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Is
surface disinfection necessary?
The effective use of disinfectants is part
of a multi-barrier strategy to prevent health-care-associated
infections. Surfaces are considered noncritical items because they
contact intact skin. Use of noncritical items or contact with
noncritical surfaces carries little risk of causing an infection in
patients or staff. Thus, the routine use of
germicidal chemicals to
disinfect hospital floors and other noncritical items is
controversial. A 1991 study expanded the Spaulding scheme by
dividing the noncritical environmental surfaces into housekeeping
surfaces and medical equipment surfaces. The classes of
disinfectants used on
housekeeping and medical equipment surfaces can be similar.
However, the frequency of decontaminating can vary. Medical
equipment surfaces (e.g., blood pressure cuffs, stethoscopes,
hemodialysis machines, and X-ray machines) can become contaminated
with infectious agents and contribute to the spread of
health-care-associated infections. For this reason, noncritical
medical equipment surfaces should be disinfected with an
EPA-registered low- or intermediate-level disinfectant. Use of a
disinfectant will provide antimicrobial activity that is likely to
be achieved with minimal additional cost or work.
Five reasons germicidal detergent is required:
Environmental surfaces (e.g., bedside
table) also could potentially contribute to cross-transmission by
contamination of health-care personnel from hand contact with
contaminated surfaces, medical equipment, or patients. Of the seven
reasons to use a disinfectant on noncritical surfaces, five are
particularly noteworthy and support the use of a germicidal
detergent.
1.
Hospital floors become contaminated with
microorganisms from settling
airborne bacteria: by contact with shoes, wheels, and other objects;
and occasionally by spills. The removal of microbes is a component
in controlling health-care–associated infections. In an
investigation of the cleaning of hospital floors, the use of soap
and water (80% reduction) was less effective in reducing the numbers
of bacteria than was a phenolic disinfectant (94%–99.9%
reduction).
However, a few hours after floor disinfection, the bacterial count
was nearly back to the pretreatment level.
2.
Detergents become contaminated and result in seeding the patient’s
environment with bacteria. Investigators have shown that mop water
becomes increasingly dirty during cleaning and becomes contaminated
if soap and water is used rather than a disinfectant. For example,
in one study, bacterial contamination in soap and water without a
disinfectant increased from 10 CFU/mL to 34,000 CFU/mL after
cleaning a ward, whereas contamination in a disinfectant solution
did not change (20 CFU/mL). Contamination of surfaces close to the
patient that are frequently touched by the patient or staff (e.g.,
bed rails) could result in patient exposures. In a study, using of
detergents on floors and patient room furniture, increased bacterial
contamination of the patients’ environmental surfaces was found
after cleaning (average increase = 103.6 CFU/24cm2). In addition, a
P. aeruginosa outbreak was reported in a hematology-oncology
unit associated with contamination of the surface cleaning equipment
when non-germicidal cleaning solutions instead of disinfectants were
used to decontaminate the patients’ environment and another study
demonstrated the role of environmental cleaning in controlling an
outbreak of Acinetobacter baumannii. Studies also have shown
that, in situations where the cleaning procedure failed to eliminate
contamination from the surface and the cloth is used to wipe another
surface, the contamination is transferred to that surface and the
hands of the person holding the cloth.
3.
The CDC
Isolation Guideline recommends that noncritical equipment
contaminated with blood, body fluids, secretions, or excretions be
cleaned and disinfected after use. The same guideline recommends
that, in addition to cleaning, disinfection of the bedside equipment
and environmental surfaces (e.g., bedrails, bedside tables, carts,
commodes, door-knobs, and faucet handles) are indicated for certain
pathogens, e.g., enterococci, which can survive in the inanimate
environment for prolonged periods.
4.
OSHA
requires that surfaces contaminated with blood and other potentially
infectious materials (e.g., amniotic, pleural fluid) be disinfected.
5.
Using a
single product throughout the facility can simplify both training
and appropriate practice.
Clean floors with detergent/disinfectant:
Reasons also exist for using a detergent alone on
floors because noncritical surfaces contribute minimally to endemic
health-care-associated infections, and no differences have been
found in healthcare–associated infections rates when floors are
cleaned with detergent rather than disinfectant. However, these
studies have been small and of short duration and suffer from low
statistical power because the outcome—healthcare–associated
infections—is of low frequency. The low rate of infections makes the
efficacy of an intervention statistically difficult to demonstrate.
Because housekeeping surfaces are associated with the lowest risk
for disease transmission, some researchers have suggested that
either detergents or a disinfectant/detergent could be used. No
data exist that show reduced healthcare–associated infection rates
with use of surface disinfection of floors, but some data
demonstrate reduced microbial load associated with the use of
disinfectants. Given this information; other information showing
that environmental surfaces (e.g., bedside table, bed rails) close
to the patient and in outpatient settings can be contaminated with
epidemiologically important microbes (such as VRE and MRSA); and
data showing these organisms survive on various hospital surfaces;
some researchers have suggested that such surfaces should be
disinfected on a regular schedule.
Spot decontaminating fabrics:
Spot decontamination on fabrics that remain in
hospitals or clinic rooms while patients move in and out (e.g.,
privacy curtains) also should be considered. One study demonstrated
the effectiveness of spraying the fabric with 3% hydrogen peroxide.
Future studies should evaluate the level of contamination on
noncritical environmental surfaces as a function of high and low
hand contact and whether some surfaces (e.g., bed rails) near the
patient with high contact frequencies require more frequent
disinfection. Regardless of whether a detergent or disinfectant is
used on surfaces in a health-care facility, surfaces should be
cleaned routinely and when dirty or soiled to provide an
aesthetically pleasing environment and to prevent potentially
contaminated objects from serving as a source for
health-care–associated infections. The value of designing surfaces
(e.g. hexyl-polyvinylpyridine) that kill bacteria on contact or have
sustained antimicrobial activity should be further evaluated.
Mops to be frequently decontaminated:
Several investigators have recognized heavy microbial
contamination of wet mops and cleaning cloths and the potential for
spread of such contamination. They have shown that wiping hard
surfaces with contaminated cloths can contaminate hands, equipment,
and other surfaces have been published that can be used to formulate
effective policies for decontamination and maintenance of reusable
cleaning cloths. For example, heat was the most reliable treatment
of cleaning cloths as a detergent washing followed by drying at 80°C
for 2 hours produced elimination of contamination. However, the dry
heating process might be a fire hazard if the mop head contains
petroleum-based products or lint builds up within the equipment or
vent hose (American Health Care Association, personal communication,
March 2003). Alternatively, immersing the cloth in hypochlorite
(4,000 ppm) for 2 minutes produced no detectable surviving organisms
in 10 of 13 cloths. If reusable cleaning cloths or mops are used,
they should be decontaminated regularly to prevent surface
contamination during cleaning with subsequent transfer of organisms
from these surfaces to patients or equipment by the hands of
health-care workers.
A
new mop cleaning technique…
Some hospitals have begun using a new mopping
technique involving microfiber materials to clean floors.
Microfibers are densely constructed, polyester and polyamide (nylon)
fibers, that are approximately 1/16 the thickness of a human hair.
The positively charged microfibers attract dust (which has a
negative charge) and are more absorbent than a conventional,
cotton-loop mop. Microfiber materials also can be wet with
disinfectants, such as quaternary ammonium compounds. In one study,
the microfiber system tested demonstrated superior microbial removal
compared with conventional string mops when used with a detergent
cleaner (94% vs. 68%). The use of a
disinfectant
did not improve the microbial elimination
demonstrated by the microfiber system (95% vs. 94%). However, use of
disinfectant significantly improved microbial removal when a
conventional string mop was used (95% vs. 68%) (WA Rutala,
unpublished data, August 2006). The microfiber system also prevents
the possibility of transferring microbes from room to room because a
new microfiber pad is used in each room.
See the complete recommendations on
sterilizer and disinfection at
www.cdc.gov
“Guideline for Disinfection and Sterilization in Healthcare
Facilities, 2008”.
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