Copyright © 2004 WA Rutala
The Benefits of Surface Disinfection
William A. Rutala, Ph.D., M.P.H.UNC Health Care System and UNC School of Medicine,
Chapel Hill, NC
Copyright © 2004 WA Rutala
The Benefits of Surface Disinfection
Introduction and principles of disinfection Review the contribution of the noncritical environment to
disease transmission Justify the use of a disinfectant on noncritical surfaces Provide recommendations for surface disinfection
Copyright © 2004 WA Rutala
Disinfection Introduction
Effective use of disinfectants constitutes an important factor in preventing healthcare-associated infections
Spaulding proposed three categories of germicidal action to prevent a risk of infection associated with the use of equipment or surfaces
Three categories: critical; semicritical; noncritical Surfaces considered noncritical (contact intact skin) Use of noncritical items or contact with noncritical surfaces carries a low
risk of transmitting a pathogen to patients
Copyright © 2004 WA Rutala
Surface Disinfection
Noncritical Surfaces Medical equipment surfaces (BP cuff, stethoscopes)
May frequently become contaminated with patient materialRepeatedly touched by health care personnelDisinfectant may be used
Housekeeping surfaces (bed rails, bedside tables)May play a theoretical but less significant role in diseases transmissionDisinfectants or detergents may be used
Copyright © 2004 WA Rutala
Low Level Disinfection for “Noncritical” Objects
Exposure time >60 secGermicide Use ConcentrationEthyl or isopropyl alcohol 70-90%Chlorine 100ppm (1:500 dilution)Phenolic UDIodophor UDQuaternary ammonium UD_____________________________________UD=Manufacturer’s recommended use dilution
Copyright © 2004 WA Rutala
Surface Disinfection Introduction (continued)
Use of noncritical items or contact with noncritical surfaces carries little risk of transmitting pathogens to patients
Thus, the routine use of disinfectants to disinfect housekeeping surfaces (e.g., bedside tables, bed rails) is controversial
However, while noncritical surfaces have not been directly implicated in disease transmission, they may potentially contribute to cross-transmission by acquisition of transient hand carriage by HCW due to contact with a contaminated surface, or patient contact with contaminated surfaces or medical equipment
Copyright © 2004 WA Rutala
Copyright © 2004 WA Rutala
The Benefits of Surface Disinfection Justification for Using a Disinfectant
Surfaces may contribute to transmission of epidemiologically important microbes (e.g., VRE, MRSA, C. difficile)
Needed for surfaces contaminated by blood and OPIM Disinfectants are more effective in reducing microbial load Detergents become contaminated and result in seeding the patients
environment with bacteria CDC recommends disinfection of noncritical equipment and surfaces for
patients on isolation precautions One product for decontamination of noncritical surfaces (that is, floors
and equipment)
Copyright © 2004 WA Rutala
Surfaces May Contribute to Transmission Pathogens implicated in transmission via contaminated noncritical surfaces Bacteria
Acinetobacter, Pseudomonas, Clostridium difficile Oxacillin-resistant Staphylococcus aureus Vancomycin-resistant Enterococcus spp.
Viruses SARS Rotavirus Respiratory syncytial virus (RSV)
Copyright © 2004 WA Rutala
Surfaces May Contribute to Transmission Why do we believe that surfaces may contribute to
transmission of epidemiologically important microbes (e.g., VRE)? Does VRE survive in the environment? Are surfaces near infected/colonized patients contaminated and
does surface contamination play a role in patient-to-patient transmission?
Are there trials demonstrating reduced transmission with disinfection?
Copyright © 2004 WA Rutala
Surfaces May Contribute to Transmission VRE ENVIRONMENTAL SURVIVAL
Enterococcus Countertops: E. faecalis = 5 d, E. faecium = 7 d Bedrails = 24 hours Telephone handpieces = 60 minutes Stethoscopes = 30 minutes Gloved and ungloved fingers >60 minutesNoskin G, et al. ICHE 1995;16:577-581.
Copyright © 2004 WA Rutala
Surfaces May Contribute to Transmission Why do we believe that surfaces may contribute to
transmission of epidemiologically important microbes (e.g., VRE)? Does VRE survive in the environment? Are surfaces near infected/colonized patients contaminated and
does surface contamination play a role in patient-to-patient transmission?
Are there trials demonstrating reduced transmission with disinfection?
Copyright © 2004 WA Rutala
Surfaces May Contribute to Transmission VRE ENVIRONMENTAL CONTAMINATION
Reference Sites Contaminated Frequency Karanfil 1992 EKG pressure monitor
dials, doorknob 12%
Boyce 1994 Patient gowns, linens, bedrails, IV pumps, BP cuff
28%
Boyce 1995 Patient gowns, linens, bedrails, BP cuff, IV pump
37%
Slaughter 1996 Bed linen, siderails, BP cuffs, bedside tables
7%
Weber DJ, Rutala WA. ICHE 1997;18:306-309.
Copyright © 2004 WA Rutala
Surfaces May Contribute to Transmission Why do we believe that surfaces may contribute to transmission of
epidemiologically important microbes (e.g., VRE)? Does VRE survive in the environment? Are surfaces near infected/colonized patients contaminated and does
surface contamination play a role in patient-to-patient transmission? Do antibiotic-resistant organisms (e.g., VRE) develop cross-resistance to
commonly used environmental disinfectants or antiseptics? Are there trials demonstrating reduced transmission with disinfection?
Copyright © 2004 WA Rutala
Surfaces May Contribute to Transmission Surfaces in the Spread of Infections
In experimental settings, treatment of surfaces with germicide has been found to interrupt transmission Prevention of surface-to-human rotavirus transmission by treatment with disinfectant
spray (J Clin Microbiol 1991;29:1991) Interrupts transfer of rhinovirus from environmental surfaces to hands (Appl Environ
Microbiol 1993;59:1579) Studies demonstrating reduced transmission with improved disinfection
Aggressive environmental control program credited with eradicating VRE from a burn unit and Acinetobacter from a neurosurgical ICU
Reduction in C. difficile-associated diarrhea rates in the BMTU (8.6 to 3.3) during the period of bleach disinfection (1:10)
Copyright © 2004 WA Rutala
Surfaces May Contribute to Transmission CONCLUSIONS
Widespread surface contamination may occur with some pathogens (e.g. VRE) and hands may become transiently colonized from contact with surfaces
Noncritical surfaces may play a role in the transmission of some pathogens (e.g., VRE, C.difficile)
Meticulous disinfection and handwashing will prevent transmission
Copyright © 2004 WA Rutala
Impact of Surface Disinfection on HAIs Dharan et al, 1999
No change in incidence of HAIs during 4 mo trial compared to preceding 12 mo; but detergents associated with increase in bacterial counts.
Danforth et al, 1987 NI rate did not differ between disinfectant (8.0/100 patients) and detergent
(7.1/100 patients); 8 acute care units; 3 mo periods; phenol. Daschner et al, 1980
No difference in NI rate in ICU over 6 mo (15.6% vs 15.5%).Comment: Studies are small, short duration and suffer from low statistical power since
the outcome (HAI) is one of low frequency (not detect small decrease-0.1%, 1750 HAIs). Requirement for reducing HAI stringent, not met by most infection control interventions.
Copyright © 2004 WA Rutala
The Benefits of Surface Disinfection Justification for Using a Disinfectant
Surfaces may contribute to transmission of epidemiologically important microbes (e.g., VRE, MRSA, C. difficile)
Needed for surfaces contaminated by blood and OPIM Disinfectants are more effective in reducing microbial load Detergents become contaminated and result in seeding the patients
environment with bacteria CDC recommends disinfection of noncritical equipment and surfaces for
patients on isolation precautions One product for decontamination of noncritical surfaces (that is, floors
and equipment)
Copyright © 2004 WA Rutala
The Benefits of Surface Disinfection Needed for surfaces contaminated by blood and OPIM
In the US, to comply with OSHA rule on bloodborne pathogens, a blood spill must be cleaned using a disinfectant
The compliance directive states that the blood should be disinfected using an EPA-registered disinfectant, a disnfectant with a HBV/HIV claim, or a solution of bleach between 1:10 and 1:100 with water.
Copyright © 2004 WA Rutala
The Benefits of Surface Disinfection Justification for Using a Disinfectant
Surfaces may contribute to transmission of epidemiologically important microbes (e.g., VRE, MRSA, C. difficile)
Needed for surfaces contaminated by blood and OPIM Disinfectants are more effective in reducing microbial load Detergents become contaminated and result in seeding the patients
environment with bacteria CDC recommends disinfection of noncritical equipment and surfaces for
patients on isolation precautions One product for decontamination of noncritical surfaces (that is, floors
and equipment)
Copyright © 2004 WA Rutala
Cleaning and Disinfection of Floors% Reduction
Soap and water 80.4%
Phenol 99.0%
Copyright © 2004 WA Rutala
The Benefits of Surface Disinfection Justification for Using a Disinfectant
Surfaces may contribute to transmission of epidemiologically important microbes (e.g., VRE, MRSA, C. difficile)
Needed for surfaces contaminated by blood and OPIM Disinfectants are more effective in reducing microbial load Detergents become contaminated and result in seeding the patients
environment with bacteria CDC recommends disinfection of noncritical equipment and surfaces for
patients on isolation precautions One product for decontamination of noncritical surfaces (that is, floors
and equipment)
Copyright © 2004 WA Rutala
Microbial Contamination of Mop WaterSoap(CFU/ml)
Phenol(CFU/ml)
Before cleaning 10 20
After cleaning one-third of ward
650 10
After cleaning two-thirds of ward
15,000 30
After cleaningcomplete ward
34,000 20
Copyright © 2004 WA Rutala
The Benefits of Surface Disinfection Justification for Using a Disinfectant
Surfaces may contribute to transmission of epidemiologically important microbes (e.g., VRE, MRSA, C. difficile)
Needed for surfaces contaminated by blood and OPIM Disinfectants are more effective in reducing microbial load Detergents become contaminated and result in seeding the
patients environment with bacteriaDharan found use of detergents alone on floors and furniture led to
an increase in contamination in patients environmental surfaces after cleaning (average increase 103.6cfu/24cm2)
Copyright © 2004 WA Rutala
The Benefits of Surface Disinfection Justification for Using a Disinfectant
Surfaces may contribute to transmission of epidemiologically important microbes (e.g., VRE, MRSA, C. difficile)
Needed for surfaces contaminated by blood and OPIM Disinfectants are more effective in reducing microbial load Detergents become contaminated and result in seeding the patients
environment with bacteria CDC recommends disinfection of noncritical equipment and
housekeeping surfaces for patients on isolation precautions (eg, MRSA) One product for decontamination of noncritical surfaces (that is, floors
and equipment)
Copyright © 2004 WA Rutala
Recommendations for Surface DisinfectionEurope
Dettenkofer, Merkel, Mutter, Daschner – 2004 Recommended that the MRSA patient room be disinfected 3
times per day on intensive care units and once per day on normal wards
But given the high prevalence of MRSA among hospitalized patients in many countries and routine screening is rarely conducted, shouldn’t we employ disinfectants for all hospitalized patients as unspecified colonization is a routine occurrence?
Copyright © 2004 WA Rutala
The Benefits of Surface Disinfection Justification for Using a Disinfectant
Surfaces may contribute to transmission of epidemiologically important microbes (e.g., VRE, MRSA, C. difficile)
Needed for surfaces contaminated by blood and OPIM Disinfectants are more effective in reducing microbial load Detergents become contaminated and result in seeding the patients
environment with bacteria CDC recommends disinfection of noncritical equipment and surfaces for
patients on isolation precautions One product for decontamination of noncritical surfaces (that is,
noncritical housekeeping and equipment, isolation, blood)
Copyright © 2004 WA Rutala
The Benefits of Surface Disinfection Reasonable to use hospital disinfectants on noncritical
patient equipment surfaces (e.g., blood pressure cuffs, stethoscopes, radiograph machines), and housekeeping surfaces (e.g., bedside tables and bed rails).
Copyright © 2004 WA Rutala
Recommendations for Surface DisinfectionEurope
Robert Koch Institute, Germany Tasked to produce guidelines by a federal infection protection
law Recommends the use of surface disinfectants for patient
equipment surfaces and noncritical housekeeping surfaces in patient care areas.
French Authorities Recommends using disinfectants for surface disinfection in
patient care areas
Copyright © 2004 WA Rutala
Surface Disinfection Concerns?
Allergy-Literature review (Medline) from 1966 to April 2004, provided no evidence that suggests the use of LLD results in allergic symptoms in health care workers. “BAC is one of the leading allergens affecting HCP” discussed Quat use as a risk factor for allergies in pig farmers.
Environment-Adverse effects on human health, due to the disposal of LLD into soil/rivers/streams, have not been proposed or demonstrated. EPA does not regulate the discharge of LLD via waste water.
Increased resistance-No evidence that using LLD selects for antibiotic-resistant organisms in nature or mutants survive.
Copyright © 2004 WA Rutala
The Benefits of Surface Disinfection
Introduction and principles of disinfection Review the contribution of the noncritical environment to
disease transmission Justify the use of a disinfectant on noncritical surfaces Provide recommendations for surface disinfection
Top Related