Selection of an Ideal Disinfectant

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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

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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

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DISINFECTION AND STERLIZATION

• EH Spaulding believed that how an object will be
  disinfected depended on the objects 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.

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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

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Low-Level Disinfection for Noncritical Objects

• Exposure time gt 1 min
• Germicide Use Concentration
• Ethyl or isopropyl alcohol 70-90
• Chlorine 100ppm (1500 dilution)
• Phenolic UD
• Iodophor UD
• Quaternary ammonium UD
• Improved hydrogen peroxide 0.5, 1.4
• __________________________________________________
  ____
• UDManufacturers recommended use dilution

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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

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KEY PATHOGENS WHERE ENVIRONMENTIAL SURFACES PLAY
A ROLE IN TRANSMISSION

• MRSA
• VRE
• Acinetobacter spp.
• Clostridium difficile
• Norovirus
• Rotavirus
• SARS

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ENVIRONMENTAL CONTAMINATION ENDEMIC AND EPIDEMIC
MRSA
Dancer SJ et al. Lancet ID 20088(2)101-13
12
ENVIRONMENTAL SURVIVAL OF KEY PATHOGENS ON
HOSPITAL SURFACES
Pathogen Survival Time
S. aureus (including MRSA) 7 days to gt12 months
Enterococcus spp. (including VRE) 5 days to gt46 months
Acinetobacter spp. 3 days to 11 months
Clostridium difficile (spores) gt5 months
Norovirus (and feline calicivirus) 8 hours to gt2 weeks
Pseudomonas aeruginosa 6 hours to 16 months
Klebsiella spp. 2 hours to gt30 months
Adapted from Hota B, et al. Clin Infect Dis
2004391182-9 and Kramer A, et al. BMC
Infectious Diseases 20066130
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Thoroughness of Environmental CleaningCarling et
al. Am J Infect Control. 201341S20-S25
gt110,000 Objects
Mean 32
14
Mean proportion of surfaces disinfected at
terminal cleaning is 30
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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 p0.59)
Stiefel U, et al. ICHE 201132185-187
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TRANSMISSION MECHANISMS INVOLVING THE SURFACE
ENVIRONMENT
Rutala WA, Weber DJ. InSHEA Practical
Healthcare Epidemiology (Lautenbach E, Woeltje
KF, Malani PN, eds), 3rd ed, 2010.
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ACQUISITION OF MRSA ON HANDS AFTER CONTACT WITH
ENVIRONMENTAL SITES
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TRANSFER OF MRSA FROM PATIENT OR ENVIRONMENT TO
IV DEVICE AND TRANSMISSON OF PATHOGEN
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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 (p0.002)

Shaughnessy MK, et al. ICHE 201132201-206
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Increased Risk of Acquisition of HA Pathogen
from Prior Room Occupant120
Prior room occupant infected Any room
occupant in prior 2 weeks infected
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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.

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FREQUENCY (mean) OF HCP CONTACT FOR SURFACES IN
AN ICU (N28) AND WARD (N24)
ICU WARD
Huslage K, Rutala WA, Sickbert-Bennett E, Weber
DJ. ICHE 201031850-853
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MICROBIAL BURDEN ON ROOM SURFACES AS A FUNCTION
OF FREQUENCY OF TOUCHING
Surface Prior to Cleaning Mean CFU/RODAC (95 CI) Post Cleaning (mean) Mean CFU/RODAC (95 CI)
High 71.9 (46.5-97.3) 9.6
Medium 44.2 (28.1-60.2) 9.3
Low 56.7 (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.
201334211-212
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Thoroughness of Environmental CleaningCarling et
al. Am J Infect Control. 201341S20-S25
gt110,000 Objects
Mean 32
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ENVIRONMENTAL CONTAMINATION LEADS TO
HAIsSuboptimal 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

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Quality Improvement
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MONITORING THE EFFECTIVENESS OF CLEANINGCooper
et al. AJIC 200735338

• Visual assessment-not a reliable indicator of
  surface cleanliness
• ATP bioluminescence-measures organic debris
  (each unit has own reading scale, lt250-500 RLU)
• Microbiological methods-lt2.5CFUs/cm2-pass can be
  costly and pathogen specific
• Fluorescent marker

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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.
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MONITORING THE EFFECTIVENESS OF CLEANINGCooper
et al. AJIC 200735338

• Visual assessment-not a reliable indicator of
  surface cleanliness
• ATP bioluminescence-measures organic debris
  (each unit has own reading scale, lt250-500 RLU)
• Microbiological methods-lt2.5CFUs/cm2-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)

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Fluorescent Marking Solution
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Target After Marking
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Target Enhanced
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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 2008291035-41
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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

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PROPERTIES OF AN IDEALSURFACE 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 201435855-865
37
PROPERTIES OF AN IDEALSURFACE 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 201435855-865
38
PROPERTIES OF AN IDEALSURFACE 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 201435855-865
39
PROPERTIES OF AN IDEALSURFACE 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 201435855-865
40
PROPERTIES OF AN IDEALSURFACE 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 150oF

Rutala WA, Weber DJ. Infect Control Hosp
Epidemiol 201435855-865
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LOW-LEVEL DISINFECTION FOR NONCRITICAL EQUIPMENT
AND SURFACES

• Exposure time gt 1
  min
• Germicide Use Concentration
• Ethyl or isopropyl alcohol 70-90
• Chlorine 100ppm (1500 dilution)
• Phenolic UD
• Iodophor UD
• Quaternary ammonium UD
• Improved hydrogen peroxide 0.5, 1.4
• __________________________________________________
  __
• UDManufacturers recommended use dilution

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LOW-LEVEL DISINFECTION FOR NONCRITICAL EQUIPMENT
AND SURFACES

• Exposure time gt 1
  min
• Germicide Use Concentration
• Ethyl or isopropyl alcohol 70-90
• Chlorine 100ppm (1500 dilution)
• Phenolic UD
• Iodophor UD
• Quaternary ammonium UD
• Improved hydrogen peroxide (HP) 0.5, 1.4
• __________________________________________________
  __
• UDManufacturers recommended use dilution

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BACTERICIDAL ACTIVITY OF DISINFECTANTS (log10
reduction) WITH A CONTACT TIME OF 1m WITH/WITHOUT
FCS. Rutala et al. ICHE. 2012 331159-61
Improved hydrogen peroxide is significantly
superior to standard HP at same concentration and
superior or similar to the QUAT tested
Organism 0.5 IHP 0.5 HP HP Cleaner-Dis 1.4 IHP 1.4 HP 3.0 HP QUAT
MRSA gt6.6 lt4.0 gt6.5 lt4.0 lt4.0 5.5
VRE gt6.3 lt3.6 gt6.1 lt3.6 lt3.6 4.6
MDR-Ab gt6.8 lt4.3 gt6.7 lt4.3 lt4.3 gt6.8
MRSA, FCS gt6.7 NT gt6.7 NT lt4.2 lt4.2
VRE, FCS gt6.3 NT gt6.3 NT lt3.8 lt3.8
MDR-Ab, FCS gt6.6 NT gt6.6 NT lt4.1 gt6.6
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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)
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Decontamination of Curtains with Activated HP
(1.4)Rutala, Gergen, Weber. Am J Infect
Control. 201442426-428
CP for Before Disinfection CFU/5 Rodacs (Path) After Disinfection CFU/5 Rodacs (Path) Reduction
MRSA 330 (10 MRSA) 21(0 MRSA) 93.6
MRSA 186 (24 VRE) 4 (0 VRE) 97.9
MRSA 108 (10 VRE) 2 (0 VRE) 98.2
VRE 75 (4 VRE) 0 (0 VRE) 100
VRE 68 (2 MRSA) 2 (0 MRSA) 97.1
VRE 98 (40 VRE) 1 (0 VRE) 99.0
MRSA 618 (341 MRSA) 1 (0 MRSA) 99.8
MRSA 55 (1 VRE) 0 (0 MRSA) 100
MRSA, VRE 320 (0 MRSA, 0 VRE) 1 (0 MRSA, 0 VRE) 99.7
MRSA 288 (0 MRSA) 1 (0 MRSA) 99.7
Mean 2146/10215 (432/1044) 33/103 (0) 98.5
All isolates after disinfection were Bacillus
sp now treat CP patient curtains at discharge
with IHP
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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

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Efficacy of Green Products to Inactivate MDR
PathogensRutala, Gergen, Weber. Unpublished
results. 2013

• No measurable activity against A. baumannii, A.
  xyloxidans, Burkholderia cenocepacia, K.
  pneumoniae, MRSA and P. aeruginosa, VRE,
  Stenotrophomonas maltophilia

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Transfer of C. difficile Spores by Nonsporicidal
WipesCadnum et al. ICHE 201334441-2

• Detergent/nondisinfectant-nonsporicidal wipes
  transfer or spread microbes/spores to adjacent
  surfaces disinfectants inactivate microbes

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LOW-LEVEL DISINFECTION FOR NONCRITICAL EQUIPMENT
AND SURFACES

• Exposure time gt 1
  min
• Germicide Use Concentration
• Ethyl or isopropyl alcohol 70-90
• Chlorine 100ppm (1500 dilution)
• Phenolic UD
• Iodophor UD
• Quaternary ammonium UD
• Improved hydrogen peroxide 0.5, 1.4
• __________________________________________________
  __
• UDManufacturers recommended use dilution

50
Quaternary ammonium compounds (e.g., didecyl
dimethyl ammonium bromide, dioctyl dimethyl
ammonium bromide)Rutala, Weber. Am J Infect
Control 201341S36-S41

• Advantages

• Disadvantages

• 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

• 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

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Sodium HypochloriteRutala, Weber. Am J Infect
Control 201341S36-S41

• Advantages

• Disadvantages

• 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

• 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.

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AlcoholRutala, Weber. Am J Infect Control
201341S36-S41

• Advantages

• Disadvantages

• 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

• 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

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PhenolicsRutala, Weber. Am J Infect Control
201341S36-S41

• Advantages

• Disadvantages

• Bactericidal, tuberculocidal, fungicidal,
  virucidal
• Inexpensive (in dilutable form)
• Non-staining
• Not flammable
• EPA registered

• 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

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Improved Hydrogen PeroxideRutala, Weber. Am J
Infect Control 201341S36-S41

• Advantages

• Disadvantages

• 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

• More expensive than most other disinfecting
  actives
• Not sporicidal at low concentrations

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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 FacilityRutala, Weber.
Infect Control Hosp Epidemiol. 201435855-865
Consideration Question to Ask Score (1-10)
Kill Claims Does 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.
Safety Does the product have an acceptable toxicity rating, flammability rating
Ease-of-Use Odor acceptable, shelf-life, in convenient forms (wipes, spray), water soluble, works in organic matter, one-step (cleans/disinfects)
Other factors Supplier 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).
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SELECTION OF THE IDEAL SURFACE DISINFECTANTKill
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

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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

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Middle East Respiratory Syndrome-CoronavirusMERS-
CoV
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New and Emerging PathogensMERS-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
Most Resistant
Prions Bacterial spores (C. difficile) Mycobacteri
a 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 Susceptible
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Inactivation of Coronavirus by Disinfectants/Antis
eptics and Survival on Surfaces
Disinfectants and antiseptics effective in 1min

• Sattar, Springthorpe, Karim, Loro. Epidemiol
  Infect 1989102493
• 3 log10 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 201139401
• 2 log10 reduction in 1m by phenolic
  (use-dilution), OPA, 70 ethanol, 62 ethanol,
  71 ethanol

65
Decreasing Order of Resistance of Microorganisms
to Disinfectants/Sterilants
Most Resistant
Prions Bacterial spores (C. difficile) Mycobacteri
a 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 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 lt2 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
Most Resistant
Prions Bacterial spores (C. difficile) Mycobacteri
a 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 Susceptible
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C. difficile EPA-Registered Products

• List K EPAs Registered Antimicrobials Products
  Effective Against C. difficile spores, April 2014
• http//www.epa.gov/oppad001/list_k_clostridium.pdf
  
• 34 registered products most chlorine-based, some
  HP/PA-based

69
Key Considerations for Selecting the Ideal
Disinfectant for Your FacilityRutala, Weber.
Infect Control Hosp Epidemiol. 201435855-865
Consideration Question to Ask Score (1-10)
Kill Claims Does 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.
Safety Does the product have an acceptable toxicity rating, flammability rating
Ease-of-Use Odor acceptable, shelf-life, in convenient forms (wipes, spray), water soluble, works in organic matter, one-step (cleans/disinfects)
Other factors Supplier 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 DISINFECTANTKill
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 gt1 minute based on CDC guideline and
  scientific literature
• Prepare a risk assessment http//www.unc.edu/depts
  /spice/dis/SurfDisRiskAssess2011.pdf

73
Key Considerations for Selecting the Ideal
Disinfectant for Your FacilityRutala, Weber.
Infect Control Hosp Epidemiol. 201435855-865
Consideration Question to Ask Score (1-10)
Kill Claims Does 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
Safety Does the product have an acceptable toxicity rating, flammability rating
Ease-of-Use Odor acceptable, shelf-life, in convenient forms (wipes, spray), water soluble, works in organic matter, one-step (cleans/disinfects)
Other factors Supplier 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 DISINFECTANTSafety

• 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 FacilityRutala, Weber.
Infect Control Hosp Epidemiol. 201435855-865
Consideration Question to Ask Score (1-10)
Kill Claims Does 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.
Safety Does the product have an acceptable toxicity rating, flammability rating 10, 9
Ease-of-Use Odor 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 factors Supplier 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 DISINFECTANTEase
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 facilitys 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 ANDHEALTHCARE 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 FacilityRutala, Weber.
Infect Control Hosp Epidemiol. 201435855-865
Consideration Question to Ask Score (1-10)
Kill Claims Does 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.
Safety Does the product have an acceptable toxicity rating, flammability rating
Ease-of-Use Odor acceptable, shelf-life, in convenient forms (wipes, spray), water soluble, works in organic matter, one-step (cleans/disinfects) 10, 7
Other factors Supplier 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 DISINFECTANTOther
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 FacilityRutala, Weber.
Infect Control Hosp Epidemiol. 201435855-865
Consideration Question to Ask Score (1-10)
Kill Claims Does 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.
Safety Does the product have an acceptable toxicity rating, flammability rating
Ease-of-Use Odor acceptable, shelf-life, in convenient forms (wipes, spray), water soluble, works in organic matter, one-step (cleans/disinfects)
Other factors Supplier 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 FacilityRutala, Weber.
Infect Control Hosp Epidemiol. 201435855-865
Consideration Question to Ask Score (1-10)
Kill Claims Does 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
Safety Does the product have an acceptable toxicity rating, flammability rating 10, 9
Ease-of-Use Odor acceptable, shelf-life, in convenient forms (wipes, spray), water soluble, works in organic matter, one-step (cleans/disinfects) 10, 7
Other factors Supplier 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 DisinfectantConclusions

• 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