Sterilization & Disinfection

Allison McGeer, MSc, MD, FRCPC

How can microorganisms be killed?

Denaturation of proteins (e.g. wet heat, ethylene oxide) Oxidation (e.g. dry heat, hydrogen peroxide) Filtration Interruption of DNA synthesis/repair (e.g. radiation) Interference with protein synthesis (e.g. bleach) Disruption of cell membranes (e.g. phenols)

Factors that influence efficacy of disinfection/sterilization

3 4 5 6 7 Contact time Physico-chemical environment (e.g. pH) Presence of organic material Temperature Type of microorganism Number of microorganisms Material composition

Ideal sterilization/disinfection process

Highly efficacious Fast Good penetrability Compatible with all materials Non-toxic Effective despite presence of organic material Difficult to make significant mistakes in process Easily monitored

Spaulding Classification
Category Critical Semi-critical Description Enters sterile body cavity Contacts mucous membranes, non-intact skin Contacts intact skin Requirement Sterile High level disinfection

Non-critical

Low level disinfection

Types of microorganisms and levels of disinfection

sterilization Bacterial endospores high level disinf Mycobacteria (tuberculosis)

low level disinf

Non-lipid (small) viruses (polio) Fungi Vegetative bacteria (Salmonella) Lipid viruses (Herpes, HepB, HIV)

Sterilization
Steam Ethylene oxide Peracetic acid (.2%) Hydrogen peroxide gas plasma Vapourized hydrogen peroxide Ozone

Sterilization process
Clean items Package items Load sterilizer Monitor
Physical (time/temp/pressure) Chemical Biological

Biological Monitors
Steam: Geobacillus stearothermophilus Dry heat: B. atrophaeus (formerly B. subtilis) ETO: B. atropheus Peracetic acid: G. stearothermophilus Plasma (Sterrad): G. stearothermophilus

Ontario guidelines:
Steam: monitor daily, every load with implantables ETO: monitor every load

Sterilization process
Clean items Package items Load sterilizer Monitor
Physical (time/temp/pressure) Chemical Biological

Storage post-sterilization Documentation

Problems with sterility

Lack of understanding of risk/process
physicians introducing new products (borrowed, samples) Multidose vials What is sterile vs not

Lack of understanding of components of process

MDs, technologists have less training than nurses (anaesthesiology, imaging, urology)

Flash Sterilization
Unwrapped objects, 132C, 3mins, 27-28lbs pressure in gravity Acceptable for processing items that cannot be sterilized and stored before use

Bryce E; ICHE 1997;18(9):654-6

Reprocessing for Prions

High risk patient
Known/suspected CJD or other TSEs Rapidly progressive dementia Family history of CJD or other TSE History of dura mater transplant, cadaver-derived pituitary hormone injection

High risk tissue

Brain, spinal cord, eyes

High risk device

Critical or semi-critical

Inactivation of Prions
Steam sterilization with NaOH Alkaline cleaner (pH 2.2, 1 hr 23C) Copper plus peracetic acid Vapourized hydrogen peroxide (Sterrad NX)

Yan ICHE 2004;25:280, Fichet Lancet 2004;384:251, Baier JHI 2004;57:80, Lemmer J Gen Virol 2004;85:3805; Roger-Kreuz, ICHE 2009;30(8):769-77 Lehman Hosp Infect. 2009;72(4):342-50;

Semi-critical items
Endoscopes/bronchoscopes Laryngoscopes Respiratory therapy and anaesthesia equipment Tonometers Endocavitary probes Vaginal specula, diaphram fitting rings

Problems with semi-critical items

Complex and delicate pieces of equipment Expensive equipment used frequently
Centralizing process difficult Time an important factor

Absence of regulation/guidance for design Narrow margin of safety

Endocavitary probes
Prostate & vaginal ultrasounds, TEE Trans-rectal biopsies Transvaginal probes for IVF Infrared coagulation for hemmorhoids

Laryngoscopes - blades are semi-critical - handles are non-critical (but still need to be disinfected)

Biopsy forceps, endoscopy

Applanation tonometers

Disinfection of tonometers

Rutala AAC 2006;50:1419

Recent Toronto problems

Badly designed connectors (Steris) Inadequate manufacturers instructions (transrectal biopsies) Belief that a freeze thaw cycle for cryotherapy probe will kill microbes Both reservoirs in endoscopy washer/disinfector filled with detergent 2% hydrogen peroxide for high level disinfection Vaginal ultrasound probes Breast pump kits Sterilizer failures

Solutions
Centralization of disinfection & sterilization wherever possible Standards: PIDAC, CSA
Processes, monitoring, training

New technology
Endoscopes that can be steam sterilized Better sterilization technology

Elimination of high-level disinfection

Outbreaks (1999-2007
Failure to clean/disinfect/sterilize adequately
Manual balloons for ventilation (B. cereus) Pasteurizer failure (x2) Thermometers (E. cloacae, NICU) x3 Temperature sensors for ventilators (S. maltophilia) x 2 Ophthalmology equipment (adenovirus) Endoscopes (TB x3, P.aeruginosa x2, pseudo outbreaks x5) OR sterilization/high-level disinfection failure Forceps in cystoscopy (P. aeruginosa) Rigid laryngoscopes in NICU (P. aeruginosa, M. tuberculosis) Transrectal prostate needle biopsies (P. aeruginosa x2) Transesophageal echocardiography probes (E. cloace) Bite blocks (P. aeruginosa, Group A streptococci) Laparoscopy ports (Mycobacterium chelonae)

Outbreaks (2)
Contaminated disinfectants.
Non-antimicrobial soap x2 Benzalkonium chloride and other quaternary ammonium compounds 0.5% chlorhexidine Chlorhexidine without alcohol Improperly diluted disinfectants (disinfectant spray, environmental cleaning solutions) Open containers with soaked cotton balls

S. marcescens, P. aeruginosa, M. abscessus, R. picketii, A. xylosoxidans, K. oxytoca,

Outbreaks (3)
Other
Incompetent waste drain ports on hemodialysis machines x2 Inadequately maintained endoscopy washer/disinfector Incorrect hook-up for endoscopes to sterilizer Environmental contamination with Acinetobacter

Outbreaks (4) Adverse effects

Anterior segment syndrome post cataract surgery due to residual glutaraldehyde
Toxic endothelial cell destruction (TECD) syndrome after ophthalmologic surgery due to brass degradation by plasma gas sterilization

Non-critical items

Factors necessary for environmental transmission

The organism must survive in the environment Environmental contamination must occur frequently The organism must maintain its virulence The organism must be transported from the environment to (new) patients

Epidemiology of streptococcal infections Transmission of epidemic and non-epidemic

streptococci in military barracks
70 60
Acquisition of GAS per 1000 man-weeks

50 40 30 20 10 0 Blankets harbouring streptococci Blankets not harbouring streptococci

Wannamaker, Chap 12 in McCarty, Streptococcal Infections, 1954

MRSA and environmental transmission

20 month retrospective study in 8 ICUs where patients were screened weekly Assessed odds of acquiring MRSA among patients admitted to rooms just vacated by MRSA + and + patients MRSA acquired by: 2.9% of those admitted to MRSA- pt room 3.9% of those admitted to MRSA + pt room
Huang SS, Arch Int Med 2006;166:1945

Effect of improved environmental cleaning on VRE transmission

Hayden MK, Clin Infect Dis 2006:42:1552

Can environmental cleaning reduce MRSA transmission?

Setting: ward with endemic MRSA, and widespread environmental contamination Before-after study
Cleaning time increased by 57 hours per week Responsibility for routine cleaning of shared equipment delineated

In 6 months post-intervention, number of MRSA acquisitions decreased fro 30 to 3 per 6 months

Rampling A JHI 2001;49:109

Contaminated Surfaces
VRE
Bed Rails Bed Table Door Knobs Doors Call Button Chair Tray Table Toilet Surface Sink Surface Bedpan Cleaner +++++++ ++++++ ++ +++ +++ ++ +++ + + -

MRSA
+ + ++ + + + ++ + -

C. difficile +++ + ++ ++ ++++ +++ +

Carling PC, et al. Am J Infect Control. 2006 Oct;34(8):513-9.

Contamination of objects/areas exclusively touched by staff

Supply cabinets, ICU telephones, keyboards 33.3% MRSA 36.6% VRE

Speck et al., Abstract, (2007) SHEA 17th Annual Scientific Meeting, Baltimore, MD

Problems
How important is environmental transmission overall? What do we mean by environment? What is the right standard for clean? How do we measure adherence?

Improving non-critical item/environment disinfection

Audit and feedback

PROPORTION OF OBJECTS CLEANED 15 ACUTE CARE HOSPITALS

100

80

% Objects Cleaned

60

40

20

Sink Toilet seat

Tray Table

Hand Side Toilet Call BR hold rails door box light Toilet Bedpan Chair Room Telephone handle cleaner door

Carling Crit Care Med Jan 2010 epub

Improving non-critical item/environment disinfection

Audit and feedback
New technology
Hydrogen peroxide vapour/gas UV room decontaminaion ?antibacterial surface coatings?

Otter ICHE 2009;30(6):574-7

 Seymour S. Block: Disinfection, sterilization and preservation Williams &Wilkins (ISBN 0812113640) PIDAC best practices for cleaning, sterilization and disinfection
http://www.health.gov.on.ca/english/providers/program/infectious/diseas es/best_prac/bp_cds_2.pdf

PIDAC best practices for environmental cleaning

http://www.health.gov.on.ca/english/providers/program/infectious/diseas es/best_prac/bp_enviro_clean.pdf

CDC guideline for disinfection and sterilization in healthcare facilities

http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf Bryce EA et al. When the biological indicator is positive: investigating autoclave failures Infect Control Hosp Epi 1997;18:654-6 Rutala WA, Weber DJ. How to assess risk of disease transmission to patients when there is a failure to follow recommended disinfection and sterilization guidelines Infect Control Hosp Epidemiol. 2007;28(2):14655