Chapter Four

Disinfection and Sterilization

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Revision: OR Design
An operating theatre or operating room is a room within a
hospital in which surgical and other operations are carried out in
a sterile environment by trained personnel.
Backbone of all surgical intervention
“heart” of any surgical hospital

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Design Team
Health care
professionals
(surgeons,
anesthetists,
nurses)
Environmental Architects
specialists

Interior Engineers
designers

Information
technology
specialists

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 Zones of OT

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Ventilation
Laminar flow: linear air flow

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Ventilation…
Positive pressure
OR~ High p0
(to pushes all bacteria
and contaminated air out)

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Disinfection…

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Outline
 Introduction
◦ Definition of terms
Disinfection
◦ Heat
◦ Radiation
◦ Chemical
Sterilization
◦ Dry heat
◦ Moist heat
◦ Chemical

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Introduction
Each medical procedure in a hospital involves contact by a
medical devices and surgical instruments with a patient’s sterile
tissue or mucous membranes
A major risk of all such procedures is the introduction of
pathogens that can lead to infection
Disinfection and sterilization are essential for ensuring that those
devices do not transmit infectious pathogens to patients

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Introduction…
Failure to properly disinfect or sterilize equipment carries not
only risk associated with breach of host barriers but also risk for
person-to-person transmission (e.g., hepatitis B virus) and
transmission of environmental pathogens (e.g., Pseudomonas
aeruginosa).
A pathogen is an organism that causes disease. Your body is
naturally full of microbes. However, these microbes only cause a
problem if your immune system is weakened or if they manage to
enter a normally sterile part of your body.

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Definition of Terms
DECONTAMINATION
Any procedure that reduces pathogenic microbes to a level where items are
safe for handling & disposal.
It can be achieved by cleaning, disinfection and sterilization..
CLEANING
A process that removes foreign material (dirt, organic matter).
Must precede disinfection and sterilization.
Usually done with soap and water or detergent.

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Definition…
DISINFECTION
Destruction of most but not necessarily all pathogenic microbes or their
spores.
STERILIZATION
Killing of all living forms of microbes including spores.

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Definition…
DISINFECTANTS
Chemical compounds applied for inanimate surfaces to inhibit the
growth of micro organisms
 Reduce the micro organisms to a level which they can’t harm
ANTISEPTICS
Chemical compounds that could be applied typically on animate surfaces
to destroy or inhibit the growth of micro organisms
Zero injurious effect on the body e.g. Sanitizer

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Disinfectants

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Antiseptics

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What to sterilize?
It is mandatory to sterilize all instruments that:
◦ Penetrate soft tissues and bone.
◦ 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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Disinfection

Destruction of most but not necessarily all pathogenic microbes or their

spores.
TYPES OF DISINFECTION
• Heat
• Radiation: (Ultraviolet rays)
• Chemical: (Disinfectants)

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Disinfection by Heat

Moist heat at
temperature
• Pasteurization
below 100
degree

• Boiling
Moist heat at
temperature
100 degree
• Steaming

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Pasteurization…
Heating liquid to a specific temperature for specific time followed by
rapid cooling and then sealing
 To remove heat susceptible microorganisms
o Used for milk disinfection.
o Milk is heated either at 63 degree for 30 minutes or 72 degree for 20
seconds and immediately cooled to below 10 degree.
o Boiling milk kills the deadly microbes and cooling milk ensures they
don’t grow back

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Boiling
2. Moist heat at temperature 100 degree:
Boiling
o Heating at 100 degree for 20 minutes.
o Used for disinfection of surgical and medical equipment in emergency.

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Steaming
o Heating at 100 degree for 30 - 60 minutes.
o Done in Koch’s steamer (a vertical metal cylinder with removable
conical lid having a small opening for escaping steam and
instruments are placed on a perforated tray situated above water
which is placed in the bottom of the cylinder)

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Tyndallization
o Intermittent sterilization by exposure to steam at 100 degree for 20-45
min. for three successive days.
o Used for sterilization of nutrient media & media containing sugar &
gelatin which decompose at high temperatures.
o The principle is that one exposure will kill only vegetative bacteria. In
the coming two days the spores will vegetate to be killed during
subsequent exposure.

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Disinfection by radiation
Ultraviolet rays
o Present in sun rays or artificially produced by mercury lamp (have weak
penetrating power)
oUsed to reduce the number of bacteria in air inside operation rooms,
laboratory safety cabinet.
oNucleic acids are damaged and become incapable of reproducing and
infecting

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Chemical disinfectants
 Chemical disinfectants are chemical substances which are used
to kill or deactivate pathogenic microorganisms.
•Hypochlorites, the most widely used chlorine disinfectants,
are available as liquid (e.g., sodium hypochlorite) or solid
(e.g., calcium hypochlorite).

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Disinfection…

High level
disinfectants

Intermediate level
disinfectants

Low level
disinfectants

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High level disinfection
large number of spores after prolonged exposure
◦ Vegetative bacteria
◦ Tubercle bacilli
◦ Fungi
◦ Viruses

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Intermediate level disinfection
Few number of spores
◦ Vegetative bacteria
◦ Tubercle bacilli
◦ Fungi
◦ Enveloped viruses (HBV, HIV)

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Low level disinfection
o Mainly vegetative bacteria
◦ Some fungi

◦ Narrow range of viruses

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Sterilization

3 different
sterilization principles

Heat sterilization Chemical sterilization Radiation sterilization

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Heat sterilization
It is the simplest, most effective and inexpensive method

• Dry heat
• Moist heat at temperature above 100 degree (Autoclave)

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Dry heat sterilization…
oOldest method of sterilizing materials
oWithout moisture using conduction and convection principle
(air)
oFor materials that can with stand high temperature

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Moist heat sterilization (Autoclaving)
1) Principle:
 When water is heated in a closed vessel under pressure,
the boiling point of water rises above 100 degree
 Water is heated at 2 atmospheric pressure and the boiling
temperature will be 121 degree or at 3 atmospheric
pressure and the boiling temperature will be 134 degree

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Autoclaving…
Its process is divided in three periods
– 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

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Autoclaving…

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Autoclaving…
2) Autoclaving is highly efficient because:
 High temperature.
 High penetrating power of the steam under pressure.
 Non toxic.
 Not time consuming.
 Maintains integrity of liquids (e.g. Lubricants) due to the
100% humidity within the chamber.

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Autoclaving…
Disadvantages:
◦Non stainless steel metal items corrode.
◦May damage plastic and rubber items
◦Sharp instruments get dulled.

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Autoclaving…

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Chemical sterilization
 Chemical sterilization procedures have the disadvantages of
presenting health hazards to users (e.g. poisonous, flammable)
The chemical compounds used can be:
a) Gas Sterilization
b) Liquid Sterilization

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Gas Sterilization
Ethylene Oxide (EtO)
Kills microorganisms, including spores.
Must have direct contact with microorganisms on the items to
be sterilized.
Due to EtO being highly flammable and explosive in air, it must
be used in an explosion-proof sterilizing chamber in a controlled
environment.

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EtO…
It is an effective, low temperature chemical sterilization method
(50-60°C)
It also takes longer than steam sterilization, typically, 16-18
hours for a complete cycle.
Items sterilized by this process must be packaged with wraps
and be aerated.
EtO gas is a reliable and safe agent for sterilization when
handled properly.

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EtO…
Note: There are also gas sterilizers available that use a mixture of
EtO with carbon dioxide or chlorofluorocarbon (CFC) to
represent it as nonflammable for use in healthcare facilities. In
addition to safety concerns, this type of sterilization process
requires an even longer aeration process compared to pure EtO
sterilization.

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EtO…
Procedure:
◦ Keep objects in constant atmospheric humidity.

◦ Heat to temperatures between 30º and 60º C.

◦ Maintain for a period of 10 - 18 hrs.

◦ Residual ethylene oxide must be ventilated

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EtO…
Disadvantages:

It can leave toxic residues on sterilized items and it possesses several
physical and health hazards to personnel and patients that merit special
attention.

Unsuitable for hospitals but used in industry (e.g. for sterilizing

disposable materials that can not tolerate high temperatures).

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Plasma gas sterilizer
o Plasma means any gas which is formed of ions, electrons, neutral
particles.
o Used for surgical instruments mainly those with narrow lumen such as
arthroscopies & laparoscopes
o Non toxic

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Liquid Sterilization
oCan be performed with buffered glutaric aldehyde.
oFrequently used on surgical cameras (endoscopes).
Procedure:
The item must be thoroughly cleaned and dried before immersion.
◦ Immerse the object in liquid for several hours.
◦ Rinse with sterile water after end of procedure.

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Radiation Sterilization
Ionizing radiation: produces ions by knocking electrons out of
atoms and converted to thermal and chemical energy. This
energy kills microorganisms by disruption of the DNA molecule,
therefore preventing cellular division and propagation of biologic
life.

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Ionizing radiation…
o Provides effective way of sterilization when used in high doses.
o Irradiation is an effective sterilization method, but it is limited
to commercial use only.
The principal sources of ionizing radiation are beta particles and
gamma rays.

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Beta particles…
Beta particles, free electrons, are transmitted through a high-
voltage electron beam from a linear accelerator.
These high-energy free electrons will penetrate into matter before
being stopped by collisions with other atoms.
This means their usefulness in sterilizing an object is limited by the
density, thickness of the object and by the energy of the electrons.
These free electrons produce their effect by ionizing the atoms they
hit, producing secondary electrons that kill microorganisms.

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Gamma rays…
Have the ability to penetrate a much greater distance than beta rays
before losing their energy from collision.
Because they travel with the speed of light, they must pass through a
thickness measuring several feet before making sufficient collisions to lose
all of their energy.
Cobalt 60 is a radioactive isotope capable of breaking down to produce
gamma rays.
Cobalt 60 is the most commonly used source for irradiation sterilization.

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Gamma rays…
Used for plastic syringes, catheters, gloves, surgical sutures.
The product to be sterilized is exposed to radiation for 10 to 20
hours, depending on the strength of the source.

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 Advantages and Disadvantages

• Posses threat to

Disadvantages:
• Clean process
Advantages:

• Dry process humans (radiation)

• Ensures full exposure of • Lengthy process
object from all • Requires very qualified
directions personnel

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Which procedure to use?

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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 tightly closed.

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Conclusion
◦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 ethics 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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…

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 END

Thank you!

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