Disinfection & Sterilization

Mr. Johny Kutty Joseph

                 
Asstt. Professor
 Introduction
Micro-organisms can be transmitted to people from
instruments, equipment and/or the environment. Where a piece of
equipment is used for more than one patient it must be
decontaminated following each and every episode of use and prior
to being sent for service or repair, to ensure the safety of both
patients and staff.
The decontamination process makes medical devices safe for
healthcare staff to handle and for use on patients The level of
decontamination required is dependent on what the equipment is
used for and the level to which it has been contaminated.
 Definition

►The term decontamination refers to a process, which removes

or destroys contamination.
►Consequently micro-organisms (or other contaminants) are
prevented from reaching a susceptible site, in sufficient
numbers necessary to initiate infection or any harmful
response.
 Decontamination Process
►These are the process to be followed to initiate correct steps in performing
decontamination:
• Cleaning: Physical removal of contaminants including dust, soil and
organic matter, along with a large proportion of micro organisms. (Drying will
cause a further reduction). This Process is essential prior to disinfection and
Sterilization.

• Disinfection: Utilizing heat or chemicals to reduce the number of viable

micro- organisms to a level which is not harmful to health (but not all viruses
and/or bacterial spores).
 Decontamination Process

• Sterilization: Renders the object free from viable micro-

organisms, including bacterial spores and viruses.

►Important Note: All decontamination procedures should be

undertaken by a qualified trained and equipped member of staff,
wearing personal protective equipment.
 Groups of risk/
Categories of Items Requiring
Decontamination

• Each instrument or piece of medical equipment which comes

into contact with a patient is a potential source of infection.

• The decontamination process required is commonly

specified as one of three levels (based on the classification
system first proposed by Dr. E H Spaulding).
 Groups of risk/
Categories of Items Requiring
Decontamination
►These are divided into 3 groups of risk:
 High risk/Critical Item

 Medium risk/ Semi critical Item

 Low risk/ Non Critical Item

 Groups of risk/
Categories of Items Requiring
Decontamination
Recommendati
Risk Application on
Item in close contact with a break in the
skin or mucous membrane or introduced
into a sterile body cavity or tissue. Critical
High items must be sterile. Some are: Sterilization
Surgical instruments
Cardiac or IV or Catheters
Implants
 Groups of risk/
Categories of Items Requiring
Decontamination
Recommendati
Risk Application on
Item in contact with nonintact mucous
membranes or skin, body fluids and
particularly after use on infected patients or
Mediu prior to use on immuno-compromised Sterilization or
m patients. These items must be free of all Disinfection
microorganisms (except spores)
Some of the items are:
Endoscopes
 Groups of risk/
Categories of Items Requiring
Decontamination
Recommendatio
Risk Application n
Items in contact with healthy/intact skin but
not mucous membranes or not in contact
with patient. Item must be clean. Some are:
Bedpans Disinfection or
Low
Linens Cleaning
Stethoscope
Furniture used by patient
 Method Selection

►Various factors influence the choice of decontamination process:

1)Nature of organisms present: The CDC recommends that all supplies,
linens, and equipment in a health care setting should be treated as if the
patient were infectious.

2)Number of organisms present: The more organisms present on an item,

the longer it takes to destroy them.
 Method Selection

3) Type of equipments: Equipment with small lumens, crevices, or joints

requires special care. Articles which are prone to damage during
decontamination requires special attention.

4) Intended use of equipment: The need for medical and surgical asepsis
influences the preparation and cleaning of equipment.
 Method Selection

5) Available means for sterilization and disinfection: The choice of method

depends on the availability and practicality of the means.

6) Time: Time is a key factor when sterilizing or disinfecting articles.

Failure to follow the recommended time periods is grossly negligent.
 Choosing the Appropriate Decontamination Process
In accordance with “Spaulding” Risk Classification

Are disposables available?

NO YES
Choose level of
decontamination required:-
Use disposables

HIGH MEDIUM LOW

Sterilization/HLD Cleaning
if heat labile) Disinfection or
Sterilization
YES – Washer Can equipment withstand
Disinfect automated cleaning? If No–
Can equipment
use immersion/Non
No- Chemical withstand heat
Immersion cleaning method
Disinfection disinfection?
 Cleaning

Definition
► CLEANING is a dirt removing process, using liquid detergent and
warm water. This process removes a high proportion of all micro-
organisms.
► It is essential for the removal of organic matter, grease and
lubricants, which might otherwise protect organisms from additional
decontamination processes such as disinfection and sterilization.
 Cleaning

General principles:
► Cleaning and thorough rinsing should always precede any attempt to
disinfect or sterilize.

►Cleaning can be achieved by either manual or automated methods.

►Cleaning should be carried out using a validated cleaning process

wherever possible.
 Types of Cleaning
1) Manual Cleaning
2) Automated Cleaning

►Effective cleaning is an essential prerequisite to all

subsequent methods of decontamination.
►Manual cleaning is an implementation of cleaning process
done by human.
 Types of Cleaning

►Automated cleaning is a controlled process that will provide

more consistent results and therefore manual cleaning of items
should only be undertaken when automated methods are
inappropriate or unavailable.
 Types of Cleaning

►List of automated cleaners

O Ultrasonic cleaner – Ultrasonic cleaning is a process that uses
ultrasound (usually from 20–400 kHz) and an appropriate
cleaning solvent (sometimes ordinary tap water) to clean
items.
 Types of Cleaning
►List of automated cleaners
O Washer disinfector - systems that are designed to clean and disinfect
specific medical utensils, surgical instruments and other articles found in
healthcare facilities.
 Types of Cleaning
►List of automated cleaners
O Thermal washer disinfector - The use of an automated thermal washer-
disinfector provides disinfection using moist heat. Thermal disinfection
takes place at 93°C with a temperature holding time in compliance.
This process incorporates both
cleaning and disinfection.
 Disinfection
►Disinfection is the killing of many, but not all microorganisms.
It is a process of reduction of number of contaminating
organisms to a level that cannot cause infection, i.e. pathogens
must be killed. Some organisms and bacterial spores may
survive.
►Disinfectants are chemicals that are used for disinfection.
Disinfectants should be used only on inanimate objects.
►Antiseptics are mild forms of disinfectants that are used
externally on living tissues to kill microorganisms, e.g. on the
surface of skin and mucous membranes.
 Disinfection
► Used when items cannot be sterilized or situations
where no method of sterilization is available.
► Chemicals used in disinfection are called disinfectants.
Different disinfectants have different target ranges,
not all disinfectants can kill all microorganisms.
► Importance of disinfection: The method of disinfection is
used internationally for the safety of humans, to decrease
the scale of transmission of diseases. A large emphasis of
sterilisation and disinfection has been placed in the food
industry, water sanitisation and medical care and hospitals.
 Disinfection
Disinfection techniques are classified according to:
 Consistency
• Liquid (Alcohols, Phenols)

• Gaseous (Formaldehyde vapour, Ethylene oxide)

 Spectrum of activity
• High level

• Intermediate level

• Low level
 Disinfection
Disinfection techniques are classified according to:

 Mechanism of action
• Action on membrane (Alcohol, detergent)

• Denaturation of cellular proteins (Alcohol, Phenol)

• Damage to nucleic acids(Ethylene Oxide, Formaldehyde)

 TYPES
► LOW – LEVEL DISINFECTANTS
FOR HOUSEKEEPING AND NON – CRITICAL ITEMS THAT DOES NOT TOUCH THE
PATIENT’S SKIN

 EX.
 TYPES

• INTERMEDIATE LEVEL DISINFECTANTS

FOR SEMI – CRITICAL ITEMS THAT COMES IN CONTACT WITH THE SKIN

 EX.
 TYPES
►HIGH LEVEL DISINFECTANT
FOR CRITICAL ITEMS THAT COMES IN CONTACT WITH THE BODY
TISSUES OR BELOW SKIN MEMBRANES

 EX.
 Methods of Disinfection

►PHYSICAL DISINFECTION:
Disinfection is best achieved by moist heat such as boiling in water (100°C for
10 minutes at sea level) or by Tindilization means boiling for 20 minutes and
then cooling, again re-boiling and cooling for three timeswhich kills all
organisms except for a few bacterial spores.
►CHEMICAL DISINFECTION:
Chemical disinfectants may be supplied ready to use or may need accurate
dilution to provide an appropriate solution.
 PHYSICAL DISINFECTANTS
►BOILING WATER
►PASTERURIZATION
► ULTRAVIOLET RAYS
 THE RAYS COMES IN CONTACT WITH THE
ORGANISMS

WEAR PROTECTIVE
SKIN COVERING!!!
 CHEMICAL DISINFECTANTS
Liquid disinfectants are preferably used for solid
surfaces and equipment. They vary greatly in their
efficiency, depending on the chemical constituents and
the agents involved.
These include alcohols, chlorine and chlorine
compounds, formaldehyde, glutaraldehyde, hydrogen
peroxide, iodophors, peracetic acid, phenolics, and
quaternary ammonium compounds.
Chemical disinfection may only be used for items
for which thermal disinfection methods are unsuitable.
 Chemical
Disinfectant
Solutions
 Phenol and Phenol Derivatives:

►concentrations 5% to 10 %.
►Unpleasant odor
►Toxic
►used for disinfection of walls, floors, bench
tops.
►They effectively kill bacteria including
Mycobacterium tuberculosis, fungi and lipid-
containing viruses.
►They are not active against spores
 Halogens (Chlorine and Iodine):
►Sodium hypochlorite is the most
common
►Common household bleach (5%
available chlorine) can be diluted 1/10
to 1/100 with water
►At high concentrations and extended
contact time, considered cold
sterilants
►They are most often used as
antiseptics and in surgical soaps and
are relatively nontoxic to humans.
 Alcohols
►Ethyl or isopropyl alcohol in concentration
of 70% to 90% are good general-use
disinfectants.
►they evaporate fast and therefore have
limited exposure time.
► They are less active against non-lipid
viruses and ineffective against bacterial
spores.
► Concentrations above 90% are less
effective. They should only be used after all
the visible surface dirt has been removed
from the area to be disinfected.
 Aldehydes

►Formalin:
►Formalin is 37% solution of formaldehyde
in water.
►Dilution of formalin to 5% results in an
effective disinfectant.
► Formaldehyde is a human carcinogen and
creates respiratory problems at low levels
of concentration.
 Glutaraldehyde:
►Chemically related to
formaldehyde, is more effective
against all types of bacteria, fungi,
and viruses.
►Vapors of glutaraldehydes are
irritating to the eyes, nasal passages
and upper respiratory tract.
 Quaternary Ammonium Compounds (Quats):

►detergents with strong surface activity.

►They are active against Gram-positive
bacteria
►They are less active against Gram-negative
bacteria .
►Quats are relatively nontoxic and can be used
for decontamination of food equipment and for
general cleaning.
 Hydrogen Peroxide

►3% Hydrogen peroxide is stable and efficient

against inanimate surfaces.
►Peroxides are often used as antiseptics in
cleaning wounds.
►The activity is highest against anaerobic
bacteria.
►It can cause damage to tissues and cause delay
in healing.
Sterilization
 Sterilization
Sterilization is the killing or removal of all
microorganisms, including bacterial spores which are
highly resistant. Sterilization is an absolute term, i.e.
the article must be sterile meaning the absence of all
microorganisms.
Sterilization destroys all microorganisms on the
surface of an article or in a fluid to prevent disease
transmission associated with the use of that item.
While the use of inadequately sterilized critical items
represents a high risk of transmitting pathogens.
 Uses of Sterilization

1.   Sterilization for Surgical Procedures: Gloves, aprons, surgical

instruments, syringes etc. are to be sterilized.

2.   Sterilization in Microbiological works like preparation of culture media,

reagents and equipments where a sterile condition is to be maintained.
 Uses of Sterilization

►COMMONLY USED IN THE OPERATING ROOM AND

DELIVERY ROOM

►NURSING PROCEDURES THAT ARE INVASIVE

 PURPOSE

►ELIMINATE ALL MICROORGANISMS THAT WILL COME

INTO CONTACT WITH BODY TISSUES.

► PROTECT PATIENTS FROM POSSIBLE

INFECTION WHEN NATURAL
DEFENSES ARE NOT NORMAL
 PROCEDURES REQUIRING STERILE
TECHNIQUE

►PROCEDURES WHEN UNDERLYING TISSUES ARE BEING

EXPOSED

► INTERNAL BODY AREAS ARE

NORMALLY STERILE
 CLASSIFICATION OF
STERILIZATION METHODS

PHYSICAL AGENTS
Thermal/Heat

Ionizing Radiation

Filtration

CHEMICAL AGENTS
Heat is
Sterilization By Heat
most effective and a rapid method of
sterilization and disinfection. Excessive heat acts by
coagulation of cell proteins. Less heat interferes with
metabolic reactions.

TYPES OF HEAT:

A.Sterilization by moist heat

B.Sterilization by dry heat

A. SterilizationSterilization
by moist heat By Heat
Moist heat acts by denaturation and
coagulation of protein, breakage of DNA strands,
and loss of functional integrity of cell membrane.
(I) Sterilization at 100C

(II)Sterilization above 100C

(III)Sterilization below 100C

A. SterilizationSterilization
by moist heat
By Heat
(I) Sterilization at 100C
1. Boiling: Boiling at 100C for 30 minutes is done in a
water bath. Syringes, rubber goods and surgical
instruments may be sterilized by this method.
2. Steaming: Steam (100C) is more effective than dry
heat at the same temperature. It is done with a
steam sterilizer. In this sterilization is done by two
methods:
a) Single Exposure for 11/2 hours
b) Tyndallization (Fractional Sterilization)
 Sterilization By Heat
A. Sterilization by moist heat
(I) Sterilization at 100C
1. Boiling:

2. Steaming:
a) Single Exposure for 11/2 hours
b) Tyndallization
(Fractional Sterilization)
A. SterilizationSterilization
by moist heat By Heat
(II) Sterilization above 100C:
Autoclaving
It is one of the most common
methods. It is a metallic
cylindrical vessel. It is done by
steam under pressure. When
the autoclave is closed and
water starts boiling above
100C and the inside pressure
increases.
 Sterilization By Heat
A. Sterilization by moist heat
(III) Sterilization below 100C
1. Pasteurization: Pasteurization is heating of milk to
such temperature and for such a period of time so as
to kill pathogenic bacteria that may be present in
milk without changing colour, flavour and nutritive
value of milk.
i) Flash Method: Heating at 72 C for 15 secs.
ii) Holding Method: Heating between 63 C and 66 C
for 30 minutes
2. Inspissation: stiffening of protein without coagulation
between 75 C to 80 C. It is done in ‘Serum
Inspissator’
Serum Inspissator
 Sterilization By Heat
B. Sterilization by dry heat
Mechanisms – By protein denaturation, oxidative
damage and toxic effect of elevated electrolyte.
Dry heat at 160 C holding for one hour.
1. Red Heat: heating to red in bunsen burner or spirit
lamp flame.
2. Flaming: the article is passed through flame without
allowing it to become red hot.
3. Incineration:ignites and reduce to ash & gas
4. Hot air oven (sterilizer): one of the most common
method used for glass wares, swab, etc. at a
temperature of 160 C.
Red Heat

Flaming
Sterilization By Radiation
 Radiation
►Gamma and X-ray are two principal types of
ionizing radiation used in sterilization.
►Their application is mainly centered on the
sterilization of prepackaged medical devices.
►Ultraviolet (UV) radiation is a practical
method for inactivating viruses, mycoplasma,
bacteria and fungi.
► UV radiation is successfully used in the
destruction of airborne microorganisms.
►UV light sterilizing capabilities are limited on
surfaces because of its lack of penetrating
power .
 IONIZING
►EXPOSURE TO IRRADIATION
RADIATION
 IRRADIATION STERILIZATION IS
SUITABLE FOR HEAT AND MOISTURE
SENSITIVE ITEMS
 Sterilization By Filtration

Sterilize solutions which are heat liable

such as sugar solutions, sera and
antibiotics are done by filtration
methods.
Types:
1. Earthen ware (Candle) filter
2. Asbestos (seitz) disc filters
3. Membrane filter
4. Syringe filter
5. Air filters
 Chemical Agents

►Chemicals are also used for sterilization. Heating provides a

reliable way to rid objects of all transmissible agents, but it is
not always appropriate if it will damage heat-sensitive
materials such as biological materials, fiber optics,
electronics, and many plastics. In these situations chemicals,
either as gases or in liquid form, can be used as sterilants. 
 Chemical Agents

►ETHYLENE OXIDE GAS (EO

( ): Is one of the common methods
used to sterilize, pasteurize, or disinfect items because of its
wide range of material compatibility.

 ITEMS THAT ARE SENSITIVE HEAT/

MOISTURE.

MONITOR!!!
► HIGHLY FLAMMABLE!!!
 Ethylene oxide
►Ethylene oxide is a colorless gas which is toxic to inhale.
► It is effective against all organisms and does not damage
equipment.
►Ethylene oxide treatment is generally carried out
between 30 °C and 60 °C with relative humidity above
30% and a gas concentration between 200 and 800 mg/l.
Typically, the process lasts for several hours. Ethylene
oxide is highly effective, as it penetrates all porous
materials, and it can penetrate through some plastic
materials and films.
►The operating cycle ranges from 2 - 24 hours so the
turnaround time is prolonged and it is a relatively
expensive process.
► HYDROGEN PEROXIDE:

►Hydrogen peroxide, in both liquid and as vaporized

hydrogen peroxide (VHP), is another chemical
sterilizing agent. 
►Hydrogen peroxide is used to sterilize heat or
temperature sensitive articles such as rigid
endoscopes. In medical sterilization hydrogen
peroxide is used at higher concentrations, ranging
from around 35% up to 90%. The biggest advantage
of hydrogen peroxide as a sterilant is the short cycle
time. It have a cycle time as short as 28 minutes.

SAFE AND NON-TOXIC

►OZONE GAS
 EXPENSIVE AND EASY TO OPERATE

CORROSIVE!!!

 NOT USED FOR ITEMS MADE OF STEEL

BRASS AND ALUMINUM
►LIQUID CHEMICAL STERILANT
ACID: (0.2%) is a recognized sterilant by the
– PERACETIC ACID: 
FDA for use in sterilizing medical devices such
as endoscopes.

LIQUID STERILANT
 SUITABLE FOR STERILIZING HEAT –
SENSITIVE ITEMS
 RINSE IN STERILE WATER BEFORE USING
 CAN BE USED IMMEDIATELY
 INDICATORS OF STERILITY
►STERILE TAPES
►PACKAGE WITH STERILE INDICATORS
►EXPIRATION DATE
 GENERAL PRINCIPLES

1. MICROORGANISMS MOVE THROUGH SPACE IN AIR

CURRENTS
2. MICROORGANISMS ARE TRANSFERRED FROM ONE
SURFACE TO ANOTHER WHEN A NONSTERILE OBJECT
TOUCHES OTHER OBJECTS
3. MICROORGANISM MOVE FROM ONE OBJECT TO
ANOTHER AS A RESULT OF GRAVITY WHEN A NON-
STERILE ITEM IS HELD ABOVE ANOTHER ITEM
4. MICROORGANISMS TRAVEL RAPIDLY ALONG ANY
MOISTURE THROUGH A WICKING ACTION
5. MICROORGANISMS MOVE SLOWLY ALONG A DRY SURFACE
6. MICROORGANISMS ARE RELEASES THROUGH THE AIR ON
DROPOLET NUCLEI WHENEVER A PERSON BREATHES OR
SPEAKS
7. MICROORGANISMS ARE IN CONSTANT MOTION IN A
VARIETY OF WAYS
8. THE EDGE OF THE STERILE FIELD IS POTENTIALLY
CONTAMINATED BY MICROORGANISMS MOVING IN FROM
THE OUTSIDE
 ALWAYS REMEMBER!!!
WHEN IN DOUBT OF STERILITY
DISCARD!!!