journal of Hospital infection (200 I) 48 (Supplement A): S64-S68

doi: IO. I053/jhin.200 I .0973, available online at http://wwv.idealibrary.com

Surface

disinfection:

IREhi

on

should

we do it?

W.A. Rutala and D. J. Weber

University of North Carolina (UNC) Health Care System and UNC School of Medicine, Chapel Hill,
NC 27514, USA

Summary:

The effective
use of disinfectants
constitutes
an important
factor in preventing
hospitalacquired infections. Surfaces are considered non-critical
items as they come in contact with intact skin. Use
of non-critical
items or contact with non-critical
surfaces carries little risk of transmitting
a pathogen to
patients. Thus, the routine use of disinfectants
to disinfect
hospital floors and other non-critical
items
is controversial.
However,
surfaces may potentially
contribute
to cross-transmission
by acquisition
of
transient hand carriage by health care personnel due to contact with a contaminated
surface or by patient
contact with contaminated
surfaces or medical equipment.
This paper reviews the epidemiological
and
microbiological
data regarding the use of disinfectants
on non-critical
surfaces. It concludes that while noncritical surfaces are uncommonly
associated with transmission
of infections
to patients, one should clean
and disinfect surfaces on a regularly scheduled basis.
0 2001 The Hospital

Keywords:

Disinfection;

environmental

Introduction
The effective use of disinfectants
is an important
factor in preventing
hospital-acquired
infections.
In 1968, E. H. Spaulding
proposed three categories
of germicidal
action to prevent a risk of infection
associated with the use of equipment
or surfaces.
These three categories
were non-critical,
semicritical, and critical.
Surfaces are considered
noncritical items if they come in contact with intact
skin since intact skin is a barrier to disease transmission. Use of non-critical
items or contact with
non-critical
surfaces carries little risk of transmitting
a pathogen to patients. Thus, the routine use of
disinfectants
to disinfect hospital floors and other
surfaces is controversial.
While non-critical
surfaces have not been directly
implicated
in disease
transmission,
they may potentially
contribute
to
cross-transmission
by acquisition
of transient hand
carriage by health care personnel
due to contact

Author
for correspondence:
William
A. Rutala, PhD, MPH,
547
Burnett-Womack
Bldg, Division
of Infectious
Diseases, UNC
School of Medicine,
Chapel Hill, NC 27599-7030,
USA.
Fax: 919-966-1451.

0 195-670 I/O I /OAOS64 + 05 $35.0010

Infection

Society

surfaces; cross-infection.

with a contaminated
surface, or by patient contact
with contaminated
surfaces or medical equipment.
The purpose of this paper is briefly to review the
epidemiological
and microbiological
data regarding
the use of disinfectants
on surfaces.

Justification
non-critical

for using a disinfectant

surfaces

for

Surfaces may contribute

to transmission
of
epidemiologically
important
microbes such as
methicillin-resistant
Staphylococcus
aureus
(MRSA), vancomycin-resistant
Enterococci
(VRE)
and viruses (rotavirus, rhinovirus)
Several

investigators
have demonstrated
that inanisurfaces near infected
patients
commonly
become contaminated
with MRSA and VRE2+ and
that the contamination
can persist for hours to
weeks on dry surfaces.3 Personnel may contaminate
their gloves (or possibly their hands)2 by touching
such surfaces so that contaminated
environmental
surfaces may serve as a reservoir
of MRSA
and
VRE in hospitals.
While the precise role of the
environment
is not known, environmental
surface
mate

0 200 I The Hospital

Infection

Society

S65

Surface disinfection

contamination
may contribute
to endemic or epidemic spread of infection as the surfaces can act as
a source from which personnel
contaminate
their
hands. An aggressive environmental
decontamination programme
has been credited with eradicating
VRE from a burn unit6
Multiple
studies have
demonstrated
that the antibiotic-resistant
bacteria are
as susceptible to germicides as antibiotic-susceptible
strains.7x
Viruses can be transmitted
from environmental
surfaces either directly
from surface-to-finger-tomouth or directly from surface-to-mouth.
Chemical
disinfection
of contaminated
environmental
surfaces
has been shown to interrupt
transfer of rhinovirus
from these surfaces to hands. In experimental
studies, the use of disinfectants
has been shown to be an
efficient
method of inhibiting
the transmission
of
rotavirus to human subjects.

Disinfectants
are needed for surfaces
contaminated
by blood and other potentially
infective materials
In the USA,
to comply
with the Occupational
Safety and Health Administration
rule on bloodborne pathogens, a blood spill must be treated with a
disinfectant.
The compliance directive states that the
blood should be disinfected using an Environmental
Protection
Agency-registered
tuberculocidal
disinfectant, a disinfectant
with a HBV/HIV
inhibition
claim, or a solution of 5.25% sodium hypochlorite
(household
bleach) diluted between 1 :lO and 1 :lOO
with water. A recent stu d y demonstrated
that, in
the presence of blood spills, a 1: 10 final dilution
of
bleach should be used to inactivate
blood-borne
viruses. * Even at this concentration
complete inactivation cannot be assured.

Disinfectants
are more effective than detergents
in reducing microbial
load on floors
Hospital
floors become contaminated
with microorganisms by settling of airborne bacteria, by contact with shoes, wheels and other objects,
and
occasionally
by spills. The removal of microbes is a
component
in the control of healthcare-associated
infections.
In an investigation
on the cleaning of
hospital
floors, the use of soap and water (80%
reduction)
was less effective in reducing the numbers of bacteria than a phenolic
disinfectant
solution (99% reduction). l3 However, a few hours after

floor disinfection
the bacterial
count
nearly to the pretreatment
level.13,

Detergents
become contaminated
seeding the patients environment

was

back

and result in
with bacteria

Investigators
have shown that mop water becomes
increasingly
dirty during
cleaning
of floors, and
that mop water becomes contaminated
if soap and
water is used rather than a disinfectant.
Table I
bacterial count in water from
shows an increasing
the mop bucket during cleaning with soap and water
but no comparable
increase in counts occurred
when a disinfectant
was used.

Disinfection
of non-critical
equipment
surfaces is recommended
for patients
isolation precautions

and
on

The Center for Disease Control

and Prevention
recommends
in their Isolation Guideline
that noncritical equipment
contaminated
with blood, body
fluids, secretions or excretions be cleaned and disinfected after use. The same guideline
recommends
that, in addition to cleaning, disinfection
of the bedside equipment
and environmental
surfaces (e.g., bed
rails, bedside tables, carts, commodes,
door-knobs,
faucet handles) is indicated
for certain pathogens,
especially enterococci, which can survive in the inanimate environment
for prolonged periods of time.16

Newer disinfectants
may have persistent
antimicrobial
activity
Recent investigations
have evaluated antimicrobials
with a persistent action that may be used on animate
and inanimate
surfaces. A new product
undergoing clinical
trials incorporates
a water-insoluble
antimicrobial
compound
(silver
iodide)
into
a
Table
I
disinfectant

Bacteria/

contominotion

of mop water

Soap
(cfu/ml)
Before cleaning
After cleaning one-third
of ward
After cleaning two-thirds
of ward
After cleaning complete
ward
Adapted

from Ayliffe GAJ et al.5

IO
650

with and without

Disinfectant
(cfulml)
20
IO

15000

30

34 000

20

S66

W.A. Rutala and D. JWeber

surface-immobilized
coating which is capable of
chemical recognition
and interaction
with the lipid
bilayer of the bacterial
outer cell membrane
via
electrostatic
attraction.
The intimate microbial
contact with the surface results in transfer
of the
antimicrobial
component
(silver) directly from the
coating to the organism due to a favourable binding
energy. Micro-organisms
contacting
the coating
accumulate
silver until the toxicity
threshold
is
exceeded. Preliminary
studies show that treated surfaces result in excellent elimination
of VRE inoculated directly on to various surfaces at challenge levels
of 100 CFU/in*
for at least 13 days. Antimicrobial
activity
is retained even when the surface is subjected to repeated dry wiping
or wiping
with a
quaternary
ammonium
compound.
There are advantages of using a single product
for decontamination
of non-critical
surfaces,
both floors and equipment
Environmental
cleaning is often conducted
by less
skilled
workers.
Hence,
using a single product
throughout
the health care facility
may simplify
both training and appropriate
practice.

Justification

for using a detergent

on floors

Non-critical
surfaces contribute
minimally
endemic hospital-acquired
infections

to

findings
that suggest that
Maki et al. published
micro-organisms
in the inanimate hospital environment-particularly
on
surfaces
and
in
the
air-contribute
negligibly
to endemic
rates of
hospital-acquired
infections. Maki et al. assessed the
levels of environmental
contamination
and the incidence of hospital-acquired
infections
in an old
hospital that was scheduled to be closed, and a new
hospital.
Despite striking contrasts in the physical
configuration
of the two hospitals, which were associated with significant
differences in the profile and
levels of microbial
contamination
during the study
periods,
the incidence
and profile
of hospitalacquired infection in patients remained the same.

There is no difference in hospital-acquired

infection rates when floors are cleaned with
detergent versus disinfectant
Three studies have evaluated the need for daily disinfection of environmental
surfaces not contaminated

with body fluids via bacteriological

monitoring
or
infection rates. Daschner et al. reported no difference
in hospital-acquired
infection rates in an intensive
care unit when floors were cleaned for six months
with disinfectants
compared with six months with
detergents. l9 Danforth et al. conducted a six-month
study comparing
disinfectant
versus plain soap on
hospital-acquired
infection rates. Surface microbial
cultures were obtained at three and six months to
assess microbial
contamination.
The combined
nosocomial
infection
rate for the eight acute care
nursing wards did not differ between disinfectant
(8.0 per 100 patient discharges) and detergent (7.1
per 100). No differences
in floor contamination
were observed. 2o Dharan et al. found that use of a
detergent
alone was associated with a significant
increase in bacterial
counts compared
with the
methods using disinfectants. However, they observed
no change in the incidence
of hospital-acquired
infections during the four-month
trial compared to
the preceding 12 months.21

No restrictions

on disposal

Some states, counties, municipalities

and countries
have restricted the disposal of certain disinfectants
into sanitary
sewers. Reasons for restricting
disposal via the sanitary sewer include the potential for
disinfectants
to harm aquatic life and that they may
not biodegrade
to less toxic substances.
No such
restrictions
exist on the disposal of detergents.

No occupational

health

exposure

issues

A disinfectant
is considered toxic if it causes illness
or death if inhaled, ingested or absorbed through
the skin. There have been a few reports of occupationally acquired skin diseases among cleaning personnel who have had prolonged
contact with a
variety of chemical germicides.22

There is an additional
cost associated with the use
of disinfectants
rather than detergents
for floor
cleaning. One 930-bed hospital estimated the additional costs at approximately
$2000 per year (in US
dollars in 1987). 2o This difference in price is modest by hospital
costs. Further,
a single hospitalacquired
infection
is likely
to be as or more
expensive than the yearly costs to a facility of using
disinfectants
rather than detergents.

S67

Surface disinfection

More

aesthetically

pleasing

floors

Detergents
have the benefit of producing
shiny
floors that may be more aesthetically
pleasing.

Use of antiseptics
and disinfectants
for antibiotic
resistant bacteria

may

select

Some researchers
have suggested that the use of
disinfectants
or antiseptics
(e.g., triclosan)
could
facilitate
the development
of antibiotic-resistant
micro-organisms.
23-25 While there is evidence
in
laboratory
studies of low-level
resistance
to the
bisphenyl,
triclosan, this was to low concentrations
of triclosan
(generally
~1 pg/mL)
which are dissimilar to the higher levels used in antimicrobial
products (2000-20 000 p,g/mL).26 Thus, researchers
can create laboratory-derived
mutants that demonstrate reduced susceptibility
to antiseptics
or disinfectants. In some experiments,
such bacteria have
demonstrated
reduced
susceptibility
to certain
antibiotics.
However,
there is no evidence
that
antiseptic/disinfectant
or antibiotic
resistance has
occurred
in nature
or that mutants
survive
in
nature.27

Conclusion
The use of disinfectant-detergents
for surface disinfection is common in the USA and some European
countries while in the UK a detergent alone is commonly used. In 1991, Favero and Bond provided
a
useful expansion of the Spaulding scheme by dividing the non-critical
environmental
surfaces into
housekeeping
surfaces
and medical
equipment
surfaces. 28 Medical equip ment surfaces (e.g., blood
pressure cuffs, stethoscopes, haemodialysis
machines,
X-ray
machines)
may become contaminated
with
infectious agents and have served as the vehicle for
person-to-person
transmission
in outbreaks.
For
this reason, non-critical
medical equipment
surfaces
should be disinfected
with a low- or intermediatelevel disinfectant.
Use of a disinfectant
will provide
antimicrobial
activity that is likely to be achieved at
minimal additional
cost or work.
Environmental
surfaces (bedside table, bed rails)
in close proximity
to the patient have been demonstrated to become contaminated
with epidemiologitally important
microbes such as VRE and MRSA.
Data also demonstrate
that important
hospitalacquired pathogens (VRE, MRSA)
can survive on
environmental
surfaces for an extended
period of

time and this may allow for environmentally

mediated disease transmission.
For this reason, these
surfaces should be disinfected
regularly
and at discharge cleaning.
Favero and Bond suggested that since housekeeping surfaces (e.g., floors) are associated with
the lowest risk of disease transmission,
detergents
or a disinfectant-detergent
could be used.28 While
there are no data that demonstrate
a reduction
in
hospital-acquired
infection
rates with the use of
surface disinfection
of floors, available data show a
reduction
in microbial
load associated with the use
of some disinfectants.
In addition, the use of a disinfectant throughout
the hospital simplifies training
and use. Given the minimal
extra cost, the use of
disinfectants
on floors is reasonable.
The bloodborne pathogen rule in the USA requires the use of
a disinfectant
when there is a blood spill. Regardless
of whether a detergent
or disinfectant
is used on
surfaces in a health care facility, cleaning should be
undertaken
routinely
and when environmental
surfaces are dirty or soiled in order to provide an aesthetically
pleasing
environment
and to prevent
potentially
contaminated
objects from serving as a
source of micro-organisms
that cause hospitalacquired infections.
In summary, while non-critical
surfaces are not
commonly associated with transmission
of infections
to patients, one should clean and disinfect surfaces
on a regular basis. Most US hospitals use low-level
(non-tuberculocidal)
and intermediate-level
disinfectants (tuberculocidal)
for the routine removal and/or
inactivation
of soil and micro-organisms
from noncritical surfaces. Non-critical
medical equipment
has
been demonstrated
to serve as the vehicle for outbreaks and should be disinfected
between patient
use. Environmental
surfaces (e.g., bedside tables,
side rails) may become contaminated
with epidemiologically
important
microbes and should be disinfected regularly
and at patient
discharge
as per
hospital policy. It is reasonable to disinfect
floors
given the minimal
cost and added antimicrobial
activity. Additional
studies should be undertaken
to
determine
the clinical
impact of current
surface
disinfection
practices.

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S68

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