals are produced with either microwave- frequency or radio-frequency energy efficient sterilizing method does not produce toxic byproducts will replace many of the applications for ethylene oxide cannot be used with materials that absorb hydrogen peroxide or react with it Sterilization

12. Chemical sterilants; – Peracetic acid oxidizing agent excellent activity end products (i.e., acetic acid and oxygen) are nontoxic – Glutaraldehyde safety is a concern – care must be used when handling this chemical Sterilization

13. Microbes are also destroyed by disinfection procedures, but more resilient organisms can survive. Disinfection procedures categorized as; – high level, – intermediate level, and – low level. Disinfection Methods of disinfection

14. High-level disinfection; – can approach sterilization in effectiveness Intermediate-level disinfection; – spore forms can survive Low-level disinfection; – many microbes can remain viable However; classification of disinfectants by their level of activity is misleading – because: effectiveness of these procedures is influenced by; – the nature of the item to be disinfected, – number and resilience of the contaminating organisms, – amount of organic material present (which can inactivate the disinfectant), – type and concentration of disinfectant, and – duration and temperature of exposure Levels of Disinfection

15. High-level disinfectants; – used for items involved with invasive procedures (critical devices) that cannot withstand sterilization procedures certain types of endoscopes, surgical instruments with plastic or other components that cannot be autoclaved – disinfection of these and other items is most effective if; » cleaning the surface to remove organic matter precedes treatment – examples; moist heat, and liquids – glutaraldehyde, – hydrogen peroxide, – peracetic acid, – chlorine compounds Levels of Disinfection

16. Intermediate-level disinfectants; – used to clean surfaces or instruments in which; contamination with bacterial spores and other highly resilient organisms is unlikely – semicritical instruments and devices » flexible fiberoptic endoscopes, » laryngoscopes, » vaginal specula, » anesthesia breathing circuits » other items – examples; alcohols, iodophor compounds, phenolic compounds Levels of Disinfection

17. Low-level disinfectants; used to treat noncritical instruments and devices; – blood pressure cuffs, – electrocardiogram electrodes, – stethoscopes, and other items these items come into contact with patients, but they do not penetrate through mucosal surfaces or into sterile tissues example; – quaternary ammonium compounds The level of disinfectants used for environmental surfaces; – is determined by the relative risk these surfaces pose as a reservoir for pathogenic organisms to clean the surface of instruments contaminated with blood; – a higher level of disinfectant to clean surfaces that are "dirty," such as floors, sinks, and countertops; – a lower level of disinfectant – exception to this rule is: a particular surface that is implicated in a nosocomial infection; – a bathroom contaminated with Clostridium difficile (spore-forming anaerobic bacterium) or – a sink contaminated with Pseudomonas aeruginosa, etc. a disinfectant with appropriate activity against the implicated pathogen should be selected Disinfection

18. Antiseptic agents; – used to reduce the number of microbes on skin surfaces Antisepsis

19. Germicidal and other properties of disinfectants and antiseptics

20. Overview of disinfectants

21. Overview of antiseptics

22. – Alcohols; excellent activity against all groups of organisms – except spores nontoxic – tend to dry the skin surface because they remove lipids do not have residual activity inactivated by organic matter ; – surface of the skin should be cleaned before alcohol is applied – Iodophors; excellent skin antiseptic agents – having a range of activity similar to that of alcohols slightly more toxic to the skin limited residual activity inactivated by organic matter Iodophors and iodine preparations are frequently used with alcohols for disinfecting the skin surface – Chlorhexidine; broad antimicrobial activity – kills organisms at a much slower rate than alcohol activity persists – although organic material and high pH levels decrease its effectiveness – parachlorometaxylenol (PCMX); is limited primarily to gram-positive bacteria nontoxic and has residual activity – used in handwashing products – Triclosan; active against bacteria but not against many other organisms a common antiseptic agent in deodorant soaps and some toothpaste products Antisepsis