European

Infectious Disease
Volume 6 • Issue 2 • Winter 2012 • Extract

Automated Room Surface

Disinfection – Proposals for
an International Standard

Christine Roques,1 Lionel Pineau2

and Arnaud Florentin3

1. Professor of Microbiology, University Paul

Sabatier, Fonderephar, Toulouse, France;
2. CEO and Scientific Director, Biotech-Germande,
Marseille, France; 3. Medical Doctor of Public
Health, Faculty of Medicine, University Lorraine,
Lorraine, France

www.touchinfectiousdisease.com
Healthcare-associated Infections

Automated Room Surface Disinfection –

Proposals for an International Standard
Christine Roques,1 Lionel Pineau2 and Arnaud Florentin3

1. Professor of Microbiology, University Paul Sabatier, Fonderephar, Toulouse, France; 2. CEO and Scientific Director, Biotech-Germande, Marseille, France;
3. Medical Doctor of Public Health, Faculty of Medicine, University Lorraine, Lorraine, France

Abstract
There is a growing interest for automated area decontamination (aad), as an alternative or complement to manual surface disinfection
procedures. however, unlike for liquid disinfection or sterilisation, consensus on efficacy evaluation benchmarks and dedicated
international standard are missing for aad. attempts are currently made to fill those gaps. Standards for liquid disinfectants will serve as
a basis, but it remains to be determined to which extent these norms formulate an appropriate basis for aad. The objective of this article
is not to discuss the content for a future aad standard but rather to provide a brief overview of items which might deserve a debate
before defining the details of an appropriate evaluation framework. Preliminary observations by confocal microscopy on Candida albicans
inoculi prepared according to usual suspension standards are provided as an example of experiments which should be driven to help
define that framework.

Keywords
automated area decontamination, surface decontamination, healthcare-associated infection, environment, hydrogen peroxide

Received: 28 September 2012 Accepted: 24 october 2012 Citation: European Infectious Disease, 2012;6(2):94–7
Correspondence: christine Roques, FoNdeRePhaR, Faculté des Sciences Pharmaceutiques, 35 chemin des maraîchers, 31062 Toulouse cedeX 09, France.
e: ch.roques@wanadoo.fr

Support: The publication of this article was supported by advanced Sterilization Products.

Healthcare-associated Infections Manual or Automated

healthcare-associated infections (hais) are an important challenge For automated area decontamination (aad), like for instruments
faced by healthcare facilities worldwide. The clinical and economic reprocessing, studies have shown that well defined and controlled
burden of hais can be high and can have a substantial impact on automated procedures yield more consistent results than
patients and healthcare facilities alike.1 manual procedures.

Such infections can be contracted through contact with an
infected or colonised individual, a contaminated environment or
a contaminated instrument. evidence supporting the important
role of the environment as a source of hai pathogens is growing,
highlighting the importance of interventions that can reduce
environmental bioburden.2–6
Surface Disinfection, Pending Questions
Cleaning and/or Disinfection
depending on country guidelines, hospitals, type of rooms and
circumstances, various combinations of surface cleaning and/or
disinfection procedures can be used including: cleaning with detergent
formulation only, cleaning with detergent enriched with disinfectant,
and cleaning followed by disinfection.7
current thinking for surface cleaning and disinfection seems to be
that specialised cleaning or disinfectant formulations will give better
results than mixed disinfectant and detergents and that two
separated cleaning and disinfection steps will be safer than a single
step combining cleaning and disinfection.
Toxicity and Compatibility
limitation of exposure of staff to vapours of surface disinfectants
such as chlorine or quaternary ammonium are becoming a concern
following allergies or discomfort complaints from cleaning staff.8
compatibility of materials with oxidative ingredients is another
important consideration. The impact of the disinfection process on
surfaces will inevitably increase with the concentration or total dose
of active ingredients.
Evaluation Benchmarks
all the above advocate for the adoption of a two-step procedure with
detergent first and then automatic rather than manual disinfection.
international efficacy criteria and benchmarks allowing objective
evaluation of automatic reprocessing processes between themselves
and versus manual disinfection remains to be defined however.
Automated Area Decontamination –
General Considerations
Terminology
different terminologies can be used when referring to room surface

© Touch medical media 2012 3

Healthcare-associated Infections
Figure 1: Confocal Microscopy Observations of
Candida albicans Prepared in Sterile Distilled Water
and Skimmed Milk 1/20 at Various Concentrations
a B
6,5lo
c d
5,0lo
e F
3,8lo
Fluorescent markers (syto 9 and propidium iodure) have been added to underline
physiological stage of cells after drying. A, C, E: the centre of the inoculums;
B, D, F: the border of the inoculums. Note the low proportion of red cells.
disinfection: aad, room surface disinfection, and airborne
surface disinfection. in this article we will use aad.
Definition
modern aad can be seen as a replacement of formaldehyde, which
progressively disappeared from the healthcare environment due to its
toxicity.9 aad covers a large variety of processes which have in common:
• the absence of mechanical effect applied on the surface being
treated; and
• no immersion of the surface to be decontaminated. if immersion
occurs, even in small layers, the process should fall under
existing suspension standards.10–13
automated means that no human has to be present in the room
during the disinfection cycle. area or surface express that aad is
intended for decontamination of room surfaces, including external
surfaces of equipments, which could possibly contribute to cross
contamination. decontamination or disinfection indicates that, unlike
for sterilisation, the objective of aad is not total kill of germs and that
efficacy will hence be evaluated as a log reduction of initial load.
Pervasiveness
Since aad can be used to replace or complement manual disinfection
procedures, pervasiveness should be at least comparable to
manual disinfection.
By pervasiveness we mean the ability to remain efficient in all spaces
that can be reached by hands of staff or patients. This includes hidden
4 euRoPeaN iNFecTiouS diSeaSe
surfaces which will not be directly exposed to the aad system and are
not easy to disinfect manually.
although they present less risk for patients and staff, areas which
cannot be reached by hands and cleaning may also be subject
to progressive colonisation. This supports the interest of using aad in
routine disinfection to preventively control the level of contamination
in narrower spaces.
Automatic Area Decontamination Technologies
although dominant, chemicals are not the only active ingredients
for aad. Physical agent such as ultraviolet (uV) should also be
considered in the scope of the standard.14
Chemical Processes, Principles, Categories
and Vocabulary
until now most modern commercialised aad processes are based
on hydrogen peroxide (h2o2) at different concentrations. Peracetic
acid and ozone are already existing alternatives.
For years, high concentration h2o2 has been used for atmospheric
pressure surface sterilisation of laboratories and manufacturing
installations in rooms or isolators. in these applications, the geometry
and the material present in the room is adapted or specifically designed
for the sterilisation objective leading to an optimised dispersion and
control of material degradation. control of efficacy is usually made
against sterilisation standards (i.e. total kill with sterility assurance
level [Sal] of 10-6).
The objective significantly differs for aad which is intended for use in
variable hospital room environments and will target a controlled
contamination level. Sterilisation and total kill of germs are clearly not
reasonable criteria and objectives.
The exact mode of action of h2o2 surface sterilisation or disinfection
remains to be better understood. Some argue that condensation is
required for efficacy, others say it should be avoided. abundant
literature on h2o2 atmospheric pressure sterilisation technologies
gives evidence that, at least in the conditions in which those
processes are applied, comparable efficacy is obtained by 'dry' and
'wet' processes.15–17 more condensation is known to increase the risk
of corrosion however.
another subject of debate relates to the technology used to diffuse
h2o2 in the room (vapour or mist). The difference between the two
might not be as simple as often presented. under the saturation point,
small droplets of mist will easily evaporate. inversely, vapour becomes
mist when dew point is reached. a higher concentration of h2o2 in
room air will lower the dew point and accelerates condensation on the
surfaces. The future discussion on mist and vapour should hence at
least take into consideration the impact of concentration and dose
applied and focus on what happens on the surfaces, which probably
matters the most, as much as on the diffusion method.
Physical Processes
it is known that efficacy of uV will depend on exposure of surface to
the light source and is impaired in shadowed areas. improvements
were proposed to compensate that limitation of uV considering highly
variable room configurations. The principle relies on reflection by all
surfaces of the room for distribution of photon energy. Power is
 Automatic Room Surface Disinfection – Proposals for an International Standard
maintained until sufficient reflected energy is measured by sensors
placed on the uV source. it could be of interest to drive further studies
to check that appropriate minimal level of efficacy can be consistently
obtained for all hidden areas reachable by human hands. This is of
particular importance if automated disinfection is intended for
replacement of manual disinfection. Future standards should take into
account that pervasiveness parameter.
Efficacy Objective and Test Challenges
What are the appropriate realistic objectives for aad? in which
conditions (clean and/or dirty) will aad be applied? What are the
true levels of bioburden on surfaces to decontaminated? These are
only some of the key questions to be answered before attempting to
define a standard.
it was already explained in the preceding paragraphs that the aim of
surface disinfection cannot be to ‘sterilise’ the patient environment but
rather to reach and maintain a contamination level coherent with
patient health.18
it is generally accepted that aad can occur only after cleaning
(i.e. clean conditions). however, in some exceptional urgent situations
(such as an accident in a P3 or P4 lab) reprocessing before humans
are allowed into the room to proceed with cleaning could be of
interest. hospital rooms will not be concerned by that approach. even
after contamination by a Norovirus or Clostridium difficile infected
patient, thorough manual cleaning will take place before disinfection
(manual or automatic) occurs.
The level of bioburden and the way the germs spread on surfaces in
real life are important considerations. literature gives useful and
consensual indications on contamination levels on 'real life'
surfaces.19–22 Surface sampling tests are usually performed with
contact plates or swabbing controls, generally on 25 cm2 surfaces.
Findings are that, in usual practice (i.e. after cleaning in line with local
guidelines) measured contamination levels (often by colony forming
unit [cFu] numeration) are below 2 log with some rare peaks at 3 log.
This is also the case when taking into account the recovery rate of the
sampling method (data to be published).
unfortunately, no or limited information is available on repartition of
germs and soil on the 25 cm2 pre-cleaned surface. additional
studies would be useful to help define the appropriate microbiological
worst-case conditions and challenges for in vitro evaluation of aad. as
we will see in the next paragraphs, true configuration of inoculum is of
particular importance for surface disinfection.
Inoculum Distribution (Confocal Microscopy
Observations of Candida albicans Samples)
details of this work will be provided in a future publication. To
demonstrate the level that the contamination reaches in actual
standard on surface disinfection, we have tested three inocula of
C. albicans (approximately 6, 5 and 4 log) deposited under a 50 μl
volume on glass carriers. assays were performed in the presence or
absence of milk 1/20, simulating clean conditions.
The numerations of cultivable C. albicans assimilated to viable cells in
all standards were combined to confocal microscopy observations,
which are able to differentiate between viable and non-viable germs
(Syto 9 and propidium iodide (Pi) labelling) (see Figure 1).
euRoPeaN iNFecTiouS diSeaSe
The key findings are:
• Significant differences between the preservation of cell cultivability
(cFu numeration) and viability (confocal observations) at the three
inoculi tested. The drying step led to an evaluation of initial cFu
reduction between 90 to 99 %, which is not coherent with confocal
results after Syto 9 and labelling with Pi (>99 % of viable cells).
• an important accumulation of germs and interfering substance on
periphery of the inoculum.
• Significant difference in inoculi configuration:
• at 6 log, multilayers of germs in different status (viable, etc.) and a
protein load of germ, which is far above the level brought by the
interfering substance itself; and
• at lower initial titre, microcolonies are observed as well as a higher
aad efficiency. This might correspond to an easier access to yeast.
• a log reduction (cFu) of germs during drying, adding interfering
effect, which is comparable for the three initial titre (at least for
Candida albicans) and lower than without interfering substance.
These observations shows that current in vitro assay conditions as
described in suspension standards are very far from reality and
inappropriately raise the challenge, efficacy and dose requirement
(product quantities, contact time) without justifications.
Appropriate In Vitro Test Challenge for
Surface Disinfection
it is well admitted that the high germ density and configuration of a
50 μl inoculum dried on a small surface prepared according to methods
described in existing standards is not representative of reality.
Test carriers methods of suspension standards usually define the titre
of the suspension as well as the minimal load to be obtained after
drying. This minimal load after drying is not accurately controlled and
often significantly overachieved. This does not seem to be an issue for
suspension tests.
Not surprisingly, experiences show that things are very different for
aad. Small differences in initial titre and spreading can yield opposite
conclusions in terms of log reduction and hence efficacy (internal data,
not published).
The impact of variations in initial titre increases exponentially with
targeted germ load (an additional 1 log above a target of 6 log is not
equivalent to 1 additional log at 4 log).
This leads to the broader debate on the role that standards should
play, in particular for the human health domain. Should they
conservatively impose the highest level of efficacy independently of
any other consideration or define a safe but reasonable margin above
observed real life worst case conditions?
Before making that choice it should not be forgotten that, unlike
instrument reprocessing, aad takes place in an open environment and
that impact on surrounding materials may increase with frequency of
application and power of process. achieving efficacy while maintaining
the integrity of materials including sensitive medical-electrical
equipment is an important consideration.
considering that the maximum contamination level observed in real
life is 3 log/25 cm2 (i.e. 1,000 germs/25 cm2) what could be the
5
Healthcare-associated Infections

appropriate in vitro efficacy margin for aad? is, 6 log of germs (i.e. it should be noted that germs such as Pseudomonas aeruginosa
1,000,000 micro-organisms) on less than 1 cm2 a reasonable margin? present specific methodological challenges for aad. To compensate
4 or 5 log after drying on a standardised surface might be more for the important loss during drying, the titre of the test suspension
appropriate. it could also be convenient to define two levels of has to be significantly increased. consequently, a micro-organism,
challenges according to the situation (high level for outbreak situations which is not known to be highly resistant to desiccation on surfaces
and low level for routine preventative use). can become a significant experimental in vitro challenge and even the
limiting germ.
The log reduction objectives will be deducted from the initial level
discussed above. Since total kill is excluded, a minimal 1 log difference although, unlike in water, Pseudomonas aeruginosa is not a major
between the initial titre after drying and the log reduction objective is risk on dry surfaces, it could be kept in the reference list if and only if
required. For instance, if the high level initial titre target is at 5 log the the test protocol can be adapted to avoid methodological bias.
in vitro log reduction objective will be 4 log. increased amount of protective substance to limit death during drying
are among the options.
That log reduction objective should be achieved for a position
and orientation of the sample which will be defined as the most Phase 2 or Phase 3
challenging for aad processes (i.e. hidden to the source of active Phase 2.2 standard with one or a very limited number of
ingredient although accessible to human hands). Reaching that level sample positions per room is preferable to a Phase 3 field test
of efficacy in narrower spaces might not be necessary. as discussed approach. it will allow objective and simple comparison between
earlier, however, some level of efficacy in areas which cannot be processes and ease implementation of test by a larger number
reached by manual cleaning will be useful to prevent colonisation. in of laboratories.
addition to germ load itself, sample preparation should be improved
to mimic the real life situation. Conclusion
considering the growing interest for aad as an alternative or
as we have seen above, clean conditions might be the most complement to manual surface disinfection procedures, there is a
appropriate for most, if not all, hospital usage. higher levels of soil clear need for dedicated aad benchmark guidelines or standard.
might, however, be considered for other domains such as veterinary
or specific applications. Spreading of sample on a limited surface These benchmarks can be inspired by existing suspension
would allow homogeneous repartition of interfering substance standards but must be adapted to specificities and objectives of
and germ (refer to above observations by confocal microscopy surface disinfection.
showing accumulation of interfering substance and germs on the
periphery of the experimental inoculum). ongoing experiments in particular, a good understanding of true real life challenges,
show that reproducible spreading can be easily obtained (internal conditions of use, as well as recognition that aad is an alternative to
data not published). manual disinfection procedures should help to define comprehensive
but realistic in vitro evaluation methodology as well as appropriate
Test Germs For In Vitro Evaluation of efficacy and pervasiveness targets.
Automated Area Decontamination Processes
Similarly to what is done for evaluation of disinfecting solution, a This approach will allow a simple and fair comparison of processes
representative variety of reference germs; bacteria, spores, fungi and help avoid inflation in expectations and gaps in performances
and yeast, but also viruses, would be of interest. evaluations. ■

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