American Academy of Micropigmentation

Hand Washing, Cleaning, Disinfection and Sterilization in Health Care

Date of Publication: December 1998

Volume 24S8

Canada Communicable Disease Report

ISSN 1188-4169

infection control guidelines.Our mission is to help the people of Canada

maintain and improve their health

Health Canada

This publication was produced by the Document Dissemination

Division at the Laboratory Centre for Disease Control, Health

Canada.

To obtain additional copies or subscribe to the Canada

Communicable Disease Report, please contact the Member Service

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Ottawa, ON, Canada K1G 3Y6, Tel.: 888-855-2555 or by FAX:

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This publication can also be accessed electronically via Internet

using a Web browser at http://www.hc-sc.gc.ca/hpb/lcdc.Infection Control Guidelines

Hand Washing, Cleaning,

Disinfection and Sterilization in Health Care

Health Canada

Laboratory Centre for Disease Control

Bureau of Infectious Diseases

Nosocomial and Occupational Infections.Introductory Statement

The primary objective in developing clinical

guidelines at the national level is to help health care

professionals improve the quality of health care.

Guidelines for the control of infection are needed to

assist in developing policies, procedures and evaluative

mechanisms to ensure an optimal level of care.

Guidelines facilitate the setting of standards but respect

the autonomy of each institution and recognize the

governing body’s authority and responsibility of

ensuring the quality of patient/client care provided by the

institution.

The guidelines, whenever possible, have been based

on research findings. Where there is insufficient

published research, consensus of experts in the field has

been utilized to provide guidelines specific to

conventional practice. The encouragement of research

and frequent revision and updating are necessary if

guidelines are to remain relevant and useful.

The Steering Committee acknowledges, with sincere

appreciation, the many practising health professionals

and others who contributed advice and information to

this endeavour.

The guidelines outlined herein are part of a series that

has been developed over a period of years under the

guidance of the Steering Committee on Infection Control

Guidelines. Infection Control Guidelines for Hand

Washing, Cleaning, Disinfection and Sterilization in

Health Care presents an overview and provides

recommendations to assist in preventing the transmission

of infection in health care facilities. This document is

part of the Health Canada series of Infection Control

Guidelines and is intended to be used with the other

Infection Control Guidelines, which include the

following:

Preventing the Transmission of Bloodborne Pathogens in

Health Care and Public Services Settings (1997)

Isolation and Precaution Techniques (1990) (under

revision - to be published March, 1999)

Preventing the Spread of Vancomycin-Resistant

Enterococci (1997)

Preventing the Transmission of Tuberculosis in

Canadian Health Care Facilities and Other Institutional

Settings (1996)

Canadian Contingency Plan for Viral Hemorrhagic

Fevers and Other Related Diseases (1997)

Prevention of Infections Associated with Indwelling

Intravascular Access Devices (1997)

Foot Care by Health Care Providers (1997)

Occupational Health in Health Care Facilities (1990)

(under revision)

Prevention of Nosocomial Pneumonia (1990) (under

revision)

Long Term Care Facilities (1994)

Antimicrobial Utilization in Health Care Facilities

(1990)

Prevention of Surgical Wound Infections (1990)

Prevention of Urinary Tract Infections (1990)

Perinatal Care (1988)

Organization of Infection Control Programs in Health

Care Facilities (1990)

iii.For information regarding these Health Canada

publications, contact:

Division of Nosocomial and Occupational Infections

Bureau of Infectious Diseases

Laboratory Centre for Disease Control

Health Canada, PL 0603E1

Ottawa, Ontario K1A 0L2

Telephone: (613) 952-9875

Fax: (613) 998-6413

iv.Steering Committee on Infection Control Guidelines

STEERING COMMITTEE MEMBERS

Dr. Lindsay Nicolle (Chair)

H.E. Sellers Professor and Chair

Department of Internal Medicine

University of Manitoba Health Sciences Centre

GC 430, 820 Sherbrooke Street

Winnipeg, Manitoba

R3A 1R9

Tel: (204) 787-7772

Fax: (204) 787-4826

e mail: nicolle@cc.umanitoba.ca

Dr. John Conly

Hospital Epidemiologist and Associate Professor

of Medicine

The Toronto Hospital, Room 117A-NU13

200 Elizabeth Street

Toronto, Ontario

M5G 2C4

Tel: (416) 340-4858

Fax: (416) 340-5047

e mail: jconly@torhosp.toronto.on.ca

Dr. Charles Frenette

Hôpital Charles Lemoyne

121 Taschereau Blvd.

Greenfield Park, Qc

J4V 2H1

Tel: (514) 466-5000 locale 2834

Fax: (514) 466-5778

Agnes Honish

Manager, Communicable Disease Control

Capital Health Authority

Community and Public Health

Suite 300, 10216 - 124th Street

Edmonton, Alberta

T5N 4A3

Tel: (403) 413-7944

Fax: (403) 413-7950

Dr. B. Lynn Johnston

Hospital Epidemiologist and Associate Professor

of Medicine

Queen Elizabeth II Health Sciences Centre,

Room 5-014 ACC

1278 Tower Road

Halifax, N.S.

B3H 2Y9

Tel: (902) 473-8477

Fax: (902) 473-7394

Linda Kingsbury

Nurse Consultant

Nosocomial and Occupational Infections

Bureau of Infectious Diseases, Health Canada

Laboratory Centre for Disease Control, 0603E1

Tunney’s Pasture

K1A 0L2

Tel: (613) 957-0328

Fax: (613) 998-6413

e mail: Linda_Kingsbury@hc-sc.gc.ca

Louise Meunier

Conseillère en prévention des infections

Prévention des infections

Hôpital Saint-Luc

1058 rue St. Denis

Montréal, Québec

H2X 3J4

Tel: (514) 281-3255, ext 5902

Fax: (514) 281-3293

v.Catherine Mindorff

Community and Institutional Infection Prevention

and Control

202 Yahara Place

Ancaster, Ontario

L9G 1Y5

Tel: (905) 304-1196

Fax: (905) 304-1999

Dr. Dorothy Moore

Division of Infectious Diseases

Montreal Children’s Hospital

2300 Tupper

Montréal, Québec

H3H 1P3

Tel: (514) 934-4485

Fax: (514) 934-4494

e mail: dmooinf@mch.mcgill.ca

Laurie O’Neil

Infection Prevention Consultant

4908 Nelson Rd. N.W.

Calgary, Alberta

T2K 2L9

Tel: (403) 282-2340

Shirley Paton

Chief, Nosocomial and Occupational Infections

Bureau of Infectious Diseases, Health Canada

Laboratory Centre for Disease Control, 0603E1

Ottawa, Ontario K1A 0L2

Tel: (613) 957-0326

Fax: (613) 998-6413

e mail: Shirley_Paton@hc-sc.gc.ca

Diane Phippen

Epidemiologist Nurse Coordinator

Cadham Provincial Laboratory

Box 8450, 750 William Avenue

Winnipeg, Manitoba

R3C 3Y1

Tel: (204) 945-6685 (direct line)

(204) 945-6123 (switchboard)

Fax: (204) 786-4770

LIAISON REPRESENTATIVES

Association des médecins microbiologistes

infectiologues du Québec (AMMIQ)

Dr. Charles Frenette

Association pour la prévention des infections à l’hôpital

et dans la communauté (APPI)

Yolaine Rioux, Monique Delorme

Canadian Association for Clinical Microbiology and

Infectious Diseases (CACMID)

Dr. Mary Vearncombe

Canadian Council on Health Services Accreditation

Mrs. Marilyn Colton, Assist. Executive Director

Canadian Healthcare Association

Rosa Paliotti, Barbara Lyons

Canadian Infectious Disease Society (CIDS)

Dr. Gary Garber, Dr. John Conly

The Community and Hospital Infection Control

Association - Canada (CHICA Canada)

Deborah Norton, Clare Barry

EX-OFFICIO MEMBER

Dr. John Spika

Director

Bureau of Infectious Diseases

Laboratory Centre for Disease Control, 0603E1

Health Canada

Ottawa, Ontario

K1A 0L2

Tel: (613) 957-4243

Fax: (613) 998-6413

MEMBERS OF SUBCOMMITTEE ON

HAND WASHING, CLEANING,

DISINFECTION AND STERILIZATION IN

HEALTH CARE

Agnes Honish (Chair)

Manager, Communicable Disease Control

Capital Health Authority

Community and Public Health

Suite 300, 10216 - 124 Street

Edmonton, Alberta

T5N 4A3

Tel: (403) 413-7944

Fax: (403) 413-7950

Dr. Gloria Delisle

Director, Medical Microbiology

Queen’s University

116 Brock Street

Kingston, Ontario

K7L 5G2

Tel: (613) 544-3400

Fax: (613) 531-7953

vi.Dr. Lynn Johnston

Hospital Epidemiologist and Associate Professor of

Medicine

Queen Elizabeth II Health Sciences Centre,

Room 5-014 ACC

1278 Tower Road

Halifax, Nova Scotia

B3H 2Y9

Tel: (902) 473-8477

Fax: (902) 473-7394

Linda Kingsbury

Nurse Consultant

Nosocomial and Occupational Infections

Bureau of Infectious Diseases, Health Canada

Laboratory Centre for Disease Control, 0603E1

Tunney’s Pasture

K1A 0L2

Tel: (613) 957-0328

Fax: (613) 998-6413

e mail: Linda_Kingsbury@hc-sc.gc.ca

Susan Lafferty

Infection Control Practitioner

Royal Alexandra Hospital

10240 Kingsway

Edmonton, Alberta

T5H 3V9

Tel: (413) 491-5864

Fax: (403) 491-5886

Maureen Miller

Infection Control Manager

Caritas Health Group

1100 Youville Drive, West

Edmonton, Alberta

T6L 5X8

Tel: (413) 450-7308

Fax: (403) 450-7259

Pat Piaskowski

Thunder Bay Regional Hospital

325 S. Archibald St.

Thunder Bay, Ontario

P7E 1G6

Tel: (807) 343-7123

Fax: (807) 343-7165

e mail: ppiaskow@microage-tb.com

Dr. Syed Sattar

Professor of Microbiology and Director

Centre for Research on Environmental Microbiology

Faculty of Medicine

University of Ottawa

Ottawa, Ontario

Tel: (613) 562-5800, ext. 8314

Fax: (613) 562-5452

Dr. Ann Skidmore

Medical Microbiologist

Surrey Memorial Hospital

13750 - 96th Avenue

Surrey, British Columbia

V3V 1Z2

Tel: (604) 581-2211

Fax: (604) 588-3322

The Steering Committee gratefully acknowledges the

assistance of the Editorial and Production Unit,

Document Dissemination Division, LCDC, Health

Canada, and Translation Services, Montreal.

vii.Table of Contents

HAND WASHING AND GLOVES.........................................1

A. Microbiology of the Skin ...........................................1

B. Soaps and Antiseptic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

C. Waterless Hand Scrubs ............................................2

D. Hand Washing Techniques ..........................................2

Table 1. Soaps and Antimicrobial Agents for Hand Washing ...... ........ ........ 3

Table 2. Characteristics of Antiseptic Agents...... ........ ........ ........ 4

E. Compliance with Hand Washing Protocols..................................5

Table 3. How to Wash Hands ...... ........ ........ ........ ........ 5

Table 4. Proposed Strategies to Improve Hand Washing Technique and Compliance . ........ 6

Recommendations on Hand Washing ....................................6

F. Gloves .................................................8

i) Glove use..............................................8

ii) Selection of gloves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

iii) Glove types ............................................8

iv) Problems of glove use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Recommendations on Glove Use.......................................8

CLEANING, DISINFECTING AND STERILIZING PATIENT CARE EQUIPMENT ...........10

A.Classification of Medical Devices......................................10

B. Cleaning Equipment and Instruments ....................................10

Table 5. Reprocessing of Commonly Used Equipment in Health Care Settings

in Usual Situations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

i) Sorting and soaking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

ii) Removal of organic material ...................................12

iii) Rinsing ..............................................12

iv) Drying ..............................................13

ix.C. Disinfection ................................................13

i) Chemical disinfection ......................................13

ii) Relative resistance of microorganisms ..............................13

iii) Creutzfeldt-Jakob disease (CJD).................................13

Figure 1. Classes of Microorganisms Ranked in Descending Order from

Least to Most Susceptible to Chemical Disinfectants. ..... ........ ....... 14

Table 6. Major Classes of Chemical Disinfectants and their Relative

Advantages and Disadvantages. ...............................15

Table 7. Directions for Preparing and Using Chlorine-based Disinfectants..............17

iv) Reuse of chemical disinfectants .................................17

v) Disinfectants and safety .....................................18

vi) Registration of disinfectants in Canada .............................18

vii) Product labelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

viii) Pasteurization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

ix) Ultraviolet radiation .......................................19

x) Boiling ..............................................19

xi) Sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

xii) New technologies .........................................20

xiii) Monitoring of the sterilization cycle ...............................20

Table 8. Advantages and Disadvantages of Currently Available Sterilization Methods........21

xiv) Maintenance of sterility .....................................25

a. Packaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

b. Storage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Recommendations on Cleaning, Disinfection and Sterilization.......................25

MICROBIOLOGIC SAMPLING OF ENVIRONMENT ............................27

Recommendations for Microbiologic Sampling ..............................27

HOUSEKEEPING ................................................29

A.Routine Cleaning ..............................................29

Table 9. Cleaning Procedures for Common Items...........................30

Recommendations for Routine Housekeeping ...............................31

B. Special Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

i) Special organisms of epidemiologic significance . . . . . . . . . . . . . . . . . . . . . . . . 32

ii) Blood spills ............................................32

Recommendations for Cleaning Blood Spills .............................32

iii) Surgical settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Recommendations for Cleaning Surgical Settings ...........................32

x.LAUNDRY ................................................34

Recommendations for Laundry .......................................34

1. Collection and handling .....................................34

2. Bagging and containment.....................................35

3. Transport ...... ........ ........ ........ ........ ....... 35

4. Washing and drying .......................................35

5. Dry cleaning ...........................................36

6. Sterile linen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

7. Protection of laundry workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

WASTE MANAGEMENT.............................................37

A. Public Health Risk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Table 10. Recommendations for Management of Untreated Infectious Waste ...............38

B. Treatment of Waste ...... ........ ........ ........ ........ ....... 39

i) Chemical decontamination ....................................39

ii) Steam sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

C. Disposal Methods for Waste ........................................39

i) Landfill ....... ........ ........ ........ ........ ....... 39

ii) Sanitary sewer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

iii) Incineration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

D. Safety for Waste Handlers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Recommendations for Waste Management.................................40

REFERENCES ................................................41

Appendix 1. Glossary .............................................52

Appendix 2. Guideline Rating System .....................................54

Table 11. Strength and Quality of Evidence for Recommendations . . . . . . . . . . . . . . . . . . . . 54

Appendix 3. Drugs Directorate Guidelines ..................................55

xi.Hand Washing and Gloves*

Disease-causing microorganisms can frequently be

isolated from the hands. Hand carriage of bacteria is an

important route of transmission of infection between

patients or from the health care worker to the

patient/client (1-6) . Appropriate hand washing results in a

reduced incidence of both nosocomial and community

infections

(1,7,8)

. Guidelines from national and inter-national

infection prevention and control organizations

have repeatedly acknowledged that hand washing is the

single most important procedure for preventing

infections

(9-11)

. Despite this, health care

providers’compliance with hand washing is poor

(12-14)

This section will review the current literature on skin

flora, antimicrobial agents used for hand antisepsis, hand

washing techniques and other aspects of hand care and

protection, and will make recommendations to be applied

in the health care setting. Routine hand washing is

discussed in this guideline, and the surgical hand scrub is

discussed in Infection Control Guidelines: Prevention of

Surgical Wound Infections

(15)

A. Microbiology of the Skin

Larson has provided an extensive review of the

physiologic and bacteriologic characteristics of the

skin (16) . The finger nail area is associated with a major

portion of the hand flora. The subungual areas (located

under the fingernail) often harbour high numbers of

microorganisms, which may serve as a source of

continued shedding, especially under gloves

(17)

Artificial nails

(18)

and chipped nail polish

(19)

may be

associated with a further increase in the number of

bacteria on fingernails.

The microbial flora of the skin consist of resident

(colonizing) and transient (contaminating) micro-organisms.

The resident microorganisms survive and

multiply on the skin. Resident flora include the

coagulase-negative staphylococci, members of the genus

Corynebacterium (diphtheroids or coryneforms),

Acinetobacter species, and occasionally members of the

Enterobacteriaceae group

(20)

. Resident skin micro-organisms

are not usually implicated in nosocomial

infections, other than minor skin infections; however,

some can cause infections after invasive procedures,

when the patient/client is severely immunocompromised

or has an implanted device, such as a heart valve or

artificial hip.

The transient microbial flora represent recent

contaminants of the hands acquired from colonized or

infected patients/clients or contaminated environment or

equipment. Transient microorganisms are not

consistently isolated from most persons. In contrast to

the resident flora, the transient microorganisms found on

the hands of health care personnel are more frequently

implicated as the source of nosocomial infections. The

most common transient flora include gram negative

coliforms and Staphylococcus aureus.

Hand washing with plain soap (detergents) is effective

in removing most transient microbial flora (20-22) . The

components of good hand washing include using an

adequate amount of soap, rubbing the hands together

to create some friction, and rinsing under running

water. The mechanical action of washing, rinsing and

drying removes most of the transient bacteria present

(23-25)

* See Appendix 1 for definitions of the following terms: antimicrobial agent, antiseptic, hand wash(ing), hand antisepsis, heavy microbial

soiling, plain or nonantimicrobial soap, sharps, surgical hand scrub..In some studies, air dryers have been shown to reduce

the number of organisms on hands after hand washing

(26-28)

Several studies have demonstrated that air hand dryers

are unsuitable for use in critical patient care areas

because of the potential for cross infection, either

through airborne dissemination or contaminated

personnel

(24,29-31)

. Air dryers may be an impediment to

hand drying because of the time taken to dry hands and

the need to ensure that the equipment is functioning.

B. Soaps and Antiseptic Agents

The purpose of hand washing is to remove soil,

organic material and transient microorganisms from the

skin. Few clinical studies have defined the absolute

indications for hand washing with plain soaps

(detergents) versus hand antisepsis with antimicrobial

products. Controlled trials have not documented

decreased infection with the use of an antiseptic agent

over plain soap for routine hand washing in the general

health care setting. The degree of reduction in microbial

numbers on the hands of health care providers necessary

to protect the recipient of care has not been defined. A

few studies have suggested that antiseptic agents may be

preferable for the care of patients if there is a possibility

of antimicrobial-resistant organisms, such as in intensive

care units

(3,32)

, in the presence of antimicrobial-resistant

organisms

(33-36)

, and under conditions of heavy microbial

soiling (e.g., in the presence of infection or a high level

of contamination with organic matter such as feces)

(37)

Understanding the distinctive ingredients and uses of

the soap and antiseptic products available is important in

choosing the appropriate agent for the appropriate

situation. If an antiseptic product is used, it should be

selected for its chemical composition, its type and

spectrum of activity, its onset and duration of activity,

the application for which it will be used, its cost,

allergenic potential and acceptability to the users.

Whatever product is used, it should be applied at the

right dilution for the recommended time with standard

methods of application.

Antiseptic hand cleansers are designed to rapidly

wash off the majority of the transient flora by their

mechanical detergent effect and to exert an additional

sustained antimicrobial activity on the resident hand flora

(Tables 1 and 2)

(38,39)

C. Waterless Hand Scrubs

Several studies have demonstrated superior efficacy of

waterless hand scrubs compared with hand washing with

soap and water or chlorhexidine

(36,47-50)

. Alcohol-based

compounds for hand antisepsis predominate in several

European countries

(51-53)

. Alcohol preparations offer

rapid reduction in microbial counts on skin

(54)

: a

vigorous, 1-minute rubbing with enough alcohol to wet

the hands completely has been shown to be an effective

method of hand antisepsis

(20,36,51,55,56)

. Alcohol

applications as short as 15 seconds in duration have been

effective in preventing hand transmission of gram-negative

bacteria (37,57) . The advantages of alcohol rubs

include the following: (1) they have an immediate and

delayed antimicrobial performance, (2) no wash basin is

necessary for their use and (3) alcohol rubs can be

conveniently available near every patient/client and are

more practical when there is insufficient time to wash

hands

(42,57,58)

. Alcohol preparations are useful in home

care when proper facilities for hand washing may be

lacking

(59)

A major disadvantage of alcohol for skin antisepsis is

its effect on the user. Waterless hand scrubs may have a

drying effect on the skin of the hands, and product

odours may be irritating for health care workers. The

addition of emollients to minimize skin drying increases

the acceptability of alcohol-based solutions on the

hands

(55)

. The antimicrobial efficacy of alcohols is

sensitive to dilution with water, therefore alcohol

preparations must be rubbed onto dry hands

(55)

. The

activity of alcohol does not appear to be significantly

affected by small amounts of blood

(60)

; however, further

studies are needed to determine activity in the presence

of large amounts of organic matter.

See Table 2 for a description of the antimicrobial

activity and uses of antiseptic agents.

D. Hand Washing Techniques

The absolute indications for and the ideal frequency of

hand washing have not been well studied. The

indications for hand washing depend on

(a) the type, intensity, duration and sequence of

activity;

(b) the degree of contamination associated with the

contact; and

recipient.

2.Table 1. Soaps and Antiseptic Agents for Hand Washing

Product Indications Special considerations

Plain soap, bar soap,

liquid*, granules

For routine care of patients/residents/clients

(10,20,40)

For washing hands soiled with dirt, blood or other organic

material

May contain very low concentrations of antimicrobial agents to

prevent microbial contamination growth in the product.

Bar soap should be on racks that allow water to drain; small bars that

can be changed frequently are safest

(11,41)

Waterless antiseptic agents:

- rinses

- foams

- wipes

- towelettes

Demonstrated alternative to conventional agents

(42)

For use where hand washing facilities are inadequate,

impractical or inaccessible (e.g., ambulances, home care, mass

immunization)

For situations in which the water supply is interrupted (e.g.,

planned disruptions, natural disasters)

Not effective if hands are soiled with dirt or heavily contaminated

with blood or other organic material.

Follow manufacturer’s recommendations for use.

Efficacy affected by concentration of alcohol in product.

Hand creams should be readily available to protect skin integrity

(43-45)

Antiseptic agents Refer to recommendations at end of this chapter.

May be chosen for hand scrubs prior to performance of invasive

procedures (e.g., placing intravascular lines or devices)

(34)

When caring for severely immunocompromised individuals

Based on risk of transmission (e.g., specific microorganisms)

Critical care areas

Intensive care nurseries

Operating room scrub

When caring for individuals with antimicrobial resistant

organisms

(33)

Antiseptic agents may be chosen if it is felt important to reduce the

number of resident flora or when the level of microbial

contamination is high.

Antiseptic agents should be chosen when persistent antimicrobial

activity on the hands is desired.

They are usually available in liquid formulations*.

Antiseptic agents differ in activity and characteristics

(38,39)

Routine use of hexachlorophene is not recommended because of

neurotoxicity and potential absorption through the skin

(46)

Alcohol containers should be stored in areas approved for flammable

materials.

* Disposable containers are preferred for liquid products. Reusable containers should be thoroughly washed and dried before refilling, and routine maintenance schedules should be followed and document ed.

Liquid products should be stored in closed containers and should not be topped-up..Table 2. Characteristics of Antiseptic Agents

Group and

subgroup

Gram-positive

bacteria

Gram-negative

bacteria

Mycobacterium

tuberculosis Fungi Virus

Speed of killing

sensitive

bacteria

Inactivated by

mucus or

proteins

Comments

Alcohols Good Good Good Good Good Fast Moderate Optimum strength 70% to 90% with added

emollients (glycerine or cetyl alcohol is less

drying), not recommended for physical cleaning

of skin; good for hand antisepsis and for surgical

site preparation.

Chlorhexidine

2% and 4%

aqueous

Good Good Fair Fair Good Intermediate Minimal Has persistent effect; good for both hand

washing and surgical site or preoperative patient

skin preparation; do not use near mucous

membranes; toxic effects on ears and eyes

reported; activity neutralized by nonionic

surfactants.

Hexachloro-

phene 3%

aqueous

Good Poor Poor Poor Poor Slow Minimal Provides persistent, cumulative activity after

repeated use (washing with alcohol reduces

persistent action), can be toxic when absorbed

from skin especially in premature infants; good

for hand washing but not for surgical site

preparation; limited spectrum of antimicrobial

activity.

Iodine

compounds,

iodine in

alcohol

Good Good Good Good Good Fast Marked Causes skin "burns," but this is unusual with 1%

tincture, especially if it is removed after several

minutes; too irritating for hand washing but

excellent for surgical site preparation.

Iodophors Good Good Fair Good Good Intermediate Moderate Less irritating to the skin than iodine; good for

both hand washing and surgical site preparation;

rapidly neutralized in presence of organic

materials such as blood or sputum

Para-chloro-

meta-xylenol

(PCMX)

Good Fair* Fair Fair Fair Intermediate Minimal Activity neutralized by nonionic surfactants

Triclosan Good Good Fair Poor Good Intermediate Minimal

*Activity improved by addition of chelating agent such as EDTA.

Note: Some of these agents, such as iodine or chlorhexidine, are combined with alcohol to form tinc tures and are available in the combined formulation (10) .

Table used with permission of author and publisher (10) ..5

Table 3. How to Wash Hands

Procedure Rationale

Remove jewelry before hand wash procedure (38,61) .

Rinse hands under warm running water. This allows for suspension and washing away of the loosened

microorganisms.

Lather with soap and, using friction, cover all surfaces of the

hands and fingers.

The minimum duration for this step is 10 seconds (25) ; more time

may be required if hands are visibly soiled.

For antiseptic agents 3-5 mL are required (38) .

Frequently missed areas are thumbs, under nails, backs of

fingers and hands.

Rinse under warm running water. To wash off microorganisms and residual hand washing agent

Dry hands thoroughly with single-use towel or forced air dryer. Drying achieves a further reduction in number of

microorganisms (24,29,38) .

Reusable towels are avoided because of the potential for

microbial contamination.

Turn off faucet without recontaminating hands. To avoid recontaminating hands.

Do not use fingernail polish or artificial nails. Artificial nails or chipped nail polish may increase bacterial

load and impede visualization of soil under nails (18,62) .

The efficacy of a hand wash depends on the time

taken and the technique. The recommended hand

washing technique is outlined in Table 3. It is important

to avoid potential microbial contamination by splashing

of clothing, other skin surfaces or inanimate items during

hand washing.

E. Compliance with Hand Washing Protocols

Although hand washing is considered the most

important single intervention for preventing nosocomial

infections

(1-6)

, studies have repeatedly shown poor

compliance with hand washing protocols by hospital

personnel

(3,12,13,63,64)

. Failure to comply is a complex

problem that includes elements of lack of motivation and

lack of knowledge about the importance of hand wash-ing.

It may also be due to real or perceived obstacles,

such as understaffing, inconveniently located hand

washing facilities, an unacceptable hand washing product

or dermatitis caused by previous hand washing. A

number of strategies have been suggested to improve

compliance (Table 4). Long-term success will require

development of programs and sustained efforts at

promoting compliance with hand washing. Effective

interventions will probably be multidimensional, and will

require the application of behavioural science theory

combined with engineering and/or product

innovation

(7,8)

..Recommendations on Hand Washing

1. Hands must be washed

(i) between direct contact with individual

patients/residents/clients;

(ii) before performing invasive procedures

(11,20)

;

(iii) before caring for patients in intensive care units

and immunocompromised patients

(11,20)

;

(iv) before preparing, handling, serving or eating

food, and before feeding a patient;

(v) when hands are visibly soiled

(13,20)

;

(vi) after situations or procedures in which

microbial or blood contamination of hands is

likely;

(vii) after removing gloves

(11,20,74)

; and

(viii) after personal body functions, such as using the

toilet or blowing one’s nose. Category B;

Grade II*

2. Hand washing should be encouraged whenever a

health care provider is in doubt about the necessity

for doing so. Category B; Grade III

Table 4. Proposed Strategies to Improve Hand Washing Technique and Compliance

Obstacle Strategy

Lack of knowledge Education with supportive literature, videotaped instructions, hand washing

demonstrations; frequent refreshers; involvement of personnel in education and

feedback (7,8,65)

Feedback on infection rates (64)

Lack of motivation Direct observation and feedback on regular basis (65) ; role models; involvement of

staff in studies; application of new technologies (63,66-69)

Programs on hand hygiene for patients and families (64,70)

Availability of hand washing facilities Hand washing facilities conveniently located throughout the health care

setting (67,68)

A sink accessible to personnel in or just outside every room; more than one sink

per room may be necessary if a large room is used for several individuals.

Hand washing facilities in or adjacent to rooms where health care procedures are

performed

Accessible, adequately supplied and proper functioning soap and towel dispensers

or hand dryers

Faucets with foot, wrist or knee operated handles; faucets with an electric eye are

also desirable.

Waterless antiseptic agents readily available in wall mounted dispensers, or in

small containers for mobile care such as home care and for emergency

responders.

Hand washing product Hand washing products that have a high level of acceptability to staff, with

appropriateness, cost, supply, etc., being taken into consideration (55,59)

Dermatitis Lotions to prevent skin dryness

Lotion supplied in small, non-refillable containers (43-45,72)

Compatibility between lotion and antiseptic products and effect on glove integrity

Lotions approved by personnel in infection control and occupational health (73)

* See Appendix 2 for the rating system used in these recommendations..3. As well as between patient/resident/client contacts,

hand washing may be indicated more than once in

the care of one person, for example after touching

excretions or secretions and before going on to

another care activity for the same person

(37)

Category B; Grade II

4. Superficial contact with an object not suspected of

being contaminated, such as when touching or

collecting food trays, generally does not require hand

washing. Category B; Grade III

5. Hand washing facilities should be conveniently

located throughout the health care setting. They

should be available in or adjacent to rooms where

health care procedures are performed. If a large room

is used for several individuals, more than one sink

may be necessary. Sinks for hand washing should be

used only for hand washing and not for any other

purpose, e.g., as a utility sink. There should be access

to adequate supplies and proper functioning soap and

towel dispensers or hand dryers, or liberal use of

waterless hand wash agents

(41,68,69)

. Category B;

Grade II

6. To avoid recontaminating hands, faucets with foot,

wrist, or knee operated handles should be installed

wherever possible; faucets with an electric eye are

also desirable. If automated faucets are not available,

single-use towels should be supplied for user to turn

off faucets. Category B; Grade III

7. Hands should be dried thoroughly with either a

single-use towel or electric air dryer (26,27) . Category

A; Grade II

8. Hand lotion may be used to prevent skin damage

from frequent hand washing

(55)

. Lotion should be

supplied in disposable bags in wall containers by

sinks or in small, non-refillable containers to avoid

product contamination. Skin lotions for patient

and/or staff use have been the reported source of

outbreaks

(43-45,72,73)

. Category B; Grade II

9. Compatibility between lotion and antiseptic products

and lotion’s potential effect on glove integrity should

be checked

(75,76)

. Category A; Grade II

10. Liquid hand wash products should be stored in closed

containers and dispensed from either disposable

containers or containers that are washed and dried

thoroughly before refilling. Category A; Grade II

11. Hand washing with plain soap is indicated in routine

health care and for washing hands soiled with dirt,

blood or other organic material. Plain soap and water

will remove many transient organisms

(20-22,40,59,77)

Category A; Grade II

12. Hand washing with an antiseptic agent is indicated

for the following situations:

(i) when there is heavy microbial soiling, e.g., in

the presence of infection or a high level of

contamination with organic matter such as

infected wounds and feces

(36,47,48,78)

. Category

A; Grade II;

(ii) prior to performing invasive procedures (e.g.,

the placement and care of intravascular

catheters, indwelling urinary catheters)

(2,5,6)

Category A; Grade I;

(iii) before contact with patients who have immune

defects, damage to the integumentary system

(e.g., wounds, burns), or percutaneous

implanted devices

(3,6)

. Category A; Grade II;

(iv) before and after direct contact with patients

who have antimicrobial-resistant

organisms

(32,35,36)

. Category A; Grade II

13. Hand washing with waterless/alcohol-based agents is

equivalent to soap and water, and these agents should

be made available where access to water is

limited (42,59,78) . If there is heavy microbial soiling,

hands must first be washed with soap and water to

remove visible soiling (20) . Hands must be dry before

an alcohol-based agent is used because moisture from

wet hands dilutes the alcohol. Category A; Grade II

14. Compliance with hand washing procedures should be

encouraged by involving users as much as possible in

product selection, facilities design, studies,

application of new technologies, education programs

and feedback

(63,64,69)

. Category A; Grade II

15.Patients/clients/residents in settings where patient

hygiene is poor should have their hands washed.

Patients/residents should be helped to wash their

hands before meals, after going to the bathroom,

before and after dialysis, and before leaving their

room. Category B; Grade III

7.F. Gloves

i) Glove use

Gloves are worn to

a. provide an additional protective barrier between

health care workers’ hands and blood, body fluids,

secretions, excretions and mucous membranes

(74,79)

and

b. reduce the potential transfer of microorganisms from

infected patients to health care workers, and from

patient to patient via health care workers’ hands

(81)

Glove use should be an adjunct to, not a substitution

for, hand washing. If hand washing is performed

carefully and appropriately by all personnel, gloves are

not necessary to prevent transient colonization of health

care workers' hands and subsequent transmission to

others

(82)

In 1987, the Laboratory Centre for Disease Control

(LCDC) recommended the use of gloves for specific

situations, primarily to protect the health care worker

from exposure to bloodborne pathogens (83) . Application

of universal precautions (82-84) significantly increased the

use of gloves in the health care setting. Some institutions

adopted body substance isolation precautions

(85)

, which

expanded the use of gloves to prevent contamination of

hands.

ii) Selection of gloves

It is important to assess and select the most

appropriate glove to be worn for the circumstances.

Selection of gloves should be based on a risk analysis of

the type of setting, type of procedure, likelihood of

exposure to blood or fluid capable of transmitting

pathogens, length of use and amount of stress on the

glove

(86)

. Factors such as personal comfort and fit, cost

and latex allergy in employees and clients/residents are

also important considerations.

iii) Glove types

Non-sterile gloves sold in Canada must meet the

requirements of Health Canada Information Letter No.

777 (April 30, 1990). Health Canada recommends

purchasing gloves with the Canadian General Standards

Board certification mark, which ensures that voluntary

national standards are met during manufacturing.

However some types of glove materials are not available

in certified brands. The Medical Devices Bureau of

Health Canada has an information package on glove

quality and certification, and on latex allergy (1-800-

267-9675)

(87)

Studies have demonstrated varying effectiveness of

gloves as barrier protection. Some studies have

concluded that latex gloves were associated with less

leakage than vinyl gloves

(74,88-92)

. Other studies have

shown non-latex gloves to be effective

(79,93-96)

iv) Problems of glove use

Constant use of gloves may cause irritant dermatitis.

The cause of the dermatitis may be mechanical irritation

from the glove or glove powder; it may also be chemical

agents, such as residual soap, trapped between the glove

and skin.

Latex allergy is an increasing concern in health care

settings because of the potentially serious outcomes in

workers and clients who are allergic to latex. Some

employees affected by latex allergy may be able to work

in an area where others are using low protein, non-powdered

latex gloves. Employees and clients who are

severely allergic to latex need to avoid all contact with it.

For further information on latex allergy in health care

facilities, refer to the Canadian Healthcare Association

publication Guidelines for the Management of Latex

Allergy and Safe Latex Use in Health Care Facilities

(97)

Recommendations on Glove Use

For further information and recommendations on

glove use, refer to Health Canada’s Infection Control

Guidelines Preventing the Transmission of Bloodborne

Pathogens in Health Care and Public Services

Settings

(84)

and the revision of Health Canada’s Isolation

and Precaution Techniques

(98)

1. Gloves should be used as an additional measure, not

as a substitute for hand washing

(74,99)

. Category B:

Grade II

2. Gloves are not required for routine patient care

activities if contact is limited to a patient's intact skin,

e.g., when transporting patients. Category B;

Grade III

3. Gloves may not be needed for routine diaper changes

if the procedure can be done without contaminating

the hands with stool or urine. Category C

4. Clean non-sterile gloves should be worn

(i) if exposure is anticipated to blood and body

fluids capable of transmitting bloodborne

infection

(84)

(ii) if exposure is anticipated to potentially

infectious material such as pus, feces,

8.respiratory secretions or exudate of skin

lesions

(81,85)

(iii) when the health care worker has non-intact skin

on his or her hands. Category A; Grade II

5. Sterile gloves must be worn for procedures in which

the hands or the instruments being handled are

entering a sterile body cavity or tissue (2,100) .

Category A; Grade I

6. The accepted standard should be that medical gloves

be worn for all blood collection procedures.

However, if phlebotomists choose not to wear gloves

routinely, they must be gloved for perfoming

phlebotomy if they have cuts, scratches or other

breaks in their skin, or when hand contamination

with blood is anticipated. All students or new

trainees must wear medical gloves during their

training period and in subsequent blood collection

procedures

(84)

7. Worn gloves should be changed

(i) between patient/client/resident contacts,

(ii) if a leak is suspected or the glove tears,

(iii) between care activities and procedures on the

same patient after contact with materials that

may contain high concentrations of micro-organisms

(e.g., after manipulating an

indwelling urinary catheter and before

suctioning an endotrachial tube) (74,88). .

Category A; Grade II

8. Hands must be washed after gloves are

removed

(74,86,89,91)

. Category A; Grade II

9. Potentially contaminated gloves should be removed

prior to touching clean environmental surfaces (e.g.,

lamps, blood pressure cuffs)

(74,101)

. Category A;

Grade II

10.Single-use disposable gloves should not be washed

or reused. Category A; Grade II

11. Disposable, good quality medical gloves made of

vinyl, nitrile, neoprene or polyethylene serve as

adequate barriers, particulary when latex allergies are

a concern. Category A; Grade II

The Health and Safety Act requires that employers

provide appropriate personal protective apparatus

(102)

They should make suitable gloves available to

employees to prevent the transmission of infection to

residents/clients/patients. Employees should assess

the risk in each procedure, choose gloves that are

appropriate to the task, and recommend alternative

gloves if the ones available are not adequate

(84,86)

The following is suggested as a guide.

(i) If latex gloves are chosen, low protein and

unpowdered gloves should be selected.

(ii) Non-latex gloves should be available for

individuals with latex sensitivity.

(iii) Vinyl gloves should be used for short tasks or

for tasks in which there is minimal stress to

glove material.

(iv) For housekeeping activities, instrument

cleaning and decontamination procedures,

general purpose reusable household gloves

(e.g., neoprene, rubber, butyl) are recom-mended.

Medical gloves are not durable

enough for these activities.

9.Cleaning, Disinfecting and Sterilizing

Patient Care Equipment*

Appropriate cleaning, disinfection and sterilization of

patient care equipment are important in limiting the

transmission of organisms related to reusable patient care

equipment. Decisions concerning the appropriate

processes, methods or products are complex, given the

many types and compositions of medical devices and the

great variety and combination of cleaning, disinfection

and sterilization methods available

(103-108)

The reprocessing method required for a specific item

will depend on the item’s intended use, the risk of

infection to the patient, and the amount of soiling

(59,109-111)

Cleaning is always essential prior to disinfection or

sterilization. An item that has not been cleaned

cannot be assuredly disinfected or sterilized. See

Table 5 for examples.

A. Classification of Medical Devices

In the 1970s, E.H. Spaulding developed a system to

classify the cleaning, disinfection and sterilization

requirements for equipment used in patient/client care.

This system divides medical devices, equipment and

surgical materials into three categories based on the

potential risk of infection involved in their use

(117)

. The

three categories are noncritical, semicritical, and critical.

The categories are defined in the glossary at the end of

this document.

B. Cleaning Equipment and Instruments

Cleaning is an extremely important part of

equipment and instrument reprocessing and is

necessary to permit maximum efficacy of subsequent

disinfection and sterilization treatments.

Effective cleaning can physically remove large

numbers of microorganisms (118) . Soil or other foreign

materials can shield microorganisms and protect them

from the action of disinfectants or sterilants or interact

with the disinfectant or sterilant to neutralize the activity

of the process

(119-122)

. Organic material left on a medical

device is extremely difficult to remove after treatment

with glutaraldehyde, which acts as a fixative.

Manufacturers must provide detailed directions for

effective cleaning of all reusable products. The method

and effectiveness of cleaning an item must be considered

prior to purchase. Do not purchase products that cannot

be cleaned. If such products are purchased the health care

setting has the responsibility to develop detailed cleaning

procedures. Effective reprocessing requires rigorous

compliance with recommended protocols. Even full

compliance with protocols may be insufficient if the

method or product selected is inadequate or inappropriate

for cleaning and subsequent disinfection or sterilization

of a particular device.

Staff responsible for cleaning contaminated health

care equipment must be properly trained and conversant

with the purpose of their task. They should wear personal

protective equipment appropriate to the task to protect

themselves from exposure to potential pathogens and

chemicals and to protect the integrity of their skin.

Employees should also be immunized against hepatitis B

(84)

* See Appendix 1 for definitions of the following items: noncritical items, semicritical items, criti cal items, biofilm, cleaning,

decontamination, disinfection, germicides, low level disinfection, intermediate level disinfection, high level disinfection, sanitation,

sterilization..11

Table 5. Reprocessing of Commonly Used Equipment in Health Care Settings in Usual Situations

(See the section on Housekeeping for routine environmental cleaning; outbreaks may require

special disinfection measures)

MANUFACTURERS’ RECOMMENDATIONS FOR CONCENTRATION AND EXPOSURE TIME MUST BE FOLLOWED.

Process Equipment Examples of items* Products or methods†

Cleaning

Some items may

require low level

disinfection ‡

All reusable

equipment

All reusable equipment, since such

equipment requires cleaning after use and

before further disinfection processes are

initiated

Certain environmental surfaces (e.g., of

dental lamps) touched by personnel during

procedures involving parenteral or mucous

membrane contact

Bedpans, urinals, commodes

Stethoscopes

Blood pressure cuffs

Ear specula

Hemodialysis surfaces in contact with

dialysate

Physical removal of soil, dust or foreign

material. Chemical, thermal or mechanical

aids may be used.

Cleaning usually involves soap and water,

detergents or enzymatic agents.

Quaternary ammonium compounds

Phenolics should not be used in nurseries

Some iodophors

3% hydrogen peroxide

Cleaning

followed by

intermediate level

disinfection ‡

Some

semicritical

items

After large environmental blood spills or

spills of microbial cultures in the laboratory

Glass thermometers

Electronic thermometers

Hydrotherapy tanks used for patients whose

skin is not intact ‡

Alcohols

Hypochlorite solutions

Iodophors

Phenolics should not be used in nurseries.

Cleaning

followed by high

level disinfection

Semicritical

items

Flexible endoscopes ‡

Laryngoscopes ‡

Respiratory therapy equipmenta ‡

Nebulizer cups ‡

Anesthesia equipment ‡

Endotrachial tubes ‡

Nasal specula

Tonometer foot plate ‡

Ear syringe nozzles

Vaginal specula

Vaginal probes used in sonographic

scanning ‡

Pessary and diaphragm fitting rings ‡

Cervical caps

Breast pump accessories

Items intended for sterilization in the plasma

or EO sterilizers must be meticulously

cleaned prior to sterilizing (112) .

Pasteurization (113)

2% glutaraldehyde

6% hydrogen peroxide

Peracetic acid

Chlorine or chlorine compounds

* For products that appear in two categories, manufacturers’ directions differ for length of exposure time and concentration.

† Manufacturers' recommendations for concentration and exposure time must be followed.

‡ For guidelines regarding disinfection, refer to comprehensive discussion of disinfection issues (110,114-116) ..i) Sorting and soaking

Unless they can be cleaned immediately, instruments

and small items should be sorted and then submerged in

water and/or detergent to prevent the organic matter from

drying on them. Complete disassembly of each item is

necessary to allow effective cleaning. Heavy or nonim-mersible

items should be wrapped in or covered with a

wet towel.

ii) Removal of organic material

Removal is done with the use of detergents, enzymatic

cleaners, or elevated temperature with or without the use

of mechanical devices such as washer-sterilizer, ultra-sonic

cleaner, dishwasher, utensil washer or washer-disinfectors.

A detergent is used to reduce surface

tension and suspend the soil in water. The detergent

selected must be compatible with the subse quent dis-infection

process because some products can interfere

with chemical disinfection or sterilization. An enzymatic

solution may be used to help in the removal of protein-

aceous material when plain water and/or a detergent

solution is considered inadequate. Combination low level

disinfectant-detergent products (also referred to as

germicidal detergents) are frequently used to clean items

that do not require further disinfection or sterilization

(e.g., intravenous [IV] poles, commodes, wheelchairs).

iii) Rinsing

A thorough rinsing is necessary to remove all the soil

and cleaning agent from the items, to avoid spotting and

to ensure thorough cleanliness. Depending upon the

quality of the available water supply, the final rinse may

require distilled or de-ionized water

(119)

. Cleaning agents

(i.e., detergents) may also make surfaces slippery or

leave residuals that impair equipment integrity and

function. When cleaning is to be followed by

disinfection, it must be ensured that residuals of the

cleaning agent are removed to prevent neutralization of

the disinfectant (120,123) .

Process Equipment Examples of items* Products or methods†

Cleaning

followed by

sterilization

Critical items All items contacting sterile tissue

Surgical instruments

All implantable devices

Needles and syringes

Cardiac and urinary catheters

Hemodialysis, plasmapheresis and heart-lung

oxygenator surfaces in contact with blood

All intravascular devices

Biopsy forceps or biopsy equipment

associated with endoscopy equipment

Bronchoscopes ‡

Arthroscopes ‡

Laparoscopes ‡

Cystoscopes ‡

Transfer forceps

Acupuncture needles and body piercing

objects

Neurologic test needles

Arterial pressure transducers ‡

High speed dental handpieces

All instruments used for footcare

Steam under pressure

Dry heat

Ethylene oxide gas

2% glutaraldehyde

6-25 % hydrogen peroxide

Peracetic acid

Chlorine dioxide

6-8% formaldehyde

* For products that appear in two categories, manufacturers’ directions differ for length of exposure time and concentration.

† Manufacturers' recommendations for concentration and exposure time must be followed.

‡ For guidelines regarding disinfection, refer to comprehensive discussion of disinfection issues (110,114-116) ..iv) Drying

Drying prevents microbial growth. All items that

require no further treatment must be dried prior to

storage. Immediate drying is necessary to prevent

corrosion of stainless steel equipment. While they are

drying, the items should be inspected to ensure that they

are free of all organic soil, oil, grease, and other

matter

(124)

. Post-disinfection flushing of endoscopes with

70% alcohol to ensure thorough drying prior to storage

has been recommended

(118)

Bacteria grow attached to surfaces because of their

hydrophobicity (insolubility in water)

(119,125)

. When

nonsterile surfaces are moist or continuously wet, they

may become coated with a "biofilm", which is a layer of

bacteria encased in an extracellular substance. Biofilm

and its bacteria can be released when disrupted (e.g., in

the lumens of endoscopes). Biofilm development may

also protect bacteria from subsequent disinfection or

sterilization.

Items that require further disinfection or sterilization

may also need to be dried, as water may dilute the action

of the chemical disinfectant.

C. Disinfection

Disinfection is required when cleaning processes

alone do not render an item safe for its intended use.

There are three major methods of disinfection: liquid

chemicals, pasteurization and ultraviolet radiation.

Failure to use disinfection products or processes

appropriately has repeatedly been associated with the

transmission of nosocomial infections

(117,126, 127)

. Table 5

shows the cleaning and disinfection levels required for

many commonly used items of equipment.

In health care settings, the precise nature of the

microbial burden may not be known. In the natural

environment, microorganisms are usually found in

mixtures. For example, fecal material contains vegetative

as well as spore forms of bacteria along with fungi,

viruses and protozoa. Therefore, products and procedures

selected to disinfect instruments must be known to be

effective against pathogens with varying levels of

resistance (See Figure 1). The level of disinfection

achieved depends on factors such as contact time,

temperature, extent of soil, type and concentration of the

active ingredients of the chemical disinfectant, and the

nature of the microbial contamination

(121,126,128)

A variety of factors influence the efficacy of

disinfectant processes, including the innate resistance of

the microorganisms (Figure 1), the concentration and

type of organic and inorganic material present

(cleanliness, presence of biofilm), the intensity and

duration of the treatment, the concentration (on initial

and repeated use) of the disinfectant, the temperature

associated with the process, the contact time associated

with the process, the pH of the solution, the hardness of

water used as the diluent, and interfering residues that

may remain after cleaning

(126,128, 129)

i) Chemical disinfection

In Canada, chemical disinfectants used in health care

settings are regulated by the Health Protection Branch of

Health Canada (see the discussion of Registration of

Disinfectants in Canada later in this section).

ii) Relative resistance of microorganisms

Microorganisms have variable susceptibility to

disinfectant agents (see Fi gure 1). Vegetative bacteria

and enveloped viruses are usually the most sensitive, and

bacterial spores and protozoan cysts the most resistant.

Some pathogens (e.g., Pseudomonas aeruginosa) have

been shown to be significantly more resistant than

their laboratory grown counterparts to a variety of

disinfectants in their "naturally occurring" state,

(i.e., in body fluids and tissues) (110) .

Major classes of disinfectant chemicals and their

relative advantages and disadvantages are summarized in

Table 6. The manufacturer of the chemical disinfectant

will provide instructions for use, including the

recommended exposure time. Manufacturers’

recommendations regarding exposure time must be

followed.

iii) Creutzfeldt-Jakob Disease (CJD)

The Laboratory Centre for Disease Control is

developing CJD protocols

(134,135)

. The prion that causes

Creutzfeldt-Jakob resists normal inactivation methods.

Human infection with the CJD agent has resulted from

either direct exposure of the brain to the CJD agent (e.g.,

dura mater graft) or peripheral injection of CJD agent-contaminated

product derived from human brain

(pituitary hormone). Special CJD-specific infection

control precautions are recommended for patients who

have developed, are suspected of having developed, or

are at substantially increased risk of developing CJD

(i.e., persons who have received human pituitary

hormone [growth hormone and gonadotrophin] or dura

mater grafts, or members of a family in which CJD is

recognized as being familial)

(135)

Needles, needle electrodes, scalpels, ophthalmic

tonometers, autopsy instruments, dedicated equipment

cryostats and all other potentially contaminated materials

should be sterilized by special procedures.

13.Figure 1.

Classes of Microorganisms Ranked in Descending Order from Least to Most Susceptible to Chemical Dis infectants

Least susceptible

Most susceptible

BACTERIA WITH SPORES

(Bacillus subtilis, Clostridium tetani, C. difficile

C. botulinum)

PROTOZOA WITH CYSTS

(Giardia lamblia, Cryptosporidium parvum)

MYCOBACTERIA NON-ENVELOPED VIRUSES

(Mycobacterium tuberculosis (Coxsackieviruses, polioviruses,

M. avium-intracellulare, M. chelonae) rhinoviruses, rotaviruses,

Norwalk virus, hepatitis A virus)

VEGETATIVE BACTERIA

(Staphylococcus aureus, Salmonella typhi, Pseudomonas aeruginosa,

coliforms)

ENVELOPED VIRUSES

(Herpes simplex, varicella-zoster virus, cytomegalovirus, Epstein-Barr

virus, measles virus, mumps virus, rubella virus, influenza

virus, respiratory syncytial virus, hepatitis B and C viruses,

hantaviruses, and human immunodeficiency virus)

FUNGI

(Candida species, Cryptococcus species, Aspergillus species, Dermatophytes).15

Table 6. Major Classes of Chemical Disinfectants and their Relative Advantages and

Disadvantages

MANUFACTURERS’ RECOMMENDATIONS FOR CONCENTRATION AND EXPOSURE TIME MUST BE FOLLOWED.

Disinfectant Uses Advantages Disadvantages

Alcohols Intermediate level disinfectant

Disinfect thermometers, external

surfaces of some equipment (e.g.,

stethoscopes).

Equipment used for home health care (59)

Used as a skin antiseptic

Fast acting

No residue

Non staining

Volatile

Evaporation may diminish

concentration

Inactivated by organic material

May harden rubber or cause

deterioration of glues

Use in the OR is contraindicated

Chlorines (131) Intermediate level disinfectant

Disinfect hydrotherapy tanks, dialysis

equipment, cardiopulmonary training

manikins, environmental surfaces.

Effective disinfectant following blood

spills; aqueous solutions (5,000 parts

per million) used to decontaminate area

after blood has been removed; sodium

dichloroisocyanurate powder sprinkled

directly on blood spills for

decontamination and subsequent

cleanup.

Equipment used for home health

care (59)

See Table 7 for uses for and dilution of

chlorines.

Low cost

Fast acting

Readily available in

non hospital settings

Corrosive to metals

Inactivated by organic material

Irritant to skin and mucous membranes

Unstable when diluted to usable state

(1:9 parts water)

Use in well-ventilated areas

Shelf life shortens when diluted

Ethylene oxide Used as gas for the sterilization of heat

sensitive medical devices

Sterilant for heat or

pressure sensitive

equipment

Slow acting and requires several hours

of aeration to remove residue. One of

its carriers (chlorofluorocarbon) is now

a restricted chemical.

Formaldehyde Very limited use as chemisterilant

Sometimes used to reprocess

hemodialyzers

Gaseous form used to decontaminate

laboratory safety cabinets

Active in presence of

organic materials

Carcinogenic

Toxic

Strong irritant

Pungent odour

Glutaraldehydes 2% formulations — high level

disinfection for heat sensitive

equipment

Most commonly used for endoscopes,

respiratory therapy equipment and

anesthesia equipment

Noncorrosive to metal

Active in presence of

organic material

Compatible with

lensed instruments

Sterilization may be

accomplished in 6-10

hours

Extremely irritating to skin and mucous

membranes

Shelf life shortens when diluted

(effective for 14-30 days depending on

formulation)

High cost

Monitor concentration in reusable

solutions

Fixative.16

Disinfectant Uses Advantages Disadvantages

Hydrogen

peroxide

3% — low level disinfectant

Equipment used for home health care (59)

Cleans floors, walls and furnishings

6% — high level disinfectant

Effective for high level disinfection of

flexible endoscopes (132)

Foot care equipment

Disinfection of soft contact lenses

Higher concentrations used as

chemisterilants in specially designed

machines for decontamination of heat

sensitive medical devices

Strong oxidant

Fast acting

Breaks down into

water and oxygen

Can be corrosive to aluminum, copper,

brass or zinc

Iodophors Intermediate level disinfectant for some

equipment (hydrotherapy tanks,

thermometers)

Low level disinfectant for hard

surfaces and equipment that does not

touch mucous membranes (e.g., IV

poles, wheelchairs, beds, call bells)

Rapid action

Relatively free of

toxicity and irritancy

Note: Antiseptic iodophors are NOT

suitable for use as hard surface

disinfectant

Corrosive to metal unless combined

with inhibitors

Disinfectant may burn tissue

Inactivated by organic materials

May stain fabrics and synthetic

materials

Peracetic acid High level disinfectant or sterilant for

heat sensitive equipment

Higher concentrations used as

chemisterilants in specially designed

machines for decontamination of heat

sensitive medical devices

Innocuous

decomposition (water,

oxygen, acetic acid,

hydrogen peroxide)

Rapid action at low

temperature

Active in presence of

organic materials

Can be corrosive

Unstable when diluted

Phenolics Low/intermediate level disinfectants

Clean floors, walls and furnishings

Clean hard surfaces and equipment that

does not touch mucous membranes

(e.g., IV poles, wheelchairs, beds, call

bells)

Leaves residual film

on environmental

surfaces

Commercially

available with added

detergents to provide

one-step cleaning and

disinfecting

Do not use in nurseries

Not recommended for use on food

contact surfaces

May be absorbed through skin or by

rubber

Some synthetic flooring may become

sticky with repetitive use

Quaternary

ammonium

compounds

Low level disinfectant

Clean floors, walls and furnishings

Clean blood spills (133)

Generally non-

irritating to hands

Usually have detergent

properties

DO NOT use to disinfect instruments

Non-corrosive

Limited use as disinfectant because of

narrow microbicidal spectrum.iv) Reuse of chemical disinfectants

Several physical and chemical factors influence

disinfectant action, including temperature, pH, relative

humidity, and water hardness (110,128) . Extremes of acidity

or alkalinity can effectively limit growth of micro-organisms.

Moreover, the activity of antimicrobial agents

may be profoundly influenced by relatively small

changes in the pH of the medium

(136)

. An increase in pH

improves the antimicrobial activity of some disinfectants

(e.g., glutaraldehyde, quaternary ammonium compounds)

but decreases the antimicrobial activity of others (e.g.,

phenols, hypochlorites, iodine). The pH influences the

antimicrobial activity by altering the disinfectant

molecule or the cell surface

(110)

Many chemical disinfectants require dilution prior to

use. It is mandatory that users follow exactly the

manufacturer’s directions regarding dilution and mixing.

If the concentration of the disinfectant is too low the

efficacy will be decreased. If the concentration is too

high the risk of the chemical damaging the instrument or

causing toxic effects on the user increases.

Once diluted some disinfectants may be used (if

handled properly) for a period of days or weeks.

Dilutions are inherently unstable once mixed and the

manufacturer’s directions as to duration of use must be

followed.

Glutaraldehydes require special discussion. Glutar-aldehydes

may be in acidic or alkaline formulations, and

are usually purchased in concentrated forms and diluted

for use. These dilutions are time limited. During reuse,

the concentration of active ingredient(s) in the product

may drop as dilution of the product occurs (incomplete

drying), and while organic impurities accumulate

(incomplete cleaning)

(128)

. Chemical test strips are

available for determining whether an effective

concentration of active ingredients (e.g., glutaraldehyde)

is present despite repeated use and dilution. The

frequency of testing should be based on how frequently

the solutions are used (e.g., used daily, test daily). The

strips should not be considered a way of extending the

use of a disinfectant solution beyond the expiration date.

The glutaraldehyde solution should be considered unsafe

Table 7. Directions for Preparing and Using Chlorine-based Disinfectants

Product Intended use Recommended dilution Level of available chlorine

Household bleach

(5% sodium hypochlorite

solution with 50,000 ppm *

available chlorine)

Cleanup of blood spills Use concentrations ranging

from 1 part of bleach to be

mixed with 99 parts of tap

water (1:100) or one part of

bleach to be mixed with 9

parts of tap water (1:10),

depending on the amount of

organic material (e.g., blood or

mucus) present on the surface

to be cleaned and disinfected.

0.05% or 500 ppm

0.5% or 5,000 ppm

To add to laundry water One part (one 8 ounce cup) of

bleach to be mixed with about

500 parts (28 gallons†) of tap

water

0.01% or 100 ppm

Surface cleaning

Soaking of glassware or

plastic items

One part (one 8 ounce cup) to

be mixed with about 50 parts

(2.8 gallons) of tap water

0.1% or 1,000 ppm

NaDCC (Sodium dichloro-isocya

nurate) powder with

60% available chlorine

Cleanup of blood spills Dissolve 8.5 g in one litre of

tap water

0.85% or 5,000 ppm

Chloramine-T powder with

25% available chlorine

Cleanup of blood spills Dissolve 20 g in one litre of

tap water

2.0% or 5,000 ppm

* Parts per million

† Imperial gallon (4.5 litres)

For further information on uses of bleach in health care refer to article on subject

(131)

..when the concentration of glutaraldehyde falls below the

minimum effective concentration (MEC) for the product

or the dilution falls below 1% glutaraldehyde

(110)

v) Disinfectants and safety

Chemical disinfectants are a double-edged sword.

Although their use is necessary in many routine health

care settings, the ability of these products to kill

infectious agents also makes them potentially harmful to

humans and the environment. Although manufacturers

continue to work to improve their formulations, it is

unrealistic to expect that highly effective disinfectants

that are also completely safe will be available in the near

future.

Products containing glutaraldehyde require special

attention. Glutaraldehydes are used exten sively in the

disinfection of semicritical instruments because they are

noncorrosive and relatively fast acting in addition to

possessing a broad spectrum of activity. However, the

pungent and irritating nature of glutaraldehyde fumes

and the toxic effects of this disinfectant on skin make it a

workplace hazard. The expanding use of glutaraldehyde

in many health care settings has led to legislation or

regulations in some provinces (e.g., British Columbia)

that limit workers’ exposure to glutaraldehyde fumes, for

instance through the installation of fume hoods and

extraction fans in units using glutaraldehyde.

vi) Registration of disinfectants in Canada

In Canada, the main control of antimicrobials rests on

two pieces of legislation. Antimicrobial products that are

labelled for use in health care facilities or food

processing plants or on medical devices and are

produced for the purposes of disease prevention and

health preservation are regulated as drugs under the Food

and Drugs Act and Regulations, which are administered

by the Therapeutic Products Programme, Bureau of

Pharmaceutical Assessment, Health Protection Branch,

Health Canada. Products used for disinfection or

antimicrobial purposes in domestic or household

applications, non-food industrial applications, etc. are

regulated under the Pest Control Products Act and

Regulations, which are administered by the Pest

Management Regulatory Agency, Health Canada.

For disinfectant drugs, manufacturers must obtain a

drug identification number (DIN) from Health Canada

prior to marketing. To obtain this they must submit a

DIN application, with labelling and supporting data (if

required) to the Therapeutic Products Directorate for

evaluation. For a DIN to be issued, it must be established

that the product is effective and safe for its intended

use

(137)

The extent of premarket assessment of disinfectant

products is based on the relative risk associated with the

use of the product, which varies depending on the

established knowledge of the active ingredients and the

proposed uses for the product. On the basis of this

premise, disinfectants or sterilants for use on medical

instruments undergo a more rigorous pre-market

assessment than disinfectants containing well-known

active ingredients for use on environmental surfaces such

as floors and walls.

Specific efficacy test methodologies and data

requirements for disinfectants to be marketed in Canada

are recommended by the Canadian General Standards

Board. These requirements vary according to the

proposed use(s) of the product, resulting in specific test

methodologies and test organisms to match specific

claims of efficacy. The most stringent requirements exist

for sterilants, products that are to be used for the

sterilization of critical instruments. High level

disinfectants carry less stringent requirements and are

labelled for use on semicritical instruments. Low level

disinfectants are labelled for the disinfection of

noncritical items and environmental surfaces, and thus

have the least stringent efficacy requirements.

The label on the disinfectant must clearly indicate the

following information: the product name, a quantitative

statement of active ingredient(s), its intended use, the

area and site of use, and specific directions for use,

including the specific types of surfaces/instruments to be

disinfected, any dilution procedure required, the mode of

application, the contact time, any cleaning and rinsing

procedures, the temperature for use and the reuse period.

The labelling must also include appropriate pre-cautionary

symbols and statements as well as first aid

instruction.

The proposed label claims are reviewed, and in order

to be considered acceptable they must have been

substantiated with data demonstrating with a great level

of confidence that the product is effective under the

proposed conditions of use. The label claims must not be

misleading.

Should there be any questions regarding the label

claims, conditions of use, etc., of a product, the

reviewing bureau within the Health Protection Branch

(Bureau of Pharmaceutical Assessment) should be

contacted for verification. See Appendix 3 for

information.

18.vii) Product labelling

• The product label must have a Drug Identification

Number (DIN). The presence of a DIN indicates that,

upon review, it has been established that the product is

safe and effective for its intended use.

• The prod uct la bel must be read care fully for in struc -tions

on use. Fail ure to do so of ten leads to in appro -priate

use, stor age or dis posal of the prod uct and may

expose the pa tient as well as the health care worker

to an in creased risk of in fections or toxic chemi cal

effects. In appropriate stor age of chemi cal dis infec -tants

may re duce their shelf life, and if they be come

contaminated, may also lead to bac terial growth.

• The product label should include mixing instructions,

including concentrations for dilution, and length of

disinfection time.

• The prod uct label needs to be read for fac tors that may

influence the activ ity of the dis infectant, such as tem -perature,

pH, rela tive humid ity and water hard ness.

viii) Pasteurization

Pasteurization is a process of hot water disinfection,

which is accomplished through the use of automated

pasteurizers or washer disinfectors. Semicritical items

suitable for pasteurization include equipment for

respiratory therapy and anesthesia.

Exposing respiratory and anesthesia equipment to

water above 75

C for 30 minutes is a recognized

alternative to chemical disinfection. Items to be

pasteurized must be thoroughly cleaned with detergent

and water prior to disinfection

(109)

. The items must be

totally immersed in water during the pasteurization

cycle.

The advantages of pasteurization include its

nontoxicity, rapid disinfection cycle, and moderate cost

of machinery and upkeep.

The major disadvantages of pasteurization are that

(1) it is not sporicidal, (2) it may cause splash burns,

(3) there is a lack of standardization of the equipment

and (4) there is difficulty validating the effectiveness

of the process. The process may be monitored by

temperature gauges and timing mechanisms.

Since pas teurization is not a ster ilization pro cess,

extreme care must be taken to en sure that the pro cess is

appropriately per formed so that in fectious agents consid -ered

to be par ticularly im portant are in activated

(138)

. Af ter

pasteurization, spe cial care must be taken to dry (re sidual

water tends to col lect) and pre vent re contamination of

the equip ment dur ing stor age and trans port

(138,139)

ix) Ultraviolet radiation

Microorganisms are inactivated by ultraviolet (UV)

light in wavelengths within a range of 250-280 nm

(140)

Modern mercury-vapor lamps emit radiation within that

level. Ultraviolet radiation has several potential appli-cations,

but its germicidal effectiveness and use is

influenced by organic matter, wavelength, type of

suspension, temperature, type of microorganism, and UV

intensity (which is affected by distance and dirty tubes).

The application of UV light in the hospital is limited to

the destruction of airborne organisms or inactivation of

microorganisms located on surfaces. Ultraviolet

germicidal irradiation is a method of air cleaning that can

be used to supplement other tuberculosis control

measures. Installing ultraviolet lamps in ventilation ducts

has two advantages: high levels of UV irradiation may be

produced and, since the UV light is in the duct, the risk

of human exposure is reduced or eliminated (141) . The

Health Canada Guidelines for Preventing the Trans-mission

of Tuberculosis in Canadian Health Care

Facilities and Other Institutional Settings

(140)

concludes

its discussion of UV germicidal irradiation by saying that

it may be a useful adjunct in ventilation ducts or in high-risk

areas, such as bronchoscopy suites, autopsy suites,

or other areas where patients with undiagnosed TB may

be seen frequently.

No data support the use of UV lamps in isolation

rooms

(110)

. Portable ultraviolet light devices should not

be used for disinfection purposes in community settings

(e.g., of esthetic or body piercing equipment).

UV light may cause skin and eye burns, and may

theoretically cause cataracts and skin cancer. Problems

have occurred when UV lights have not been installed

properly or have not been monitored and maintained

correctly

(139,140)

x) Boiling

Boiling is not an acceptable method of sterilization in

health care. In home care, boiling has been used to

disinfect some items if they do not deteriorate in the pro -cess.

Home care guidelines should be followed

(59,142,143)

The use of boiling water to clean instruments and

utensils cannot be called sterilization. Research has

shown that boiling water or moist heat at a temperature

of 100 0 C (212 0 F) is inadequate for the destruction of

bacterial spores and some viruses (144) . Another major

disadvantage of using boiling water to clean instruments

and utensils is that the items are not packaged so that

they can be stored and transported without

contamination.

19.xi) Sterilization

All critical items that are in contact with the blood

stream, nonintact mucous membranes or normally sterile

body sites must be sterile. Sterilization is a process, not

just a single event. Appropriate procedures must be

followed to achieve and maintain sterility. The sterili-zation

process must be validated and documented.

Table 8 summarizes the advantages and disadvantages

of sterilization methods as well as recommended appli-cations

and monitoring strategies. Manufacturers of

sterilizers should be contacted for specific instructions on

installation and use of their equipment. Storage and

transportation practices must maintain sterility to the

point of use. Manufacturers of sterilizers should be

specific as to which devices can be sterilized in their

machines, and manufacturers of medical devices and

equipment should be specific as to the recommended

sterilization methods.

xii) New technologies

Because of difficulties in disinfecting and sterilizing

equipment, such as heat-labile medical devices and

devices with small lumens, new technologies are being

developed. New technologies will have limited appli-cations

(e.g., may not be appropriate for instruments with

lumens or may be incompatible with some materials). No

single method will work for all hospitals. Policies and

procedures must be established to ensure that the

reprocessing of equipment follows the principles of

infection prevention.

There is controversy about the monitoring of the

efficacy of liquid chemical sterilization cycles. Biologic

monitoring of liquid chemical sterilization processes

using traditional biologic indicators does not appear

feasible at this time

(154)

xiii) Monitoring of the sterilization cycle

Monitoring of sterilization cycles can be divided into

three distinct methods

(139)

Mechanical: time and temperature graphs, charts

or printouts

Chemical: time/temperature and/or humidity

sensitive tape, strips or pellets

(155)

Biologic: spore-laden strips or vials

(156)

Mechanical and chemical monitors merely provide a

visible indicator that the conditions required to achieve

sterilization, such as time, temperature and pressure,

have been met.

Only biologic indicators monitor the actual

effectiveness of the sterilization process, which is

intended to kill all microbes, including spores

(157)

. An

ideal biologic indicator should have the following

characteristics: a well characterized organism, widely

available, standardized preparation, more resistant to the

sterilization process than human pathogens, rapid

readout, easy to use, nonpathogenic, and inexpensive (158) .

The spores chosen for biologic monitoring must be

appropriate for the method of sterilization being

monitored

(154)

. For example Bacillus stearothermophilus

spores are used for steam sterilization and Bacillus

subtilis for dry heat and ethylene oxide cycles. The

frequency of monitoring is indicated in Table 8.

Traditionally, commercially prepared biologic

indicators require an incubation time of 24 to 48 hours

prior to reading. The recent development of rapid readout

biologic monitors, which use fluorometric detection of a

spore-bound enzyme at 60 minutes, may offer an

alternative to observation of spore growth. Use of rapid

readout biologic indicators may enable release of

sterilized implants for use or rapid recall of inadequately

sterilized devices

(156,157)

. The manufacturer’s instructions

should be followed in the use of all commercially

prepared biologic monitoring systems.

Although indicators are an important part of quality

assurance of sterilization processes, the validation of the

process and documentation of the operating parameters

of the process are of paramount importance. Testing with

spore and chemical indicators is only as good as the

placement of the spore suspensions or indicators. All

sterilization processes should be thoroughly evaluated

before being put into service, and at regular intervals

afterwards. Autoclaves should be mapped with

thermocouples to determine potential cold spots. Filter

systems should be tested for leakage. Gas sterilization

units should be appropriately validated for such factors

as gas concentration, temperature, and relative humidity.

In order to ensure appropriate sterilization processes,

health care facility personnel must comply with the

manufacturer’s recommendations.

The daily operation of the sterilization must be

documented by personnel performing the process. This

documentation should be reviewed for each operation,

and any malfunction should be noted and appropriate

action taken to ensure that the product either has been

properly treated or is returned for reprocessing

(138)

The health care facility should have a protocol on the

procedure to follow if monitoring shows equipment

failure

(139)

20.Table 8. Advantages and Disadvantages of Currently Available Sterilization Methods

MANUFACTURERS’ RECOMMENDATIONS FOR CONCENTRATION AND EXPOSURE TIME MUST BE FOLLOWED.

Sterilization method Parameters Monitoring/frequency Use/advantages Disadvantages

Steam

a) Small table top sterilizers

b) Gravity displacement

sterilizers including flash

sterilizers

c) High-speed vacuum sterilizers

Flash sterilization

Raised pressure (preset by

manufacturer) to increase

temperature to 121 0 C (133 0 C for

flash sterilizers)

Time varies with temperature,

type of material and whether the

instrument is wrapped or not.

Steam must be saturated (narrow

lumen items may require

prehumidification).

Flash sterilization should be

used only in an emergency.

Flash sterilization should never

be used for implantable devices.

Air detection for vacuum

sterilizers - daily before first

cycle of day

Mechanical - each cycle (103)

Chemical - each cycle (103)

Biologic - at least weekly, but

preferably daily, and with each

load of implantable items

(Bacillus stearotherm ophilus

spores). Loads containing

implantable devices shall be

monitored and, whenever

possible, the implantable devices

quarantined until the results of

the biologic indicator testing are

available (103) .

Mechanical - each cycle

Chemical - each cycle

Biologic - at least once a week

but preferably daily (145)

Heat tolerant instruments and

accessories

Linen

Inexpensive

Rapid

Efficient

Non toxic

Can be used to sterilize liquids

Not recommended

Unsuitable for anhydrous oils,

powders, lensed instruments, heat

and moisture sensitive materials.

Some table top sterilizers lack a

drying cycle.

If the devices are used before the

results of biologic indicators are

known, personnel must record

which devices were used for

specific patients, so that they can

be followed if the load was not

processed properly (113,145-148) .

Difficult to monitor

The efficacy of flash sterilization

will be impaired if all the

necessary parameters are not met

properly (e.g., time, temper-ature),

the device is contaminated

with organic matter, air is

trapped in