1. Selection of an Ideal Disinfectant William A. Rutala, Ph.D., M.P.H. 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 at Chapel Hill, NC, USA Disclosure: Clorox

2. LECTURE OBJECTIVES  Review the role of the environment in transmission of nosocomial pathogens  Review the properties of an ideal disinfectant  Review the key considerations for selecting the ideal disinfectant Kill Claims Kill and wet-contact time Safety Ease of use Other factors

3. DISINFECTION AND STERLIZATION  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 but high numbers of bacterial spores. NONCRITICAL -objects that touch only intact skin require low- level disinfection.

5. Processing “Noncritical” Patient Care 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:Bedpans; crutches; bed rails; EKG leads; bedside tables; walls, floors and furniture. Method:Low-level disinfection

6. Low-Level Disinfection for “Noncritical” 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

7. LECTURE OBJECTIVES  Review the role of the environment in transmission of nosocomial pathogens  Review the properties of an ideal disinfectant  Review the key considerations for selecting the ideal disinfectant Kill Claims Kill and wet-contact time Safety Ease of use Other factors

8. 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

10. KEY PATHOGENS WHERE ENVIRONMENTIAL SURFACES PLAY A ROLE IN TRANSMISSION  MRSA  VRE  Acinetobacter spp.  Clostridium difficile  Norovirus  Rotavirus  SARS

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

12. 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;39:1182-9 and Kramer A, et al. BMC Infectious Diseases 2006;6:130

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

14. Mean proportion of surfaces disinfected at terminal cleaning is ~30%

15. 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;32:185-187

16. TRANSMISSION MECHANISMS INVOLVING THE SURFACE ENVIRONMENT Rutala WA, Weber DJ. In:”SHEA Practical Healthcare Epidemiology” (Lautenbach E, Woeltje KF, Malani PN, eds), 3 rd ed, 2010.

17. ACQUISITION OF MRSA ON HANDS AFTER CONTACT WITH ENVIRONMENTAL SITES

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

19. EVALUATION OF HOSPITAL ROOM ASSIGNMENT AND ACQUISITION OF CDI  Study design: Retrospective cohort analysis, 2005-2006  Setting: Medical ICU at a tertiary care hospital  Methods: All patients evaluated for diagnosis of CDI 48 hours after ICU admission and within 30 days after ICU discharge  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;32:201-206

20. Increased Risk of Acquisition of HA Pathogen from Prior Room Occupant~120% * Prior room occupant infected; ^Any room occupant in prior 2 weeks infected

21. 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.

23. 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;31:850-853

24. MICROBIAL BURDEN ON ROOM SURFACES AS A FUNCTION OF FREQUENCY OF TOUCHING SurfacePrior to Cleaning Mean CFU/RODAC (95% CI) Post Cleaning (mean) Mean CFU/RODAC (95% CI) High71.9 (46.5-97.3)9.6 Medium44.2 (28.1-60.2)9.3 Low56.7 (34.2-79.2)5.7  The level of microbial contamination of room surfaces is similar regardless of how often they are touched both before and after cleaning  Therefore, all surfaces that are touched must be cleaned and disinfected Huslage K, Rutala WA, Weber DJ. ICHE. 2013;34:211-212

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

26. ENVIRONMENTAL CONTAMINATION LEADS TO HAIs Suboptimal Cleaning  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

27. Quality Improvement

28. 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, <250-500 RLU)  Microbiological methods-<2.5CFUs/cm 2 -pass; can be costly and pathogen specific  Fluorescent marker

29. SURFACE EVALUATION USING ATP BIOLUMINESCENCE Swab surface luciferace tagging of ATP Hand held luminometer Used in the commercial food preparation industry to evaluate surface cleaning before reuse and as an educational tool for more than 30 years.

30. 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, <250-500 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)

31. Fluorescent Marking Solution

32. Target After Marking

33. Target Enhanced

34. 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;29:1035-41

35. LECTURE OBJECTIVES  Review the role of the environment in transmission of nosocomial pathogens  Review the properties of an ideal disinfectant  Review the key considerations for selecting the ideal disinfectant Kill Claims Kill and wet-contact time Safety Ease of use Other factors

36. PROPERTIES OF AN IDEAL SURFACE DISINFECTANT  Broad spectrum  Fast acting  Remains wet  Not affected by environmental factors  Nontoxic  Surface compatibility  Persistence  Easy to use  Acceptable odor  Economical  Solubility  Stability  Cleaner  Nonflammable Rutala WA, Weber DJ. Infect Control Hosp Epidemiol 2014;35:855-865

37. PROPERTIES OF AN IDEAL SURFACE DISINFECTANT  Broad spectrum Should have a wide antimicrobial spectrum, including kill claims for all pathogens that are common causes of HAIs and outbreaks  Fast acting Should have a rapid kill and short kill/contact time listed on the label  Remains wet Should keep surfaces wet long enough to meet listed kill/contact times with a single application or meet wet times recommended by evidence-based guidelines (60 seconds) Rutala WA, Weber DJ. Infect Control Hosp Epidemiol 2014;35:855-865

38. PROPERTIES OF AN IDEAL SURFACE DISINFECTANT  Not affected by environmental factors Should be active in the presence of organic matter (e.g., blood, sputum, feces) and compatible with soaps, detergents, and other chemicals encountered in use  Nontoxic Should not irritating to the user, visitors, and patients. Should not induce allergic symptoms (especially asthma and dermatitis). The toxicity ratings for disinfectants are danger, warning, caution, and none. Ideally choose products with the lowest toxicity rating.  Surface compatibility Should be proven compatible with common healthcare surfaces and devices Rutala WA, Weber DJ. Infect Control Hosp Epidemiol 2014;35:855-865

39. PROPERTIES OF AN IDEAL SURFACE DISINFECTANT  Persistence Should have sustained antimicrobial activity or residual antimicrobial effect on the treated surface  Easy to use Should be available in multiple forms, such as wipes (large and small), sprays, pull tops, and refills; directions for use should be simple and contain information about personal protective equipment as required  Acceptable odor Should have an odor deemed acceptable by users and patients  Solubility Should be soluble in water Rutala WA, Weber DJ. Infect Control Hosp Epidemiol 2014;35:855-865

40. PROPERTIES OF AN IDEAL SURFACE DISINFECTANT  Economical Costs should not be prohibitively high but when considering the costs of a disinfectant one should also consider product capabilities, cost per compliant use, etc.  Stability Should be stable in concentrate and use dilution  Cleaner Should have good cleaning properties  Nonflammable Should have a flash point above 150 o F Rutala WA, Weber DJ. Infect Control Hosp Epidemiol 2014;35:855-865

41. 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 peroxide0.5%, 1.4% ____________________________________________________ UD=Manufacturer’s recommended use dilution

42. 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

43. BACTERICIDAL ACTIVITY OF DISINFECTANTS (log 10 reduction) WITH A CONTACT TIME OF 1m WITH/WITHOUT FCS. Rutala et al. ICHE. 2012; 33:1159-61 Organism0.5% IHP0.5% HPHP Cleaner- Dis 1.4% IHP 1.4% HP3.0% HPQUAT MRSA>6.6<4.0>6.5<4.0 5.5 VRE>6.3<3.6>6.1<3.6 4.6 MDR- Ab >6.8<4.3>6.7<4.3 >6.8 MRSA, FCS >6.7NT>6.7NT<4.2 VRE, FCS>6.3NT>6.3NT<3.8 MDR- Ab, FCS >6.6NT>6.6NT<4.1>6.6 Improved hydrogen peroxide is significantly superior to standard HP at same concentration and superior or similar to the QUAT tested

44. 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)

45. Decontamination of Curtains with Activated HP (1.4%) Rutala, Gergen, Weber. Am J Infect Control. 2014;42:426-428 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

46. How About “Green” Products?  Today, the definition of green is unregulated  It can mean: Sustainable resources/plant-based ingredients Free of petrochemicals Biodegradable No animal testing Minimal carbon footprint Traded fairly  It can, but does not always mean “safer”

47. Efficacy of “Green” Products to Inactivate MDR Pathogens Rutala, Gergen, Weber. Unpublished results. 2013  No measurable activity against A. baumannii, A. xyloxidans, Burkholderia cenocepacia, K. pneumoniae, MRSA and P. aeruginosa, VRE, Stenotrophomonas maltophilia

48. Transfer of C. difficile Spores by Nonsporicidal Wipes Cadnum et al. ICHE 2013;34:441-2  Detergent/nondisinfectant-nonsporicidal wipes transfer or spread microbes/spores to adjacent surfaces; disinfectants inactivate microbes

49. 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 peroxide0.5%, 1.4% ____________________________________________________ UD=Manufacturer’s recommended use dilution

50. Quaternary ammonium compounds (e.g., didecyl dimethyl ammonium bromide, dioctyl dimethyl ammonium bromide) Rutala, Weber. Am J Infect Control 2013;41:S36-S41 Advantages  Bactericidal, fungicidal, virucidal against enveloped viruses (e.g., HIV)  Good cleaning agents  EPA registered  Surface compatible  Persistent antimicrobial activity when undisturbed  Inexpensive (in dilutable form)  Not flammable Disadvantages  Not sporicidal  In general, not tuberculocidal and virucidal against non-enveloped viruses  High water hardness and cotton/gauze can make less microbicidal  A few reports documented asthma as result of exposure to benzalkonium chloride  Affected by organic matter  Multiple outbreaks ascribed to contaminated benzalkonium chloride

51. Sodium Hypochlorite Rutala, Weber. Am J Infect Control 2013;41:S36-S41 Advantages  Bactericidal, tuberculocidal, fungicidal, virucidal  Sporicidal  Fast acting  Inexpensive (in dilutable form)  Not flammable  Unaffected by water hardness  Reduces biofilms on surfaces  Relatively stable (e.g., 50% reduction in chlorine concentration in 30 days)  Used as the disinfectant in water treatment  EPA registered Disadvantages  Reaction hazard with acids and ammonias  Leaves salt residue  Corrosive to metals (some ready-to-use products may be formulated with corrosion inhibitors)  Unstable active (some ready-to-use products may be formulated with stabilizers to achieve longer shelf life)  Affected by organic matter  Discolors/stains fabrics  Potential hazard is production of trihalomethane  Odor (some ready-to-use products may be formulated with odor inhibitors). Irritating at high concentrations.

52. Alcohol Rutala, Weber. Am J Infect Control 2013;41:S36-S41 Advantages  Bactericidal, tuberculocidal, fungicidal, virucidal  Fast acting  Non-corrosive  Non-staining  Used to disinfect small surfaces such as rubber stoppers on medication vials  No toxic residue Disadvantages  Not sporicidal  Affected by organic matter  Slow acting against non-enveloped viruses (e.g., norovirus)  No detergent or cleaning properties  Not EPA registered  Damage some instruments (e.g., harden rubber, deteriorate glue)  Flammable (large amounts require special storage)  Evaporates rapidly making contact time compliance difficult  Not recommended for use on large surfaces  Outbreaks ascribed to contaminated alcohol

53. Phenolics Rutala, Weber. Am J Infect Control 2013;41:S36-S41 Advantages  Bactericidal, tuberculocidal, fungicidal, virucidal  Inexpensive (in dilutable form)  Non-staining  Not flammable  EPA registered Disadvantages  Not sporicidal  Absorbed by porous materials and irritate tissue  Depigmentation of skin caused by certain phenolics  Hyperbilirubinemia in infants when phenolic not prepared as recommended

54. Improved Hydrogen Peroxide Rutala, Weber. Am J Infect Control 2013;41:S36-S41 Advantages  Bactericidal, tuberculocidal, fungicidal, virucidal  Fast efficacy  Easy compliance with wet-contact times  Safe for workers (lowest EPA toxicity category, IV)  Benign for the environment  Surface compatible  Non-staining  EPA registered  Not flammable Disadvantages  More expensive than most other disinfecting actives  Not sporicidal at low concentrations

55. LECTURE OBJECTIVES  Review the role of the environment in transmission of nosocomial pathogens  Review the properties of an ideal disinfectant  Review the key considerations for selecting the ideal disinfectant Kill Claims Kill and wet-contact time Safety Ease of use Other factors

56. Key Considerations for Selecting the Ideal Disinfectant for Your Facility Rutala, Weber. Infect Control Hosp Epidemiol. 2014;35:855-865 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).

57. SELECTION OF THE IDEAL SURFACE DISINFECTANT Kill Claims  Disinfectants used in hospitals should be EPA registered  Hospital disinfectant must show activity against Salmonella, Pseudomonas and S. aureus  Label are very specific about their kill claims (1-10 min contact time)  Does the product kill the most prevalent healthcare pathogens including those that Cause most HAIs Cause most outbreaks Are of concern in your facility

60. MOST PREVALENT PATHOGENS CAUSING HAI  Most prevent pathogens causing HAI (easy to kill) S. aureus (15.6%) E. coli (11.5%) Coag neg Staph (11.4%) Klebsiella (8.0%) P. aeruginosa (8.0%) E. faecalis (6.8%) C. albicans (5.3%) Enterobacter sp. (4.7%) Other Candida sp (4.2%)  Common causes of outbreaks and ward closures (relatively hard to kill) C. difficile spores Norovirus Rotavirus Adenovirus

61. Middle East Respiratory Syndrome-Coronavirus MERS-CoV

62. 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 18-24 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, an EPA claim against poliovirus could be used for MERS-CoV as well as inactivation data of coronavirus

63. Decreasing Order of Resistance of Microorganisms to Disinfectants/Sterilants Prions Bacterial spores (C. difficile) Mycobacteria Small, non-enveloped viruses (noro, 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

64. Inactivation of Coronavirus by Disinfectants/Antiseptics and Survival on Surfaces  Sattar, Springthorpe, Karim, Loro. Epidemiol Infect 1989;102:493 3 log 10 reduction in 1m by 2% glut, 70% alcohol, 1% PI, phenolic, and 5,000 ppm chlorine  Hulkower, Casanova, Rutala, Weber, Sobsey. Am J Infect Control 2011;39:401 2 log 10 reduction in 1m by phenolic (use-dilution), OPA, 70% ethanol, 62% ethanol, 71% ethanol Disinfectants and antiseptics effective in 1min

65. Decreasing Order of Resistance of Microorganisms to Disinfectants/Sterilants Prions Bacterial spores (C. difficile) Mycobacteria Small, non-enveloped viruses (noro, 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

66. GUIDELINE FOR THE PREVENTION OF NOROVIRUS OUTBREAKS IN HEALTHCARE, HICPAC, 2011  Avoid exposure to vomitus or diarrhea. Place patients with suspected norovirus on Contact Precautions in a single room (lB) Continue Precautions for at least 48 hours after symptom resolution (lB) Use longer isolation times for patients with comorbidities (ll) or <2 yrs (ll)  Consider minimizing patient movements within a ward (ll) Consider restricting movement outside the involved ward unless essential (ll) Consider closure of wards to new admissions (ll)  Exclude ill personnel (lB)  During outbreaks, use soap and water for hand hygiene (lB)  Clean and disinfect patient care areas and frequently touched surfaces during outbreaks 3x daily using EPA approved healthcare product (lB)  Clean surfaces and patient equipment prior to disinfection. Use product with an EPA approved claim against norovirus (lC) MacCannell T, et al. http://www.cdc.gov/hicpac/pdf/norovirus/Norovirus-Guideline-2011.pdf

67. Decreasing Order of Resistance of Microorganisms to Disinfectants/Sterilants Prions Bacterial spores (C. difficile) Mycobacteria Small, non-enveloped viruses (noro, 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

68. C. difficile EPA-Registered Products List K: EPA’s Registered Antimicrobials Products Effective Against C. difficile spores, April 2014 http://www.epa.gov/oppad001/list_k_clostridium.p df http://www.epa.gov/oppad001/list_k_clostridium.p df 34 registered products; most chlorine-based, some HP/PA-based

69. Key Considerations for Selecting the Ideal Disinfectant for Your Facility Rutala, Weber. Infect Control Hosp Epidemiol. 2014;35:855-865 ConsiderationQuestion to Ask Score (1-10) Kill ClaimsDoes the product kill the most prevalent healthcare pathogens 10, 8 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).

70. SELECTION OF THE IDEAL SURFACE DISINFECTANT Kill 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?

71. Kill Times for Most Prevalent Pathogens  Each disinfectant requires a specific time it must remain in contact with the microbe to achieve disinfection. This is known as the kill time or contact time  Some disinfectants may have a kill time for bacteria of 1m, which means bacteria in label disinfected in 1m  Other low-level disinfectants, often concentrated formulas require dilution, are registered by the EPA with contact time of 10m  Such a long contact time is not practical

72. CONTACT TIMES FOR SURFACE DISINFECTION  Follow the EPA-registered contact times, ideally Some products have achievable contact times for bacteria/viruses (30 seconds-2 minutes) Other products have non-achievable contact times  If use a product with non-achievable contact time Use >1 minute based on CDC guideline and scientific literature Prepare a risk assessment http://www.unc.edu/depts/spice/dis/SurfDisRiskAsses s2011.pdf http://www.unc.edu/depts/spice/dis/SurfDisRiskAsses s2011.pdf

73. Key Considerations for Selecting the Ideal Disinfectant for Your Facility Rutala, Weber. Infect Control Hosp Epidemiol. 2014;35:855-865 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. 10, 8 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).

74. SELECTION OF THE IDEAL SURFACE DISINFECTANT Safety  Does the product have an acceptable toxicity rating (danger, warning, caution, none)?  Does the product have an acceptable flammability rating?  Is a minimum level of personal protective equipment required?  Is the product compatible with the common surfaces in your facility?

75. Key Considerations for Selecting the Ideal Disinfectant for Your Facility Rutala, Weber. Infect Control Hosp Epidemiol. 2014;35:855-865 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 10, 9 Ease-of-UseOdor acceptable, shelf-life, in convenient forms (wipes, spray, surface area wet for 1-2m; wipe not torn easily or fall apart), 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).

76. SELECTION OF THE IDEAL SURFACE DISINFECTANT Ease of Use  Is the product odor acceptable?  Does the product have an acceptable shelf life?  Does the product come in convenient forms to meet your facility’s needs (refills, sprays, liquids; surface area wet for 1- 2m; wipe not torn easily or fall apart)?  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?

77. DISINFECTANTS AND HEALTHCARE PERSONNEL SAFETY  Environmental (Low Level) disinfectants: Risks Skin irritation (dermatitis) Allergies (including asthma) Rarely reported in US  Environmental disinfectants: Protection for HCP Proper PPE by HCP (gloves, gowns) Training for proper use and disposal  Training and PPE minimize risk

78. Occupational Exposures to Disinfectants at UNC Health Care  In regard to skin or respiratory irritation and allergies in HCP, most studies refer to glutaraldehyde or formaldehyde; these products are not recommended for use on noncritical surfaces  Surface disinfection in US generally accomplished by QUAT, phenolic, improved HP and chlorine  We are evaluating all chemical exposures for ten years (2003- 2012, ~9500 employees) and have rarely seen an employee in OHS with chronic respiratory complaint related to a low-level disinfectant (~30M persons days of exposure [Weber, Rutala, Consoli. 2013. Unpublished data])  Need well-designed immunologic evaluations of randomly selected HCP and controls, not case series without controls

79. Key Considerations for Selecting the Ideal Disinfectant for Your Facility Rutala, Weber. Infect Control Hosp Epidemiol. 2014;35:855-865 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) 10, 7 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).

80. SELECTION OF THE IDEAL SURFACE DISINFECTANT 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, cost of infections that may be prevented, and cost per compliant use?  Can the product help standardize disinfectants in your facility?

81. Key Considerations for Selecting the Ideal Disinfectant for Your Facility Rutala, Weber. Infect Control Hosp Epidemiol. 2014;35:855-865 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) 10, 7 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).

82. Key Considerations for Selecting the Ideal Disinfectant for Your Facility Rutala, Weber. Infect Control Hosp Epidemiol. 2014;35:855-865 ConsiderationQuestion to Ask Score (1-10) Kill ClaimsDoes the product kill the most prevalent healthcare pathogens 10, 8 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. 10, 8 SafetyDoes the product have an acceptable toxicity rating, flammability rating 10, 9 Ease-of-UseOdor acceptable, shelf-life, in convenient forms (wipes, spray), water soluble, works in organic matter, one-step (cleans/disinfects) 10, 7 Other factorsSupplier offer comprehensive training/education, 24-7 customer support, overall cost acceptable (product capabilities, cost per compliant use, help standardize disinfectants in facility) 10, 7 50, 39 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).

83. LECTURE OBJECTIVES  Review the role of the environment in transmission of nosocomial pathogens  Review the properties of an ideal disinfectant  Review the key considerations for selecting the ideal disinfectant Kill Claims Kill and wet-contact time Safety Ease of use Other factors

84. Selection of the Ideal Disinfectant Conclusions  Disinfection of noncritical environmental surfaces/equipment is an essential component of Infection prevention  Disinfection should render surfaces and equipment free of pathogens in sufficient numbers to cause human disease  While the perfect disinfecting agent may not exist, a careful process of selection and use are necessary to reduce harm to patients and staff  When determining the optimal disinfecting product, consider the 5 components (kill claims/time, safety, ease of use, others)  Select the product with the highest score as the best choice for your healthcare facility

85. THANK YOU! www.disinfectionandsterilization.org