Disinfection: is it time to reconsider Spaulding?

Recommendations for the Cleaning of Endocavity Ultrasound Transducers Between Patients

The COVID-19 pandemic highlighted the importance of infection prevention and control measures for all medical procedures, including ultrasound examinations. As the use of ultrasound increases across more medical modalities, including point-of-care ultrasound, so does the risk of possible transmission from equipment to patients and patients to patients. This is particularly relevant for endocavity transducers, such as trans-vaginal, trans-rectal and trans-oesophageal, which could be contaminated with organisms from blood, mucosal, genital or rectal secretions. This article proports to update the WFUMB 2017 guidelines which focussed on the cleaning and disinfection of trans-vaginal ultrasound transducers between patients.

Digital technologies to unlock safe and sustainable opportunities for medical device and healthcare sectors with a focus on the combined use of digital twin and extended reality applications: A review

Medical devices have increased in complexity where there is a pressing need to consider design thinking and specialist training for manufacturers, healthcare and sterilization providers, and regulators. Appropriately addressing this consideration will positively inform end-to-end supply chain and logistics, production, processing, sterilization, safety, regulation, education, sustainability and circularity. There are significant opportunities to innovate and to develop appropriate digital tools to help unlock efficiencies in these important areas. This constitutes the first paper to create an awareness of and to define different digital technologies for informing and enabling medical device production from a holistic end-to-end life cycle perspective. It describes the added-value of using digital innovations to meet emerging opportunities for many disposable and reusable medical devices. It addresses the value of accessing and using integrated multi-actor HUBs that combine academia, industry, healthcare, regulators and society to help meet these opportunities. Such as cost-effective access to specialist pilot facilities and expertise that converges digital innovation, material science, biocompatibility, sterility assurance, business model and sustainability. It highlights the marked gap in academic R&D activities (PRISMA review of best publications conducted between January 2010 and January 2024) and the actual list of U.S. FDA's approved and marketed artificial intelligence/machine learning (AI/ML), and augmented reality/virtual reality (AR/VR) enabled-medical devices for different healthcare applications. Bespoke examples of benefits underlying future use of digital tools includes potential implementation of machine learning for supporting and enabling parametric release of sterilized products through efficient monitoring of critical process data (complying with ISO 11135:2014) that would benefit stakeholders. This paper also focuses on the transformative potential of combining digital twin with extended reality innovations to inform efficiencies in medical device design thinking, supply chain and training to inform patient safety, circularity and sustainability.

Extended Reality Head-Mounted Displays Are Likely to Pose a Significant Risk in Medical Settings While Current Classification Remains as Non-Critical

Extended reality (XR) devices, including virtual and augmented reality head-mounted displays (HMDs), are increasingly utilised within healthcare to provide clinical interventions and education. Currently, XR devices are utilised to assist in reducing pain and improving psychological outcomes for immunocompromised patients in intensive care units, palliative care environments and surgical theatres. However, there is a paucity of research on the risks of infection from such devices in healthcare settings. Identify existing literature providing insights into the infection control risk XR HMDs pose within healthcare facilities and the efficacy of current infection control and cleaning procedures. Three databases (PubMed, Embase and CINAHL) in addition to Google Scholar were systematically searched. A total of seven studies were identified for this review. Microorganisms, including pathogenic bacteria (e.g., Staphylococcus aureus and Pseudomonas aeruginosa), were found to be present on XR HMDs. Published cleaning and infection control protocols designed to disinfect XR HMDs and protect users were heterogeneous in nature. Current cleaning protocols displayed varying levels of efficacy with microbial load affected by multiple factors, including time in use, number of users and XR HMD design features. In healthcare settings, fitting XR HMDs harbouring microorganisms near biological and mucosal entry points presents an infection control risk. An urgent revision of the Spaulding classification is required to ensure flexibility that allows for these devices to be reclassified from 'Non-critical' to 'Semi-Critical' depending on the healthcare setting and patient population (surgery, immunocompromised, burns, etc.). This review identified evidence supporting the presence of microorganisms on XR HMDs. Due to the potential for HMDs to contact mucosal entry points, devices must be re-considered within the Spaulding classification as 'Semi-critical'. The existence of microbial contaminated XR HMDs in high-risk medical settings such as operating wards, intensive care units, emergency departments, labour and delivery wards and clinical areas with immunosuppressed patients requires urgent attention. Public health authorities have a duty of care to develop revised guidelines or new recommendations to ensure efficient sanitation of such devices.

Efficiency of a high-speed handpiece with anti-retraction adapter to minimize cross-contamination during the routine dental procedure: A clinical study

Background

This study aimed to detect the efficiency of anti-retraction adapter (ARA) attached to a handpiece (HP).

Materials and Methods

Two types of dental HP with and without the ARA were used in this study. A total of 30 sets of samples were obtained from two groups and were subjected to a real-time reverse transcriptase-polymerase chain reaction (RT-PCR) and microbial culture for quantitative analysis of total bacterial and Legionella count.

Statistical Analysis Used

The data obtained were tabulated using the Statistical Package for the Social Sciences (SPSS, IBM version 26.0) for statistical analysis.

Results

The water samples were analyzed using PCR, Legionella-specific PCR, and culture-based analysis. In Groups 1 and 2, there was no significant difference between bacterial load in the water samples taken from both HP and coupling of the Dental Unit Waterline (DUWL).

Conclusions

The reduction in bacterial load in DUWLs analyzed using quantitative RT-PCR was similar in both experimental groups. Overall, the bacterial load was lower in the group with ARA when compared to the group without ARA but not statistically significant. ARA was not effective in reducing the Legionella species load in DUWLs.

A proposed cleaning classification system for reusable medical devices to complement the Spaulding classification

A central tenet in infection prevention is application of the Spaulding classification system for the safe use of medical devices. Initially defined in the 1950s, this system defines devices and surfaces as being critical, semi-critical or non-critical depending on how they will be used on a patient. Different levels of antimicrobial treatment, defined as various levels of disinfection or sterilization, are deemed appropriate to reduce patient risk of infection. However, a focus on microbial inactivation is insufficient to address this concern, which has been particularly highlighted in routine healthcare facility practices, emphasizing the underappreciated importance of cleaning and achieving acceptable levels of cleanliness. A deeper understanding of microbiology has evolved since the 1950s, which has led to re-evaluation of the Spaulding classification along with a commensurate emphasis on achieving appropriate cleaning. Albeit underappreciated, cleaning has always been important as the presence of residual materials on surfaces can interfere with the efficacy of the antimicrobial process to inactivate micro-organisms, as well as other risks to patients including device damage, malfunction and biocompatibility concerns. Unfortunately, this continues to be relevant, as attested by reports in the literature on the occurrence of device-related infections and outbreaks due to failures in processing expectations. This reflects, in part, increasing sophistication in device features and reuse, along with commensurate manufacturer's instructions for use. Consequently, this constitutes the first description and recommendation of a new cleaning classification system to complement use of the traditional Spaulding definitions to help address these modern-day technical and patient risk challenges. This quantitative risk-based classification system highlights the challenge of efficient cleaning based on the complexity of device features present, as an isolated variable impacting cleaning. This cleaning classification can be used in combination with the Spaulding classification to improve communication of cleaning risk of a reusable medical device between manufacturers and healthcare facilities, and improve established cleaning practices. This new cleaning classification system will also inform future creation, design thinking and commensurate innovations for the sustainable safe reuse of important medical devices.

Germicidal efficacy of continuous and pulsed ultraviolet-C radiation on pathogen models and SARS-CoV-2

Ultraviolet radiation's germicidal efficacy depends on several parameters, including wavelength, radiant exposure, microbial physiology, biological matrices, and surfaces. In this work, several ultraviolet radiation sources (a low-pressure mercury lamp, a KrCl excimer, and four UV LEDs) emitting continuous or pulsed irradiation were compared. The greatest log reductions in E. coli cells and B. subtilis endospores were 4.1 ± 0.2 (18 mJ cm-2) and 4.5 ± 0.1 (42 mJ cm-2) with continuous 222 nm, respectively. The highest MS2 log reduction observed was 2.7 ± 0.1 (277 nm at 3809 mJ cm-2). Log reductions of SARS-CoV-2 with continuous 222 nm and 277 nm were ≥ 3.4 ± 0.7, with 13.3 mJ cm-2 and 60 mJ cm-2, respectively. There was no statistical difference between continuous and pulsed irradiation (0.83-16.7% [222 nm and 277 nm] or 0.83-20% [280 nm] duty rates) on E. coli inactivation. Pulsed 260 nm radiation (0.5% duty rate) at 260 nm yielded significantly greater log reduction for both bacteria than continuous 260 nm radiation. There was no statistical difference in SARS-CoV-2 inactivation between continuous and pulsed 222 nm UV-C radiation and pulsed 277 nm radiation demonstrated greater germicidal efficacy than continuous 277 nm radiation. Greater radiant exposure for all radiation sources was required to inactivate MS2 bacteriophage. Findings demonstrate that pulsed irradiation could be more useful than continuous UV radiation in human-occupied spaces, but threshold limit values should be respected. Pathogen-specific sensitivities, experimental setup, and quantification methods for determining germicidal efficacy remain important factors when optimizing ultraviolet radiation for surface decontamination or other applications.

A comprehensive literature scoping review of infection prevention and control methods for viral-mediated gene therapies

Objective

This comprehensive literature scoping review outlines available infection prevention and control (IPC) methods for viral-mediated gene therapies and provides one IPC strategy for the healthcare setting based on a single-center recommendation.

Methods

A team of experts in pharmacy, healthcare epidemiology, and biosafety with experience in viral-mediated gene therapy was assembled within a pediatric hospital to conduct a comprehensive literature scoping review. The comprehensive review included abstracts and full-text articles published since 2009 and utilized prespecified search terms of the five viral vectors of interest: adenovirus (AV), retrovirus (RV), adeno-associated virus (AAV), lentivirus (LV), and herpes simplex virus (HSV). Case reports, randomized controlled trials, and bench research studies were all included, while systematic reviews were excluded.

Results

A total of 4473 case reports, randomized control trials, and benchtop research studies were identified using the defined search criteria. Chlorine compounds were found to inactivate AAV and AV, while alcohol-based disinfectants were ineffective. There was a relative paucity of studies investigating surface-based disinfection for HSV, however, alcohol-based disinfectants were effective in one study. Ultraviolent irradiation was also found to inactivate HSV in numerous studies. No studies investigated disinfection for LV and RV vectors.

Conclusions

The need to define IPC methods is high due to the rapid emergence of viral-mediated gene therapies to treat rare diseases, but published clinical guidance remains scarce. In the absence of these data, our center recommends a 1:10 sodium hypochlorite solution in clinical and academic environments to ensure complete germicidal activity of viral-mediated gene therapies.

Comparison of Low-Level to High-Level Disinfection in Eliminating Microorganisms From Ultrasound Transducers Used on Skin: A Noninferiority Randomized Controlled Trial

INTRODUCTION

There is a lack of international consensus as to whether high- or low-level disinfection (HLD or LLD) is required for ultrasound (US) transducers used during percutaneous procedures. This study compared the effectiveness of LLD to HLD on US transducers contaminated with microorganisms from skin.

METHODS

Two identical linear US transducers repeatedly underwent either LLD or HLD during the study. Randomization determined which of these transducers was applied to left and right forearms of each participant. Swabs taken from transducers before and after reprocessing were plated then incubated for 4-5 days, after which colony forming units (CFU) were counted and identified. The primary hypothesis was the difference in the proportion of US transducers having no CFUs remaining after LLD and HLD would be less than or equal to the noninferiority margin of -5%.

RESULTS

Of the 654 recruited participants 73% (n = 478) had microbial growth from both transducers applied to their left and right forearms before reprocessing. These were included in the paired noninferiority statistical analysis where, after disinfection, all CFUs were eliminated in 100% (95% CI: 99.4-100.0%) of HLD transducer samples (n = 478) and 99.0% (95% CI: 97.6-99.7%) of LLD transducer samples (n = 473). The paired difference in the proportion of transducers having all CFUs eliminated between LLD and HLD was -1.0% (95% CI: -2.4 to -0.2%, P-value <.001).

CONCLUSIONS

Disinfection with LLD is noninferior to HLD when microorganisms from skin have contaminated the transducer. Therefore, using LLD for US transducers involved in percutaneous procedures would present no higher infection risk compared with HLD.

Reprocessing semicritical items: An overview and an update on the shift from HLD to sterilization for endoscopes

BACKGROUND

Semicritical medical devices are defined as items that come into contact with mucous membranes or nonintact skin (e.g., gastrointestinal endoscopes, endocavitary probes). Such medical devices require minimally high-level disinfection.

METHODS

Analyze the methods used to reprocess semicritical medical devices and identify methods and new technologies to reduce the risk of infection.

RESULTS

The reprocessing methods for semicritical medical devices is described as well as a shift from high-level disinfection to sterilization for lumened endoscopes.

CONCLUSIONS

Strict adherence to current guidelines and transition to sterilization for endoscopes is required as more outbreaks have been linked to inadequately disinfected endoscopes and other semicritical items than any other reusable medical devices.

Disinfection, sterilization and antisepsis: An overview

BACKGROUND

Each year in the United States there are approximately 100,000,000 outpatient/inpatient surgical procedures. Each of these procedures involves contact by a medical device or surgical instrument with a patient's sterile tissue and/or mucous membrane. A major risk of all such procedures is the introduction of infection.

METHODS

We searched published literature for articles on the use and effectiveness of disinfectants, sterilization methods and antiseptics.

RESULTS

The level of disinfection is dependent on the intended use of the object: critical (items that contact sterile tissue such as surgical instruments), semicritical (items that contact mucous membrane such as endoscopes), and noncritical (devices that contact only intact skin such as stethoscopes) items require sterilization, high-level disinfection and low-level disinfection, respectively. Cleaning must always precede high-level disinfection and sterilization. Antiseptics are essential to infection prevention as part of a hand hygiene program as well as other uses such as surgical hand antisepsis and pre-operative patient skin preparation.

CONCLUSIONS

When properly used, disinfection and sterilization can ensure the safe use of invasive and non-invasive medical devices. Cleaning should always precede high-level disinfection and sterilization. Strict adherence to current disinfection and sterilization guidelines is essential to prevent patient infections and exposures to infectious agents.

Study on disinfection effect of a 222-nm UVC excimer lamp on object surface

Effective disinfection of contaminated surfaces is essential for preventing the transmission of pathogens. In this study, we investigated the UV irradiance and wavelength distribution of a 222-nm ultraviolet C (UVC) excimer lamp and its disinfection efficacy against microorganisms in laboratory conditions. By using a carrier quantitative germicidal test with stainless steel sheets as carriers, we examined the disinfection effect of the 222-nm UVC lamp on three standard strains-Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa. We tested the disinfection efficacy under different conditions by adjusting irradiation time, as well as the state and temperature of the stainless steel carriers. Our results indicated that a bacterial suspension in PBS and not-dried stainless steel carriers yielded better disinfection than in TSB and dried carriers. Additionally, carrier temperature had no significant impact on disinfection efficacy. When utilizing a bacterial suspension in PBS and non-dried carriers at a temperature of 20 °C, the three bacteria were eliminated by 222-nm UVC excimer lamp irradiation in just 15 s. In contrast, when using a bacterial suspension in TSB and dried carriers at temperatures of 20 °C, 4 °C, or - 20 °C, the three bacteria were eradicated by 222-nm UVC excimer lamp irradiation in 60 s. Comparatively, the LPM lamp required more than 10 min to achieve the same disinfection effect. Our data demonstrate that the 222-nm UVC excimer lamp has higher irradiance and a more potent microbial disinfection effect than the LPM lamp, requiring significantly less irradiation time to achieve the same disinfection effect under identical conditions. Furthermore, the 222-nm UVC excimer lamp exhibited a substantial disinfection effect on bacterial propagules at low temperatures. Our findings support the optimization of "tunnel-type" cold-chain goods disinfection devices, providing an alternative, highly efficient, and practical tool to combat the spread of SARS-CoV-2 through cold-chain systems.

A review of Spaulding's classification system for effective cleaning, disinfection and sterilization of reusable medical devices: Viewed through a modern-day lens that will inform and enable future sustainability

Despite advances in medicine and innovations in many underpinning fields including disease prevention and control, the Spaulding classification system, originally proposed in 1957, remains widely used for defining the disinfection and sterilization of contaminated re-usable medical devices and surgical instruments. Screening PubMed and Scopus databases using a PRISMA guiding framework generated 272 relevant publications that were used in this review. Findings revealed that there is a need to evolve how medical devices are designed, and processed by cleaning, disinfection (and/or sterilization) to mitigate patient risks, including acquiring an infection. This Spaulding Classification remains in use as it is logical, easily applied and understood by users (microbiologists, epidemiologists, manufacturers, industry) and by regulators. However, substantial changes have occurred over the past 65 years that challenge interpretation and application of this system that includes inter alia emergence of new pathogens (viruses, mycobacteria, protozoa, fungi), a greater understanding of innate and adaptive microbial tolerance to disinfection, toxicity risks, increased number of vulnerable patients and associated patient procedures, and greater complexity in design and use of medical devices. Common cited examples include endoscopes that enable non- or minimal invasive procedures but are highly sophisticated with various types of materials (polymers, electronic components etc), long narrow channels, right angle and heat-sensitive components and various accessories (e.g., values) that can be contaminated with high levels of microbial bioburden and patient tissues after use. Contaminated flexible duodenoscopes have been a source of several significant infection outbreaks, where at least 9 reported cases were caused by multidrug resistant organisms [MDROs] with no obvious breach in processing detected. Despite this, there is evidence of the lack of attention to cleaning and maintenance of these devices and associated equipment. Over the last few decades there is increasing genomic evidence of innate and adaptive resistance to chemical disinfectant methods along with adaptive tolerance to environmental stresses. To reduce these risks, it has been proposed to elevate classification of higher-risk flexible endoscopes (such as duodenoscopes) from semi-critical [contact with mucous membrane and intact skin] to critical use [contact with sterile tissue and blood] that entails a transition to using low-temperature sterilization modalities instead of routinely using high-level disinfection; thus, increasing the margin of safety for endoscope processing. This timely review addresses important issues surrounding use of the Spaulding classification system to meet modern-day needs. It specifically addresses the need for automated, robust cleaning and drying methods combined with using real-time monitoring of device processing. There is a need to understand entire end-to-end processing of devices instead of adopting silo approaches that in the future will be informed by artificial intelligence and deep-learning/machine learning. For example, combinational solutions that address the formation of complex biofilms that harbour pathogenic and opportunistic microorganisms on the surfaces of processed devices. Emerging trends are addressed including future sustainability for the medical devices sector that can be enabled via a new Quintuple Helix Hub approach that combines academia, industry, healthcare, regulators, and society to unlock real world solutions.

Iodine contrast exposure and incident COVID-19 infection

Background

Iodine and particularly its oxidated forms have long been recognized for its effective antiseptic properties. Limited in vitro and in vivo data suggest that iodine exposure may rapidly inactivate, reduce transmission, and reduce infectivity of SARS-CoV-2. We hypothesized that iodine exposure may be associated with decreased incident COVID-19 infection.

Methods

A retrospective population-level cohort analysis was performed of the U.S. Veterans Health Administration between 1 March 2020 and 31 December 2020, before the widespread availability of vaccines against SARS-CoV-2. Multivariable logistic regression models estimated the adjusted odds ratios (OR) and 95% confidence intervals (CI) of the associations between iodinated contrast exposure and incident COVID-19 infection, adjusting for age, sex, race/ethnicity, place of residence, socioeconomic status, and insurance status.

Results

530,942 COVID-19 tests from 333,841 Veterans (mean ± SD age, 62.7 ± 15.2 years; 90.2% men; 61.9% non-Hispanic Whites) were analyzed, of whom 9% had received iodinated contrast ≤60 days of a COVID-19 test. Iodine exposure was associated with decreased incident COVID-19 test positivity (OR, 0.75 95% CI, 0.71–0.78). In stratified analyses, the associations between iodinated contrast use and decreased COVID-19 infection risk did not differ by age, sex, and race/ethnicity.

Conclusion

Iodine exposure may be protective against incident COVID-19 infection. Weighed against the risks of supraphysiologic iodine intake, dietary, and supplemental iodine nutrition not to exceed its Tolerable Upper Limit may confer an antimicrobial benefit against SARS-CoV-2. A safe but antimicrobial level of iodine supplementation may be considered in susceptible individuals, particularly in geographic regions where effective COVID-19 vaccines are not yet readily available.

Towards a Harmonized Terminology: A Glossary for Biocide Susceptibility Testing

Disinfection is a key strategy to reduce the burden of infections. The contact of bacteria to biocides-the active substances of disinfectants-has been linked to bacterial adaptation and the development of antimicrobial resistance. Currently, there is no scientific consensus on whether the excessive use of biocides contributes to the emergence and spread of multidrug resistant bacteria. The comprehensive analysis of available data remains a challenge because neither uniform test procedures nor standardized interpretive criteria nor harmonized terms are available to describe altered bacterial susceptibility to biocides. In our review, we investigated the variety of criteria and the diversity of terms applied to interpret findings in original studies performing biocide susceptibility testing (BST) of field isolates. An additional analysis of reviews summarizing the knowledge of individual studies on altered biocide susceptibility provided insights into currently available broader concepts for data interpretation. Both approaches pointed out the urgent need for standardization. We, therefore, propose that the well-established and approved concepts for interpretation of antimicrobial susceptibility testing data should serve as a role model to evaluate biocide resistance mechanisms on a single cell level. Furthermore, we emphasize the adaptations necessary to acknowledge the specific needs for the evaluation of BST data. Our approach might help to increase scientific awareness and acceptance.

Infection Control for Perioperative Ultrasonography and Echocardiography

Ultrasound technology has revolutionized point-of-care diagnostics, decision-making, and the guidance of interventional procedures in Anesthesiology and Perioperative Medicine. Recent literature has highlighted important infection control considerations when performing transesophageal or transthoracic echocardiography, point-of-care ultrasound, and ultrasound-guided procedures. This narrative review focuses on operator precautions and disinfection methods and summarizes key recommendations from the international Echocardiography and Radiology Societies.

Intranasal antisepsis to reduce influenza virus transmission in an animal model

BACKGROUND

Seasonal influenza annually causes significant morbidity and mortality, and unpredictable respiratory virus zoonoses, such as the current COVID-19 pandemic, can threaten the health and lives of millions more. Molecular iodine (I₂ ) is a broad-spectrum, pathogen-nonspecific antiseptic agent that has demonstrated antimicrobial activity against a wide range of bacteria, virus, and fungi.

METHODS

We investigated a commercially available antiseptic, a non-irritating formulation of iodine (5% povidone-iodine) with a film-forming agent that extends the duration of the iodine's antimicrobial activity, for its ability to prevent influenza virus transmission between infected and susceptible animals in the guinea pig model of influenza virus transmission.

RESULTS

We observed that a once-daily topical application of this long-lasting antiseptic to the nares of either the infected virus-donor guinea pig or the susceptible virus-recipient guinea pig, or to the nares of both animals, prior to virus inoculation effectively reduced transmission of a highly transmissible influenza A virus, even when the donor and recipient guinea pigs shared the same cage. Daily treatment of the recipient guinea pig starting 1 day after initial exposure to an infected donor guinea pig in the same cage was similarly effective in preventing detectable influenza virus infection in the recipient animal.

CONCLUSIONS

We conclude that a daily application of this antiseptic formulation is efficacious in reducing the transmission of influenza A virus in the guinea pig model, and further study in this and other preclinical models is warranted.

Removal of virus aerosols by the combination of filtration and UV-C irradiation

The COVID-19 pandemic remains ever prevalent and afflicting-partially because one of its transmission pathways is aerosol. With the widely used central air conditioning systems worldwide, indoor virus aerosols can rapidly migrate, thus resulting in rapid infection transmission. It is therefore important to install microbial aerosol treatment units in the air conditioning systems, and we herein investigated the possibility of combining such filtration with UV irradiation to address virus aerosols. Results showed that the removal efficiency of filtration towards f2 and MS2 phages depended on the type of commercial filter material and the filtration speed, with an optimal velocity of 5 cm/s for virus removal. Additionally, it was found that UV irradiation had a significant effect on inactivating viruses enriched on the surfaces of filter materials; MS2 phages had greater resistance to UV-C irradiation than f2 phages. The optimal inactivation time for UV-C irradiation was 30 min, with higher irradiation times presenting no substantial increase in inactivation rate. Moreover, excessive virus enrichment on the filters decreased the inactivation effect. Timely inactivation is therefore recommended. In general, the combined system involving filtration with UV-C irradiation demonstrated a significant removal effect on virus aerosols. Moreover, the system is simple and economical, making it convenient for widespread implementation in air-conditioning systems.

A review of HTM 01-05 through an environmentally sustainable lens

Patients deserve to be treated in a safe and clean environment with consistent standards of care every time they receive treatment. It is essential that the risk of person-to-person transmission of infections be minimised, yet it is also essential that planetary harm (and therefore public harm) is minimised with respect to resource consumption, air pollution, environmental degradation etc.In 2013, the Department of Health introduced the Health Technical Memorandum (HTM) 01-05 providing dental practices with advice on patient safety when decontaminating reusable instruments in primary care. This paper provides a commentary on HTM 01-05 and similar decontamination guidance. We believe all decontamination documents needs to reflect the so-called 'triple bottom line' - the finance, social cost and impact on the planet.The authors provide an environmental commentary on a number of items mentioned in decontamination documents, including autoclaves (including the use of helix tests), disposable paper towels, undertaking hand hygiene, using a log book, plastic bag use, the use of personal protective equipment, remote decontamination units, single use instruments, single use wipes, disinfection chemicals (for example, sodium hypochlorite) thermal disinfection and wrapping of instruments.It is hoped, in the spirit of the ever-increasing numbers of papers published to highlight how healthcare (and dentistry) could become more sustainable, that these critiques will be taken in the spirit of providing a beginning of further discussion from an environmental perspective.

An outbreak of postoperative rapidly developing and multidrug-resistant Klebsiella pneumoniae urosepsis due to a contaminated ureteroscope

INTRODUCTION

Outbreaks caused by microorganisms contaminating the inside of rigid ureteroscopes are extremely rare. Some of these outbreaks, especially those caused by multidrug-resistant (MDR) infections, can cause serious problems, even death. Among these serious infections, we have no data about Klebsiellapneumoniae outbreaks caused by rigid ureteroscopes and their management and consequences.

Advances in preparation, mechanism and applications of graphene quantum dots/semiconductor composite photocatalysts: A review

Due to the low efficiency of single-component nano materials, there are more and more studies on high-efficiency composites. As zero dimensional (0D) non-metallic semiconductor material, the emergence of graphene quantum dots (GQDs) overcomes the shortcomings of traditional photocatalysts (rapid rate of electron-hole recombination and narrow range of optical response). Their uniqueness is that they can combine the advantages of quantum dots (rich functional groups at edge) and sp² carbon materials (large specific surface area). The inherent inert carbon stabilizes chemical and physical properties, and brings new breakthroughs to the development of benchmark photocatalysts. The photocatalytic efficiency of GQDs composite with semiconductor materials (SCs) can be improved by the following three points: (1) accelerating charge transfer, (2) extending light absorption range, (3) increasing active sites. The methods of preparation (bottom-up and top-down), types of heterojunctions, mechanisms of photocatalysis, and applications of GQDs/SCs (wastewater treatment, energy storage, gas sensing, UV detection, antibiosis and biomedicine) are comprehensively discussed. And it is hoped that this review can provide some guidance for the future research on of GQDs/SCs on photocatalysis.

Efficacy of Disinfection of Rigid Endoscope by Ethyl Alcohol 70%

Introduction  Currently, there is no safe, affordable, and ecologically-sustainable guideline that helps prevent contamination through endoscopy. We evaluated the safety of intermediate-level disinfection with 70% ethyl alcohol (w/v) based on biological-load recovery from rigid endoscopes after nasal endoscopy.

Objective  To demonstrate the efficacy of 70% ethanol in disinfecting rigid endoscopes (REs) to reduce microbial growth in microbiological cultures.

Methods  After a nasal endoscopy examination, the endoscope was swabbed with gauze; this served as the positive-control sample. The standard operating procedure for intermediate-level disinfection with 70% ethyl alcohol (w/v) following prior cleaning was applied. The endoscope was again swabbed; this served as the experimental sample. The collected material from the endoscope was extracted from gauze pieces, filtered through a 0.22-μm cellulose membrane, and cultivated in different means of culture.

Results  The results revealed a significant difference between the positive-control and experimental groups regarding the presence of Streptococcus coagulase (-) ( p  < 0.001), Bacillus spp. ( p  < 0.001), and Staphylococcus aureus ( p  = 0.001). These microorganisms were detected in the control group, but not in the experimental group.

Conclusions  Microorganisms were not recovered from the samples of the experimental group, demonstrating the efficacy and the germicidal action of 70% ethyl alcohol (w/v) as a means of achieving intermediate-level disinfection.

Medical Device Sterilization and Reprocessing in the Era of Multidrug-Resistant (MDR) Bacteria: Issues and Regulatory Concepts

The emergence of multidrug-resistant (MDR) bacteria threatens humans in various health sectors, including medical devices. Since formal classifications for medical device sterilization and disinfection were established in the 1970's, microbial adaptation under adverse environmental conditions has evolved rapidly. MDR microbial biofilms that adhere to medical devices and recurrently infect patients pose a significant threat in hospitals. Therefore, it is essential to mitigate the risk associated with MDR outbreaks by establishing novel recommendations for medical device sterilization, in a world of MDR. MDR pathogens typically thrive on devices with flexible accessories, which are easily contaminated with biofilms due to previous patient use and faulty sterilization or reprocessing procedures. To prevent danger to immunocompromised individuals, there is a need to regulate the classification of reprocessed medical device sterilization. This article aims to assess the risks of improper sterilization of medical devices in the era of MDR when sterilization procedures for critical medical devices are not followed to standard. Further, we discuss key regulatory recommendations for consistent sterilization of critical medical devices in contrast to the risks of disinfection reusable medical devices.

Ultrasound-guided regional anesthesia in COVID-19 and future pandemics: infection control

PURPOSE OF REVIEW

Infection control is inherent in ultrasound-guided regional anesthesia practice, because ultrasound transducer and coupling gel can be vectors for pathogen transmission. We reviewed the current standards and recommendations of ultrasound transducer cleaning, disinfection, and safe handling of ultrasound equipment. Based on the available data, we propose a set of practical recommendations applicable to coronavirus disease 2019 (COVID-19) pandemic and future epidemics.

RECENT FINDINGS

Regional anesthesia is often preferred over general anesthesia for COVID-19 patients. Avoidance of general anesthesia reduces the need for aerosol generating procedures. Administration of ultrasound-guided regional anesthesia and surgery under regional anesthesia in COVID-19 patients requires careful infectious precautions to prevent the viral spread through the use equipment.

SUMMARY

Ultrasound machine, transducer and coupling gel can serve as a vector for transmission of pathogens. In the era of COVID-19 pandemic, standardized strategies are recommended to minimize the risk of spread of COVID-19 to both patients and the healthcare providers.

Decontamination of Bacillus Spores with Formaldehyde Vapor under Varied Environmental Conditions

Introduction

This study investigated formaldehyde decontamination efficacy against dried Bacillus spores on porous and non-porous test surfaces, under various environmental conditions. This knowledge will help responders determine effective formaldehyde exposure parameters to decontaminate affected spaces following a biological agent release.

Methods

Prescribed masses of paraformaldehyde or formalin were sublimated or evaporated, respectively, to generate formaldehyde vapor within a bench-scale test chamber. Adsorbent cartridges were used to measure formaldehyde vapor concentrations in the chamber at pre-determined times. A validated method was used to extract the cartridges and analyze for formaldehyde via liquid chromatography. Spores of Bacillus globigii, Bacillus thuringiensis, and Bacillus anthracis were inoculated and dried onto porous bare pine wood and non-porous painted concrete material coupons. A series of tests was conducted where temperature, relative humidity, and formaldehyde concentration were varied, to determine treatment efficacy outside of conditions where this decontaminant is well-characterized (laboratory temperature and humidity and 12 mg/L theoretical formaldehyde vapor concentration) to predict decontamination efficacy in applications that may arise following a biological incident.

Results

Low temperature trials (approximately 10°C) resulted in decreased formaldehyde air concentrations throughout the 48-hour time-course when compared with formaldehyde concentrations collected in the ambient temperature trials (approximately 22°C). Generally, decontamination efficacy on wood was lower for all three spore types compared with painted concrete. Also, higher recoveries resulted from painted concrete compared to wood, consistent with historical data on these materials. The highest decontamination efficacies were observed on the spores subjected to the longest exposures (48 hours) on both materials, with efficacies that gradually decreased with shorter exposures. Adsorption or absorption of the formaldehyde vapor may have been a factor, especially during the low temperature trials, resulting in less available formaldehyde in the air when measured.

Conclusion

Environmental conditions affect formaldehyde concentrations in the air and thereby affect decontamination efficacy. Efficacy is also impacted by the material with which the contaminants are in contact.

Bacterial Contamination of Equine Dentistry Equipment-Effect of Cleaning and Disinfection

Simple Summary

Some of the equipment used in equine dentistry is difficult to clean and disinfect. Since it is vital to avoid the spread of infections in equine healthcare it is important to develop practical and easy-to-follow methods for cleaning and disinfecting dental equipment. The aim of this study was to investigate hygiene in equine dentistry. Dental equipment and the head support, where horses rest their head during dental care, were sampled for the amount of bacteria between each patient before and after dental care as well as after cleaning and/or disinfecting. The amount of bacteria was, in general, high on dental equipment and the head support after dental procedures. Bacteria were found in different amounts on most of the dental equipment after cleaning or disinfecting, which indicates a risk for spreading infections when using the equipment. For the head support, cleaning and/or disinfecting generally resulted in a reduced amount of bacteria, indicating a lowered risk for spreading infections. There is a great need for evidence-based guidelines on hygiene in equine dentistry to decrease the risk of transmitting infections between patients, facilities, and stables.

Abstract

Equine dentistry has developed immensely and human dental equipment, such as handpieces, are often used. Measures to avoid the spread of infectious microorganisms are important, but this is challenging since handpieces are difficult to decontaminate. Thus, it is necessary to develop effective IPC measures in equine dentistry. The aim of this study was to contribute to the evidence needed for future evidence-based guidelines on IPC by investigating hygiene in equine dentistry. Used handpieces and dummies (i.e., handpieces not used during dental procedure, reflecting environmental bacterial contamination) and the head support were sampled each day before the first patient, for each patient after treatment, and after decontamination. All equipment was sampled with 3M ^TM Swab Samplers and the head support additionally sampled with dip slides. After dental procedures, the detected bacterial load was often high on used handpieces, dummies, and the head support. After decontamination, handpieces did not meet the criteria for high-level disinfected equipment. In all but one case decontamination of the head support resulted in a lowered bacterial load. There is a great need for evidence-based guidelines on hygiene in equine dentistry, including IPC measures, to decrease the risk of spreading infectious microorganisms between patients, facilities, and stables.

Construction and validation of an ultraviolet germicidal irradiation system using locally available components

Coronavirus disease (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, is responsible for a global pandemic characterized by high transmissibility and morbidity. Healthcare workers (HCWs) are at risk of contracting COVID-19, but this risk has been mitigated through the use of personal protective equipment such as N95 Filtering Facepiece Respirators (FFRs). At times the high demand for FFRs has exceeded supply, placing HCWs at increased exposure risk. Effective FFR decontamination of many FFR models using ultraviolet-C germicidal irradiation (UVGI) has been well-described, and could maintain respiratory protection for HCWs in the face of supply line shortages. Here, we detail the construction of an ultraviolet-C germicidal irradiation (UVGI) device using previously existing components available at our institution. We provide data on UV-C dosage delivered with our version of this device, provide information on how users can validate the UV-C dose delivered in similarly constructed systems, and describe a simple, novel methodology to test its germicidal effectiveness using in-house reagents and equipment. As similar components are readily available in many hospitals and industrial facilities, we provide recommendations on the local construction of these systems, as well as guidance and strategies towards successful institutional implementation of FFR decontamination.

Clinical Laboratory Biosafety Gaps: Lessons Learned from Past Outbreaks Reveal a Path to a Safer Future

Patient care and public health require timely, reliable laboratory testing. However, clinical laboratory professionals rarely know whether patient specimens contain infectious agents, making ensuring biosafety while performing testing procedures challenging. The importance of biosafety in clinical laboratories was highlighted during the 2014 Ebola outbreak, where concerns about biosafety resulted in delayed diagnoses and contributed to patient deaths. This review is a collaboration between subject matter experts from large and small laboratories and the federal government to evaluate the capability of clinical laboratories to manage biosafety risks and safely test patient specimens. We discuss the complexity of clinical laboratories, including anatomic pathology, and describe how applying current biosafety guidance may be difficult as these guidelines, largely based on practices in research laboratories, do not always correspond to the unique clinical laboratory environments and their specialized equipment and processes. We retrospectively describe the biosafety gaps and opportunities for improvement in the areas of risk assessment and management; automated and manual laboratory disciplines; specimen collection, processing, and storage; test utilization; equipment and instrumentation safety; disinfection practices; personal protective equipment; waste management; laboratory personnel training and competency assessment; accreditation processes; and ethical guidance. Also addressed are the unique biosafety challenges successfully handled by a Texas community hospital clinical laboratory that performed testing for patients with Ebola without a formal biocontainment unit. The gaps in knowledge and practices identified in previous and ongoing outbreaks demonstrate the need for collaborative, comprehensive solutions to improve clinical laboratory biosafety and to better combat future emerging infectious disease outbreaks.

Reuse of hospital bedpans

OBJECTIVES

to evaluate the results of two methods of hospital bedpan reprocessing.

METHODS

cross-sectional study. Hospital bedpans containing a biological material contamination simulator or organic matter were submitted to manual cleaning followed by disinfection with 70% alcohol solution or thermodisinfection. Permanence of simulated contamination was evaluated by using the fluorescence technique and presence of organic matter was verified by carrying out the protein detection test.

RESULTS

the contamination simulator was found in bedpans submitted to both processes. The seat was dirtier after manual cleaning (p=0.044) in comparison with the result obtained with thermodisinfection. Automatized decontamination led to worse results when compared to the manual procedure for the scoop and external bottom (p=0.000). The protein detection test was positive in two items after thermodisinfection.

CONCLUSIONS

manual cleaning followed by rubbing with 70% alcohol solution proved more effective than automatized cleaning in the reprocessing of hospital bedpans. There are relevant issues regarding reuse of hospital bedpans.

A Critical Review of Disinfection Processes to Control SARS-CoV-2 Transmission in the Food Industry

Industries of the food sector have made a great effort to control SARS-CoV-2 indirect transmission, through objects or surfaces, by updating cleaning and disinfection protocols previously focused on inactivating other pathogens, as well as food spoilage microorganisms. The information, although scarce at the beginning of the COVID-19 pandemic, has started to be sufficiently reliable to avoid over-conservative disinfection procedures. This work reviews the literature to propose a holistic view of the disinfection process where the decision variables, such as type and concentration of active substances, are optimised to guarantee the inactivation of SARS-CoV-2 and other usual pathogens and spoilage microorganisms while minimising possible side-effects on the environment and animal and human health.

Minimizing cross transmission of SARS-CoV-2 in obstetric ultrasound during COVID-19 pandemic

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-associated infection (COVID-19) is affecting populations worldwide. This statement may serve as guidance for infection prevention and safe ultrasound practices during the COVID-19 pandemic. Ultrasound examination is a fundamental part of obstetric care, yet it is a potential vector for transmission of SARS-CoV-2. Decontamination methods should always be implemented for ultrasound equipment, especially in the presence of suspected or confirmed COVID-19 cases. There must be workflow policies to protect pregnant women and healthcare providers from nosocomial cross transmission of SARS-CoV-2. Cleaning and disinfecting of equipment must be in accordance with their potential of pathogen transmission. Consider using telemedicine and genetic technologies as an adjunctive of obstetric ultrasound to reduce patient crowding. Patient triage and education of healthcare providers of infection prevention are crucial to minimize cross contamination of SARS-CoV-2 during obstetric ultrasound.

Hot, Humid Air Decontamination of Aircraft Confirmed That High Temperature and High Humidity Are Critical for Inactivation of Infectious, Enveloped Ribonucleic Acid (RNA) Virus

Aims: To develop infectious (live/dead) enveloped virus test indicators and response surface methodology (RSM) models that evaluate survival of an enveloped ribonucleic acid (RNA) virus on contaminated aircraft materials after exposure to hot, humid air (HHA). Methods and Results: Enveloped RNA bacteriophage Phi6 (Φ6) was dried on wiring insulation, aircraft performance coating (APC), polypropylene, and nylon at ≥ 8 log10 plaque-forming units (PFU) test coupon-1. Only 2.4 log10 inactivation was measured on APC at 70°Celsius (°C), 5% relative humidity (RH) after 24 h. In contrast, HHA RSM models showed a 90% probability of a 7 log10 inactivation at ≥63°C, 90% RH after 1 h, and decontamination kinetics were similar across different materials. HHA decontamination of C-130 and C-17 aircraft showed >7 log10 and ≥5.9 log10 inactivation of enveloped virus on 100 and 110 test indicators, respectively, with a 1-h treatment, excluding ramp-up and ramp-down times. Conclusions: Enveloped RNA virus test indicators were successfully developed, lab tested for HHA decontamination, analyzed for RSM, and field-tested in aircraft demonstrations. Significance and Impact of the Study: The utility of HHA decontamination was demonstrated after inactivating enveloped RNA virus on aircraft with a 1-h HHA treatment within aircraft temperature and RH limits.

Decontamination of Bacillus Spores with Formaldehyde Vapor Under Varied Environmental Conditions

Introduction:

This effort investigated formaldehyde vapor characteristics under various environmental conditions by the analyses of air samples collected over a time-course. This knowledge will help responders achieve desired formaldehyde exposure parameters for decontamination of affected spaces after a biological contamination incident.

Methods:

Prescribed masses of paraformaldehyde and formalin were sublimated or evaporated, respectively, to generate formaldehyde vapor. Adsorbent cartridges were used to collect air samples from the test chamber at predetermined times. A validated method was used to extract the cartridges and analyze for formaldehyde via liquid chromatography. In addition, material demand for the formaldehyde was evaluated by inclusion of arrays of Plexiglas panels in the test chamber to determine the effect of varied surface areas within the test chamber. Temperature was controlled with a circulating water bath connected to a radiator and fan inside the chamber. Relative humidity was controlled with humidity fixed-point salt solutions and water vapor generated from evaporated water.

Results:

Low temperature trials (approximately 10°C) resulted in decreased formaldehyde air concentrations throughout the 48-hour time-course when compared with formaldehyde concentrations in the ambient temperature trials (approximately 22°C). The addition of clear Plexiglas panels to increase the surface area of the test chamber interior resulted in appreciable decreases of formaldehyde air concentration when compared to an empty test chamber.

Conclusion:

This work has shown that environmental variables and surface-to-volume ratios in the decontaminated space may affect the availability of formaldehyde in the air and, therefore, may affect decontamination effectiveness.

Infection Control in Dental Anesthesiology: A Time for Preliminary Reconsideration of Current Practices

Relegated to clinical afterthought, the topic of infection control has never taken center stage in our modern dental sedation and anesthesiology practices. Surgical and procedural masks, gloves, gowns, protective eyewear, and appropriate surgical attire have remained de rigueur in both fashion and custom for decades. However, the emergence of certain seminal events throughout health care history has driven mandated changes when practitioners, staff, patients, and the surrounding communities were exposed or put at risk of exposure to infectious disease. Hepatitis, human immunodeficiency virus, and now the global COVID-19 pandemic involving the novel coronavirus SARS-CoV-2, have forced us into rethinking our current practices. This review article will contextualize previous epidemics and their influence on infection control in dental settings, and it will explore the rapid evolution of current modifications to personal protective equipment and infection mitigation practices specific to sedation and anesthesia in dentistry.

Autoclave sterilization of dental handpieces: A literature review

PURPOSE

The present review aimed to investigate autoclave sterilization of dental handpieces based on available studies.

STUDY SELECTION

The sterilizing efficiency of dental handpieces with autoclave is mainly affected by the types of apparatus (N, B, and S), the packaging with sterilizing pouch, cleaning, and lubrication. These subjects were reviewed based on the in vitro experimental studies.

RESULTS

Dental handpieces can be sterilized, including inactivation of heat-resistant bacterial spores, with type B or type S sterilizers, regardless of the use of a sterilization pouch. In contrast, although type N autoclaves are capable of sterilization of general bacteria such as Streptococcus salivarius even in a sterilization pouch if instruments are washed beforehand, complete sterilization of the wrapped handpiece is not always achieved. Therefore, to achieve sterilization efficiency with type N autoclaves, processing without any packaging is recommended. As regards cleaning of handpiece, although contamination decreases with irrigation and wiping of handpieces, all reports concluded that these treatments alone do not achieve complete decontamination of reusable handpieces.

CONCLUSION

Although type B and type S autoclaves allow us to sterilize the dental handpieces, it is important to realize that complete sterilization of the handpiece is not always achieved by type N autoclave. Understanding autoclave processing of handpieces is essential for dental practice to deliver the safe dental care.

Microbial Colonization of Pneumatic Tourniquets in the Orthopedic Operating Room

Background The rate of surgical site infections following orthopedic procedures is approximately 2% globally. Potential sources of contamination in the operating room include pneumatic tourniquets, blood pressure cuffs, and stethoscopes, among others. Our study aims to investigate microbial colonization on reusable pneumatic tourniquets stored and used in the orthopedic department of our institution and evaluate the efficacy of the cleaning protocols employed. Methods Over a course of two weeks, 26 samples were obtained. A total of 14 pneumatic tourniquets were sampled preoperatively on Monday morning following the weekly cleaning protocol of soaking the tourniquets in sodium hypochlorite for 30 minutes while 12 tourniquets were cultured immediately following the postoperative cleaning protocol of wiping the tourniquet clean with a cloth soaked in sodium hypochlorite. Samples were cultured on MacConkey and sheep blood agar and incubated at 37-degrees centigrade for a total of 48 hours. Organisms were identified and colony count was documented. The analysis was performed using the Fisher Exact test on SPSS v23 (IBM Corp., Armonk, NY, US). Results All 14 samples obtained after being soaked in sodium hypochlorite for 30 minutes cultured negative. However, four out of 12 (33%) samples obtained after simply wiping the pneumatic tourniquet with a cloth soaked in sodium hypochlorite cultured coagulase-negative Staphylococci. The difference between the two was significant (p=0.002). Conclusion Postoperative tourniquets, wiped with a cloth soaked in sodium hypochlorite and ready to be used on the next patient, were found to be contaminated with coagulase-negative Staphylococcus. This species is notorious for causing surgical site infections following implant-related surgeries potentially through direct inoculation and cross-infections intraoperatively and in storage. Efforts to identify the relationship with postoperative surgical site infections need to be made to suggest more aggressive cleaning protocols.

Disinfection, sterilization, and antisepsis: An overview

All invasive procedures involve contact by a medical device or surgical instrument with a patient's sterile tissue or mucous membranes. The level of disinfection or sterilization is dependent on the intended use of the object. Critical (items that contact sterile tissue, such as surgical instruments), semicritical (items that contact mucous membranes, such as endoscopes), and noncritical (devices that contact only intact skin, such as stethoscopes) items require sterilization, high-level disinfection, and low-level disinfection, respectively. Cleaning must always precede high-level disinfection and sterilization. Antiseptics are essential to infection prevention as part of a hand hygiene program, as well as other uses, such as surgical hand antisepsis and preoperative skin preparation.

Reprocessing semicritical items: Outbreaks and current issues

Semicritical medical devices are defined as items that come into contact with mucous membranes or nonintact skin (eg, gastrointestinal endoscopes, endocavitary probes). Such medical devices require minimally high-level disinfection. As many of these items are temperature sensitive, low-temperature chemical methods must be used rather than steam sterilization. Strict adherence to current guidelines is required as more outbreaks have been linked to inadequately cleaned or disinfected endoscopes and other semicritical items than any other reusable medical devices.

Elevating the standard of endoscope processing: Terminal sterilization of duodenoscopes using a hydrogen peroxide-ozone sterilizer

BACKGROUND

The health care community is increasingly aware of the processing challenges and infection risks associated with duodenoscopes owing to published reports of outbreaks and regulatory recalls. Studies have demonstrated that the current practices are inadequate for consistently producing patient-ready endoscopes. Alternatively, terminal sterilization would offer a greater margin of safety and potentially reduce the risk of patient infection. The purpose of this study was to evaluate the efficacy of a hydrogen peroxide-ozone sterilizer with regulatory clearance for terminal sterilization of duodenoscopes.

METHODS AND RESULTS

Validation studies were performed under laboratory simulated-use and clinical in-use conditions. The overkill method study demonstrated a reduction of at least 6-log of Geobacillus stearothermophilus spores at half-cycle, providing a sterility assurance level of 10^-6. In addition, the sterilizer achieved a 6-log reduction of G stearothermophilus in the presence of inorganic and organic soils in a simulated-use study. The clinical in-use study confirmed that the sterilizer achieved sterilization of patient-soiled duodenoscopes under actual use conditions.

CONCLUSIONS

Simulated-use and clinical in-use studies demonstrated the efficacy of a hydrogen peroxide-ozone sterilizer for terminal sterilization of duodenoscopes. This offers health care facilities a viable alternative for duodenoscope processing to enhance patient safety as part of a comprehensive infection control strategy.

Sick Building Syndrome and Other Building-Related Illnesses

Sick building syndrome (SBS) and building-related illnesses are omnipresent in modern high-rise buildings. The SBS is a complex spectrum of ill health symptoms, such as mucous membrane irritation, asthma, neurotoxic effects, gastrointestinal disturbance, skin dryness, sensitivity to odours that may appear among occupants in office and public buildings, schools and hospitals. Studies on large office buildings from USA, UK, Sweden, Finland, Japan, Germany, Canada, China, India, Netherlands, Malaysia, Taiwan, and Thailand, substantiate the occurrence of SBS phenomena. The accumulated effects of a multitude of factors, such as the indoor environmental quality, building characteristics, building dampness, and activities of occupants attribute to SBS. A building occupant manifests at least one symptom of SBS, the onset of two or more symptoms at least twice, and rapid resolution of symptoms following moving away from the workstation or building may be defined as having SBS. Based on the peer-reviewed documentation, this chapter elaborates the magnitude of building-related health consequences due to measurable environmental causations, and the size of the population affected. The mechanisms and causative factors of SBS and illnesses include, for example, the oxidative stress resulting from indoor pollutants, VOCs, office work-related stressors, humidification, odours associated with moisture and bioaerosol exposure. Related regulatory standards and strategies for management of SBS and other illnesses are elaborated.

Reprocessing Standards for Medical Devices and Equipment in Otolaryngology: Safe Practices for Scopes, Speculums, and Single-Use Devices

Stringent regulatory standards for reprocessing medical devices and equipment have proliferated in response to patient safety incidents in which improperly disinfected or contaminated endoscopes lead to large-scale disease transmission or outbreaks. This article details best practices in reprocessing reusable and single-use devices in otolaryngology, with particular attention to flexible fiberoptic endoscopes/nasophyarngoscopes, nasal speculums, and other clinic and operating room instruments. High-risk devices require sterilization, whereas lower risk devices may be reprocessed using various disinfection procedures. Reprocessing practices have implications for adequacy, efficiency, and cost. Nuanced understanding of procedures and their rationale ensures delivery of safe, ethical, and quality patient care.

Experimental Study to Develop a Method for Improving Sample Collection to Monitor Laryngoscopes after Reprocessing

BACKGROUND/AIMS

The microbiological surveillance of endoscopes and automated flexible endoscope reprocessing have been proven to be two of the most difficult and controversial areas of infection control in endoscopy. The purpose of this study was to standardize a sampling method for assessing the effectiveness of standard reprocessing operating procedures for flexible fiberoptic laryngoscopes (FFLs).

METHODS

First, the sampling devices were directly inoculated with Bacillus atrophaeus spores; second, tissue non tissue (TNT) wipes were tested on artificially contaminated surfaces and on FFLs.

RESULTS

Comparison of the sponges, cellulose, and TNT wipes indicated that the TNT wipes were more effective in releasing spores (93%) than the sponges (49%) and cellulose wipes (52%). The developed protocol provides a high efficiency for both collection and extraction from the stainless steel surface (87% of the spores were removed and released) and from the FFL (85% of the spores were removed and released), with relatively low standard deviations for recovery efficiency, particularly for the analysis of the FFL.

CONCLUSION

TNT wipes are more efficient for sampling surface areas, thereby aiding in the accuracy and reproducibility of environmental surveillance.

Review of Disinfection and Sterilization - Back to the Basics

In-depth knowledge of disinfection and sterilization is a key component of infection control. Sterilization completely removes a spore, whereas disinfection cannot. Disinfectants are classified as oxidants and non-oxidants. The decision regarding which method to apply is based on Spaulding's classification. In this article, disinfection and sterilization are thoroughly reviewed, and extensive information from basic to practical points is discussed.

High-Level Disinfection of Otorhinolaryngology Clinical Instruments: An Evaluation of the Efficacy and Cost-effectiveness of Instrument Storage

Objectives

Despite increasing interest in individual instrument storage, risk of bacterial cross-contamination of otorhinolaryngology clinic instruments has not been assessed. This study is the first to determine the clinical efficacy and cost-effectiveness of standard high-level disinfection and clinic instrument storage.

Methods

To assess for cross-contamination, surveillance cultures of otorhinolaryngology clinic instruments subject to standard high-level disinfection and storage were obtained at the start and end of the outpatient clinical workday. Rate of microorganism recovery was compared with cultures of instruments stored in individual peel packs and control cultures of contaminated instruments. Based on historical clinic data, the direct allocation method of cost accounting was used to determine aggregate raw material cost and additional labor hours required to process and restock peel-packed instruments.

Results

Among 150 cultures of standard high-level disinfected and co-located clinic instruments, 3 positive bacterial cultures occurred; 100% of control cultures were positive for bacterial species ( P < .001). There was no statistical difference between surveillance cultures obtained before and after the clinic day. While there was also no significant difference in rate of contamination between peel-packed and co-located instruments, peel packing all instruments requires 6250 additional labor hours, and conservative analyses place the cost of individual semicritical instrument storage at $97,852.50 per year.

Discussion

With in vitro inoculation of >200 otorhinolaryngology clinic instruments, this study demonstrates that standard high-level disinfection and storage are equally efficacious to more time-consuming and expensive individual instrument storage protocols, such as peel packing, with regard to bacterial contamination.

Implications for Practice

Standard high-level disinfection and storage are equally effective to labor-intensive and costly individual instrument storage protocols.