Current Principles and Practices; New Research; and New Technologies in Disinfection, Sterilization and Antisepsis: A Special Edition of the American Journal of Infection Control, May 2013;41:S1-S114

Bill Rutala

by William A. Rutala, PhD, MPH and David J. Weber, MD, MPH

Healthcare-associated infections are an important source of morbidity and mortality with an estimated 1.7 million infections and 99,000 deaths annually in the United States.  The major source of healthcare-associated pathogens is thought to be the patient’s endogenous flora, but an estimated 20% being due to other transmission routes such as the environment and 20-40% attributed to cross-infection via the contaminated hands of healthcare personnel [1].

David Weber

A Special Editor of the American Journal of Infection Control, which was primarily developed from a symposia presented at the APIC annual meeting in 2012, provides concise reviews of the scientific literature and current guidelines in three important areas of infection control.  First, the role that the contaminated room environment plays in the transmission of several important healthcare-associated pathogens (e.g., methicillin-resistant Staphylococcus aureus [MRSA], vancomycin-resistant Enterococcus spp. [VRE], Clostridium difficile, and Acinetobacter spp.).  Second, an update of issues regarding skin antisepsis including hand hygiene.  Finally, reviews of new current issues in sterilization and disinfection of medical devices and instruments including new technologies. 

In the past decade, substantial scientific evidence has clearly demonstrated that contaminated room surfaces are an important component in the transmission of key healthcare-associated pathogens.  Evidence supporting this view includes that these pathogens persist in the environment for prolonged periods of time (hours, days, months), frequent contamination occurs of the hands/gloves of healthcare personnel, contact with the environment is equally likely to lead to hand/glove contamination, and admission to a room previously occupied by a patient colonized or infected with one of these pathogens increases the risk the subsequent patient will develop an infection with one of these pathogens.
Nine papers in the Special Issue focus on the contaminated surface environment including the role of environmental surfaces in disease transmission (Otter et al), the importance of surface contamination in C. difficile transmission (Weber/Rutala), methods for assessing the adequacy of room cleaning (Carling), best practices for surface disinfection (Havill), new room decontamination technologies (Rutala/Weber), and whether improved room disinfection reduces healthcare-associated infections (Donskey).  As noted in these reviews, interventions focused on environmental service workers can improve room disinfection and reduce healthcare-associated infections.  “No-touch” methods of room disinfection (e.g., ultraviolet light, hydrogen peroxide) demonstrate promise for further improving terminal room disinfection. 

Appropriate hand hygiene remains a cornerstone of preventing patient-to-patient transmission of healthcare-associated pathogens.  In addition, new practices have been incorporated into infection control for skin antisepsis for preparation of surgical sites, skin antisepsis prior to invasive procedures, and routine bathing of patients in intensive care units.  Three papers in the Special Issue provide reviews on this topic including monitoring hand hygiene (Larson), update of issues in hand hygiene and skin antisepsis (Boyce), and irrigation of wounds, preoperative shower, and preoperative skin antisepsis with chlorhexidine gluconate (Edmiston et al).

Although the basic principles of disinfection and sterilization of patient devices, equipment and surgical instruments have not changed, new procedures and technologies continue to be introduced.  Seven chapters in the Special Issue focus on sterilization and disinfection to include improving the effectiveness and monitoring of cleaning devices (Alfa), new developments in reprocessing semi-critical devices (Rutala/Weber), the role of biofilms (Roberts), issues regarding immediate use steam sterilization (formerly called “flash” sterilization)(Seavey), new technologies (Schneider), and assessing risk of disease transmission to patients when there is a failure to follow current disinfection/sterilization guidelines (Weber/Rutala).  It is likely that new procedures and technologies will continue to be introduced as we strive to develop the “ideal” disinfectant and “ideal” sterilization process.[2, 3]

References

1.         Weinstein RA, Epidemiology and control of nosocomial infections in adult intensive care units. Am J Med, 1991. 9 (Suppl 3B): p. S179-184.

2.         Rutala WA, Weber.  Current principles and practices; new Research; and new technologies in disinfection, sterilization and antisepsis. Am J Infect Control 2013; 41:S1

3.         Schneider, P.M., Low-temperature sterilization alternatives in the 1990s. Tappi Journal, 1994. 77: p. 115-9.

4.         Rutala WA, D.W., Use of chemical germicides in the United States: 1994 and beyond, in Chemical germicides in health care, Rutala WA, Editor. 1995, Association for Professional in Infection Control and Epidemiology: Washington DC. p. 1-22.