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Cleaning/decontamination, disinfection, and sterilization

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Cleaning/decontamination, disinfection, and sterilization Kumthorn Malathum, MD Chair, ICC, Ramathibodi Hospital Scope Cleaning/decontamination, disinfection, and ... – PowerPoint PPT presentation

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Title: Cleaning/decontamination, disinfection, and sterilization


1
Cleaning/decontamination, disinfection, and
sterilization
  • Kumthorn Malathum, MD
  • Chair, ICC, Ramathibodi Hospital

2
Scope
  • Cleaning/decontamination, disinfection, and
    sterilization of medical devices
  • Environmental cleaning
  • Routine floor, bed rail, etc.
  • MDR bacteria
  • Respiratory pathogens (virus, mycobacteria)

3
Virulence is not correlated with the ease to be
destroyed!
Certain enveloped (lipophilic) viruses (e.g.,
HSV, HIV, influenza virus, and RSV are
susceptible to alcohols. Hepatitis B virus is an
enveloped virus that is somewhat less susceptible
but is killed by 6070 alcohol hepatitis C
virus also is likely killed by this percentage of
alcohol.
APIC guidelines Am J Infect Control 199624313-42
4
Cleaning
  • Removing all foreign material from objects by
    using water and detergents or soaps and washing
    or scrubbing the object
  • Must be done before any disinfection or
    sterilization process

5
Disinfection
  • A process that eliminates many or all
    microorganisms except spores
  • Done with liquid chemicals or by pasteurization
  • Proper contact time and dilution of the
    disinfectant must be followed

6
Definitions
  • High-level disinfection
  • All microorganisms except high numbers of
    bacterial spores
  • Intermediate disinfection
  • M. tuberculosis, vegetative bacteria, most
    viruses, and most fungi
  • Not necessarily kill bacterial spores

7
Sterilization
  • A process that completely eliminates or kills all
    microorganisms

8
Classification of device, process, and products
9
Chemical disinfection
  • Aldehydes glutaraldehyde ortho-phthaldehyde
    (OPA)
  • Alcohol
  • Biguanides chlorhexidine
  • Halogen and halogen releasing agents chlorine,
    iodine
  • Quaternary ammonium compound

10
Glutaraldehyde
  • High-level disinfectant
  • Working solution pH 7.5 to 8.5, 14 to 28 days
  • Mode of action cross-linking with proteins,
    inhibit synthesis of DNA, RNA
  • 2 vegetative bacteria lt 2 minutes, M.
    tuberculosis, fungi, viruses lt 10 minutes, spore
    of Bacillus Clostridium spp. 3 h
  • Use medical equipment
  • Toxic respiratory system

11
Glutaraldehyde
  • Advantages
  • Rapid low-temperature disinfection
  • OPA has greater anti-mycobacterial activity, no
    activation required, less noxious, more stable
  • Disadvantages
  • Irritating
  • Absorbed into plastics leads to toxicity (e.g.,
    colitis)

12
Alcohol
  • Optimal conc. 60 to 80
  • Not HIGH level (spores and hydrophilic virus are
    not destroyed)
  • Use oral and rectal thermometers, small surfaces
    (multiple dose medication vials), external
    surface of equipment (stethoscope, ventilators,
    manual ventilation bags)

13
Biguanides
  • Chlorhexidine (bisbiguanide)
  • Insoluble in water
  • Active against Gm ve gt Gm ve bacteria gt yeasts
    molds
  • Not sporicidal
  • Can be inactivated by nonionic surfactant
    presented in soaps, hand creams, and inorganic
    water contaminants (phosphate, chlorine)

14
Chlorine compound
  • Concentration dependent
  • 25 ppm mycoplasma and vegetative bacteria (lt1
    ppm) within seconds
  • 100 ppm Bacillus subtilis spores within 5
    minutes, fungus lt 1 h
  • 1000 ppm M. tuberculosis
  • Household bleach 5.25 52,500 ppm

15
Iodophors
  • Tincture of iodine
  • 7.5 Povidone-iodine (PVP-I), 0.7 available
    iodine
  • Bactericidal, fungicidal, tuberculocidal, and
    virucidal
  • Short time residual effect

16
Quaternary ammonium compound benzalkonium
chloride
  • Associated with many outbreaks including
    non-tuberculous Mycobacterium GNR
  • Not recommended for use as skin and tissue
    disinfectant
  • Use environmental sanitation of noncritical
    surfaces (floors, furniture, walls)

17
Problems associated with the use of disinfectants
  • Ineffective cleaning
  • Too low concentration
  • Contaminants unlikely to survive in recommended
    use-dilution

18
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19
The amount of use and costs of antiseptics/disinfe
ctants per bed per year
Danchaivijitr S et al. J Med Assoc Thai 2005 88
(Suppl 10) S133-9
20
Places where antiseptics/disinfectants were
prepared
Danchaivijitr S et al. J Med Assoc Thai 2005 88
(Suppl 10) S133-9
21
Persons who prepared antiseptics/disinfectants
used in wards
Danchaivijitr S et al. J Med Assoc Thai 2005 88
(Suppl 10) S133-9
22
Microbial contamination ()
Danchaivijitr S et al. J Med Assoc Thai 2005 88
(Suppl 10) S133-9
23
Danchaivijitr S et al. J Med Assoc Thai 2005 88
(Suppl 10) S133-9
24
Infection control in flexible endoscopy
Alvarado C et al. Am J Infect Control
200028138-55.
25
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26
Agents recommended for high-level disinfection of
flexible endoscopes
  • Glutaraldehyde preparations
  • Peracetic acid
  • Orthophalaldehyde

Alvarado C et al. Am J Infect Control
200028138-55.
27
Agents not recommended for disinfection of
flexible endoscopes
  • Hypochlorites
  • Quaternary ammonium compounds
  • Not sporicidal, tuberculocidal, or viricidal
    against hydrophilic viruses
  • Phenolics
  • Intermediate-level disinfectants

Alvarado C et al. Am J Infect Control
200028138-55.
28
Disinfection of a Probe Used in Ultrasound-Guided
Prostate Biopsy
Rutala WA., et al. Infect Control Hosp Epidemiol
2007 28916-919
29
Main findings
  • Disinfection (i.e., a reduction in bacterial load
    of greater than 7 log10 CFU) could be achieved if
    the needle guide was removed from the probe

Rutala WA., et al. Infect Control Hosp Epidemiol
2007 28916-919
30
Main findings
  • If the needle guide was left in the probe channel
    during immersion in 2 glutaraldehyde,
    disinfection was not achieved (i.e., the
    reduction was approximately 1 log10 CFU)

Rutala WA., et al. Infect Control Hosp Epidemiol
2007 28916-919
31
Treatment of endoscope after disinfection or
sterilization
  • Rinsing
  • Sterile water
  • Alcohol rinse followed by complete drying
  • Only sterile water should be used for endoscopes
    that pass through sterile tissues.

Alvarado C et al. Am J Infect Control
200028138-55.
32
Treatment of endoscope after disinfection or
sterilization
  • Drying
  • Drying with alcohol and compressed air should be
    done between each patient use when tap water is
    used to rinse the endoscope channels and before
    storage whether tap water or sterile water is
    used.
  • Storage

Alvarado C et al. Am J Infect Control
200028138-55.
33
Sterilization
  • Heat sterilization
  • Dry heat
  • Moist heat pressure steam sterilizer (autoclave)
  • Chemical
  • Ethylene oxide
  • Glutaraldehyde

34
Autoclave
  • Steam must come into direct contact with the
    surface
  • Air must be completely removed
  • Downward displacement
  • Pre-vaccuum

35
Flash sterilization
  • Steam sterilization of patient care items for
    immediate use
  • Not for convenience or an alternative to
    purchasing additional instrument sets or to save
    time
  • Not recommended for implantable devices

36
Flash sterilization
  • Lack of timely biologic indicators to monitor
    performance, absence of protective packaging
    following sterilization, possibility for
    contamination of processed items during
    transportation to operating rooms, and use of
    minimal sterilization cycle parameters (i.e.,
    time, temperature, pressure)

37
Parameters for flash sterilization
38
Ethylene oxide
  • Extremely penetrative
  • Non-corrosive
  • Toxic, irritant, and explosive when mixed with
    air at conc. gt3
  • Odorless

39
Quality assurance for sterilization
  • Mechanical monitoring
  • Exposure time, temperature, and pressure
  • Ascertain that the sterilization system function
    within parameters
  • Chemical monitoring
  • Does not verify sterilization
  • Indicate procedural errors and equipment
    malfunction

40
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AAMI ,AORN ,CDC,CSA
41
Definition of a chemical indicators
  • CI System that reveals a change in one or more
    predefined process variables based on a chemical
    or physical change resulting from exposure to a
    process.

42
CI classes
  • Class 1 Process Indicators
  • Used to show exposure to a process. No
    information about the success or failure of the
    process
  • Class 2 Specific Test Indicators (e.g. BDT)
  • Class 3 Single variable indicators
  • Respond to a single variable in the process e.g.
    temperature

43
CI classes
  • Class 4 Multivariable Indicators
  • Respond to two or more variables in the process
  • Class 5 Integrating Indicators (Chemical
    Biological Indicators)
  • Respond in a way which mimics the response of a
    BI if used in the same process

44
CI classes
  • Class 6 Emulating Indicators (Cycle
    Verification Indicators -Chemical Chart
    Recorders)
  • Respond to all critical variables of the process
    at levels associated with acceptable sterilizing
    conditions e.g. 134 for 5 mins.

45
Quality assurance for sterilization
  • Bowie-Dick test
  • Performed daily, with pre-vacuum system, in an
    empty chamber
  • Detect residual air in the sterilizer chamber

46
Biologic monitoring of steam sterilization
  • Biologic indicators demonstrated bacterial growth
    from spore strips on 15 (12) out of 125 cycles
  • Chemical indicators revealed a change of color to
    black after all 125 cycles

Kelkar U et al AJIC 2004, 512-513
47
BI changes
  • Bacillus subtilis renamed to B. atrophaeus
  • Bacillus stearothermophilus renamed to
    Geobacillus stearothermophilus

48
QA for sterilization
  • Whenever sterilizers are used, they should be
    routinely tested with biological indicators to
    ensure they are working correctly
  • Items that are sterilized should remain sterile
    until the package is torn, wet, or damaged.
    Sterility is a function of intact packaging, not
    time.

49
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??????????????????????????????????????????????????
?????? Steam 56 ? 1o C EtO 37 ? 1 o C
50
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  • ?????????????????????????????????????????? 8, 12,
    24 ??? 48??
  • ??????????????????????????????????????????????????
    ??????????????????????????????????????
  • ??????????????????????????????????????????????????
    ?????????????????????????

51
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?????? ???????????????????????????????????????????
??????????????? 8, 12, 24, 48 ???????
??????????????????????????????????????????????????
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52
??????????????
  • ???????????
  • ???????????????? ??????????
  • ????????????????????????? Glutaraldehyde
    ????????????????????????????????????/?????????????
  • ?????????
  • ?????
  • ???????
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