APIC DFW
PROFESSIONAL
ADVANCEMENT
CHAPTER 10 REVIEW:
CLEANING, STERILIZATION,
DISINFECTION & ASEPSIS
Test Your Knowledge
1. Type of germicidal action required for semi-critical
items:
a) Kills all microorganisms except high numbers of bacterial
spores
b) Kills all vegetative bacteria, fungi & lipid viruses
c) Kills all microorganisms, including bacterial spores
d) Kills all visible contamination
Test Your Knowledge
2. The first step in the sterilization process is:
a) Wrapping of the equipment prior to placing in autoclave
b) Pre-cleaning by applying enzymatic cleaner or detergent to
the used equipment
c) Taking the equipment to the Sterile Processing Dept. via
biohazard container
d) Cleaning the equipment via manual or mechanical means
Test your knowledge
3. Types of antiseptics include all of the following except:
a)
b)
c)
d)
e)
f)
Iodophors
Chlorhexidine, 2 & 4% aqeuous
Glutaraldehyde, ≥2.0%
Alcohols, 60-95%
PCMX
Triclosan
Cleaning, Sterilization,
Disinfection & Asepsis
CIC exam contains 15 questions on these topics, covering:
1. Identification & evaluation of appropriate cleaning,
sterilization & disinfection practices
2. Collaboration with others to assess products under
evaluation of their ability to be reprocessed
3. Identification & evaluation of critical steps in cleaning,
high-level disinfection & sterilization
Resources for Study
• APIC Test of Infection Control & Epidemiology, 4th
edition; focus on chapters 7, 30, 31, 32 & 106
• Ready Reference for Microbes
• Control of Communicable Diseases Manual
• The Infection Preventionist’s Guide to the Lab
(all authors/references listed in the study guide)
Supplemental reference: William Dr. Rutala’s website:
disinfectionandsterilization.org
Key Concepts
1. Disinfection & sterilization are essential to reduce the risk
of transmitting infections pathogen to patients.
2. Failure to comply with scientifically based guidelines has led
to numerous outbreaks
3. Adherence to evidence-based recommendations on the
preferential methods for cleaning, disinfection &
sterilization of patient care medical devices & for cleaning &
disinfecting the HC environment are critical components of
IP & C programs.
Definitions
EH Spaulding developed the concept that how an object would be
disinfected depended on the object’s intended use.
1. CRITICAL - objects which enter normally sterile tissue
or the vascular system or through which blood flows
should be sterile
2. SEMICRITICAL - objects that touch mucous
membranes or skin that is not intact require a
disinfection process (high-level disinfection[HLD]) that
kills all microorganisms except for high numbers of
bacterial spores
3. NONCRITICAL - objects that touch only intact skin
require low-level disinfection
Table 31-1 Methods for Disinfection and Sterilization of Patient-Care Items
and Environmental Surfaces
Process
Sterilization
High-level
disinfection
(HLD)
Level of Microbial Method
Inactivation
Destroys all
High temperature
microorganisms,
including bacterial
spores
Low temperature
Destroys all
microorganisms
except high
numbers of
bacterial spores
Examples
(with processing times)
Steam (~40 min), dry heat (1-6 hr
depending on temperature)
Healthcare
Application
Heat-tolerant critical
(surgical instruments)
and semicritical
patient-care items
Ethylene oxide gas (~15 hr), hydrogen Heat-sensitive critical
peroxide gas plasma (28-52 min),
and semicritical
ozone (~4 hr), hydrogen peroxide
patient-care items
vapor (55 min)
Liquid immersion Chemical sterilants include*: >2% glut Heat-sensitive critical
(~10 hr); 1.12% glut with 1.93%
and semicritical
phenol (12 hr); 7.35% HP with 0.23% patient-care items
PA (3 hr); 8.3% HP with 7.0% PA (5 that can be
hr); 7.5% HP (6 hr); 1.0% HP with
immersed
0.08% PA (8 hr); >0.2% PA (12 min at
50-56°C)
Heat-automated Pasteurization (65-77°C, 30 min)
Heat-sensitive
Liquid
Chemical sterilants/HLDs include*: semicritical items
immersion
>2% glut (10-90 min); 0.55% OPA
(e.g., respiratory
(12 min); 1.12% glut with 1.93%
therapy equipment)
phenol (20 min); 7.35% HP with
Heat-sensitive
0.23% PA (15 min); 7.5% HP (30
semicritical items
min); 1.0% HP with 0.08% PA (25
(e.g., GI scopes,
min); 650-675 ppm chlorine (10
bronchoscopes,
min); 2.0% HP (8 min); 3.4% glut
endocavitary
with 26% isopropanol (10 min)
probes)
Intermediate-level Destroys all
disinfection
microorganisms
except high
numbers of
bacterial spores
Heatautomated
Low-level
disinfection
Liquid contact EPA-registered hospital disinfectant
with label claim regarding
tuberculocidal activity (e.g., chlorinebased products, phenolics, improved
hydrogen peroxide-exposure times at
least 1 min)
Destroys
vegetative
bacteria,
mycobacteria,
most viruses,
most fungi but
not bacterial
spores
Liquid
immersion
Pasteurization (65-77°C, 30 min)
Heat-sensitive
semicritical items
(e.g., respiratory
Chemical sterilants/HLDs include*: therapy
>2% glut (10-90 min); 0.55% OPA (12 equipment)
min); 1.12% glut with 1.93% phenol Heat-sensitive
(20 min); 7.35% HP with 0.23% PA (15 semicritical items
min); 7.5% HP (30 min); 1.0% HP with (e.g., GI
0.08% PA (25 min); 650-675 ppm
endoscopes,
chlorine (10 min); 2.0% HP (8 min); bronchoscopes,
3.4% glut with 26% isopropanol (10 endocavitary
min)
probes)
Noncritical
patient care item
(blood pressure
cuff) or surface
with visible blood
CRITICAL/STERILIZATION
• Anything entering sterile body tissue
• Surgical instruments
• Foley Catheters
• All central & venous lines
• Implantable devices
• Hands via gloves which are entering
sterile body sites or handling sterile
instruments
Sterilization
• Killing of all microorganisms, including
bacterial spores.
• Examples: Surgical instruments and
devices; cardiac catheters; implants; etc.
• Methods: Steam, gas, hydrogen peroxide
gas plasma, vaporized hydrogen
peroxide, ozone or chemical sterilization.
Steps in Sterilization
•Immediate application of detergent/enzymatic to all surfaces
of used instruments
•Items then cleaned using water with detergents or enzymatic
cleaners
•Cleaning reduces the bioburden and removes foreign material
(organic residue and inorganic salts) that interferes with the
sterilization process.
•Cleaning and decontamination should be done as soon as
possible after the items have been used as soiled materials
become dried onto the instruments
•Basic principle: it it’s not clean, it can’t be sterilized or
disinfected!!
Washer-Disinfector
Ready to package for
sterilizer??
No…because it’s not ________!
Steam Sterilization
• Most commonly used type of sterilization
• Six parameters that must be met for
sterilization to occur
1. Time
2. Temperature
3. Moisture
4. Direct steam contact
5. Air removal
6. Drying
QA Measures to Assure Sterilization
1. Biological Indicators: considered the only true indicators of
sterilization because show “proof ” that sterilization cycle actually
killed a very hard-to-kill organism (see below)
2. Both control & the biological in sterilizer (which should be placed
deep in pack) are incubated; if cycle successful, the organism will
not grow in “sterilized” BI (but control will grow)
3. If failure (sterilized BI grows), none of equipment since last
successful cycle should be used. Sterilizer is taken out of use &
vendor notified for repairs. If any equipment since last successful
load has been used, IP & surgeon are notified.
4. Types of Biological Indicators
Bacillus stearothermophilis – Moist-heat systems – Geobacillus
stearothermophilis
Bacillus subtilis – EO, dry heat systems – Bacillus atropheus
Bacillus pumilus – Radiation-based systems
5. BIs should be run at least weekly, but most facilities run daily; they
should also be used after servicing prior to use
Sterilization QA, cont.
•Chemical Indicators: usually tape or strip with print
that changes color when temp parameter is met; placed
in every load.
•Sterilizer print-outs: show that machine completed all
cycles—the details of the process
•Bowie-Dick: also sometimes placed in packs to ensure
that sufficient vacuum condition established; must
have adequate vacuum to assure adequate steam
penetration
•Logs are kept of all sterilizer testing; surveyors will
usually ask to see the last years’ worth of data; most
facilities keep 3 years of data on file.
Immediate Use Steam Sterilization (IUSS)
• In 1969, Perkins redefined flash sterilization as an unwrapped
item exposed to 270°F for 3 minutes in a gravity sterilizer.
• Only used for items that must be used immediately
• Acceptable for processing items that cannot be
packaged, sterilized and stored before use—but
items should be placed in rigid containers prior to
IUS to help maintain sterility
• Because of the potential for serious infections, implanted
surgical devices should not be flash sterilized
• Do not use flash sterilization for reasons of convenience, as an
alternative to purchasing additional instrument sets, or to save
time
• Tracking & trending of IUS recommended to identify areas for
improvement.
Semi-critical/High
Level Disinfection
• For items with mucous membrane or non-intact skin
contact, such as:
• Endoscopes
• Laryngoscopes,
• Endocavitary probes
• Prostate biopsy probes
• Tonometers
Semi-critical/High
Level Disinfection
• Issues with Reprocessing of Semi-critical Equipment
• Reprocessing semi-critical items has been shown to have
a narrow margin of safety
• Generally, the narrow margin of safety attributed to
high microbial load and complex instruments with
lumens
• Any deviation from the recommended reprocessing
protocol can lead to the survival of microorganisms and
an increased risk of infection
• Problems encountered with reprocessing semi-critical
equipment often related to improper cleaning
Transmission of Infection by Endoscopy
Kovaleva et al. Clin Microbiol Rev 2013. 26:231-254
Scope
Outbreaks
Micro
(primary)
Pts
Contaminated
Pts Infected Cause (primary)
Upper GI
19
Pa, H. pylori,
169
56
Cleaning/Disinfection (C/D)
Salmonella
Sigmoid/
Colonoscopy
5
Salmonella, HCV
14
6
Cleaning/Disinfection
ERCP
23
Pa
152
89
C/D, water bottle,
AER
Bronchoscopy
51
Pa, Mtb,
Mycobacteria
778
98
C/D, AER, water
Totals
98
1113
249
Based on outbreak data, if eliminated deficiencies associated with cleaning, disinfection, AER ,
contaminated water and drying would eliminate about 85% of the outbreaks.
FEATURES OF ENDOSCOPES THAT
PREDISPOSE TO DISINFECTION FAILURES
• Require low temperature
disinfection
•
•
•
•
Long narrow lumens
Right angle turns
Blind lumens
May be heavily
contaminated with
pathogens (9-10 logs
inside)
• Cleaning (4-6 log10
reduction) and HLD (4-6
log10 reduction) essential
for patient safe
instrument
ENDOSCOPE REPROCESSING
1)
PRECLEAN: point-of-use (bedside) remove debris by wiping exterior and
aspiration of detergent through air/water and biopsy channels-transport to scope
cleaning area in safe manner
2)
3)
CLEAN: mechanically cleaned with water and enzymatic cleaner
4)
RINSE: scope and channels rinsed with sterile water, filtered water, or tap water.
Flush channels with alcohol and dry
5)
6)
DRY: use forced air to dry insertion tube and channels
HLD/STERILIZE: immerse scope and perfuse HLD/sterilant through all
channels for exposure time (>2% glut at 20m at 20oC). If AER used, review modelspecific reprocessing protocols from both the endoscope and AER manufacturer
STORE: hang in vertical position to facilitate drying; stored in a manner to protect
from contamination
A. CMS & TJC getting more strict on scope storage; should not touch floor or
walls of cabinet, or each other, & should be in closed closet/cabinet.
7) Sterilization of scopes with elevators now being recommended (or HLD X 2).
8) Outcome monitoring of scope reprocessing is under consideration; currently
process monitoring is all that is required; performance of outcome testing via scope
culturing/ATP testing under consideration.
High-Level Disinfectants for
Semicritical Objects
Exposure Time > 8m-45m (US), 20oC
Germicide
Glutaraldehyde
Ortho-phthalaldehyde
Hydrogen peroxide*
Hydrogen peroxide and peracetic acid*
Hydrogen peroxide and peracetic acid*
Hypochlorite (free chlorine)*
Accelerated hydrogen peroxide
Peracetic acid
Glut and isopropanol
Glut and phenol/phenate**
*May cause cosmetic and functional damage;
Concentration__
> 2.0%
0.55%
7.5%
1.0%/0.08%
7.5%/0.23%
650-675 ppm
2.0%
0.2%
3.4%/26%
1.21%/1.93%___
**efficacy not verified
Workflow, QA and Other Considerations
• Workflow must be from dirty to clean with no opportunity
for cross-contamination
• Monitoring of HLD chemical: chemical test strips are tested
X 3 when opening new bottle, solution is tested with strip
before use to make sure it has sufficient concentration
remaining; temp. of solution also monitored when using
solution
• Solution much be changed out as recommended by
manufacturer (even if concentration still adequate)
• All of this monitoring info. must be recorded without failsurveyors will ask to see 1 year of records; most facilities
keep 3 years of records on file.
Workflow, QA and Other Considerations
• Scopes which have not been used/disinfected must be
disinfected on regular basis (most using 7 days)
• Adequate PPE must be available for staff disinfecting
scopes (all HCWs must receive education on PPE use)
• Appropriate spill kits must be available in proximity of
chemical; make sure staff knows where it is, how to use
it, etc. Also, the spill kits generally outdate—educate
staff to monitor expiration dates (& check for yourself
when in dept.
• Round frequently, ask lots of questions. A VERY hot
topic for TJC & CMS (which is definitely warranted)
ENDOSCOPE REPROCESSING:
CHALLENGES:
NDM-Producing E. coli -associated ERCP
Epstein et al. JAMA 2014;312:1447-1455
• March-July 2013, 9 patients with cultures for New Delhi
Metallo-ß-Lactamase producing E. coli associated with ERCP
•
•
•
•
•
History of undergoing ERCP strongly associated with cases
NDM-producing E.coli recovered from elevator channel
No lapses in endoscope reprocessing identified
Hospital changed from automated HLD to ETO sterilization
Due to either 1)failure of personnel to complete required
process every time or 2)intrinsic problems with these scopes
(not altered reprocessing)
ENDOSCOPE REPROCESSING:
CHALLENGES
Complex [elevator channel]-109
bacteria
Surgical instruments-<102
bacteria
Reprocessing of Rigid
Laryngoscopes
JHI 2008, 68:101; ICHE 2007, 28:504; AJIC 2007, 35: 536
• Limited guidelines for reprocessing laryngoscope’s blades and
handles
• Many hospitals consider blade as semicritical (HLD) and handle
as noncritical (LLD)
• Blades linked to HAIs; handles not directly linked to HAIs but
contamination with blood/OPIM suggest its potential and blade
and handle function together
• Ideally, clean then HLD/sterilize blades and handles (UNCHC-
blades wrapped in a tray-Sterrad; handle wrapped in tray [without
batteries]-steam); the blades and handles placed together in a
Ziploc bag. Blades and handles checked for function prior to
packaging.
Laryngoscopes Blades
The Joint Commission, FAQ, October 24, 2011
• How should we process and store laryngoscope blades?
• Processed via sterilization or HLD
• Packaged in some way to prevent from contamination
• Also stored in a way that prevents recontamination.
Examples of compliant storage include, but are not
limited to, a peel pack post steam sterilization (long-term)
or wrapping in a sterile towel (short term)
• Should not place unwrapped blades in an anesthesia
drawer (or anywhere, for that manner)
ENVIRONMENTAL CONTAMINATION
LEADS TO HAIs
• There is increasing evidence to support the contribution
of the environment to disease transmission—prevent
with cleaning & low level disinfection of non-critical
items & surfaces.
• This supports comprehensive disinfecting regimens
(goal is not sterilization) to reduce the risk of acquiring a
pathogen from the healthcare environment/equipment
KEY PATHOGENS WHERE
ENVIRONMENTIAL SURFACES PLAY A
ROLE IN TRANSMISSION
•
•
•
•
•
•
•
MRSA
VRE
Acinetobacter spp.
Clostridium difficile
Norovirus
Rotavirus
SARS
ENVIRONMENTAL SURVIVAL OF KEY
PATHOGENS ON HOSPITAL SURFACES
Pathogen
S. aureus (including MRSA)
Enterococcus spp. (including VRE)
Survival Time
7 days to >12 months
5 days to >46 months
Acinetobacter spp.
Clostridium difficile (spores)
Norovirus (and feline calicivirus)
3 days to 11 months
>5 months
8 hours to >2 weeks
Pseudomonas aeruginosa
Klebsiella spp.
6 hours to 16 months
2 hours to >30 months
Adapted from Hota B, et al. Clin Infect Dis 2004;39:1182-9 and
Kramer A, et al. BMC Infectious Diseases 2006;6:130
Environmental Disinfection Interventions
Donskey CJ. Am J Infect Control 2013;41:S12
• Cleaning product changes
• Improvements in the effectiveness of cleaning and
disinfection practices
• Education
• Audit and feedback
• Addition of housekeeping personnel or specialized cleaning staff
• Automated technologies
• Conclusion: Improvements in environmental disinfection may prevent
transmission of pathogens and reduce HAIs
LOW-LEVEL DISINFECTION FOR
NONCRITICAL EQUIPMENT AND SURFACES
Exposure time per manufacturer recommendations
Germicide
Use Concentration
Ethyl or isopropyl alcohol
70-90%
Chlorine
100ppm (1:500 dilution)
Phenolic
UD
Iodophor
UD
Quaternary ammonium
UD
Improved hydrogen peroxide (HP)
0.5%, 1.4%
____________________________________________________
UD=Manufacturer’s recommended use dilution
REVIEW THE “BEST”
PRACTICES FOR CLEANING
AND DISINFECTING
SURFACES
Cleaning and disinfecting is one-step with
use of disinfectant-detergent (EPA claim in
presence of soil). No pre-cleaning necessary
unless spill or gross contamination.
ALL “TOUCHABLE”
(HAND CONTACT) SURFACES
SHOULD BE WIPED WITH
DISINFECTANT
“High touch” objects only recently defined
(no significant differences in microbial
contamination of different surfaces) and
“high risk” objects not epidemiologically
defined.
PROPERTIES OF AN IDEAL DISINFECTANT
Rutala, Weber. Infect Control Hosp Epidemiol. 2014;35:855-865
•
•
•
•
Broad spectrum: wide antimicrobial spectrum
•
•
•
•
•
•
•
•
Nontoxic: not irritating to users
Fast acting: should produce a rapid kill
Remains Wet: meets listed kill/contact times with a single application
Not affected by environmental factors: active in the presence of organic
matter
Surface compatibility: should not corrode instruments and metallic surfaces
Persistence: should have sustained antimicrobial activity
Easy to use
Acceptable odor
Economical: cost should not be prohibitively high
Soluble (in water) and stable (in concentrate and use dilution)
Cleaner (good cleaning properties) and nonflammable
Scoring Considerations for Selecting the Ideal
Disinfectant for Your Facility
Rutala, Weber. Infect Control Hosp Epidemiol. 2014;35:855-895
Consideration
Question to Ask
Kill Claims
Does the product kill the most prevalent healthcare pathogens
Kill Times and
Wet-Contact Times
How quickly does the product kill the prevalent healthcare
pathogens. Ideally, contact time greater than or equal to the kill
claim.
Safety
Does the product have an acceptable toxicity rating, flammability
rating
Ease-of-Use
Odor acceptable, shelf-life, in convenient forms (wipes, spray), water
soluble, works in organic matter, one-step (cleans/disinfects)
Other factors
Supplier offer comprehensive training/education, 24-7 customer
support, overall cost acceptable (product capabilities, cost per
compliant use, help standardize disinfectants in facility)
Score
(1-10)
Note: Consider the 5 components shown, give each product a score (1 is worst and
10 is best) in each of the 5 categories, and select the product with the highest
score as the optimal choice (maximum score is 50).
Surface Disinfection
Noncritical Patient Care
Rutala, Weber. www.cdc.gov
• Disinfecting Noncritical Patient-Care Items
• Process noncritical patient-care equipment with a EPA-registered
disinfectant at the proper use dilution and a contact time of at
least 1 min. Category IB
• Ensure that the frequency for disinfecting noncritical patient-care
surfaces be done minimally when visibly soiled and on a regular
basis (such as after each patient use or once daily or once weekly).
Category IB
Surface Disinfection
Environmental Surfaces
Rutala, Weber. www.cdc.gov
• Disinfecting Environmental Surfaces in HCF
• Disinfect (or clean) housekeeping surfaces (e.g., floors,
tabletops) on a regular basis (e.g., daily, three times per week),
when spills occur, and when these surfaces are visibly soiled.
Category IB
• Use disinfectant for housekeeping purposes where: uncertainty
exists as to the nature of the soil on the surfaces (blood vs
dirt); or where uncertainty exists regarding the presence of
multi-drug resistant organisms on such surfaces. Category II
CLEANING WIPES
• Wipes: may be cotton, disposable, microfiber
• Wipe should have sufficient wetness to achieve the disinfectant contact
time. Discontinue use of the wipe if no longer leaves the surface visibly
wet for manufacturer’s recommended wet contact time.
• When the wipe is visibly soiled, flip to a clean/unused side and continue
until all sides of the wipe have been used (or get another wipe)
• Dispose of the wipe/cloth wipe appropriately
• Do not re-dip a used wipe into the clean container of pre-saturated
wipes
DISPOSABLE WIPES
• Wetness-ideally, stays wet long enough to meet EPA-
registered contact times (e.g., bacteria-1 minute).
• Surface Coverage-premoistened wipe keeps surface area
wet for 1-2 minutes (e.g., 12”x12” wipes keep 55.5 sq ft
wet for 2m; 6”x5” equipment wipe keeps 6.7 sq ft wet
for 2m). Wipe size based on use from small surfaces to
large surfaces like mattress covers
• Durable substrate-will not easily tear or fall apart
• Top-keep closed or wipes dry out
OPTIONS FOR EVALUATING
ENVIRONMENTAL CLEANING PROCESS
Guh, Carling. December 2010. CDC
• Joint effort of EVS and IP
• Responsibilities of EVS staff and other staff for
cleaning surfaces clearly defined
•
•
•
•
Education of EVS staff to define expectations
Development of measures for monitoring
Interventions to optimize cleaning
Report results to IPC and facility leadership
MONITORING THE EFFECTIVENESS
OF CLEANING
Cooper et al. AJIC 2007;35:338
• Visual assessment-not a reliable indicator of surface cleanliness
• ATP bioluminescence-measures organic debris (each unit has own reading
scale, <250-500 RLU)
• Microbiological methods-<2.5CFUs/cm2-pass; can be costly and pathogen
specific; ENVIRONMENTAL CULTURING NOT ROUTINELY
RECOMMENDED
• Fluorescent marker- is transparent & easily cleaned, environmentally stable
marking solution that fluoresces when exposed to an ultraviolet light
(applied by IP/EVS manager unbeknownst to EVS worker; after EVS
cleaning, markings are reassessed) GREAT TEACHING TOOL!
METHODS TO IMPROVE DISINFECTION
OF ENVIRONMENTAL SURFACES
• Follow “best” practices for room cleaning and disinfection
• Follow CDC guideline for choosing disinfectant and “best” practices
• Improve training/education of environmental service workers
• Use of checklists to ensure all room surfaces are cleaned/disinfected
• Assure nursing and EVS agreed what items disinfected by nursing vs
EVS
• Use of method (fluorescent dye, ATP) to ensure proper cleaning
• “No touch” terminal disinfection
• UV light
• Hydrogen peroxide
• Self disinfecting surfaces
• New disinfection technology
Decreasing Order of Resistance of
Microorganisms to Disinfectants/Sterilants
Most Resistant
Prions
Bacterial spores (C. difficile)
Mycobacteria
Small, non-enveloped viruses (HPV, polio, EV-D68)
Fungal spores
Gram-negative bacilli (Acinetobacter)
Vegetative fungi and algae
Large, non-enveloped viruses
Gram-positive bacteria (MRSA, VRE)
Enveloped viruses (Ebola, MERS-CoV)
Most Susceptible
Best Practices in
Disinfection and Sterilization
• Disinfection and sterilization technologies and practices reduce risk
of infection associated with medical devices and surfaces.
• Endoscopes represent a nosocomial hazard. Urgent need to
understand the gaps in endoscope reprocessing. Reprocessing
guidelines must be followed to prevent exposure to pathogens that
may lead to infection. Endoscopes have narrow margin of safety and
manufacturers should be encouraged to develop practical sterilization
technology.
• The contaminated surface environment in hospital rooms is important
in the transmission of healthcare-associated pathogens (MRSA, VRE,
C. difficile, Acinetobacter). Thoroughness of cleaning should be
monitored (e.g., fluorescence).
• Emerging pathogens, such as Ebola, are susceptible to currently
available disinfectants.
Antisepsis: the removal of
pathogens from living tissue
“The goal of preoperative patient skin antisepsis is to reduce the risk of the
patient developing a surgical site infection (SSI) by removing soil and
transient microorganisms at the surgical site.1 Reducing the amount of
bacteria on the skin near the surgical incision lowers the risk of
contaminating the surgical incision site.1 As part of preparing the skin for
antisepsis, preoperative bathing and hair management at the surgical site
contribute to a reduction of microorganisms on the skin.2–4 Effective skin
antiseptics rapidly and persistently remove transient microorganisms and
reduce resident microorganisms to subpathogenic levels with minimal skin
and tissue irritation.”
--2016 AORN GUIDELINE
Pre-op Skin Antisepsis:
The Basics
• Preoperative bathing and hair removal
• Patients should bathe or shower with either soap or skin antiseptic at the
least the night before or day of surgery (2% CHG-impregnated cloths are
becoming used more frequently—due to ease of use vs. specific guideline)
• Hair at surgical site should be left in place, & only when necessary, removed
via a method that minimizes trauma to skin (clipping or depilatory)
OUTSIDE of the OR
• Selecting skin antiseptics
• No one skin antiseptic has been proven to be more effective in preventing
SSIs; a facility multidisciplinary team should select safe, effective antiseptics
for pre op antisepsis based on each patient’s need.
• Current choices are: Iodophors , Chlorhexidine, 2 & 4% aqeuous, Alcohols,
60-95%, PCMX & Triclosan.
Pre-op Skin Antisepsis:
The Basics
• Applying, handling, and storing skin antiseptics
• Skin should be free of dirt, debris, creams, cosmetics & alcohol-based
products prior to application
• Antiseptics should be applied per manufacturer recommendations vis
aseptic technique; sterile gloves are worn if the caregiver’s hands
could touch the patient’s skin during prep
• Antiseptic dry times should be followed without fail
• FDA rules recommend single-use applicators/bottles (one time/one
patient)
• Antiseptic solutions should not be diluted
• Antiseptic solutions should be stored/disposed of per local, state &
federal regulations in a manner that decreases fire risk.
Test Your Knowledge
1. Type of germicidal action required for semi-critical
items:
a) Kills all microorganisms except high numbers of bacterial
spores
b) Kills all vegetative bacteria, fungi & lipid viruses
c) Kills all microorganisms, including bacterial spores
d) Kills all visible contamination
Test Your Knowledge
1. Type of germicidal action required for semi-critical
items:
a) Kills all microorganisms except high numbers of
bacterial spores
b) Kills all vegetative bacteria, fungi & lipid viruses
c) Kills all microorganisms, including bacterial spores
d) Kills all visible contamination
Test Your Knowledge
2. The first step in the sterilization process is:
a) Wrapping of the equipment prior to placing in autoclave
b) Pre-cleaning by applying enzymatic cleaner or detergent to
the used equipment
c) Taking the equipment to the Sterile Processing Dept. via
biohazard container
d) Cleaning the equipment via manual or mechanical means
Test Your Knowledge
2. The first step in the sterilization process is:
a) Wrapping of the equipment prior to placing in autoclave
b) Pre-cleaning by applying enzymatic cleaner or detergent
to the used equipment
c) Taking the equipment to the Sterile Processing Dept. via
biohazard container
d) Cleaning the equipment via manual or mechanical means
Test your knowledge
3. Types of antiseptics include all of the following except:
a)
b)
c)
d)
e)
f)
Iodophors
Chlorhexidine, 2 & 4% aqeuous
Glutaraldehyde, ≥2.0%
Alcohols, 60-95%
PCMX
Triclosan
Test your knowledge
3. Types of antiseptics include all of the following except:
a)
b)
c)
d)
e)
f)
Iodophors
Chlorhexidine, 2 & 4% aqeuous
Glutaraldehyde, ≥2.0%
Alcohols, 60-95%
PCMX
Triclosan
Dr. William Rutala
“Mr. Clean” & one of the nicest guys
you will ever meet!!
Much of the material for this presentation prepared from his website:
disinfectionandsterilization