Basic Issues of Surface Disinfection: Green Cleaning Fits Right In

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Basic Issues of Surface DisinfectionGreen
Cleaning Fits Right In!

• Lynne Sehulster, PhD, M(ASCP)
• Division of Healthcare Quality Promotion
• Centers for Disease Control and Prevention,
  Atlanta, GA 30333

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Topics in This Portion of the Program

• The items I will cover today are
• Information resources
• Basic practices and principles involved with
  surface disinfection, pathogen transmission
• Regulations EPA, OSHA
• Clostridium difficile and MRSA control
  contemporary questions and issues

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Internet Information Resources

• CDCs EIC guideline
• www.cdc.gov/ncidod/hip/enviro/guide.htm
• EPA registration (FIFRA) information
• www.epa.gov/oppad001/
• OSHA regulations
• www.osha.gov/SLTC/etools/hospital/housekeeping/hou
  sekeeping.html
• Professional associations (ASHES, IEHA)

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Where Can I Find the EIC Guidelines?

• Part II Recommendations
• MMWR 2003 52 (RR-10) 1-44
• Errata MMWR 2003 52 (42) 1025-6
• Full text version
• www.cdc.gov/ncidod/hip/enviro/guide.htm
• Print version (ASHE)
• www.hospitalconnect.com/ashe/resources/
• Importantresources.html

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EIC Guideline Environmental Services Section
Subtopics

• Principles of cleaning and disinfection
• Cleaning spills of blood/body substance
• Carpeting, cloth furniture
• Flowers and plants
• Pest control
• Special pathogen concerns and cleaning

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Basic Principles I

• How do equipment and housekeeping surfaces fit
  with the Spaulding Classification?
• CDC modification non-critical environmental
  surfaces
• Minimal potential for disease transmission
• May serve as reservoirs of microorganisms that
  may potentially cause infection when transferred
  from the surface to patients via hands or
  aerosol-producing activities

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Cleaning and Disinfection

• Cleaning removal of soil, bioburden safe to
  handle (decontamination)
• Disinfection differs from sterilization by lack
  of sporicidal power
• Levels of disinfection high, intermediate, low
• Non-critical environmental surfaces cleaning,
  low- to intermediate level disinfection as
  appropriate
• Cleaners dont disinfect, disinfectants dont
  clean!

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Resistance Levels of Microorganisms
Bacterial Spores ? Mycobacteria ? Non-lipid or
small viruses ? Fungi ? Vegetative
bacteria ? Lipid or medium-sized viruses
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Tuberculocidal Germicides

• Use of these products will NOT prevent the spread
  of TB because TB is not acquired from
  environmental surfaces
• Measure of potency
• Mycobacteria have the highest intrinsic level of
  resistance among the vegetative bacteria,
  viruses, and fungi
• Broad spectrum antimicrobial capability

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Choosing a Disinfectant

• Clean first!
• Nature and use of the item to be disinfected
• Disinfection level
• Sufficient potency for disinfection
• Intrinsic resistance of microbes
• Chemical class of disinfectant, use conditions
• Materials compatibility
• Safety concerns hazards with use?
• Aerosols, residuals, chemical sensitivities

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Disinfectants are Pesticides!!
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EPA Regulations

• Products for which a manufacturer is claiming
  antimicrobial activity are considered to be
  pesticides as per FIFRA, and must be registered
  by EPA before such products can be legally
  marketed
• Cleaners or detergents are not registered
  products
• AOAC testing specific pathogen claims require
  pathogen-specific data

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Cleaning and Disinfecting of the Housekeeping
Surfaces

• Clean on a regular basis to remove soil and dust
• Physical removal of microorganisms and organic
  soil is as important as the antimicrobial effect
  of the disinfecting agent
• Surfaces not touched frequently by hand (i.e.,
  floors) in general care areas are cleaned and
  disinfected
• This is controversial routine disinfection of
  floors is not supported by epidemiology lack of
  consensus among infection control staff and
  hospital epidemiologists

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Cleaning and Disinfecting of the Housekeeping
Surfaces

• Follow manufacturers instructions if using
  proprietary cleaners or disinfectants.
• Clean and disinfect surfaces that are touched by
  hand on a frequent and regular basis
• Door knobs, light switches, bed rails
• Surfaces around the toilet, sink

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Cleaning and Disinfecting of Medical Equipment

• FOLLOW THE MANUFACTURERS INSTRUCTIONS!!!
• In the absence of instructions, clean and follow
  with low- intermediate-level disinfection
  depending on the degree of contamination
• Consider covering those surfaces that are
  frequently touched during delivery of care

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Housekeeping Issues That Are Not Well Studied

• Mopping procedures
• Frequency of replacing cleaning solutions during
  use how many rooms/bucket?
• Rinse procedures
• Frequency of replacing dirty mop heads and cloths
  with clean ones
• Disposable mop heads and cloths vs. those that
  can be laundered
• New! Microfiber cleaning materials

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Basic Principles of Biological Spill Management

• Know and understand the Chain of Infection
• Aerosol production and control
• Is the agent an airborne organism?
• Does the spill management activity produce
  aerosols?
• Low- to intermediate-level disinfection
• Do not let the pathogenicity of the agent
  override the science of its inactivation!
• Do not use alcohol to neutralize chlorine residue

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Enterococcus spp. (CDC Public Health Image
Library)
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Antibiotic-Resistant Gram-Positive Cocci MRSA,
VRE

• Antibiotic resistance does not confer increased
  resistance to chemical germicides
• Hand transferral is considered to be the primary
  means of spreading these bacteria to patients,
  workers, and other surfaces
• Control measures
• HANDWASHING!
• Appropriate barrier precautions
• Patient isolation measures
• Standard cleaning and disinfection of surfaces
• Standard terminal cleaning and disinfection of
  the patients room

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Clostridium difficile
CDC Public Health Image Library (L. Wiggs, J.
Carr)
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Clostridium difficileEnvironmental Control
Issues

• Hand transferral of the organism from surfaces
  and fecally-contaminated patient-care devices
  implicated in exposure
• HANDWASHING! GLOVES!
• Meticulous cleaning and disinfection using proper
  dilutions and contact times of germicides
• Spore-forming organism
• No EPA-registered product with sporicidal
  properties for surfaces

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More Unresolved Issues

• Can we use a broad spectrum approach when
  developing disinfection strategies?
• Should we be developing strategies that are
  bug-specific?
• Should the strategy that is applied to a unique
  infection problem in one area of a hospital be
  applied equally throughout the facility?
• Will there ever be an environmental surface
  disinfectant with a sporicidal claim?

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Moving Forward!

• For Green Cleaning to go mainstream
• Emphasize the benefits of frequent cleaning
• Maintain potency strive for reductions in
  toxicity
• EPA registration!
• The most important piece of advice
• Evidence-based publish results of lab- and
  in-use studies in peer-viewed journals

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Thank You!

• Division of Healthcare Quality Promotion
• Centers for Disease Control and Prevention,
  Atlanta GA 30333