Infection Control Today: Surface Disinfectants

Keeping healthcare surfaces clean is not just a matter of slapping bleach on a tabletop and calling it clean. In general, cleaning staff can use a broad-spectrum, all-purpose disinfectant, but in special cases, the healthcare team must consider which product is right for the situation.

E nvironmental services (ES) staff is often at a disadvantage they may not be aware of a particularly hardy bug that has been discovered in a patient room or a procedure room. Nurses and other healthcare personnel must be responsible for notifying ES staff if a patient is found to have C. difficile or another hard-to-kill bug. These situations call for special solutions.

Observations From the Manufacturer

Overall, in most cases, they talk about standard disinfection for noncritical surfaces, which are housekeeping surfaces (tables, etc.), and then medical (non-critical) equipment that would touch intact skin like a blood pressure cuff or a stethoscope, says Judy Anderson, marketing manager for healthcare in 3Ms Commercial Care division. Standard disinfection procedures are adequate for surfaces contaminated with blood and body fluids.

There are some antibiotic-resistant organisms like methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE), which are easy to kill with low-level disinfectants like a quaternary, she continues. They typically will kill those bugs. Norovirus is another one we hear the most about (on cruise ships), but it does happen everywhere, and it is pretty contagious. For norovirus, the Centers for Disease Control and Prevention (CDC) recommends bleach when you have an outbreak. There are some other disinfectants like phenolics that they recommend at two-to-four times the normal dilution rate.

The thing to consider is that when there is an outbreak on a regular basis, youre not going to want to do that; bleach is hard on people and hard on hands and surfaces, she adds.

Clostridium difficile

is the pathogen Anderson hears discussed most frequently.

C. difficile,

which produces spores, is particularly difficult to eradicate. The bacteria produces spores that are hard to kill, and its passed from the fecal route to the hands, Anderson says. Incontinent patients, and the toilets or other devices they use, will need special attention. Some medical devices that come into contact with the GI tract, like endoscopes and thermometers, also will require special attention, as well as the hands of caregivers. So much is dependent on the hand contact. Thats where we want to spend our time cleaning high hand-contact areas, she adds. We want to clean the floor so it looks nice, but germs arent transmitted from the floor. Theyre transmitted from the high hand-contact areas.

The physical process of cleaning reduces the bioload of C. difficile, says Anderson. The physical scrubbing or disinfectant is going to reduce the bioload. The thing with C. difficile is that the spores can survive in the environment for a long time because they have a hard shell, and they are resistant to quats and phenolics. One of our infection control consultants attended the most recent SHEA (Society for Healthcare Epidemilogy of America ) meeting and says that Bill Rutala recommended using bleach only if theres an outbreak. Dont go there if you dont have an outbreak; only if you have a high level of C. difficile cases. Bleach damages surfaces, and has no cleaning ability, so you have to clean first and then put it on. The shelf life is very short if its in an open container. The smell is bad, its hard on peoples skin, and its hard on surfaces.

And, she adds, There is no quat or intermediate or low-level disinfectant that has a C. difficile claim at this time.

So in the meantime, Anderson recommends sticking with overall good cleaning procedures. Are you paying attention to who is cleaning it? Is it an ES person? Is it somebody in nursing? A nurses aide? Who has that commode cleaning responsibility? It needs to be good cleaning, not just spritz and wipe. The first step in good disinfection is good physical cleaning.

Another topic of concern is that of avian flu. It isnt here yet but probably will get here eventually, Anderson observes. Based on the type of virus it is, its similar to other influenzas, and we know what types of viruses those are and what kills the like viruses, so we feel good that the quats are going to kill the H5N1 avian flu.

Nobody has claims against that yet, because the Environmental Protection Agency (EPA) wont allow the virus to be brought in to get the claim against it, but we feel confi dent that because of the type of virus we know it is and similar types of viruses killed by low level disinfectants, that quats and phenolics should be fi ne against that avian fl u.

Observations From Those In the Trenches

Kent Miller, CHESP/CLLM, director of environmental services/linen services at Mercy Medical Center in Cedar Rapids, Iowa, has similar feelings about bleach. For something specialized, say C. difficile or gastroenteritis, we use a bleach and water mix. I refuse to have staff use all bleach. We use it in high-contact areas only, because its so hard on floor surfaces and wall coverings, he explains.

Bleach is hard on surfaces and staff. Some places use bleach for disinfectant, but it doesnt clean; it just kills germs, he points out. Our infection control coordinator has been pushing for the use of a standard germicidal, and does not wish to use specialized disinfectants [unless its necessary]. Thats fine with me. I turn chemicals down as much as I can to make it less confusing to the staff. You know at least theyre killing 90 percent of germs with the germicidal anyway. When wiping down a surface with C. difficile on it, Miller suggests using friction to try to remove it from the surface. Thats the only way to get it off there, he says.

The hospital has encouraged nurses to notify ES of what special cleaning needs exist with customized signage. We have several postings for that; our nursing staff are required to put specialized isolation signs on the door if there is going to be contact with gastroenteritis. The sign tells the staff what product to use when they go into the room: You are supposed to use this product, is shown right on the placard, he adds.

Training the nursing staff took time, and a subtle approach. I worked with infection control on this for a while. The nurses were not observing the protocol with signage; they were not putting it up or were not putting up the right sign, designating contact, airborne, or gastro precautions. Our infection control coordinator and the committee already talk to the staff and do audits for hand hygiene. Theyre asking about signage when theyre doing that. They ask the staff, How do you wash your hands? Do you use alcohol, or are you washing your hands with soap and water for 15 seconds? What do you do for this isolation room? Its very subtle, and its more than just nursing they ask housekeeping, a lab tech who is on the floor. My staff is more educated than nursing because we talk about it all the time.

Miller observes, If ES staff members dont do their job, well have more healthcare-acquired infections (HAIs) than we need, and that emphasizes how important they are. Our infection control coordinator says the same thing when she comes to our meetings; she emphasizes how important they are. Our infection rate is quite low here. Obviously my staff is doing their job.

Observations From a Chemist

There are cases when you want to use something thats broad spectrum, that has efficacy against a wide variety of pathogens whether its bacteria, virus, or fungi, agrees Charles Allgood, PhD, technology support leader in human health for the clean and disinfect business with DuPont Safety and Protection. Allgood oversees the research and development activities in support of DuPonts line of antiseptics and disinfectants.

But there are plenty of cases when there is a specific organism that is of concern, he adds. Theres the chemistry side will this product work against this organism? Then theres the regulatory questions has it been tested for EPA protocols? Has it been submitted? Is it on the approved label? Can you make that claim in the marketplace? In a perfect world, they would all be consistent, but theres a time and a cost to doing that.

As a marketer and developer of disinfectants, you have to choose, how many organisms can I put on the label? Should I test everything out there? Obviously you have to prioritize. In some of the things we faced last year, such as with the hurricanes, when you dont know what the particular threat is, its always good to go with something broad-spectrum, because obviously you have a better chance of taking care of something that could be a problem. Conversely, there are other very legitimate reasons to target specific organisms. With bloodborne pathogens, you want something that is effective against hepatitis C and human immunodeficiency virus (HIV). In other cases, if there is a situation where you know you have a problem with MRSA, if youre in a facility or a place where its confirmed or its a high probability scenario, like a hospital or nursing home or a jail cell, then you want something that has been proven effective against MRSA, he adds.

The mere mention of some of these pathogens strikes fear into the most fearless, but Allgood points out that many of the most fearsome bugs are feeble from a durability standpoint. Some things dont hang around on surfaces very long. HIV is kind of wimpy from a virus standpoint. But some hepatitis can last a week in a dried bloodstain, just lie there dormant. When it gets moist again, it can be infectious. Some of the spores can last indefinitely. There is a range of how long things will lie around, he says.

I think the ones of concern that we see the most are hepatitis and one we get asked about a lot is the C. difficile spores, because they do hang around indefinitely. Thats the whole point of a spore-forming bacteria it forms the spore so it can survive a harsh environment, and its a survival mechanism for the species. To kill the spore is very difficult; its the most challenging from a chemistry standpoint. In the U.S., per regulations, something that is sporicidal is pretty much equivalent to a sterilant, so its the highest level of efficacy or disinfection you can get. You typically need real extreme conditions to sterilize, like a steam autoclave, which doesnt work well on spores because they are resistant to heat, so you need very powerful chemistries, which tend to be harsh, corrosive, not nice friendly chemicals, to work with or to put in your facility, and they tend to take a long time. Depending on the chemistry, glutaraldehyde and things like that tend to be very powerful chemistries, but contact times of eight hours are not unheard of. This is in contrast to the more typical 10-minute disinfection time, which is your typical hard surface disinfection.

Allgood reflects upon the options for killing hardier bugs, such as spores. That is one of the areas of research in this industry that is an unmet need something thats friendly, not so horrible to use, something that does it in a reasonable amount of time, he envisions. If youre in a hospital or something, and need to use a harsh chemistry to kill spores, that is an area that you cant let people into. Or youre in a production facility making pharmaceuticals, or in a room where medical procedures take place. Thats down time; thats lost productivity. That starts to hit the bottom line pretty quickly, he states.

There is also confusion associated with C. difficile kill claims. Some products claim to kill the vegetative form of C. difficile. Thats confusing, because its the vegetative form. When that bacteria is stressed, that is when it converts itself to spores, which are what survive, so [the disinfectant is] not effective against the spores, and the spore is whats hanging out, contaminating things, getting people sick. I question the value of a vegetative C. difficile claim, because that could potentially lead to a false sense of security. Then the spores are just getting moved around, he adds.

Anthrax is a spore, so its almost the same deal as C. difficile from a scientific standpoint on killing it. You need something very strong, something that takes a long time, and the chemistries tend to be corrosive, Allgood explains.

Other microorganisms have been a focus of disinfectants for decades. Tuberculosis (TB) has been around a long time; it was the benchmark for disinfectants for a long time, he adds. It is more difficult to kill not as difficult as bacterial spores, but an intermediate/regular bacteria. If something can kill TB, it will kill a lot of stuff that was easy to kill. In some cases, a TB claim was good, because although its not a bloodborne pathogen its an aerosolized bacteria. If a product has a TB claim on the label, it gets grandfathered in and is acceptable under the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard, which says that since it kills TB, there is a high likelihood that it will also kill Hepatitis B or HIV, something like that. TB is not a relic, but I dont hear much about it from people with immediate concerns about outbreaks. Even among first responders, TB is not on the highest list. Its always hepatitis and MRSA, which are really hitting people today, especially in the fire service, which has a big problem with hepatitis C infection, Allgood says. People are highly sensitized to hepatitis, as well as MRSA, which has moved into nursing homes, schools, and corrections facilities. People are seeing that infections are real, and that MRSA can kill you.