Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008
Many disinfectants are used alone or in combinations (e.g., hydrogen peroxide and peracetic acid) in the health-care setting. These include alcohols, chlorine and chlorine compounds, formaldehyde, glutaraldehyde, ortho-phthalaldehyde, hydrogen peroxide, iodophors, peracetic acid, phenolics, and quaternary ammonium compounds. Commercial formulations based on these chemicals are considered unique products and must be registered with EPA or cleared by FDA. In most instances, a given product is designed for a specific purpose and is to be used in a certain manner. Therefore, users should read labels carefully to ensure the correct product is selected for the intended use and applied efficiently.
Disinfectants are not interchangeable, and incorrect concentrations and inappropriate disinfectants can result in excessive costs. Because occupational diseases among cleaning personnel have been associated with use of several disinfectants (e.g., formaldehyde, glutaraldehyde, and chlorine), precautions (e.g., gloves and proper ventilation) should be used to minimize exposure 318, 480, 481. Asthma and reactive airway disease can occur in sensitized persons exposed to any airborne chemical, including germicides. Clinically important asthma can occur at levels below ceiling levels regulated by OSHA or recommended by NIOSH. The preferred method of control is elimination of the chemical (through engineering controls or substitution) or relocation of the worker.
The following overview of the performance characteristics of each provides users with sufficient information to select an appropriate disinfectant for any item and use it in the most efficient way.
Overview. In the healthcare setting, "alcohol" refers to two water-soluble chemical compounds—ethyl alcohol and isopropyl alcohol—that have generally underrated germicidal characteristics 482. FDA has not cleared any liquid chemical sterilant or high-level disinfectant with alcohol as the main active ingredient. These alcohols are rapidly bactericidal rather than bacteriostatic against vegetative forms of bacteria; they also are tuberculocidal, fungicidal, and virucidal but do not destroy bacterial spores. Their cidal activity drops sharply when diluted below 50% concentration, and the optimum bactericidal concentration is 60%–90% solutions in water (volume/volume) 483, 484.
Mode of Action. The most feasible explanation for the antimicrobial action of alcohol is denaturation of proteins. This mechanism is supported by the observation that absolute ethyl alcohol, a dehydrating agent, is less bactericidal than mixtures of alcohol and water because proteins are denatured more quickly in the presence of water 484, 485. Protein denaturation also is consistent with observations that alcohol destroys the dehydrogenases of Escherichia coli 486, and that ethyl alcohol increases the lag phase of Enterobacter aerogenes 487 and that the lag phase effect could be reversed by adding certain amino acids. The bacteriostatic action was believed caused by inhibition of the production of metabolites essential for rapid cell division.
Microbicidal Activity. Methyl alcohol (methanol) has the weakest bactericidal action of the alcohols and thus seldom is used in healthcare 488. The bactericidal activity of various concentrations of ethyl alcohol (ethanol) was examined against a variety of microorganisms in exposure periods ranging from 10 seconds to 1 hour 483. Pseudomonas aeruginosa was killed in 10 seconds by all concentrations of ethanol from 30% to 100% (v/v), and Serratia marcescens, E, coli and Salmonella typhosa were killed in 10 seconds by all concentrations of ethanol from 40% to 100%. The gram-positive organisms Staphylococcus aureus and Streptococcus pyogenes were slightly more resistant, being killed in 10 seconds by ethyl alcohol concentrations of 60%–95%. Isopropyl alcohol (isopropanol) was slightly more bactericidal than ethyl alcohol for E. coli and S. aureus 489.
Ethyl alcohol, at concentrations of 60%–80%, is a potent virucidal agent inactivating all of the lipophilic viruses (e.g., herpes, vaccinia, and influenza virus) and many hydrophilic viruses (e.g., adenovirus, enterovirus, rhinovirus, and rotaviruses but not hepatitis A virus (HAV) 58 or poliovirus) 49. Isopropyl alcohol is not active against the nonlipid enteroviruses but is fully active against the lipid viruses 72. Studies also have demonstrated the ability of ethyl and isopropyl alcohol to inactivate the hepatitis B virus(HBV) 224, 225 and the herpes virus, 490 and ethyl alcohol to inactivate human immunodeficiency virus (HIV) 227, rotavirus, echovirus, and astrovirus 491.
In tests of the effect of ethyl alcohol against M. tuberculosis, 95% ethanol killed the tubercle bacilli in sputum or water suspension within 15 seconds 492. In 1964, Spaulding stated that alcohols were the germicide of choice for tuberculocidal activity, and they should be the standard by which all other tuberculocides are compared. For example, he compared the tuberculocidal activity of iodophor (450 ppm), a substituted phenol (3%), and isopropanol (70%/volume) using the mucin-loop test (106 M. tuberculosis per loop) and determined the contact times needed for complete destruction were 120–180 minutes, 45–60 minutes, and 5 minutes, respectively. The mucin-loop test is a severe test developed to produce long survival times. Thus, these figures should not be extrapolated to the exposure times needed when these germicides are used on medical or surgical material 482.
Ethyl alcohol (70%) was the most effective concentration for killing the tissue phase of Cryptococcus neoformans, Blastomyces dermatitidis, Coccidioides immitis, and Histoplasma capsulatum and the culture phases of the latter three organisms aerosolized onto various surfaces. The culture phase was more resistant to the action of ethyl alcohol and required about 20 minutes to disinfect the contaminated surface, compared with <1 minute for the tissue phase 493, 494.
Isopropyl alcohol (20%) is effective in killing the cysts of Acanthamoeba culbertsoni (560) as are chlorhexidine, hydrogen peroxide, and thimerosal 496.
Uses. Alcohols are not recommended for sterilizing medical and surgical materials principally because they lack sporicidal action and they cannot penetrate protein-rich materials. Fatal postoperative wound infections with Clostridium have occurred when alcohols were used to sterilize surgical instruments contaminated with bacterial spores 497. Alcohols have been used effectively to disinfect oral and rectal thermometers 498, 499, hospital pagers 500, scissors 501, and stethoscopes 502. Alcohols have been used to disinfect fiberoptic endoscopes 503, 504 but failure of this disinfectant have lead to infection 280, 505. Alcohol towelettes have been used for years to disinfect small surfaces such as rubber stoppers of multiple-dose medication vials or vaccine bottles. Furthermore, alcohol occasionally is used to disinfect external surfaces of equipment (e.g., stethoscopes, ventilators, manual ventilation bags) 506, CPR manikins 507, ultrasound instruments 508 or medication preparation areas. Two studies demonstrated the effectiveness of 70% isopropyl alcohol to disinfect reusable transducer heads in a controlled environment 509, 510. In contrast, three bloodstream infection outbreaks have been described when alcohol was used to disinfect transducer heads in an intensive-care setting 511.
The documented shortcomings of alcohols on equipment are that they damage the shellac mountings of lensed instruments, tend to swell and harden rubber and certain plastic tubing after prolonged and repeated use, bleach rubber and plastic tiles 482 and damage tonometer tips (by deterioration of the glue) after the equivalent of 1 working year of routine use 512. Tonometer biprisms soaked in alcohol for 4 days developed rough front surfaces that potentially could cause corneal damage; this appeared to be caused by weakening of the cementing substances used to fabricate the biprisms 513. Corneal opacification has been reported when tonometer tips were swabbed with alcohol immediately before measurement of intraocular pressure 514. Alcohols are flammable and consequently must be stored in a cool, well-ventilated area. They also evaporate rapidly, making extended exposure time difficult to achieve unless the items are immersed.
Chlorine and Chlorine Compounds
Overview. Hypochlorites, the most widely used of the chlorine disinfectants, are available as liquid (e.g., sodium hypochlorite) or solid (e.g., calcium hypochlorite). The most prevalent chlorine products in the United States are aqueous solutions of 5.25%–6.15% sodium hypochlorite (see glossary), usually called household bleach. They have a broad spectrum of antimicrobial activity, do not leave toxic residues, are unaffected by water hardness, are inexpensive and fast acting 328, remove dried or fixed organisms and biofilms from surfaces 465, and have a low incidence of serious toxicity 515-517. Sodium hypochlorite at the concentration used in household bleach (5.25-6.15%) can produce ocular irritation or oropharyngeal, esophageal, and gastric burns 318, 518-522. Other disadvantages of hypochlorites include corrosiveness to metals in high concentrations (>500 ppm), inactivation by organic matter, discoloring or "bleaching" of fabrics, release of toxic chlorine gas when mixed with ammonia or acid (e.g., household cleaning agents) 523-525, and relative stability 327. The microbicidal activity of chlorine is attributed largely to undissociated hypochlorous acid (HOCl). The dissociation of HOCI to the less microbicidal form (hypochlorite ion OCl¯) depends on pH. The disinfecting efficacy of chlorine decreases with an increase in pH that parallels the conversion of undissociated HOCI to OCl¯ 329, 526. A potential hazard is production of the carcinogen bis(chloromethyl) ether when hypochlorite solutions contact formaldehyde 527 and the production of the animal carcinogen trihalomethane when hot water is hyperchlorinated 528. After reviewing environmental fate and ecologic data, EPA has determined the currently registered uses of hypochlorites will not result in unreasonable adverse effects to the environment 529.
Alternative compounds that release chlorine and are used in the health-care setting include demand-release chlorine dioxide, sodium dichloroisocyanurate, and chloramine-T. The advantage of these compounds over the hypochlorites is that they retain chlorine longer and so exert a more prolonged bactericidal effect. Sodium dichloroisocyanurate tablets are stable, and for two reasons, the microbicidal activity of solutions prepared from sodium dichloroisocyanurate tablets might be greater than that of sodium hypochlorite solutions containing the same total available chlorine. First, with sodium dichloroisocyanurate, only 50% of the total available chlorine is free (HOCl and OCl¯), whereas the remainder is combined (monochloroisocyanurate or dichloroisocyanurate), and as free available chlorine is used up, the latter is released to restore the equilibrium. Second, solutions of sodium dichloroisocyanurate are acidic, whereas sodium hypochlorite solutions are alkaline, and the more microbicidal type of chlorine (HOCl) is believed to predominate 530-533. Chlorine dioxide-based disinfectants are prepared fresh as required by mixing the two components (base solution [citric acid with preservatives and corrosion inhibitors] and the activator solution [sodium chlorite]). In vitro suspension tests showed that solutions containing about 140 ppm chlorine dioxide achieved a reduction factor exceeding 106 of S. aureus in 1 minute and of Bacillus atrophaeus spores in 2.5 minutes in the presence of 3 g/L bovine albumin. The potential for damaging equipment requires consideration because long-term use can damage the outer plastic coat of the insertion tube 534. In another study, chlorine dioxide solutions at either 600 ppm or 30 ppm killed Mycobacterium avium-intracellulare within 60 seconds after contact but contamination by organic material significantly affected the microbicidal properties535.
The microbicidal activity of a new disinfectant, "superoxidized water," has been examined The concept of electrolyzing saline to create a disinfectant or antiseptics is appealing because the basic materials of saline and electricity are inexpensive and the end product (i.e., water) does not damage the environment. The main products of this water are hypochlorous acid (e.g., at a concentration of about 144 mg/L) and chlorine. As with any germicide, the antimicrobial activity of superoxidized water is strongly affected by the concentration of the active ingredient (available free chlorine) 536. One manufacturer generates the disinfectant at the point of use by passing a saline solution over coated titanium electrodes at 9 amps. The product generated has a pH of 5.0–6.5 and an oxidation-reduction potential (redox) of >950 mV. Although superoxidized water is intended to be generated fresh at the point of use, when tested under clean conditions the disinfectant was effective within 5 minutes when 48 hours old 537. Unfortunately, the equipment required to produce the product can be expensive because parameters such as pH, current, and redox potential must be closely monitored. The solution is nontoxic to biologic tissues. Although the United Kingdom manufacturer claims the solution is noncorrosive and nondamaging to endoscopes and processing equipment, one flexible endoscope manufacturer (Olympus Key-Med, United Kingdom) has voided the warranty on the endoscopes if superoxidized water is used to disinfect them 538. As with any germicide formulation, the user should check with the device manufacturer for compatibility with the germicide. Additional studies are needed to determine whether this solution could be used as an alternative to other disinfectants or antiseptics for hand washing, skin antisepsis, room cleaning, or equipment disinfection (e.g., endoscopes, dialyzers) 400, 539, 540. In October 2002, the FDA cleared superoxidized water as a high-level disinfectant (FDA, personal communication, September 18, 2002).
Mode of Action. The exact mechanism by which free chlorine destroys microorganisms has not been elucidated. Inactivation by chlorine can result from a number of factors: oxidation of sulfhydryl enzymes and amino acids; ring chlorination of amino acids; loss of intracellular contents; decreased uptake of nutrients; inhibition of protein synthesis; decreased oxygen uptake; oxidation of respiratory components; decreased adenosine triphosphate production; breaks in DNA; and depressed DNA synthesis 329, 347. The actual microbicidal mechanism of chlorine might involve a combination of these factors or the effect of chlorine on critical sites 347.
Microbicidal Activity. Low concentrations of free available chlorine (e.g., HOCl, OCl-, and elemental chlorine-Cl2) have a biocidal effect on mycoplasma (25 ppm) and vegetative bacteria (<5 ppm) in seconds in the absence of an organic load 329, 418. Higher concentrations (1,000 ppm) of chlorine are required to kill M. tuberculosis using the Association of Official Analytical Chemists (AOAC) tuberculocidal test 73. A concentration of 100 ppm will kill ≥99.9% of B. atrophaeus spores within 5 minutes 541, 542 and destroy mycotic agents in <1 hour 329. Acidified bleach and regular bleach (5,000 ppm chlorine) can inactivate 106 Clostridium difficile spores in <10 minutes 262. One study reported that 25 different viruses were inactivated in 10 minutes with 200 ppm available chlorine 72. Several studies have demonstrated the effectiveness of diluted sodium hypochlorite and other disinfectants to inactivate HIV 61. Chlorine (500 ppm) showed inhibition of Candida after 30 seconds of exposure 54. In experiments using the AOAC Use-Dilution Method, 100 ppm of free chlorine killed 106–107 S. aureus, Salmonella choleraesuis, and P. aeruginosa in <10 minutes 327. Because household bleach contains 5.25%–6.15% sodium hypochlorite, or 52,500–61,500 ppm available chlorine, a 1:1,000 dilution provides about 53–62 ppm available chlorine, and a 1:10 dilution of household bleach provides about 5250–6150 ppm.
Data are available for chlorine dioxide that support manufacturers' bactericidal, fungicidal, sporicidal, tuberculocidal, and virucidal label claims 543-546. A chlorine dioxide generator has been shown effective for decontaminating flexible endoscopes 534 but it is not currently FDA-cleared for use as a high-level disinfectant 85. Chlorine dioxide can be produced by mixing solutions, such as a solution of chlorine with a solution of sodium chlorite 329. In 1986, a chlorine dioxide product was voluntarily removed from the market when its use caused leakage of cellulose-based dialyzer membranes, which allowed bacteria to migrate from the dialysis fluid side of the dialyzer to the blood side 547.
Sodium dichloroisocyanurate at 2,500 ppm available chlorine is effective against bacteria in the presence of up to 20% plasma, compared with 10% plasma for sodium hypochlorite at 2,500 ppm 548. "Superoxidized water" has been tested against bacteria, mycobacteria, viruses, fungi, and spores 537, 539, 549. Freshly generated superoxidized water is rapidly effective (<2 minutes) in achieving a 5-log10 reduction of pathogenic microorganisms (i.e., M. tuberculosis, M. chelonae, poliovirus, HIV, multidrug-resistant S. aureus, E. coli, Candida albicans, Enterococcus faecalis, P. aeruginosa) in the absence of organic loading. However, the biocidal activity of this disinfectant decreased substantially in the presence of organic material (e.g., 5% horse serum) 537, 549, 550. No bacteria or viruses were detected on artificially contaminated endoscopes after a 5-minute exposure to superoxidized water 551 and HBV-DNA was not detected from any endoscope experimentally contaminated with HBV-positive mixed sera after a disinfectant exposure time of 7 minutes552.
Uses. Hypochlorites are widely used in healthcare facilities in a variety of settings. 328 Inorganic chlorine solution is used for disinfecting tonometer heads 188 and for spot-disinfection of countertops and floors. A 1:10–1:100 dilution of 5.25%–6.15% sodium hypochlorite (i.e., household bleach) 22, 228, 553, 554 or an EPA-registered tuberculocidal disinfectant 17has been recommended for decontaminating blood spills. For small spills of blood (i.e., drops of blood) on noncritical surfaces, the area can be disinfected with a 1:100 dilution of 5.25%-6.15% sodium hypochlorite or an EPA-registered tuberculocidal disinfectant. Because hypochlorites and other germicides are substantially inactivated in the presence of blood 63, 548, 555, 556, large spills of blood require that the surface be cleaned before an EPA-registered disinfectant or a 1:10 (final concentration) solution of household bleach is applied 557. If a sharps injury is possible, the surface initially should be decontaminated 69, 318, then cleaned and disinfected (1:10 final concentration) 63. Extreme care always should be taken to prevent percutaneous injury. At least 500 ppm available chlorine for 10 minutes is recommended for decontaminating CPR training manikins 558. Full-strength bleach has been recommended for self-disinfection of needles and syringes used for illicit-drug injection when needle-exchange programs are not available. The difference in the recommended concentrations of bleach reflects the difficulty of cleaning the interior of needles and syringes and the use of needles and syringes for parenteral injection 559. Clinicians should not alter their use of chlorine on environmental surfaces on the basis of testing methodologies that do not simulate actual disinfection practices 560, 561. Other uses in healthcare include as an irrigating agent in endodontic treatment 562 and as a disinfectant for manikins, laundry, dental appliances, hydrotherapy tanks 23, 41, regulated medical waste before disposal 328, and the water distribution system in hemodialysis centers and hemodialysis machines 563.
Chlorine long has been used as the disinfectant in water treatment. Hyperchlorination of a Legionella-contaminated hospital water system 23 resulted in a dramatic decrease (from 30% to 1.5%) in the isolation of L. pneumophila from water outlets and a cessation of healthcare-associated Legionnaires' disease in an affected unit 528, 564. Water disinfection with monochloramine by municipal water-treatment plants substantially reduced the risk for healthcare–associated Legionnaires disease 565, 566. Chlorine dioxide also has been used to control Legionella in a hospital water supply. 567 Chloramine T 568 and hypochlorites 41 have been used to disinfect hydrotherapy equipment.
Hypochlorite solutions in tap water at a pH >8 stored at room temperature (23ºC) in closed, opaque plastic containers can lose up to 40%–50% of their free available chlorine level over 1 month. Thus, if a user wished to have a solution containing 500 ppm of available chlorine at day 30, he or she should prepare a solution containing 1,000 ppm of chlorine at time 0. Sodium hypochlorite solution does not decompose after 30 days when stored in a closed brown bottle 327.
The use of powders, composed of a mixture of a chlorine-releasing agent with highly absorbent resin, for disinfecting spills of body fluids has been evaluated by laboratory tests and hospital ward trials. The inclusion of acrylic resin particles in formulations markedly increases the volume of fluid that can be soaked up because the resin can absorb 200–300 times its own weight of fluid, depending on the fluid consistency. When experimental formulations containing 1%, 5%, and 10% available chlorine were evaluated by a standardized surface test, those containing 10% demonstrated bactericidal activity. One problem with chlorine-releasing granules is that they can generate chlorine fumes when applied to urine 569.