Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008
Miscellaneous Inactivating Agents
Several compounds have antimicrobial activity but for various reasons have not been incorporated into the armamentarium of health-care disinfectants. These include mercurials, sodium hydroxide, β-propiolactone, chlorhexidine gluconate, cetrimide-chlorhexidine, glycols (triethylene and propylene), and the Tego disinfectants. Two authoritative references examine these agents in detail 16, 412.
A peroxygen-containing formulation had marked bactericidal action when used as a 1% weight/volume solution and virucidal activity at 3% 49, but did not have mycobactericidal activity at concentrations of 2.3% and 4% and exposure times ranging from 30 to 120 minutes 750. It also required 20 hours to kill B. atrophaeus spores 751. A powder-based peroxygen compound for disinfecting contaminated spill was strongly and rapidly bactericidal 752.
In preliminary studies, nanoemulsions (composed of detergents and lipids in water) showed activity against vegetative bacteria, enveloped viruses and Candida. This product represents a potential agent for use as a topical biocidal agent. 753-755.
New disinfectants that require further evaluation include glucoprotamin756, tertiary amines 703. and a light-activated antimicrobial coating 757. Several other disinfection technologies might have potential applications in the healthcare setting 758.
Metals as Microbicides
Comprehensive reviews of antisepsis 759, disinfection 421, and anti-infective chemotherapy 760 barely mention the antimicrobial activity of heavy metals 761, 762. Nevertheless, the anti-infective activity of some heavy metals has been known since antiquity. Heavy metals such as silver have been used for prophylaxis of conjunctivitis of the newborn, topical therapy for burn wounds, and bonding to indwelling catheters, and the use of heavy metals as antiseptics or disinfectants is again being explored 763. Inactivation of bacteria on stainless steel surfaces by zeolite ceramic coatings containing silver and zinc ions has also been demonstrated 764, 765.
Metals such as silver, iron, and copper could be used for environmental control, disinfection of water, or reusable medical devices or incorporated into medical devices (e.g., intravascular catheters) 400, 761-763, 766-770. A comparative evaluation of six disinfectant formulations for residual antimicrobial activity demonstrated that only the silver disinfectant demonstrated significant residual activity against S. aureus and P. aeruginosa 763. Preliminary data suggest metals are effective against a wide variety of microorganisms.
Clinical uses of other heavy metals include copper-8-quinolinolate as a fungicide against Aspergillus, copper-silver ionization for Legionella disinfection 771-774, organic mercurials as an antiseptic (e.g., mercurochrome) and preservative/disinfectant (e.g., thimerosal [currently being removed from vaccines]) in pharmaceuticals and cosmetics 762.
Ultraviolet Radiation (UV)
The wavelength of UV radiation ranges from 328 nm to 210 nm (3280 A to 2100 A). Its maximum bactericidal effect occurs at 240–280 nm. Mercury vapor lamps emit more than 90% of their radiation at 253.7 nm, which is near the maximum microbicidal activity 775. Inactivation of microorganisms results from destruction of nucleic acid through induction of thymine dimers. UV radiation has been employed in the disinfection of drinking water 776, air 775, titanium implants 777, and contact lenses 778. Bacteria and viruses are more easily killed by UV light than are bacterial spores 775. UV radiation has several potential applications, but unfortunately its germicidal effectiveness and use is influenced by organic matter; wavelength; type of suspension; temperature; type of microorganism; and UV intensity, which is affected by distance and dirty tubes 779. The application of UV radiation in the health-care environment (i.e., operating rooms, isolation rooms, and biologic safety cabinets) is limited to destruction of airborne organisms or inactivation of microorganisms on surfaces. The effect of UV radiation on postoperative wound infections was investigated in a double-blind, randomized study in five university medical centers. After following 14,854 patients over a 2-year period, the investigators reported the overall wound infection rate was unaffected by UV radiation, although postoperative infection in the "refined clean" surgical procedures decreased significantly (3.8%–2.9%) 780. No data support the use of UV lamps in isolation rooms, and this practice has caused at least one epidemic of UV-induced skin erythema and keratoconjunctivitis in hospital patients and visitors 781.
Pasteurization is not a sterilization process; its purpose is to destroy all pathogenic microorganisms. However, pasteurization does not destroy bacterial spores. The time-temperature relation for hot-water pasteurization is generally ~70ºC (158ºF) for 30 minutes. The water temperature and time should be monitored as part of a quality-assurance program 782. Pasteurization of respiratory therapy 783, 784 and anesthesia equipment 785 is a recognized alternative to chemical disinfection. The efficacy of this process has been tested using an inoculum that the authors believed might simulate contamination by an infected patient. Use of a large inoculum (107) of P. aeruginosa or Acinetobacter calcoaceticus in sets of respiratory tubing before processing demonstrated that machine-assisted chemical processing was more efficient than machine-assisted pasteurization with a disinfection failure rate of 6% and 83%, respectively 783. Other investigators found hot water disinfection to be effective (inactivation factor >5 log10) against multiple bacteria, including multidrug-resistant bacteria, for disinfecting reusable anesthesia or respiratory therapy equipment 784-786.
Flushing- and Washer-Disinfectors
Flushing- and washer-disinfectors are automated and closed equipment that clean and disinfect objects from bedpans and washbowls to surgical instruments and anesthesia tubes. Items such as bedpans and urinals can be cleaned and disinfected in flushing-disinfectors. They have a short cycle of a few minutes. They clean by flushing with warm water, possibly with a detergent, and then disinfect by flushing the items with hot water or with steam. Because this machine empties, cleans, and disinfects, manual cleaning is eliminated, fewer disposable items are needed, and fewer chemical germicides are used. A microbiologic evaluation of one washer/disinfector demonstrated complete inactivation of suspensions of E. faecalis or poliovirus 787. Other studies have shown that strains of Enterococcus faecium can survive the British Standard for heat disinfection of bedpans (80ºC for 1 minute). The significance of this finding with reference to the potential for enterococci to survive and disseminate in the health-care environment is debatable 788-790. These machines are available and used in many European countries.
Surgical instruments and anesthesia equipment are more difficult to clean. They are run in washer-disinfectors on a longer cycle of approximately 20–30 minutes with a detergent. These machines also disinfect by hot water at approximately 90ºC 791.