Asepsis: Sterilization and Disinfection

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Asepsis
It is keeping medical instruments free from microorganisms This is accomplished by:
I. II. Sterilization Disinfection

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I. Sterilization
It is one of the basic steps in surface asepsis. Definition: Sterilization refers to the use of different procedures to destroy all forms of microorganisms including bacterial spores.

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What to sterilize?
It is mandatory to sterilize :
all instruments that penetrate soft tissues and bone. Instruments that are not intended to penetrate the tissues, but that may come into contact with oral tissues.

If the sterilization procedure may damage the instruments, then, sterilization can be replaced by Disinfection procedure
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II. Disinfection
It a is less lethal process than sterilization. Definition: It is a procedure intended to reduce microorganisms as far as possible (but not bacterial spores). Thus, disinfection can never replace sterilization

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Which procedure to use?

Category
Critical Items in each category
Items that: (1) enter the tissue; (2) Enter vascular system; (3) through which blood flows Items that: (1) touch mucous membranes; (2) touch non-intact skin (e.g. endoscopes, respiratory therapy equipment, and diaphragms)

Procedure Sterilization High level disinfection

Semi-critical

Non-critical
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Items such as bedpans, blood pressure cuffs, and bedside tables

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Low level disinfection

Sterilization

I. Sterilization - Process

Sterilization instrument Packing

Often instruments are packed for sterilization to be stored and handled without being contaminated. Packing depend on the intended shelf life after sterilization. The available packing options are:
Textile has shelf life of 1 month Paper has shelf life of 1 6 months Nylon, glass, and metal have shelf life of 1 year if BMT_335 Sterilization tightly closed

Sterilization Principles
There are 3 different sterilization principles:
1. Heat sterilization 2. Chemical sterilization 3. Radiation sterilization

Each principles is discussed in the following sections.

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1. HEAT STERILIZATION

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1. Heat Sterilization
Advantages: It is the simplest, most effective and inexpensive method. There are 2 procedures depending on the tolerance of the material used:
a) Steam sterilization (Autoclaving) b) Dry heat sterilization

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1.a. Heat Steam Sterilization

Use saturated steam above 100 C on packed items. Objects occupy 4/5 of autoclave volume to facilitate circulation. Process is divided into 3 periods as follows:
Pre-vacuum period: air is withdrawn from device Sterilizing period: steam is introduced under pressure to specific temperatures & times. Post-vacuum: steam is withdrawn to dry autoclave Table shows samples of time-temperature relationships for steam
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Steam Sterilization
Advantages & Disadvantages Advantages:
good penetration maintains integrity of liquids (e.g. Lubricants) due to the 100% humidity within the chamber.

Disadvantages:
Non stainless steel metal items corrode may damage plastic and rubber items sharp instruments get dulled.
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1.b. Dry-Heat Sterilization

Involves heating at atmospheric pressure and often use a fan to obtain uniform temperature by circulation. Heat at 180 for half hour , 170 for 1 hr., or 160 C for 2 hrs. Times are the periods during which object is maintained at the respective temp.

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Dry-Heat Sterilization
Disadvantages Disadvantages:
Less reliable than autoclaving Large temp difference may arise within device. sharp instruments get dulled Many materials do nottolerate dry heat

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2. CHEMICAL STERILIZATION

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2. Chemical Sterilization - Types

The chemical compounds used can be:
a) Gas Sterilization b) Liquid Sterilization

Generally, chemical sterilization procedures have the disadvantages of presenting health hazards to users (e.g. poisonous, flammable, )

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2.a) Gas Sterilization

The gas used in this procedure is ethylene oxide. Procedure:
Keep objects in constant atmospheric humidity. Heat to temperatures between 30 and 60 C. maintain for a period of 10 hrs. Residual ethylene oxide must be ventilated

Formalin gas autoclaves have been developed for sterilizing endoscopes and ansthetic apparatus.
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Gas Sterilization Disadvantages

Ethylene oxide (& formalin) autoclaves have the following disadvantages:
Difficult to operate Unsuitable for hospitals but used in industry (e.g. for sterilizing disposable materials that can not tolerate high temperatures).

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2.b) Liquid Sterilization

Can be performed with buffered glutaric aldehyde. Procedure:
Immerse object in liquid for several hours. Rinse with sterile water after end of procedure.

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3. RADIATION STERILIZATION

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3. Radiation Sterilization
Provides effective way of sterilization when used in high doses. Gamma radiation (from 60Co). Procedure:
Objects on belt conveyer Expose objects to 25 to 30 kGy for about 24 hrs.

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Radiation Sterilization
Advantages and Disadvantages Advantages:
Clean process Dry process Ensures full exposure of object from all directions

Disadvantages:
Posses threat to humans (radiation) Lengthy process Requires very qualified personnel
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II. DISINFECTION

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Disinfection - Types
As mentioned before, disinfection can not kill all microorganisms but only reduce its number. Disinfection can be accomplished with:
1. Heat disinfection 2. Chemical disinfection

Object that can be disinfected are bedpans, patient skin before operation and surgeon hands before putting gloves.
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1. Heat Disinfection
It is accomplished by boiling water at atmospheric pressure for at least 5 mins

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2. Chemical disinfection
Number of different agents are used according to tolerance of objects and infectious agents.
Using phenol with cleaning component destroy the membrane of microorganisms. Using 70% alcohol for skin which denatures proteins of microorganisms. Use soap containing hexachlorophene for hands. In case of hepatitis use 5% solution of chloramines or heat disinfection
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Asepsis Summary
Asepsis Sterilization Disinfection

Heat

Chemical

Radiation

Heat

Chemical

Steam

Gas

Gamma

Boiling water

Phenol

Dry heat

Ethylene oxide

70% Alcohol

Formalin

Hexachlorophene

Liquid Glutaric Aldehyde BMT_335

Heat or chloramines solution

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Conclusion
In summary:
Sterilization and disinfection are costly and time consuming process However, it is an essential in all health care facilities to avoid spread of diseases. It depends on the ehtics of the instrument users. Users should keep in mind that contaminated instrument present risk to patient as well as the user himself.
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Disinfection and Sterilization - New methods

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Table 1. New Process Disinfection

methods in disinfection and sterilization

Regulatory agency action

Agent

Ortho-phthalaldehyde (Cidex FDA cleared, October 1999 OPA) Antimicrobial coating (Surfacine) Superoxidized water (Sterilox) Not FDA/EPA cleared Not FDA/EPA cleared

Sterilization Liquid sterilization process (Endoclens)

Not FDA cleared

Rapid readout ethylene oxide Not FDA cleared biological indicator (Attest) New plasma sterilizer (Sterrad 50)
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FDA cleared, January 1999

Sterilization

1. Ortho-Phth-alaldehyde (OPA)
Chemical Sterilizaer Adventages:
not eye and nasal passages irritant has excellent stability over a wide range of pH (3 to 9) has a barely perceptible odor Like glutaric aldehyde, it has excellent material compatibility

Disadvantage:
It stains proteins gray (including unprotected skin)

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OPA vs. Glutaric Aldehyde

Table 2. Activity of glutaraldehyde and ortho-phthalaldehyde against Mycobacterium bovis

Disinfectant 1.5% glutaraldehyde 2.5% glutaraldehyde 0.21% ortho-phthalaldehyde

aRange
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Time for 6-log10 reductiona 28-36 minutes 14-18 minutes 4.8-6.3 minutes

of values from two different laboratories (4).

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2. Surfacine
Surface disinfectants such as phenols Advantages
Effective in significantly reducing microbial contamination Cost-effective Have long-term residual activity

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3. Superoxidized Water
Based on the concept of electrolyzing saline. Advantages:
Cheap The end product (water) is not damaging to the environment

Available in the United Kingdom; Sterilox

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4. Endoclens
A New rapid automated liquid Chemical Sterilization System. The sterilant is produced, as needed, by automatic mixing of solutions of hydrogen peroxide and formic acid. Advantages:
automatic cleaning process

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capability to process two flexible scopes at same time automated channel blockage and leak detection filter water rinsing and scope drying after sterilization hard-copy documentation of key process parameters user-friendly machine interface total cycle time less than 30 minutes
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5. Hydrogen Peroxide Plasma

A New Low-Temperature Sterilization Technique. Can be used for temperature-sensitive equipment.

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6. low-temperature plasma
Technique for decontaminating thermolabile products without the severe drawbacks of gas sterilization methods. Advantages:
Alternative to steam sterilization for sterilizing easily corroding products or electronic instruments Takes less time.

However, Steam sterilization proved to be the cheapest method of sterilizing

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Sterilization & Disinfection End

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