Disinfection

and
Sterilization
SINDILE NTULI
MEDICAL
MICROBIOLOGIST

Lecture prepared by Dr Ntuli included some slides from Prof Lekalakala

Definition of terms
Cleaning is the removal of visible soil (e.g., organic and inorganic
material) from objects and surfaces and normally is accomplished
manually or mechanically using water with detergents or
enzymatc products.
Decontaminaton removes pathogenic microorganisms from
objects so they are safe to handle, use, or discard.

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Defnition of term
Sterilizaton describes a process that destroys or eliminates all forms of
microbial life and is carried out in health-care facilites by physical or chemical
methods.
◦ Mycobacterium tuberculosis ,vegetatve bacteria viruses , fungi and spores
Defnition of term
Disinfecton describes a process that eliminates many or all pathogenic
microorganisms, except bacterial spores, on inanimate objects.
In health-care setngs, objects usually are disinfected by liquid chemicals or
wet pasteurizaton.
The destructon of micro-organism but not usually bacterial spores. The
process does not necessarily kill all the micro-organisms, but reduces them
to a level which is not harmful to health
A Rational Approach to Disinfection and
Sterilization

EH Spaulding believed that how an object will be disinfected

depended on the object’s intended use.
CRITICAL - objects which enter normally sterile tssue or the
vascular system or through which blood fows should be sterile.
SEMICRITICAL - objects that touch mucous membranes or skin
that is not intact require a disinfecton process (high-level
disinfectin[HLD]) that kills all microorganisms except bacterial
spores.
NONCRITICAL -objects that touch only intact skin require liw-level
disinfectin.
Classification of infection risk from equipment or
environment
Low risk
Intermediate risk
High risk

The level of decontaminaton should be such that there is no risk for

infecton when using the equipment.
The choice of the method depends on a number of factors:
- type of material of object,
- number and type of organisms involved
- risk of infecton to patents or staf.

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 High risk (Critcal)
◦ Items in close contact with non-intact skin or mucous membranes or
introduced in a sterile body cavity,
◦ e.g. surgical instruments, vascular catheters.
◦ Cleaning followed by sterilisaton is required.

Intermediate risk ( Semi-critcal)

◦ Equipment that does not penetrate the skin or enter sterile areas of the body
but is in contact with intact mucous membranes or other items contaminated
with virulent or transmissible organisms
◦ e.g. endoscopes, thermometers. Cleaning followed by disinfecton is
usually adequate.

Low risk ( Noncritcal)

◦ Items in contact with normal and intact skin, or the inanimate environment
not in contact with the patent (e.g. walls, foors, ceilings, furniture, sinks and
drains). Cleaning and drying is usually adequate.
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Processing “Critical” Patient Care Objects
Classifcaton: Critcal objects enter normally sterile
tssue or vascular system, or through
which blood fows.
Object: Sterility.
Level germicidal acton: Kill all microorganisms, including
bacterial spores.
Examples: Surgical instruments and devices; cardiac
catheters; implants; etc.
Method: Steam, gas, hydrogen peroxide plasma or
chemical sterilizaton.
Critcal objects: Surgical instruments, Cardiac catheters, Implants
Processing “Semicritical” Patient Care
Objects
Classifcaton: Semicritcal objects come in contact with
mucous membranes or skin that is not intact.
Object: Free of all microorganisms except high
numbers of bacterial spores.
Level germicidal acton: Kills all microorganisms except high numbers of
bacterial spores.
Examples: Respiratory therapy and anesthesia equipment,
GI endoscopes, thermometer, etc.
Method: High-level disinfecton

Semicritcal objects: Endoscopes, Respiratory therapy equipment,

Anesthesia equipment, Endocavitary probes,
tonometers, Diaphragm ftng rings
Processing “Noncritical” Patient Care
Objects
Classifcaton: Noncritcal objects will not come in
contact with mucous membranes or
skin that is not intact.
Object: Can be expected to be contaminated
with some microorganisms.
Level germicidal acton: Kill vegetatve bacteria, fungi and lipid
viruses.
Examples: Bedpans; crutches; bed rails; EKG leads;
bedside tables; walls, foors and
furniture.
Method: Low-level disinfecton
Noncritical
Noncritcal Surfaces
◦ Medical equipment surfaces (BP cuf, stethoscopes)
◦ May frequently become contaminated with patent material
◦ Repeatedly touched by health care personnel
◦ Disinfectant/detergent should be used

◦ Housekeeping surfaces (bed rails, bedside tables)

◦ May play a theoretcal but less signifcant role in diseases transmission
◦ Disinfectants/detergents may be used (II) and detergents (non-patent care areas)
 Cleaning methods
• Thorough cleaning and drying will remove most organisms from a surface and should
always precede disinfecton and sterilisaton procedures.

• Cleaning is normally accomplished by the use of water, mechanical acton and

detergents.

• It may be manual or automated

e.g washer/disinfectors that may facilitate cleaning and decontaminaton of items
and reduce the need for handling.
ultrasonic cleaners for lumened devices.
Cleaning removes:
◦ Potentally infectous micro-organisms
◦ Organic material on which micro-organisms thrive
N.B All equipment/devices have ti be thiriughly cleaned befire being sterilized !

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Disinfection
Thermal ir chemical
Thermal disinfecton is preferred whenever possible. It is generally more
reliable than chemical processes, leaves no residues, is more easily
controlled and is non-toxic.

Thermal
Washer-disinfectors (automated system) Temp 850C for 15 min
Pasteurizaton > 700 C for 30 min  respiratory and anesthetc equipment
Chemical disinfectants
- can be used alone or in combinaton
- alcohols,
- chlorine and chlorine compounds, - - gluteraldehyde,
- hydrogen peroxide,
- phenolics,
- quarternary ammonium compounds

catergorized according to spectrum of actvity:

- high level
- intermediate level
- low level
High level disinfection
High level disinfecton is ofen kills Mycobacterium tuberculosis and entero-
viruses in additon to other vegetatve bacteria, fungi and more sensitve
viruses.
May not kill all spores
Used for heat-sensitve items such as endoscopes
10-45 min exposure tme at 20-260C to disinfect
e.g gluteraldehyde , orthopthaldehyde 0.55% (Cidex), hydrogen peroxide
7.5%
Afer disinfecton items require rinsing with sterile or fltered water to
remove any residual disinfectant
Intermediate level

• Destroy all vegetatve bacteria incl. mycobacteria, fungi and most but not
all viruses.

• Do not kill endospores even with prolonged exposure

• E.g phenolics  used for environmental surfaces

• alcohols (60-90%) incl ethanol or isopropanol  oral and rectal

thermometers
Low level
Only destroy fungi

Vegetatve bacteria (except mycobacteria),

Enveloped viruses

E.g quaternary ammonium compounds

 Anti-microbial activity

Disinfectant Spores Mycobacteria Other bacteria Viruses

Enveloped Non- enveloped

Glutaraldehyde Good Good* Good Good Good

2% 10 h 20 min 10 min 10 min 10 min
(3h-10 min)
Peracetic acid Good Good Good Good Good
0.2-0.35%
(10 min)
Alcohol 60-70% None Moderate Good Good Moderate
(ethanol or
isoprpanol1-
10min
Peroxygen None Poor Good Good Moderate
compounds 3-6%
(20 min)

Chlorine Good Good Good Good Good

releasing agents
>1000 ppm Cl2
(15-60 min)
Clear soluble None Good Good Poor None
phenolics 1-2%
Potentially toxic
QUATs 0.1-0.5% None Variable Moderate Moderate Poor
Dilute sol. may
allow growth- 20
 Correct use of disinfectants

• Chemical disinfectants must be made up freshly to the correct concentratons

according to the manufactures' instructons and discarded afer the correct period of
tme or number of uses.

• They should be stored in clean botles with plastc stoppers. When the botle is empty
it should be thoroughly cleaned before re-flling.

• Partally empty botles should not be topped up since this will encourage
contaminaton with and multplicaton of disinfectant resistant organisms.

• The object must be thoroughly rinsed with sterile water afer disinfecton. If sterile
water is not available, freshly boiled water can be used. Afer rinsing, items must be
kept dry and well protected from being re-contaminated.

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Phenolics
From carbolic acid (from coal tar)

 Generally used for environment only, not inactivated by organic

matter. Irritant to human skin.

 Clear soluble phenolics most commonly used eg, hospitals and

laboratory. Strength 2%,
e.g stericol, steriphen, Jeyes fluid, Lysol too strong, irritant; smell, PS -
Phenol used as preservatives in vaccines

 The following are weak and can be used on skin:

Chloroxylenol: (Dettol) Gram +ve, easily inactivated by organic matter.
Not used in hospitals now.
A few important points concerning
disinfectants
Antseptcs and disinfectants di nit make dirt safe
A small range of disinfectants is sufcient
Disinfectants must nit be used for routne cleaning
Disinfectants must not be used where sterility is required
There is ni instant sterilant ir disinfectant - all need tme to work
Never mix two disinfectants unless the one is alcohol
The storage of instruments in a disinfectant or sterilant of any kind
is unacceptable

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Chlorhexidine
• Disinfect human skin and mucous membranes
• Non-toxic. Active against Gram + and most Gram -
bacteria
• Compatible with alcohol. Most spores and viruses
resistant.
• Inactivated by soap, cork, organic matter (not used
for environment )
• Uses:
4% hand scrub = ‘hibisrub’ eg. pre- operative, major
procedures.
0,5% in 70% alcohol = ‘hibicol’ = alcoholic hibitane
for routine and hand disinfection and preoperative
skin preparation.
0,5% + 15% cetrimide = (‘savlon’) for cleaning dirty
wounds.
 Aldehydes (Glutaraldehyde)
Toxic, irritant. Not for human use.
Broad spectrum. Used on inanimate items
only.
E.g Gluteraldehyde ( Cidex ) Used as 2%
aqueous soluton ( with alkali )
Stable for 2 weeks. Disinfect in 30 minutes, "
sterilises " in 10 hours.
Used for heat sensitve items
( bronchoscopes ), ventlator, tubings, virus
contaminated item( HBV +ve, HIV+ve )
Glutaraldehyde
Advantages
◦ Numerous use
◦ Relatvely inexpensive
◦ Excellent materials compatbility

Disadvantages
◦ Respiratory irritaton from vapor
◦ Pungent and irritatng odor
◦ Relatvely slow mycobactericidal actvity
◦ Coagulate blood and fx tssues to surfaces
◦ Allergic contact dermatts
 Ortho-phthalaldehyde
Advantages Disadvantages
• Fast actng HLD
Stains protein gray
• No actvaton
Slow sporicidal actvity
• Excellent materials
compatbility Eye irritaton with contact
• Not a known irritant to
eyes and nasal passages
• Weak odor
 Alcohol
Bactericidal, poor virucidal and sporocidal actvity.
Rapid acton.
Dries rapidly. Best conc 70% ( Ethyl, isopropyl )
Used as skin disinfecton prior to injecton or venesecton.
Skin preparaton with Iodine ( 1 to 2% ), chlorhexidine (0,5% )
Hydrogen Peroxide
Advantages
◦ No actvaton required
◦ Enhanced removal of organisms
◦ No disposal issues
◦ No odor or irritaton issues
◦ Does not coagulate blood or fx tssues to surfaces
◦ Use studies published
Disadvantages
◦ Material compatbility concerns for brass, zinc, copper, and
nickel/silver platng (cosmetc and functonal damage)
◦ Eye damage with contact
 Detergents
SURFACE ACTIVE AGENTS

weakly bacterial.

soap- helps in removal of microorganisms during washing.

quaternary ammonium compounds = QAC, bacteriostatc, non toxic,

catonic detergent, e.g., cetrimide with chlorhexidine, e.g., savlon,

Priblem: inactvated by soap, organic mater.

No actvity against spores, most viruses, mycobacteria.

INFECTIOUS SPILL e.g. blood on the foor

• Wear appropriate protectve clothing (disposable gloves and

apron) and remove the spill as soon as possible

• Small splashes/drips of blood should be wiped up using a

paper towel soaked in hypochlorite soluton

• Discard into medical waste bag (Red)

• For large spills, sprinkle with hypochloride powder soluton,

cover with paper towel, allow 2-5 minutes contact period,
clean the spill with paper towel discarding into medical waste
bag, wipe with freshly prepared hypochloride soluton, rinse
with clean water and wipe dry with paper towel

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Lecture 2

Sterilizaton
Sterilization
Def: Process that destroys all microorganisms incl bacterial
spores

Diferent methods:
◦ Moist heat (steam sterilizaton)
◦ Dry heat
◦ Chemical (low temp)
“Ideal” Sterilization Method
Highly efcacious
Rapidly actve
Strong penetrability
Materials compatbility
Non-toxic
Organic material resistance
Adaptability
Monitoring capability
Cost-efectve
Schneider PM. Tappi J. 1994;77:115-119
Steam sterilization
Steam sterilisaton is the most common and preferred method employed
for sterilisaton of all items that penetrate the skin and mucosa, providing
they are not damaged by heat and moisture.

Requires exposure to direct steam contact at a required temperature and

pressure for a specifed tme

Autoclave = a closed vessel using steam and increased pressure -

temperature > 100°C. Steam condenses to form water and liberates latent
heat which kills microbes by protein coagulaton.
Steam
• Advantages
◦ Inexpensive
◦ Non-toxic
◦ Cycle easy to control and monitor
◦ Rapidly microbicidal
◦ sporicidal
◦ Least afected by organic/inorganic soils
◦ Rapid cycle tme
◦ Penetrates medical packing, device lumens
Disadvantages
◦ Deleterious for heat labile instruments
◦ Potental for burns
Typical Eagle Century Series sterilizer for laboratory applications.
 Steam sterilizatin methid
◦ The steam must be applied for a specifed tme so that the items reach a
specifed temperature.
◦ 121°C for 15 min at 1Bar (15.03psi) above atmospheric pressure.

◦ 134°C for 3 min 2 Bar (29.41 psi) above atmospheric pressure.

• Tests fir efcacy if sterilizatin by auticlaves
◦ Sterilizaton-cycle graph, Biological indicator – Atest (Bacillus stereothermophilus
), Bowie-Dick tape

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Dry heat
Dry heat is preferred for reusable glass syringes, and ointments,
powders, oils etc.

Methid
◦ A hot air oven equipped with fan or conveyor, which will ensure even distributon of heat. The
recommended temperature and tme for sterilisaton of medical equipment is as follows:
◦ 160°C for 2 hrs, 1800C for 1 hr
◦ Sterile items should be protected against recontaminaton.

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Ethylene oxide (EO)

Used for sterilizaton of items that cannot withstand heat, pressure or moisture e.g fexible
endoscopes, cardio-thoracic and opthalmic equipment
EO is a colourless gas that is fammable and explosive
Exposure to gas at 55 or 370C . Time : 1 – 6 hrs
Disadvantages: lengthy cycle with lengthy aeraton , toxic, irritant, potentally mutagenic
Advantages
◦ Very efectve at killing microorganisms
◦ Penetrates medical packaging and many plastcs
◦ Compatble with most medical materials
◦ Cycle easy to control and monitor
Disadvantages
◦ Some states (CA, NY, TX) require ETO emission reducton of 90-99.9%
◦ CFC (inert gas that eliminates explosion hazard) banned afer 1995
◦ Potental hazard to patents and staf
◦ Lengthy cycle/aeraton tme
Gas Plasma
Referred to as the 4th state of mater (i.e liquids, solids, gases, and gas plasma)
Generated in an enclosed chamber under deep vaccuum using radio frequency
or microwave energy to excite hydrogen peroxide gas molecules and produce
charged partcles, free radicals
Heat sensitve equipment, electrical devices

Low temp processing  450C

Cycle tme  45 – 75min

Gas plasma
Advantages:
Safe
Low temp, short cycle
no aeraton necessary
items can be used immediately afer being processed

Disadvantages
High cost
cannot be used for lumened items, powders, liquids
need special packing material
Sterilization
Monitoring
Sterilizaton monitored routnely by combinaton of
mechanical, chemical, and biological parameters
Physical - cycle tme, temperature, pressure
Chemical - heat or chemical sensitve inks that
change color when germicidal-related
parameters present
Biological - Bacillus spores that directly measure
sterilizaton
Biological Monitoring
Steam - Geobacillus stearothermophilus
Dry heat - B. atrophaeus (formerly B. subtlis)
ETO - B. atrophaeus
Reference
1. Guideline for Disinfecton and Sterilizaton in Healthcare
Facilites,CDC, 2008
2. Sherris Medical Microbiology, Sixth Editon by Kenneth Ryan, C.
George Ray. ISBN-13: 978-0071818216: ISBN-10: 0071818219