APSIC Abstracts on Disinfection and Sterilization

The following abstracts on the topic of disinfection and sterilization are from the meeting of the eighth International Congress of the Asia Pacific Society of Infection Control (APSIC), held in Bangkok, Thailand, Feb. 12-15, 2017.

Reference: Antimicrobial Resistance & Infection Control. Abstracts from the 8th International Congress of the Asia Pacific Society of Infection Control (APSIC) Volume 6, Supplement 2. February 2017.

DS1: Processing of reusable medical devices in health service organizations: preventing HAIs at Macquarie University hospital: an Australian experience

Roel Beltran Castillo

Background
The global community demands standardization to approaches in patient safety. Protocols differ to meet the specific demands of health care facilities; patient safety has always been the common end. An introduction and understanding of compliance under the Australian setting would reaffirm this common end. Our similarities and differences in achieving the purpose are interesting to note.This study aimed to share information between infection control professionals, how Australia kept pace with the technological evolution of reusable medical devices (RMDs) and caters to specific reprocessing requirements to ensure patient safety. How RMDs are reprocessed to minimize, control and prevent healthcare-associated infections (HAIs)

Materials and methods
The Australian Commission on Safety and Quality in Healthcare requires health service organizations to comply with 10 standards ensuring patients get the quality of care they truly deserve. All CSSD throughout Australia are responsible for:

Standard 3.16: Reprocessing of RMDs in accordance with relevant International standards and instructions for reprocessing or IFUs;

Standard 3.17: Systems to enable identification of a process to a patient;

Standard 3.18: Ensuring workforces to decontaminate RMDs undertake competency based training.

Are RMDs reprocessed to minimize the risk of infection at Macquarie University Hospital?

Results
Macquarie University Hospital: ISO accredited and CSSD received on all criteria: Meet with Merit – this is the highest possible achievement on an ISO accreditation

Conclusions
Prevention of healthcare associated infections in patients undergoing surgeries is an essential component of patient safety. Compliance with standards is a critical aspect.

DS2: Fumigation free operating rooms in developing world- a reality

Dorairajan Sureshkumar, Ram Gopalakrishnan, Venkatasubramanian Ramasubramanian, Subramanian Sreevidya, Ranganathan Jayapradha

Background
Fumigation of operating rooms (OR) with high concentration of toxic chemicals is an age old tradition practiced in most of the developing world to control hospital acquired infections. This approach lost favor in the developed world due to questionable efficacy and toxicity concerns. However, most of the hospitals in developing world continue to use fumigation practices with variable frequency. Here we report our experience of fumigation free OR in India.

Materials and methods
This quasi-experimental before and after intervention study was conducted in a 50-bed tertiary care referral women and children hospital in Chennai (South India) between January 2015 and September 2016. The practice of OR disinfection using quaternary ammonium compounds fumigation was allowed in addition to standard cleaning methods in before-intervention phase (Jan 2015 to Dec 2015). In after-intervention phase (Jan 2016) onwards the fumigation practice was stopped and standard cleaning methods alone followed. The monthly environmental microbiological surveillance cultures and surgical site infection (SSI) rates were compared and analyzed.

Results
In the before-intervention phase there were 715 surgical procedures were carried out with 2 SSIs and 156 environmental samples tested all were within acceptable limits as per defined standards. In the after-intervention phase 535 surgeries were carried out with no SSIs and all 117 environmental samples collected were within acceptable limits.

Conclusions
The standard cleaning methods alone without chemical fumigation is sufficient for operating rooms disinfection in India. However, this finding should be confirmed in large multi-site studies before universal recommendation.

DS3: Change of the contamination rate caused by skin antiseptic change during blood culture collection

Atsushi Umetsu, Tetsuhiro Noda, Kenyuu Hashimoto, Akihiro Hayashi, Mikie Kabashima

Background
It is reported that skin antiseptic with a chlorhexidine-alcohol concentration of more than 0.5% usedduring blood cultures lowers contamination rate more effectively than povidone-iodine skin antiseptic. As an approach to enhance precision of blood cultures, I heldcampaigns for appropriate sterilization methods in 2010 also changed 10% povidone-iodine to 1% chlorhexidine-alcohol antiseptic during blood cultures in 2012, and reported results.

Material and methods
Study periods:April,2010-March,2011(A), August,2011-July,2012 after the sterilization methods campaign(B), and August,2012-July,2013 after the antiseptic change(C). I investigated and compared each period. The contamination was calculated by dividing the number of cases in which there was only one positive result of two sets or more of blood culture specimens submitted on the same day by the total of all paired sets collected. The contaminants were defined as CoNS, Bacillus spp., Corynebacterium spp., Micrococcus spp., Propinonibacterium spp. which a doctor took as causative organism of the infection were excluded.

Results
The contamination of the blood culture for periods A: 2.25%, B: 0.98%, and C: 1.05%.

Conclusions
There’s significant decrease in the contamination during blood cultures after sterilization methods campaign (A-B)(p < 0.05). It suggests contamination decreased by performing appropriate sterilization methods. There were no contamination differences in B-C after changing disinfectant (p = 0.86). It was suggested that an equal skin sterilization effect was provided when I performed the sterilization with1% chlorhexidine-alcohol and10% povidone-iodine, which was appropriate.The 1% chlorhexidine-alcohol has an immediate effect and durability in comparison with povidone-iodine, shorting the time for drawing blood after sterilization. Reflecting importance for busy on-site blood cultures.

DS4: Flexible endoscope decontamination - is it good enough?

Ursula Jadczak, Knut Elvelund, Marit Johnsen, Bente Borgen, Egil Lingaas

Background
Lovisenberg Diakonale Hospital has Olympus EDT machines for cleaning of endoscopes. In the standard program the wash time is 3 minutes with special detergent and the disinfection time is 5 minutes. Periodical testing of final rinse-water is performed regularly with good results. Microbiological control of the final rinse-water from the washer-disinfector for endoscopes (EWD) is the most widely used methods for detecting growth of bacteria. The validation process is a comprehensive procedure that requires both resources, time, knowledge, special equipment and access to the microbiological laboratory. The hospital wanted to assure the quality of decontamination of their endoscopes. We have established a partnership with the Department of Infection Control at Oslo University Hospital in order to validate the EWD.

Materials and methods
The decontamination of flexible endoscopes must be tested and validated according to the standard EN ISO 15883. To validate the disinfection process and secure a repeatable method, we used a surrogate endoscope (Spypach). This is equipped with biological indicators, temperature sensors and pressure- and flow-measures.

Results
Microbiological control of final rinse-water: satisfactory results according to standard.Cultivation of biological indicators: unsatisfactory results according to standard. Discovery of protein and fibrin in surrogate endoscope: unsatisfactory results according to standard. Measurement of temperature, pressure and flow: no deviation

Conclusions
The endoscope was not adequately cleaned during decontamination. Final rinse-water had satisfactory quality but remaining biological indicators and protein residues showed that the decontamination was not satisfactory. Alternative solutions may include: increasing the wash time and/ or modify the contents of detergent.

DS5: Can we use the super rapid readout biological indicator to replace traditional biological indicator?

Chia-Hua Mao, Fu-Chieh Chang, Chang-Pan Liu

Background
As we know, the biological indicators are the most accepted means of the QC in sterilization. Because the biological indicators contain Geobacillus stearothermophilus that have spore inside the cell, if the sterilization were successful, the G.sterothermophilus should be killed, and the Biological indicator can’t detected by color or machine. So, in this study, we aimed to make sure whether the super Rapid Biological Indicator can replace the traditional Biological Indicator or not. According to the instruction of the super Biological Indicator, after 60 minutes, the data will show pass or not. So we using the culture method to make sure the result are the same or not.

Materials and methods
In this study, we collected 214 super Rapid Readout Biological Indicators from Feb.2016 to Mar. 2016, and all the result showed that was no bacteria growth after 1 hour incubated. Then we used thioglycolate and TSA to make sure the results .

Results
According to the experiment’s result, all of the culture data showed that 214 super Rapid Readout Biological Indicators were the same. The accuracy were 100% and the sensitivity and specificity were 100% and 100%.

Conclusions
Based on this study, we assented that super Rapid Readout Biological Indicator can replace the traditional Biological Indicator. Otherwise, BI results are available about the time (1 hour) it takes to cool a load, and instruments and implants can be released to the OR much sooner

DS6: Using crepe paper to substitute cotton in sterilization

Ru-Hui Chao, Fu-chieh Chang, Chang-pan Liu

Background
Sterilization wrap is commonly used for instrument trays or cassettes. There are many different types and sizes of wraps available. Typically, two sheets are needed to provide an effective barrier and a specific technique is recommended [CDC, AAMI ST79] to allow for aseptic opening. Wrapped instruments should be secured with sterilization tape that also serves as an external indicator. Before closing, a multi-parameter chemical indicator should be included inside along with the instruments. Before this study, we used cotton of wraps. And the problem we focused was the expiry date. According to the Taiwan CDC suggestion, the cotton’s expiry date is 7 days. But it’s too short for us. This study aimed to find some types that can replace the cotton.

Materials and methods
In this study, we used the crepe paper of wraps to replace cotton. Otherwise, we want to elongate the expiry date. So we collected the instruments that cover by crepe paper and that storage in CSR (HEPA level: 100000) for 1, 4, 8, 12, 16, 20, 24, 28 weeks. Then we used the broth methods to make sure whether the instruments were contamination or not.

Results
In this study, we found all of the instruments were clean on 20 weeks. After 20 weeks, the culture result showed that some bacteria were growth on the instruments.

Conclusions
According to the experiment’s results, we suggested that the crepe paper can replace the cotton of wraps, and it could elongate the expiry date for 20 weeks in our CSR.

DS7: Development of the sterilization process to prevent the breakage of mouth mirror in central sterile supply department at Wanonniwas hospital

Junpen Pawapotako

Background
In 2014, 47 pieces of the mouth mirrors from dental unit were broken as they were packed and mixed with the other tools that were heavy, shape, and without protection. It broke the mouth mirrors from a process of packaging. The important is to prevent the broke of mouth mirror in order to have the good quality and enough instruments to service patients.This study aimed to determine the result of development of sterilization process toprevent the broke of mouth mirror in CSSD of Wanonniwas hospital.

Materials and methods
The sample group was composed of 1) Mouth mirror and 2) Personnel from the CSSD 8 persons.The process included 3 steps: 1) prepare process is to learn the reason of the breaking of mouth mirror and create the system in every process from caring, washing, packaging, sterilization, keeping, sending to dental unit, 2) methods process is inform the personnel about the reason, why mouth mirror were broken, change the methods of sterilization of mouth mirror, and 3) evaluation : This study were collected during fiscal year 2014 through 2016.

Results
The breaking of mouth mirror in year 2014, 2015, and 2016 (May) were 48 pieces, 33, and 4 pieces, respectively. It has a clearly decrease.

Conclusions
The sterilization to prevent the broke of mouth mirror that caring keep the mouth mirror into the box with a lid. The process of washing and drying, sorting the mouth mirror. Packing cloth wrapped. Sterilization, distribution and storage kit for the side impact protection.

DS8: Evaluation on the cleaning performance of different cleaning processes using the protein residue check test

Chadanan Prasertpan, Wantanee Malaihuan, Phisit Uirungroj

Background
The medical instrument cleaning and disinfection procedures are important process to remove organic and inorganic matter, due to concerns about contamination risks especially protein residue, to prevent cross-contamination and ensure the safety. This study aimed to determine the cleaning efficacy of two different cleaning methods, manual cleaning process and an automatic washer disinfector machine, using the protein residue check test in the Central Sterile Supply Department (CSSD), Maharaj Nakorn Chiang Mai Hospital.

Materials and methods
The 35, 40, and 25 samples of medical instrument washed and cleaned by manual cleaning process, the automatic washer disinfector machine, and re-sterile (without washing process), respectively, were collected from July to August, 2014 to determine the protein residue. The protein residue was detected with two different detections, the protein residue check test (Pose Health Care Co., Ltd., Thailand) and fluorescence-based protein detection test (Lab Focus Co., Ltd.).

Results
The 27 (77.14%), 33 (82.50%), and 11 (44.00%) samples of manual cleaning process, the automatic washer disinfector machine, and re-sterile produced undetectable protein residues, respectively (p-value = 0.002). The 8 (22.86%), 7 (17.50%), and 14 (56.00%) samples of manual cleaning process, the automatic washer disinfector machine, and re-sterile produced detectable protein residues, respectively.

Conclusions
The results indicated that, the medical instrument using the re-sterile process should pre-clean instrument with enzymatic detergent to remove gross soil immediately and must be thoroughly washed and cleaned before being sterile. Moreover, the manual cleaning process and an automatic washer disinfector machine must be optimized to eliminate protein contamination and minimize the cross-contamination.

DS9: Evaluation on the cleaning performance of an alkaline detergent used in an automatic washer disinfector machine

Chadanan Prasertpan, Chalermpong Saenjum, Teerapat Ouirungrog, Phisit Uirungroj

Background
Different medical device cleaning and disinfection procedures are used on a large scale. It is an important procedure to remove organic and inorganic from medical device to prevent cross-contamination. This study aimed to determine the cleaning efficacy of an alkaline detergent used in an automatic washer disinfector machine in the Central Sterile Supply Department (CSSD), Maharaj Nakorn Chiang Mai Hospital.

Materials and methods
An alkaline detergent was developed by Pose Health Care Co., Ltd., Thailand. The programs were designed with different concentrations of alkaline detergent 50, 60, 80, and 100 mL (0.15, 0.18, 0.24, and 0.30 v/v, respectively) and two different temperatures (60 and 65 °C). The cleaning efficacy was monitored using a TOSI (EN ISO 15883) and Brown STF loaded check strips. Each program used three TOSI test kits and five Brown STF strips to evaluate the cleaning efficacy. Additionally, protein residue was detected with the Pyromol® test, protein residue check test, and fluorescence-based protein detection test. Moreover, biofilm and microorganisms were determined using a scanning electron microscope (SEM).

Results
The optimum concentration of the alkaline-based cleaning detergent and temperature were 60 mL (0.18 v/v) and 60 °C, respectively. This program (60 mL and 60 °C) produced undetectable protein residues, biofilm, and microorganisms on medical instruments after the cleaning process.

Conclusions
Comparable to the recent condition of 100 mL (0.30 v/v) concentration and at 65 °C, the optimum condition of 60 mL concentration and at 60 °C reduced the cleaning costs by 40% per each cleaning process.

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