1. SOURCES OF INFECTION AND DISINFECTION AND STERILIZATION IN HOME CARE AND HOSPICE SETTINGS Module E

2. OBJECTIVES Disease transmission in the home Environmental Contamination in the home Role of the environment in infections Properties of an ideal disinfectant Use antimicrobials in the home

3. FACTORS FOR DISEASE TRANSMISSION Disease Agent Host Transmission

4. SOURCES OF INFECTION Human Patients Healthcare Personnel Visitors/household members Environmental Common Vehicles Vectorborne

5. HOST FACTORS Age Mobility Incontinence Dysphagia Chronic diseases Loss of functional status Medications Indwelling devices

6. Contact (MRSA) Direct Indirect Droplet (Flu) Airborne (TB) Combination (shingles, SARS) Modes of Transmission

7. PATHOGENS OF CONCERN IN THE HOME Bacterial (Streptococcus, Salmonella, Staphylococcus) Viral (Influenza, Rhinovirus, Herpes, Adenovirus) Mycobacterial (M. tuberculosis) Fungal (Trichophyton) Helminths (Enterobius) Mycoplasma (M. pneumoniae)

8. VIRUS TRANSMISSION IN THE HOME Virus discharge (Rhinovirus 10 3, Norovirus 10 7 ) Virus contamination of surface/objects (hands) Virus survival on inanimate (Hepatitis B, Adeno-50 d, Rhino-hr) Virus survival on hands Virus transfer between vehicles (hands)

9. SOURCES OF MICROBIAL CONTAMINATION IN THE HOME Contamination of wet/moist areas Sinks Drains Toilets Food preparation areas Contamination of dry areas Floors, carpets Curtains Furniture

10. BACTERIAL CONTAMINATION Staphyloccocus sp. 100% Micrococcus 100% Bacillus subtilis 56.5% Enterobacter cloacae 52.2% Bacillus sp. 39.1% Enterobacter sp. 26.1% Klebsiella pneumoniae 23.9% E. coli 19.6% Bacillus lichenformis 17.4% Klebsiella sp. 15.2% Pseudomonas aeruginosa 15.2% Spiers JP, et al. Intern J Environmen Health Research 1995;5:109-122

11. RISK OF INFECTION SURFACESRISK OF INFECTION HighFood, toilets, pets, infected people Neonates, elderly, immunocompromised ModerateSinks, drains, baths, cleaning utensils Mild host defense abnormalities (diabetes), ill persons LowFloors, walls, furniture, linens, clothing Healthy subjects

12. MITIGATING THE RISK

13. FREQUENCY OF DISINFECTION Surfaces should be disinfected routinely (e.g., daily, weekly, etc.), and when visibly soiled Frequency of disinfection could be based on frequency of use of the surface and the level of soil present on the surface. Frequency may need to vary based on host susceptibility and environmental site

14. DISINFECTION OF PATIENT CARE EQUIPMENT AND DEVICES

15. A RATIONAL APPROACH TO DISINFECTION AND STERILIZATION EH Spaulding believed how an object will be disinfected depends 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) that kills all but high numbers of bacterial spores. NONCRITICAL - objects that touch only intact skin require low-level disinfection.

16. NON-CRITICAL OBJECTS Classification:Noncritical objects will not come in contact with mucous membranes or skin that is not intact. Object:Can be expected to be contaminated with some microorganisms. Level germicidal action:Kill vegetative bacteria, fungi and lipid viruses. Examples:Floors, walls, bedside tables, and furniture, curtains Method:Low level disinfection

17. EXAMPLES OF NON-CRITICAL OBJECTS Blood Pressure cuffs Crutches Stethoscopes Dopplers Apnea monitor Urinal, bed pans Pulse oximeter

18. LOW-LEVEL DISINFECTION OF NON-CRITICIAL OBJECTS 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; if prepared on- site, document correct concentration at some frequency

19. SEMI-CRITICAL OBJECTS Classification:Semicritical objects come in contact with mucous membranes or skin that is not intact. Object:Free of all microorganisms except high numbers of bacterial spores. Level germicidal action:Kills all microorganisms except high numbers of bacterial spores. Examples:Respiratory therapy, thermometer, etc. Method:High-level disinfection

20. OTHER SEMI-CRITICAL ITEMS Humidifiers CPAP Nebulizers Laryngeal mirror Feeding tubes/Syringes Thermometers Tracheostomy tubes Wound care items

21. HIGH-LEVEL DISINFECTION OF SEMI-CRITICAL ITEMS 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)* 650-675 ppm Accelerated hydrogen peroxide 2.0% Glut and isopropanol 3.4%/26% Glut and phenol/phenate** 1.21%/1.93%___ * May cause cosmetic and functional damage; **efficacy not verified

22. HIGH-LEVEL DISINFECTION IN HOME CARE Items thoroughly cleaned before disinfection and sterilization Modifications to routine disinfection may be made in the home setting Semicritical item (i.e., tracheostomy tubes)- agents/exposure times 1:50 dilution (1000 ppm) of 5.25%-6.15% bleach/5 minutes 70% isopropyl alcohol/5 minutes 3% hydrogen peroxide/30 minutes

23. CRITICAL ITEMS Classification: Critical objects enter normally sterile tissue or vascular system, or through which blood flows. Object:Sterility. Level germicidal action:Kill all microorganisms, including bacterial spores. Examples:Hypodermic syringes, IV medication and tubing, and hemodialysis tubing and solutions Method: Steam, gas, hydrogen peroxide plasma, ozone, VHP or chemical sterilization.

24. STORAGE OF STERILE/CLEAN ITEMS Items should be stored in a designated, well ventilated area Items should be protected from dust, moisture, and temperature and humidity extremes Packaged items should be stored so packaging is not compromised

25. SUMMARY Disinfection Rational approach to disinfection/sterilization Disinfectants used in home health and hospice Disinfection practices Sterilization Sterilization practices used in home health and hospice

26. REFERENCES Rutala WA, Weber DJ. CJD: Recommendations for disinfection and sterilization. Clin Inf Dis 2001;32:1348 Rutala WA, Weber DJ. New disinfection and sterilization methods. Emerg Inf Dis 2001;7:348 Rutala WA, Weber DJ. Clinical effectiveness of low- temperature sterilization technologies. Infect Control Hosp Epidemiol 1998;19:798-804. Rutala WA. APIC guideline for selection and use of disinfectants. Am J Infect Control 1996;24:313 Rutala WA and DJ Weber. CDC Guideline for disinfection and sterilization in healthcare facilities, 2008.