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Thursday, March 29, 2012

Disinfectant Chemistry Report Card #3 – What Degree Have Phenols Achieved?

The versatile phenolic compound, in all its derivatives and variations, has become accustomed to a more scrutinized disinfectant portfolio. Suffice it to say that the young guns of disinfection technologies have boasted more impressive characteristics as opposed to the withered profile of phenolics. However, the phenol family of disinfectants, unlike many things its age, have managed to avoid extinction altogether. In this week’s blog we will thoroughly analyze the characteristics of this adaptive disinfectant technology in today’s dynamic environment.

There are numerous variations of phenolic disinfectants. This adaptive quality is an important factor in the use of phenols today, as they can be synthesized to serve specific purposes. Common examples of these derivatives include thymols, xylenol, o-phenyl-phenol (OPP) and triclosan. Phenols used today do not pose an extreme health risk because the more volatile versions have been banned. However, even the most common phenol used, OPP, is considered moderately toxic and an indirect carcinogen. Furthermore, triclosan, a common disinfectant used in hand and oral hygiene applications has been shown to produce bacterial resistance upon repeated exposure. These are alarming factors in considering the usage of phenols.

The disinfection capabilities of phenolic compounds have been recognised for an extremely long time. Since the 17th century, phenols have been used as dressing on wounds. Today, phenols exhibit a broad range of disinfection capabilities. They show broad efficacy against bacteria, mycobacteria and fungi. In contrast, the range of viruses that phenols show efficacy against is limited to enveloped (easy to kill) viruses such as influenza.

The efficaciousness of phenols largely depends on a multitude of environmental factors. They are susceptible to changes such as pH, temperature, dilution and soil load challenge. Positively, phenolic disinfectants show a strong ability to perform on surfaces contaminated with soil. Also, phenols perform the best as highly concentrated solutions in acidic conditions (low pH). However, solubility significantly drops at these pH values, and vice versa. This interchanging characteristic further emphasizes the opportunity cost associated with phenolic compounds. One must forego a specific characteristic in order to improve on another.

So where do phenols fall upon our grade scheme for disinfectant technologies?

1. Speed of Disinfection – C
Most phenols retain 10 minute contact times. This is not an ideal contact time, and can only be reached through multiple applications.

2. Spectrum of Kill – B to C
There are intermediate level phenols, that is, they are efficacious against mycobacterium
However, phenols are known to be unable to eradicate non-enveloped viruses such as Norovirus, which is a major weakness of the technology.

3. Cleaning effectiveness – B
Phenols exhibit a high affinity for working in an organically contaminated environment, although best practices always recommend pre-cleaning of surfaces prior to disinfection.

4. Safety Profile – D
Phenols consistently exhibit harsh safety profile and typically warrant careful usage and handling instructions.

5. Environmental Profile – C
Phenols are readily biodegradable compounds; however they are also extremely reactive disinfectants and can contaminate the environment with harmful by-products.

6. Cost Effectiveness – C
Although commonly misconstrued, phenols are quite expensive because usage requires highly concentrated solutions.
Also, diluting generally requires deionized water due to the reactivity of phenols.

**For more in-depth scientific information about Phenol-based Compounds and other disinfectant chemistries, stay tuned to www.infectionpreventionresource.com.


Bugging Off!


Nicole



Wednesday, March 21, 2012

Acronyms, Abbreviations, and Infection Control Messaging

Many moons ago I attended a management seminar entitled something like, “Five Essential Qualities of the Modern Manager”. The second through fifth qualities might very well have been brilliant, though they have disappeared into the fog of the intervening years. What I have never forgotten was the first essential quality, which was … wait for it … “Be self-aware”!!

In truth, it wasn’t the words themselves that struck me as odd, but the apparent belief on the part of the noted psychologist / management guru that his audience would know what being “self-aware” meant, and how we would know if we were or were not. As I recall, he expended fewer than a dozen words in his explanation of that essential managerial quality. And we, the 200 or so aspiring managers in the room, sought no further explanation because were too intimidated by his reputation for undisguised exasperation at what he invariably saw as unworthy questions.

My intent here is not catharsis (I achieved that years ago by writing a review of this same guru’s widely lauded but almost unintelligible book on his new-age approach to management). I simply present this as an exaggerated example of what we all tend to do – underdescribe and overexpect. And unless we become fully aware of what we are expecting and how we are communicating that expectation, the frustration of partial success or temporary success will be our constant companion.

What’d he say?
Every industry has its shorthand and insider terminology. I mean let’s face it, we are living in an acronymic world. “Twitter-speak” is creeping into our normal communication, and all those letters and abbreviations inhibit people’s understanding of what we want them to do. For example, we all know that “ICP” stands for either Infection Control Practitioner or Infection Control Professional (even we can’t agree). However, if someone in our audience doesn’t understand that acronym and subsequently googles “ICP”, they’ll find out that it most likely stands for Insane Clown Posse … seriously. We assume that everyone to whom we are speaking knows that “UTI” stands for Urinary Tract Infection. However, it is also a very common acronym for Uniform Type Indicator, a widely referred-to component of Apple software. According to Wiki (abbreviation for “Wikipedia” of course) “BSI” means Backside Illumination!! And all this time I thought that BSI stood for Blood Stream Infection – who knew I was so wrong.

Before anything else, we need to stop using acronyms and abbreviations unless we have defined them and are certain that our audience understands them. Of course we first need to have some awareness of the acronyms that we use. Perhaps an “acronym buddy” system would be useful, preferably with someone from outside our specialty.

Say again
We need to repeat ourselves, and repeat, and repeat, and repeat, in as many ways as possible. A lecture on how to clean a patient room can be repeated in posters, video refreshers, games, I-phone apps, and multitude other creative ways. Even better would be to recruit members of the intended audience to create the memory aids themselves, or even to give the education sessions themselves.

Of course before we open our mouths we need to define what we want to say, and what practical outcomes or actions we expect. If we can set short term and long term objectives, explain them properly, and repeat them frequently enough that everyone understands, it should be possible to succeed.

So ultimately, regardless of one’s “self-awareness”, communicating in infection prevention and control is the same as communicating in the airline industry, or the hospitality industry, or anywhere else. There’s no magic. It’s really about intentional and oft repeated sharing of a well-planned message and of course not assuming everyone knows what we are talking about or the acronyms we are using.


TFR!

Paul

PS – TFR … Thanks for Reading!




Paul Webber is from Belleville, Ontario Canada. In the late 1990’s Paul met Lois Rae, the infection control professional at his local hospital, who introduced him to the world of infection control and challenged him to get involved. In the years since that introduction Paul co-founded (with Prof. Syed Sattar) an initiative called Teleclass Education that arranges lectures by some of the brightest minds in the world on infection prevention and control topics. In 2011, that initiative celebrated 10 years of providing first class education around the globe. Paul has also authored articles that have been published in North America, the UK, Australia, and New Zealand, and is regularly invited to participate in infection control conferences around the globe.





Thursday, March 15, 2012

Toys – Playful items for a child’s delight...Or, vehicles for deadly pathogens??

I don’t know about you, but when I recite that title in my head that stereotypical organ music synonymous with an ominous statement – “Dum, Dum, Dummmm...” – follows suit.

So what’s the verdict?


BOTH!


I think we can all agree that toys bring a lot of joy to a young child. Certainly I’m preparing myself for the mountain of toys that will soon take up residence in my living room as my 8-week old daughter grows older. Unfortunately, these items can also be a reservoir for potentially pathogenic microorganisms that may be present in saliva, feces and other bodily secretions. This begs the question – how can we address this potential contamination?


Lucky for us, CHICA-Canada published their practice recommendations for the handling of toys in late 2011. The Paediatric Interest Group within CHICA developed the position statement and included some clear and concise infection prevention practice recommendations for toys.

The pillars of CHICA’s IPAC recommendations for toys do not drastically differ from those encountered with medical devices our found in more traditional settings. Hand hygiene; toy material/design; frequency and responsibility for cleaning and disinfection; toy storage; and proper procedure for toy cleaning and disinfection are all included.

Hand Hygiene:
-Children should be encouraged to clean and disinfect their hands before and after playing with toys
-To facilitate compliance, play areas should have access to Alcohol Based Hand Rub (ABHR) or hand wash station


Toy Material/Design:
-Toys that are shared should be non-porous with smooth surfaces to facilitate effective cleaning


Frequency and Responsibility of Toy Cleaning and Disinfection:
-All toys should be cleaned and disinfected between users following written procedures
-Responsibility for cleaning and disinfecting toys should be assigned to specific personnel
-Large toys such as playhouses should have their high touch surfaces cleaned and disinfected daily
-For porous items that cannot be cleaned and disinfected, such as books or magazines, these should be discarded when visibly soiled


Toy Storage:
-An area to segregate dirty or used toys should be defined
-Clean toys should be stored in a manner to prevent contamination


Cleaning and Disinfection Procedure for Toys:
-Inspect toys for damage; if damaged, toy should be discarded
-Best practice recommends that toys are cleaned using hot soapy water prior to disinfection; if an approved one-step disinfectant cleaner is used, it can be effectively used for both the cleaning and disinfection of the toy
-Ideally the disinfectant being used is safe, effective against pathogens of concern (enteric viruses such as Rotavirus and Norovirus) and fast acting
-Toys should be rinsed thoroughly after the disinfection contact time has elapsed.


All in all, the recommendations are straightforward and easy to follow. My colleagues and I receive regular inquiries from child care facilities pertaining to their IPAC practices and CHICA’s Practice Recommendations have already proved to be a valuable tool in our assisting these end-users.

For the full recommendations, please refer to CHICA’s Website:


http://www.chica.org/pdf/Toys%20Practice%20Recommendations%202011.pdf

Now where should the dirty toy bin should be at my house.....


Hasta la vista

Lee – The Germinator

Wednesday, March 7, 2012

Overcoming the Magpie Syndrome of the Shiny Surface Syndicate

When I start a blog I like to get the creative juices flowing by running a series of Google searches to see what pops up for the concept or key points I plan to talk about in my blog. Most are generally irrelevant to the concept of cleaning and disinfection, but you never know what you may learn that can take you down a path that may lead to an “Ah-Ha” moment. As the title alludes to the focus of this blog is our obsession of shiny surfaces and the unfortunate correlation that if it is shiny the surface or medical device must be clean and free of germs.

I’m a girl; I like shiny things…especially when they come wrapped in a Tiffany box. If I’m honest any box bearing the logo of a Jeweler will do! While “girls” are certainly known to love shiny things, a verifiable truth if I use one of my female colleagues as a case study, men are by no means impervious from the predilection towards shiny objects. In fact, as I learned in my Google search the fall of the Roman Empire can be attributed to Augustulus Romulus’ distraction on the battle field by something shiny. It is said his last words before being struck down were "Give me liberty or give me death! Ooh shiny!" (DISCLAIMER I did not verify accuracy…I am simply using the example found to illustrate my point)

In fact the term, Shiny Things comes from the Latin "Shinus Thintustus" meaning "thing that distracts the easily amused”. I kid you not – I found it on Google! Most of us are probably familiar with the term “Magpie Syndrome” which is defined as an irrational affinity for shiny objects. Most shiny things of course are smooth surfaces made of rock (gem stones, granite or marble), glass (including mirrors), silver, gold, or metal (think stainless steel or chrome) and of course we cannot forget flooring material such as terrazzo, marmoleum and good old highly waxed vinyl tile! When a highly shiny object is seen by the obsessed it often may induce a compulsive need to claim it (if it’s portable) or at the very least requires several minutes of staring at said object to bask in its shininess!

Now you may ask, how on earth does this relate to cleaning and disinfection? Well, in today’s world we are inundated with commercials that are all glimmer and sparkly after using the latest and greatest cleaning agent. As I wrote about in my SCUFF OFF BLOG as consumers when we enter a building the shinier the floor, the more confidence we have in the facility. We are a population that believes “If it’s shiny it must be clean (and free of germs)!” As introduced in our TOP 10 BLOG, my pet name for our housekeeping employees that are obsessed with shiny surfaces is THE SHINY SURFACE SYNDICATE. This obsession often leads them to abandon infection control principles in search of the product, Spic & Span and Windex are two of the most commonly used culprits, that leaves the surfaces all sparkly. The upside is that staff / patients / residents believe the environment is safe because it is so shiny. The downside is that Windex, Spic & Span or whatever product has been used puts these people at risk for transmitting and acquiring deadly germs.

Don’t get me wrong, I am not saying that shiny is bad. Certainly, streaky mirrors, windows and stainless steel is aesthetically unappealing, and without a doubt there are areas such as the NICU where we need to ensure we can clearly see into the incubator in order to observe a critically ill baby. The key take home message is aesthetics be it the shine of a surface or passing the white glove test is not a quality indicator that should be used to determine a surface or device’s level of cleanliness when it comes to pathogens. Disinfectants are designed to kill not shine. There are surfaces where shine matters and there are surfaces where kill is the ultimate goal. If we need the surface to be both free of pathogens and shiny we have to be cognizant that this may take an added step such as a buffing with a dry cloth or wiping with a clean damp cloth. We need to instill in our housekeeping staff the importance of disinfection, the proper use of disinfectants to ensure we are achieving our infection prevention goals and reaffirm that we should not be swayed into thinking shiny is safe.

Magpie...I mean Melissa, this one’s for you!

Bugging Off!


Nicole

Friday, March 2, 2012

Disinfectant Chemistry Report Card #2 - Is Chlorine Still at the Head of the Class??

Similar to quaternary ammonium solutions, most people are very familiar with the antimicrobial qualities of chlorine based solutions. Chlorine compounds were recognized for their deodorizing and disinfecting properties in 19th century and their wide use began soon thereafter. Today, chlorine’s antimicrobial capabilities are most commonly harnessed for use in water treatment or surface disinfection.

Chlorine solutions, even in very low levels, can show high antimicrobial activity. The microbicidal action is attributed to hypochlorous acid, often referred to more generally as “free available chlorine”. The antimicrobial activity of chlorine is very dependent on the pH of the solution as this determines the concentration of dissociated (available) hypochlorous acid in solution. An example of the “pH effect” can be illustrated by a study that found 25 PPM chlorine to kill 99% of bacterial spores within 2.5 minutes when the solution is at a pH of 6, however, the contact time required to achieve the same level of kill with a 25 PPM solution at a pH of 12.86 was 465 minutes. One caveat that I must make is to note that a product requires a 99.9999% kill in order to achieve EPA or Health Canada sporicidal claims so don’t be fooled into thinking a 25ppm concentration of chlorine is sporicidal!

A significant disadvantage of chlorine solutions, particularly hypochlorites (bleach) is that their overall performance is tied so closely to the stability of the hypochlorous acid. The stability of hypochlorous acid in the solution significantly depends on chlorine concentration (the lower the concentration, the lower the efficacy, but the higher the stability), presence of catalysts or reducing agents (catalysts reduce the stability), pH of the solution (higher alkalinity increases stability, but decreases efficacy), temperature of the solution (lower temperature increases stability), presence of organic material (organic material reduces both stability and efficacy). In short, there is a multitude of factors that need to be taken into account to ensure the effectiveness of a chlorine solution for use as a disinfectant.

For those of you with keen eyes, you will have identified the competing interests inversely affected by pH. On one hand, the disinfectant capabilities of hypochlorite solutions are much better at lower pH values, however at these lower values the solutions are also very unstable. Therefore, most commercially available products are only available as higher pH solutions to ensure stability but compromise with either contact times that are too long (10 minutes) to be realistically achieved or concentrations at 5000ppm or higher that while improving upon speed also increase occupational health and safety risks.

As we have dwelled upon in previous blogs, another very important consideration is a product’s ability to clean and aid in the ability to lift and removal soils from a surface. Chlorine is a bleaching agent and while excellent at helping to whiten and brighten, Chlorine does not have any detergency properties. It is unable to reduce the surface tension between soils and a surface and as a result chlorine’s cleaning ability or efficiency is equivalent to water. Certainly, there are some ready-to-use formulations that incorporate both chlorine and surfactants which will improve cleaning performance, but in concentrated formulations of chlorine the addition of surfactants will degrade both the chlorine and the surfactant resulting in a product that can neither kill nor clean.

Similar to efficacy, the concentration of chlorine is directly related to the chemical’s toxicity. Chlorine is a strong oxidizing agent that is highly reactive not only with other chemicals, but with cell components such as DNA, proteins, lipids and carbohydrates. While ingestion of chlorine solutions can be lethal, the extent of toxicity is directly related to the concentration. Toxicity studies of exposure of chlorine to skin and eyes exposure have found that concentrations <1000ppm to be non skin sensitizing and cause only slight irritation to skin and eyes, at concentrations >1000ppm the irritation increases significantly as the concentration increases.

Both the concentration pH chlorine has a direct affect on respiratory irritation and toxicity. Studies on the rates of asthma in children and competitive swimmers have found a link between the exposures to chlorine from indoor swimming pools to increased rates in asthma. Concentrations of bleach >5000ppm especially if used in enclosed spaces with little ventilation have been found to be irritating to the user. At pH of 5 or higher, the development of chlorine gas is negligible; however acidified solutions with a pH less than 5 will release chlorine gas and can be toxic if inhaled.

Lastly, one advantage to chlorine is that it readily degrades and is not persistent in the environment as it degrades to oxygen and chloride. This limits the chance pathogens will develop chemical resistance, however does not in any way make it environmentally benign. Chlorine as we have stated is highly reactive. It can create toxic bi-products when mixed with chemicals and if released directly into water is very lethal to aquatic life.

With these key points fresh in your mind, how would you grade chlorine as a disinfectant chemistry?
Remember that chlorine, particularly hypochlorites, is utilized within a spectrum of various concentrations. Taking this into account, here’s how we would score chlorine based compounds on the key decision making criteria:

1. Speed of Disinfection – A to C
- Most best practice guidelines recommend 10 minute contact times be utilized with bleach based solutions
- Higher concentrations (>1000ppm) can elicit more rapid kill against bacteria and viruses

2. Spectrum of Kill – A to C
- Similar to the speed of disinfection, performance in this criteria is tied to the in-use concentration
- 5000ppm is recognized as sporicidal; 1000ppm as effective against non-enveloped viruses; <1000ppm solely for use as a low level disinfectant

3. Cleaning Effectiveness – D
- Chlorine solutions have no inherent detergency capabilities; best practice guidelines unanimously support the practice of cleaning surfaces with a detergent prior to using bleach as a disinfectant

4. Safety Profile – B to D
- This is another parameter largely affected by the in-use concentration of the solution >1000ppm solutions are generally irritating to eyes and skin (respiratory irritation also becomes a greater concern at higher concentrations); <1000ppm solutions require less precaution

5. Environmental Profile – C
- Although chlorine compounds are not persistent in the environment upon disposal, because they tend to be so highly reactive the risk lies more in the potential cross-reactions with other chemicals that may be present in waste-water

6. Cost Effectiveness – A
- Bleach is a commodity that is readily available in concentrated formats, however the diluted solutions must be replaced regularly which may result in wasted product

**For more in-depth scientific information about Chlorine Releasing Compounds and other disinfectant chemistries, stay tuned to
www.infectionpreventionresource.com.


The Germinator

Lee