Disinfectant Use

In Hospital

 Dr. Yogita Mistry

 GMC,Surat
Objectives:
 Definition
 Categories of disinfectant
 Factors affecting efficacy of disinfectant
 Property of Ideal Disinfectant
 Different disinfectant with few points
 Use of disinfectant in hospital
 Use of disinfectant in our hospital
Definition
Sterilization- is the process that kills all the living
micro-organisms including spores, viruses and
fungi.

Disinfectants –are those germicides or chemical

substances which are used to destroy or inhibit
the growth of pathogenic vegetative bacteria (not
their spores) on inanimate (nonliving )surfaces
such as glassware or surgical instruments.

Antiseptics-are those germicides or chemical

substances which are used to destroy the
pathogenic bacteria (not the spores) on animate
(living) surfaces such as skin /mucous
membranes.
Definition
 Decontamination- means marked reduction
or destruction of viable pathogenic organisms
to a level that will allow a healthy persons
natural defenses to prevent any infection.

 Sanitation- means reduction in microbial load

from an inanimate surface to a level set forth
by public health department.
 Chemical steriliant: When chemical are used to
destroy all forms of microbial life(including spores) , it is
called chemical sterilient. For these disinfectant are
used with prolonged exposure time.(3-12 hours).

 High level disinfectant: When a chemical sterilient

with same concentration is used for shorter exposoure
period, it can kill all microorganisms except large
number of bacterial spores.

 Low level disinfectant: Can kill most vegetative

bacteria, some fungi and virus.

 Intermediate level disinfectant: Might be cidal for

mycobacteria, vegetative bacteria, most viruses, most
fungi, but not spore.
 Cleaning: Removal of visible soil (organic and
inorganic material) from objects and surface. It is
an essential step before high level disinfectant or
sterilization.
A rational approach to
disinfection and
sterilization
 Spaulding believed the nature of disinfection
could be understood readily if instruments and
items for patient care were categorized as
critical, semicritical, and noncritical according
to the degree of risk for infection involved in
use of the items.
 Critical Items
 Critical items confer a high risk for infection if they
are contaminated with any microorganisms.
 Object that enter sterile tissue/vascular system
 Example:
 Surgical instruments
 Cardiac & urinary catheter
 Implants
 USG probes used in sterile body cavity
 Sterile
 Heat sensitive items: ETO, hydrogen peroxide or
 Liquid chemical sterilients:
 2.4% gluteraldehyde based formulation
 0.95% gluteraldehyde + 1.64% phenol /phenate
 7.5% stabilized hydrogen peroxide
 7.35% stabilized hydrogen peroxide+0.23%
peracetic acid
 0.2% peracetic acid
 0.08% peracetic acid+1% hydrogen peroxide
 Semicritical Items:
 Items which contact mucous membrane/ non intact skin

 Respiratory therapy, anesthesia equipment

 Laryngoscope blade
 Esophageal manometry probes
 Cystoscope

 As these mucous membrane are usually infected by

microorganisms and not by spores. So small no. of
spores are permissible.

 High level disinfectant used for short time/ Intermediate

level disinfectant (sodium hypochlorite/iodophors)
 Non critical items:
 Those that come in contact with intact skin but not
mucous membrane

 Bedpans
 Blood pressure cuff
 Computers
 Bedside table, furniture,floor

 Cleaning at regular interval

 Mopping with water, detergent, disinfectant(low
level disinfectant-phenol/quternary ammonium
componds)
Factors affecting the
efficacy of disinfectant
 Number and location of microorganism

 Innate resistant of microorganisms

 Bacterial spore>
cryptosporidium>mycobacteria>nonlipid /small
viruses> fungi> vegetative bacteria> Lipid/medium
size virus

 Gn=Gp

 Rickettsia, chlamydia, mycoplasma

 prions
 Concentration and potency of disinfectant

 Physical and chemical factors

 Temperature
 High pH=Gluteraldehyde, Quternary ammoniym
compounds
 Low pH= Phenol, Hypochlorite, Iodine
 pH works by altering the disinfectant molecules/cell
surface

 Humidity= effects on gaseous

disinfectant(formaldehyde,chlorine dioxide)

 Water hardness= high cations=make insoluble ppt with

disinfectant= decrease killing of organisms
 Organic and Inorganic matters:
 Interfere with antimicrobial activity of disinfectant by
 Chemical reaction between organic materials and
disinfectant resulting in a complex formation that
are less or no germicidal.
 By protection of microorganisms from attack

 Duration of exposure

 Biofilms
 Residual proteins and salt
 Microbial Contamination Of
Disinfectant
 Leads to HAI
 Not reported with high level disinfectant/ sterilient
 They are usually not contaminated at point of
manufacture, but contaminated during use, storage,
dilution
Property Of Ideal Disinfectant
 Broad spectrum: should have a wide
antimicrobial spectrum
 Fast acting: should produce a rapid kill
 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 be harmful to the user or
patient
 Surface compatibility: should not corrode
instruments and metallic surfaces and should not
cause the deterioration of cloth, rubber, plastics,
and other materials
 Residual effect on treated surfaces: should leave
an antimicrobial film on the treated surface
 Easy to use with clear label directions
 Odorless: should have a pleasant odor or no odor to
facilitate its routine use
 Economical: should not be prohibitively high in cost
 Solubility: should be soluble in water
 Stability: should be stable in concentrate and use-
dilution
 Cleaner: should have good cleaning properties
 Environmentally friendly: should not damage the
environment on disposal
High Level Disinfectant
 Formaldehyde
 Gluteraldehyde
 Orthophtahdehyde
 Hydrogen peroxide
 Peracitic acid
Formaldehyde
 Formaldehyde is used as
a disinfectant and sterilant
both in the liquid and
gaseous states.
Formaldehyde is sold and
used principally as a
water-based solution
called formalin, which is
37% formaldehyde by
weight. The aqueous
solution is bactericidal,
tuberculocidal, fungicidal,
virucidal and sporicidal
Formaldehyde
 Formaldehyde should be
handled in the workplace as a
potential carcinogen with an
employee exposure standard
that limits an 8 hour time-
weighted average exposure to a
concentration of 0.75 ppm. For
this reason, employees
should have limited
direct contact with
formaldehyde and these
considerations limit its
role in sterilization and
disinfection processes
Formaldehyde
 MOA: Alkylating amino and sulfhydral groups of
proteins and ring nitrogen atoms of purine base

 Microbicidal action:
 2%=Most virus
 8%=Poliovirus
 4%=Tuberculocidal in 2 minutes for 104 bacilli
 2.5% =Salmonella typhi
 4%=Sporicidal with 2 hour exposure

 Use: to prepare viral vaccine (polio, influenza)

 To preserve anatomical specimen
Gluteraldehyde
 Aldehydes have a wide
germicidal spectrum.
Gluteraldehydes are
bactericidal, virucidal,
fungicidal, sporicidal and
parasiticidal. They are
used as a disinfectant or
sterilant in both liquid and
gaseous forms. They
have moderate residual
activity and are effective
in the presence of limited
amounts of organic
material
Gluteraldehye
 High level disinfectant & chemical sterilent
 Aqueous solution=acidic and not sporicidal, only
when it is alkaline “activated” solution and it will
be sporicidal
 Once activated self life is 14 days

 Newer gluteraldehyde formulation:

 Gluteraldehyde+phenol+ sodium phenate

 Potentiated acid gluteraldehyde
 Stabilized alkaline gluteraldehyde
 MOA: alkylation of sulfhydryl , hydroxyl, carboxy
and amino groups of microorganism which alters
RNA, DNA, protein systhesis

 Use: As a high level disinfectant for medical

equipment such as endoscope, spirometry tubing,
dialyzer, anaesthesia and respiratory equipment

 S/e: irritant, dermatitis, mucosal irritation,

pulmonary syndrome, epistaxis, asthama,rhinitis
Hydrogen peroxide
 MOA: Generate destructive hydroxyl free radical
which attack membrane lipid, DNA, essential cell
membrane
 Broad acting
 Use: stable and effective disinfection of inanimate
surfaces
 0.5%=Bactericidal & virucidal in 1 minutes,
tuberculocidal in 5 minutes
 3%=VRE
 7%=Sporicidal
 6%-25%=Chemical steriliant
 13.4%= New rapid acting available
Hydrogen Peroxide
 Stabilized peroxides
may also be blended
with iodophors or
quaternary ammonia.
Hydrogen peroxide is
also blended with
paracetic acid in high
concentrations for use
as a high-level
disinfectant
Orthophthaldehyde
 MOA: interaction with aminoacid, protein,
microorganism
 Excellent microbicidal activity in vitro over a wider
pH range as comparable as gluteraldehye
 Not irritant to eye/nasal mucosa
 Disadvantage: it will stain the protein gray
 Use as a high level disinfectant
Peracetic acid
 Rapid action against all microorganisms
 Enhance the removal of organic material and
leaves no residue
 Remain effective in presence of organic matter
and is sporicidal even at low temperatures
 MOA: denaturation of proteins, disrupt the cell
wall permiability
 Use: as a high level disinfectant for cleaning of
endoscopes
Intermediate Level
Disinfectant
 Chlorine and chlorine compounds
 Iodine and Iodophors
 Chlorine and Chlorine compunds

 Hypochlorite available as :
 Liquid(sodium hypochlorite)
 Solid (calcium hypochlorite)

 5.25%-6.25% sodium hypochlorite=House hold

bleach

 Its microbial activity is attributed largely to

undissociated hypochlorous acid (HOCL)
 Dissociation of HOCL depends on pH
 Disinfectant efficacy of clorine decreases with
increase in pH that lead to HOCL=OCL-
 Chlorine agents are most
commonly used due to:
 Broad spectrum of
antimicrobial activity
 No toxic residue
 Unaffected by water
hardness
 Inexpensive
 Fast acting
 Remove dried/fixed
organism and biofilms from
surface
 Low incidence of serious
toxicity
Hypochlorite's
 Other disadvantages of
hypochlorites include
corrosiveness to metals in
high concentrations (>500
ppm), inactivation by
organic matter, discoloring
or “bleaching” of fabrics,
and release of toxic
chlorine gas when mixed
with ammonia or acid.
Side effects of household bleach
concentration
 Occular irritation/ oropharyngeal, esophageal
gastric burns
 Discolouration/ bleaching of fabrics
 Release of toxic chlorine gas when mixed with
amonia/acid
 Alternative chlorine compounds are:
 Demand release chlorine dioxide
 Sodium dichloroisocyanurate
 Chloramine-T

 Advantage:
 They retain chlorine longer
 More prolonged bactericidal effects
 It is acidic from so HOCL remain for longer time
Microbicidal activity
Bleach Dilution Chlorine level in
ppm
5.25-6.25% None 52500-61500 (5 liter)
1:10 5250-6150 (4500-
500)
1:100 525-615 (4900-
100)
 5000ppm=10 1:1000
6 Cl.difficle spore in less than
53-62 (4950-
10
minutes 50)
 1000 ppm=M.tb
 500 ppm=Candida in 30 seconds
 100 ppm=B.atropheaus in lesstthan 5 minutes,
106-107 S.aureus, Salmonella, Proteus,
pseudomonas
Use:

 Tonometer head,
 For decontamination of blood spill
 Disinfection of water supply
 Legionella contaminated hospital water
Iodine And Iodophor
Disinfectants
Iodine tinctures:
2% iodine + 2.4% sodium
iodide (NaI) in 50% ethanol; It
is used as a skin disinfectant,
as a nonirritant antiseptic on
wounds and abrasions.

Strong iodine tincture:

Contains 7% iodine and 5%
potassium iodide (KI)
dissolved in 95% ethanol.
It is more potent but also more
irritating than tincture of
iodine.
Idophors
 Combination of iodine and solubilizing agent/ carrier
 Which causes sustained release of iodine
 Example: povidone iodine=polyvinylpyrrolidone and
Iodine, which is free of toxicity and irritant effects
 It must be diluted according to manufacturer’s
direction
 MOA: protein and nucleic acid disruption
 It is bactericidal, tuberculocidal, virucidal but it require
prolong contact time
 Use: disinfection of blood culture bottles, medical
equiment-thermometer, endoscope
 Not use on silicone catheter: due to adverse effects
on silicone tubing
 Skin disinfectant Surgical
scrubs
Low Level Disinfectant
 Phenol
 Quaternary ammonium compounds
 Alcohol
 Surfactant
 Heavy metals
Alcohol
 Ethyl alcohol, Isopropyl alcohol, Methyl alcohol
 MOA: Denaturation of protein
 Absolute ethyl alcohol= less batericidal than
water+ alcohol because denaturation is quick in
presence of water.
Microbicidal activity

No acitivity when diluted by 50%

Methyl alcohol Ethyl alcohol Isopropyl alcohol

Weak bactericidal 60-80% = All except non

Bactericidal, enveloped virus
Virucidal(enveloped/nonenvelo
ped)fungicidal (tissue phase>
culture phase)

95%= Tuberculocidal
Alcohols
 Alcohols are commonly
used topical antiseptics.
 They can be used as a
reasonable substitute
for handwashing as
long as hands are not
visibly soiled.
 They are also used to
disinfect the surface of
medical equipment.
Alcohols require time to
work and they may not
penetrate organic
material.
Alcohols
 They also evaporate
rapidly which makes
extended exposure time
difficult to achieve unless
the items are immersed.
Alcohol irritates tissues.
They are generally too
expensive for general use
as a surface disinfectant
 Not recommonded for sterilizing medical and
surgical material due to lack of sporicidal action
and they can not penetrate protein rich material

 Use in disinfection of oral/rectal thermometer,

scissers, stethoscopes
PHENOLICS
 Examples: Benzyl-4-chlorophenol, Amyl phenol,
Phenyl phenol
 Advantages and disadvantages: good general
purpose disinfectants, not readily inactivated by
organic matter, active against wide range of
organisms (including mycobacterium), but not
sporicidal.
Phenol as Disinfectant
 They are not effective
against nonenveloped
viruses and spores. These
disinfectants maintain
their activity in the
presence of organic
material. This class of
compounds is used for
decontamination of the
hospital environment,
including laboratory
surfaces, and noncritical
medical items
Phenol as Disinfectant
 Phenolics are not
recommended for semi
critical items because of
the lack of validated
efficacy data for many of
the available formulations
and because the residual
disinfectant on porous
materials may cause
tissue irritation even when
thoroughly rinsed.
Phenol as Disinfectant
 Phenolics are not
recommended for semi
critical items because of
the lack of validated
efficacy data for many of
the available formulations
and because the residual
disinfectant on porous
materials may cause
tissue irritation even when
thoroughly rinsed.
Surfactants
 Decrease surface tension
 Soaps and detergents
 Quaternary ammonium compounds : microbicidal
Antiseptics
 Biguanides:
Chlorhexidine
 Low toxicity
 Used on skin
and mucous
membranes
Although chlorhexidine is effective in the presence of
blood, soap, and pus, its activity is reduced
 Heavy Metals
 Denature proteins
 silver nitrate (topical cream)
 mercuric chloride (paint)
 copper sulfate (algaecide)
 zinc (mouthwash, paints)
Mercurochrome-antiseptic
Zinc+ ferric oxide
Antifungal action
Uses Of
Disinfectant In
Hospital
 Hospital equipments

 Reprocessing of Endoscope
 HAI
 Heat sensitive endoscopes-GI , Bronchoscope, nasopharyngeoscope
 All must be properly cleaned first .
 Should minimally subjected to high level disinfectant
 Most common in use : 2% gluteraldehyde for 20 minutes
 Other imp: Orthophthaldehyde 0.55% (is now replacing gluteraldehyde due
to its less irritant property on eye and nasal mucosa,12 minutes)

 Other:
 7.35% hydrogen peroxide + 0.23% peracitic acid
 1 % hydrogen peroxide+ 0.08% peracitic acid
 7.5 % hydrogen peroxide
 But all 3 are more corrosive and causing functional damage on endoscope

 Automated endoscope reprocessors

Cleaning:
 Important process before using disinfectant
 Removal of soil and organic material from objects
 Normally done by water with detergent and enzymatic
products

 Enzymes: proteases: to remove blood and pus

 Lipase: enzymatic action on fat
 Amylase: starch

 It can be done mannually or by ultrasonic cleaners/water

-disinfector
 2 essential components of manual cleaning
 Friction-rubbing/scrubbing the soiled area with a brush
 Fluidics-fluids under pressure, use to remove soil and
debris from internal channels after brushing

 All enzymes =must be rinsed

 5 steps in reprocessing
 Cleaning: Mechanically cleaning of internal and external
surfaces by brushing, flushing with water and detergent
with /without enzymes

 Disinfection: Immerse endoscope in high level

disinfectant / chemical sterilient & perfuse. Disinfect all
accessible channels.

 Rinse: With sterile /filtered/tap water (that meets federal

clean water standard at point of use)

 Dry: Rinse with alcohol and dry with forced air after
disinfectant and before storage

 Storage: To prevent redecontamination and to promote

drying. Hanging vertically in a ventilated cabinets-good
method
Dental instruments
Type of instruments Example Method of
disinfection
Instruments that Extraction forcep, Critical items
penetrates soft tissue scalpel blade, bone
and bone chisels, periodontal Should be discarded or
scales, surgical burs sterilized only
Not penetrating bone Air / water syringe, Semicritical items
and soft tissue amalgam condensors
Sterilized/ high level
disinfectant
Clinical contact Light handles, Use barrier protective
(Surfaces that might be switches, dental x-ray covering, disinfect on
touched frequently with equipments, chair side each day of use with
gloved hands during equipment low or intermediate
patient care) level disinfectant

House keeping Clean with water,

surfaces detergent, disinfectant
Disinfection of HBV, HCV, HIV,
Tb contaminated items
 High level disinfectant is appropriate (CDC)

 For HCV : 2% gluteraldehyde for 20 minutes

 Chlorine compound are ineffcetive
In Hemodialysis Units
 In includes Hemodialysis machines, Water supply,
Water treated systems, Distribution system

 Non –critical surface: Dialysis chair/bed,

Countertops, External surface of machine,
Equipments
 Disinfect with EPA registered disinfectant/
hypochlorite solution (500-600 free chlorine)

 Hemodialyser: 7.2% peracetic acid, 20%

formaldehyde,
Inactivation Of Cl.difficle
 Carpeted room> non carpeted room
 Hypochlorite solution(1600 ppm available
chlorine)

 Contaminated medical devices like

colonoscopes & thermometers= 2%
gluteraldehyde for 20 minutes or
orthophthaldehyde with peracetic acid

 Hand washing, barrier methods, environmenta

cleaning
For Occupational exposure Of
Blood borne pathogens
 Disinfectant must be tuberculocidal
 M/c is hypochlorite solution (1:10 or 1:100
dilution)
 In presence of large spill: 1:10
Emerging pathogens
 Cryptosporidium: Most disinfectant not effective
except 6%-7.5% hydrogen peroxide

 E.coli O157:H7: Chlorine 1 ppm for 1 minutes

 H.pylori: Ethanol (80%), Gluteraldehyde (0.5%),

Chorhexidine gluconate (0.05-1%), Povidone iodine
(0.1%), Sodium hypochlorite (150 ppm)

 Rotavirus: 95% Ethanol, 70% Isopropanol, 2 %

Gluteraldehyde, 0.35% Peracetic acid, Sodium
hypochlorite(800 ppm free chlorine), Phenol based
products (14.7% )
 HPV and noroviruses: Not 100 % inactivation by
disinfectant

 SARS: 70% Ethanol and Povidone iodine for 1

minutes, 2.5% Gluteraldehyde for 5 minutes
Bioterrorist agents
 Susceptibility of these agents to germicide invitro
is similar to that of other related pathogen
(B.anthrax=B.athropheus)

 Many of them are stable enough in the

environment leads to transmission of agents.

 Data suggest that current disinfection and

sterilization practices are appropriate for
managing patient care equipment and
environment surfaces when potentially
contamination with bioterrosrist agents
Suceptibility Of Antibiotic
Resistant Bacteria To Disinfcetion
 Both are not related to each other except with few
exceptions like:
 MRSA strains –less susceptible than MSSA
starins to chlorhexidine, propamide, quternary
ammonium compounds, but are equally
susceptible to phenol
 Air disinfection in patient care
areas
 Disinfection spray fog techniques are unsatisfactory
in patient care area.
 Other methods: Air filteration, UV radiation, Chlorine
dioxide
 OT Disinfection
 Sterilization 100% is not achivable.
 It require standard air flow pattern, standard cleaning,
disinfection also.

 Fumigation: Formaldehyde gas is use

 Prepared by adding 150 gram of KMNO4 to 300 ml of
formaline for every 1000 cubic feet of space.
 Room should be tightly closed and sealed for 12-24 hours.
 It is carcinogenic
 Neutralization should be done by 250 ml of 10% amonia/
liter of formaline used is placed in centre of room for 3
hours.
 OT should be ventilated before the entry of any person.

 Ideally should be done on week ends.

 Newer agents: Hydrogen peroxide with silver
nitrate/ peracetic acid/other compounds
 Contact hours: 1 hour
 OT can be used within 1 hour

 VIKRON: Contain
 Pottasium peroxymonosulphate,
 Sodium dodecyl benzenesulphate, sulphanic acid,
inorganic buffer.
 Can be used for managing spill in OT.
Surface cleaning/
disinfection
 Non critical items
 Divided as Housekeeping and medical
equipments surface

 Housekeeping: Hospital floor, bed site table,

furniture, door knobs, handles
 Only soap and water are ineffective. Disinfectant
should be used. Phenolic compounds=94-99.9%
 Major problem:
 Bacterial counts are nearly back to its pretreatment
level within few hours.

 Ideally disinfectant should be left for 10 minutes on

surface, but such long time is not practical.
 Multiple scientific paper have demonstrated significant
microbial reduction with contact time of 30-60 seconds.

 Mop water become increasingly dirty during cleaning.

 Some hospital uses a new mopping technique
‘microfiber material’ to clean the floor.
 They are densly constructed, polyester/polyamide fibers
 1/16 the thickness of a human hair
 Positively charged , so attract the dust are more
absorbant than a conventional cotton-mop.
In our hospital
OT disinfection Formaldehyde gas
Instruments Sterilied by autoclave / ETO/ plasma
sterilized supplied by CSSD
Patient care before OT Betardine wash
At the time-local site cleaning By betardine
Endoscope Gluteraldehyde/ Automated machine
ENT ward instruments Kept in savlon. Then boied in DW
for 20 minutes. The dried and
reused.
OT table, Trolley Cleaning with hypochlorite
MICU Diluted savlon is kept in container
for health workers to clean the
hands inbetween
Hemodializer Company provided disinfectant run
by machine itself
References:
 Top ten disinfectants to control HAIs.
http://www.hospitalmanagement.net/features/feat
ureppcdisinfectantshaiglobaldata.
 Guideline for Disinfection and Sterilization in
Healthcare Facilities, 2008.
William A. Rutala, Ph.D., M.P.H.1,2, David J. Weber, M.D., M.P.H.1,2,
and the Healthcare Infection Control Practices Advisory Committee
(HICPAC).
 CDC-A Guide to Selection and Use of
Disinfectants.
 Shridhar rao- Testing of disinfectant.
Thank you