A clean healthcare environment is an important part of an infection prevention and control (IPC) programme. Evidence suggests that the transmission of pathogens whilst being treated in a healthcare facility, from environmental surfaces and equipment, a patient’s surroundings contribute to increased healthcare associated infection (HAI). A wide range of decontamination technology, methods and products are available; however, there is much debate as to what is best practice and this is demonstrated in the diverse application and acceptance of methods and cleaning and disinfection agents.
Factors that influence successful removal of pathogens from surfaces
The increase in resistant organisms, novel pathogens and emerging infectious diseases has led to a growth in research looking at the efficacy of environmental decontamination in the healthcare setting. This has been accelerated by the COVID pandemic and the subsequent rapid shift in environmental cleaning and disinfection protocols. Factors that can determine the effectiveness of an environmental cleaning program and subsequent reduction in surface based transmission rates include:
- Cleaning and disinfection agents
- Level of training and competency of staff
- Consistency of the processes
- Monitoring of cleaning practices
- Bio-burden (Biofilm) of the surface
- Properties of surface being cleaned
- Product application and contact time exposure
- Specific pathogens and resistance
Most studies have concluded that human factors play a significant part in effective decontamination of the environment.
Choosing a neutral detergent or disinfectant
The choice of cleaning agent is very much an independent one and relevant to the facility, local risks, environmental surfaces and equipment in use. Different products may be suitable for different situations within the same location. Facilities may use a neutral detergent for everyday routine cleaning but change to a disinfectant in the event of an outbreak. As a result of the pandemic we saw a significant increase in active disinfectant application, with adjustment to the frequency of cleaning and disinfection in order to prevent transmission from surfaces.
Broadly the difference between cleaning and disinfection is simple. Cleaning is the removal of soil and contaminants from surfaces, whereas disinfection relates to the inactivation, neutralisation or killing of pathogens by use of a chemical disinfectant.
The topic of whether routine environmental cleaning should be undertaken with a neutral detergent or a disinfectant remains controversial as there are concerns about overuse of disinfectants contributing to additional micro-organism mutation and a rise in antimicrobial resistance.
For regular, everyday cleaning of healthcare surfaces, a neutral detergent product provides a cost-effective solution. The cleaning process itself and the removal of dirt and contaminants that can harbor pathogens will minimise pathogens and micro-organisms in the environment. Use of the detergent and regular removal of dirt and dust should minimise the build-up of pathogens in the environment. It has been found though that bulk detergent solutions that are then diluted for broader application have been known to become contaminated with bacteria if not changed frequently. This can result in the cleaning process contributing to the spread of pathogens around the environment instead of removing them. This can also occur if you re-use a cloth or wipe on multiple surfaces without a disinfectant.
This risk can be minimised by using single use, pre-moistened disposable wipes. Recommended process for use of wipes is as follows:
- Use an S-shaped motion to reduce cross contamination
- Clean Equipment and surfaces from the Top to the Bottom
- Wipe from Clean to Dirty to stop re-contamination of clean areas
- Ensure contact times are as per instruction to ensure effective disinfection
- Use one wipe per surface/equipment — minimise the risk of cross contamination
Care should always be taken for users of products to take the relevant protective measures when using any product. Disinfectants by definition are chemicals that kill or render inactive pathogens at a cellular level, so a detergent will nearly always be less toxic than a disinfectant.
There are several indications when a disinfectant would be the product of choice, primarily in situations of high levels of contamination. Disinfectants reduce higher bacterial counts than detergents. It should be noted that many disinfectant compounds can be inhibited by dirt and soil, the presence of which may significantly reduce efficacy. It is for this reason that it is accepted that a surface should be cleaned first prior to disinfecting.
It is recommended to use a disinfectant to decontaminate the room after the discharge of a patient who had been colonised or infected with MRO or other infectious disease. Multiple studies have demonstrated that a patient is at a higher risk of MRO acquisition if they were admitted to a room previously occupied by a patient positive for MRO. A disinfectant product is also used when there is persistent contamination with a pathogen, such as during an outbreak or when the area has endemic rates of disease. Additionally, there are some pathogens which have potential resistance to detergent-based cleaning including C. difficile, MROs, and norovirus.
Aside from the potential environmental toxicity issues, one of the drawbacks of disinfectants is that they require a minimum contact time to kill the pathogens. Having a robust process that facilitates the adherence to the contact time is essential in the optimal disinfection outcome. Contact time can be defined as the minimum time a pathogen needs to be exposed to the active ingredient in order for it to be killed or rendered inactive. In practice this is effectively wet exposure time so a surface needs to be wet with disinfectant for 60 seconds in order to achieve a 60-second contact time. It should be noted that contact time can change from product to product and pathogen to pathogen.
More recently there is an increase in combination detergent and disinfectant products that use the latest generation disinfectant active ingredients combined with detergent surfactants. The active ingredients in these are typically less affected by dirt and soil and will clean and disinfect the surface. For best outcomes it is still recommended that two wipes are used on any surface, the first to clean and the second to disinfect.
Important to note that detergents and disinfectants have different material compatibility profiles that will differ from product to product. Care should be taken to assess the surfaces that the products will be applied to for compatibility prior to use. Of particular importance are surfaces and materials on pieces of medical equipment. These can comprise a variety of materials including metals, alloys, plastics, polymers and glass. All of these may react differently to cleaning and disinfection ingredients and you should always consult with the equipment manufacturer for guidance. Use of the correct products will ensure the lifespan of the surface or equipment is not unduly compromised by the environmental cleaning protocol.
In summary, there are pros and cons to using detergents and disinfectants. End users should consider the environment, current risks, existing protocols and processes, staff competence and choose their products appropriately. Sound application of any environmental cleaning and disinfection protocol is essential in achieving the very best outcomes. The best product available if it is not used correctly, will not achieve the desired outcomes. If you do not adhere to contact times for disinfection you aren’t really doing anything.
For more information, visit: https://reynardhealth.com.au/.