MODULE IV

Creation and maintenance of a safe

environment for patient care in
healthcare settings through application of
infection control principles and practices
of cleaning , disinfection and sterilisation
 Cleaning
Sterilisation
and Disinfection

Dr. Jyoti S.
 LECTURE 1 - Learning Objective

• Definitions of Cleaning , Disinfection

and Sterilisation
• Methods of sterilisation and disinfections
• Factors Affecting Efficacy of
sterilization and Disinfection
• Outline the process for
cleaning patient care items
• Principles and working of different
types of sterilisation methods
• Sterilisation process monitoring
 DEFINATIONS

 CLEANING - It is a process which removes visible

contamination but does not necessarily destroy micro
organisms. It is necessary prerequisite for effective
disinfection or sterilization.

 STERLIZATION - it is the process of destruction or

removal ( complete killing ) of all microorganisms from
article, surface or medium, including bacterial spores.
 DISINFECTION - it is a process of killing or reduction of the
number of viable vegetative microorganisms to an acceptable
level but may not inactive or kill some viruses and bacterial
spores.

 ASEPSIS -Term used to describe methods which prevent

contamination of wounds and other sites, by ensuring that
only sterile object and fluids come into contact with them.
 ANTISEPSIS - It is the procedure or application of an antiseptic
solution or an agent which inhibits the growth of
microorganisms, while remaining in the contact with them.

 BACTERIOCIDE – Agents which kill microbes

fungicide , virucide , grmicide

 BACTERIOSTATIC – prevents or stops microbial growth

fungistatic , virustatic
 SANITIZATION - process that reduces microbial population
on object to a safe level.

 DECONTAMINATION - A process of treatment that renders a

medical device , instrument or environmental surface safe to
handle.
Does not necessarily mean that the item is safe for patient
reuse.
 Factors Affecting the Efficacy of Disinfection and Sterilization

• 1. Number and location of microorganisms

• 2. Innate Resistance of microorganisms
• 3. Concentration and potency of Disinfectants
• 4. Physical and Chemical factors
• 5. Organic and inorganic matter
• 6. Duration of exposure
• 7. Biofilms
 Resistance of Microorganisms
Sterilization
Spores
bacterial, fungal Bacillus stearothermophilus
Bacillus subtilis
Clostridium sporogenes

High Level Disinfection

Mycobacteria, TB bacilli

Intermediate Disinfection

Hydrophilic viruses Polio, Coxsackie, Rhino

Low Disinfection

Vegetative fungi & bacteria Trichophyton, Cryptococcus,Candida

Lipophilic viruses Pseudomonas, Staphylococcus,Salmonella
HSV, CMV, RSV, HBV, HIV
 Classification of the method of
sterilization/Disinfection
A. PHYSICAL
1- Sun Light
2- Drying
3- Heat i- Dry
                    ii-Moist
4- Filtration
5- Gas
6- Irradiation
7- Ultra sonic cleaning
B. CHEMICAL
1. Phenol Derivatives : Phenol, Cresol, resorcinol, chloroxylenol
2. Oxidizing agents :Pot.Permanganate, Hydrogen Peroxide,Benzoyol Peroxide
3. Halogens : Iodine, chlorine
4. Biguanide : Chlorhexidine
5. Quarternary Ammonium (Cationic) : Cetrimide, Zephiran
6. Alcohols : Ethanol, Isopropanol.
7. Aldehydes : Formaldehyde, Glutaraldehyde
8. Acids : Boric acid, acetic acid
9. Metallic salts ; Silver Nitrate, Zince Sulfate, Zinc Oxide, calamine,
10. Dyes : Gentian violet, proflamine, Acriflamine
11. Furan derivatives : Nitro flurazone
 
 To achieve sterilization of any instrument three
definite stages are to be completed-

 Pre sterilization cleaning

 Sterilization process
 Aseptic storage
 Pre-Cleaning / Cleaning

• Everyone responsible for handling and reprocessing

contaminated items must :

• Receive adequate training and periodic retraining.

• Wear appropriate personal protective equipment (PPE).
• Receive adequate prophylactic vaccination.
 Presterilization cleaning
• Objective-
Removal of the organic matters, blood and
saliva which provide protective barrier for
microorganisms and prevents its destruction.
• There are three methods for cleaning
-Manual
-Ultrasonic
-Mechanical washing
 MANUAL CLEANING

• Simplest and the cheapest method, but time

consuming and difficult to achieve.
• heavy duty gloves and glasses must be worn
to protect needle stick injury and to protect
eye.
• Material used for manual cleaning
-Soaps
-Detergents
MECHANICAL WASHING

Principle- High-pressure jets of

water with or without a detergent
which removes debris from
instrument.
Small instrument like burs, blade
are not suitable for this type of
cleaning.
ULTRASONIC CLEANING

Principle- conversion of electrical energy

into vibratory sound waves which pass
through a soap solution containing the
instrument.

Used mainly for burs, bone files, bone

cutter, artery forceps, saw etc.

Improves efficacy

Reduces employee exposure to splash

and sharps.
 STERILISATION

• The complete elimination or destruction of all forms of

microbial life.

• Includes large numbers of highly resistant bacterial spores.

• After sterilisation , instruments – store in clean , dry place

• Protect wrapping

• Inspect before use.

 HEAT
Most common and one of the most effective methods of sterilization.
Factors influencing sterilization by heat are : -
i. Nature of heat
a.        Dry
b.       Moist
ii. Temperature & time
iii. No. of organism present
iv. Whether organism has sporing capacity
v. Type of material from which organism is to be eradicated
A. DRY HEAT
Killing is due to :
- Dehydration and oxidation of organisms
- Protein denaturation
- Toxic effects of elevated levels of electrolytes
 DRY HEAT STERILISATION
• Hot-air ovens are used for dry-heat sterilisation.

• They can reach high temperatures and should be

equipped with a fan for even distribution of heat.

• Preheating is essential before starting the sterilisation

cycle.

• Hot-air ovens are simpler in design and safer for use than
autoclaves and are suitable for sterilisation of glassware,
metallic items, powders, and anhydrous materials (oil and
grease).
Hot air oven
• Sterilisation takes two hours at 160°C, or one hour at 180°C.

• It is used to sterilize items, which do not get damaged by high

temp. such as laboratory glass, flasks, instruments with sharp
cutting edges, B.P. handles, Powders, Dapen dishes, mouth
mirrors.

• Plastics, rubber, paper, and cloth must not be placed in them to

avoid the risk of fires.
• Dry heat in an oven kills by oxidation, which is a much slower
process. Dry heat is used to sterilise moisture-sensitive
materials (powders) or items which steam cannot penetrate
(oils and waxes).
Advantages
• Can be used for powders, anhydrous oils
• Inexpensive
• No corrosive effect on instrumentsthe ability to sterilise
goods in sealed or non-porous containers
• the ability to sterilise complex goods while assembled
• the ability to sterilise goods which are impossible to dry
in a steam steriliser or which may be damaged/corroded
by the moisture of steam sterilisation
• the relative mechanical simplicity of a dry heat steriliser
Disadvantages
• High temperature damages some items
• Penetration of heat slow, uneven
• long times involved in heating, sterilising and cooling goods being
sterilised
• possible damage to packaging materials or to some of the items
themselves arising from the high temperatures used
• close monitoring and control of sterilisation conditions within packs
being sterilised can be very time consuming
• due to the high temperature, dry heat sterilisers provide the greatest
potential for injury to personnel following contact with parts of the steriliser
or the goods being processed (while they are hot), compared to the other
in-facility sterilisation processes
• equipment at the ‘low cost’ end of the market does not adequately
maintain constant temperature conditions within the steriliser. Purchasers
may not be adequately aware.
Temp. & Time: The sterilization is complete if these two factors are
achieved throughout the load.

Temperature Time(Min)

140oC 180

150oC 150

160oC 60

170oC 45

180oC 18

190oC 7.5
 Sterilization Control of Hot Air Oven
• The spores of non-toxigenic strain of Bacillus subtilis and Clostridium tetani are used
as a microbiological test of dry heat.

• Browne’s test strip available that contain a chemical indicator.

MOIST HEAT
AUTOCLAVE :
 Steam Sterilization
• Requires direct contact of an item with steam at a required
temperature and pressure for a specified time
• Most reliable
• Non-toxic
• Has broad-spectrum microbiocidal activity
• Good penetrating ability
• Cheap and easy to monitor for efficacy
• 2 main types: gravity and pre-vacuum
• Steam is the most reliable means of sterilisation.
• It is non-toxic (when generated from water free of volatile chemicals),
• has broad-spectrum microbicidal activity, and good penetrating ability,
while being cheap and easy to monitor for efficacy.
• Sterilisation requires direct contact of an item with steam at a required
temperature and pressure for a specified time.
• Autoclaves are specially designed chambers in which steam under
pressure produces high temperatures. They are based on the same
principle as pressure-cookers.
• There are two main types of steam sterilisers - gravity and pre-vacuum.
• ‘Pressure cooker’ type sterilisers are designed to sterilise unwrapped,
non-porous, non-fabric items such as instruments and syringes. Moist
heat, when used as steam under pressure in an autoclave, kills
microbes by denaturing their proteins.
 Factors Influencing Steam
Sterilisation
• Proper loading must occur
• All items in load must have contact with
steam
• Items in load must be free from grease
and oil
• Instruments to be autoclaved must be wrapped in materials that
allow steam penetration while keeping the processed item
sterile during storage. Over-loading of autoclaves must be
avoided to permit free access of steam throughout a load.
Packages must be marked to identify their contents and date of
sterilisation along with steriliser and load number to facilitate
any recall and to aid in rotation of supplies.
•
• All steam sterilisers must be tested upon installation and
regularly thereafter; written records of routine operation and
maintenance must be kept. All staff must be thoroughly trained
in autoclave operation and safety.
Autoclaves, or steam sterilizers essentially consist of following:
i) A cylindrical or rectangular chamber, with capacities ranging from 400 to 800
liters.
ii) Water heating system or steam generating system
iii) Steam outlet and inlet valves
iv) Single or double doors with locking mechanism.
v) Thermometer or temperature gauge
vi) Pressure gauges
• To achieve sterility, a holding time of at least
15 minutes at 121 °C (250 °F) or 3 minutes at
134 °C (273 °F) at 15 psi (100 kPa) above
atmospheric pressure is required.

• To Avoid corrosion Crawford and Oldenburg

recommended addition of ammonia to the
autoclave
 Gravity Displacement Autoclaves

• Steam introduced to purge out

air and build pressure
• Raise temperature normally to
121°C at 15 pounds/square inch
and maintain it for 15-45
minutes
• For sterilising liquids and items
in wraps that steam can
penetrate
• In gravity (downward) displacement autoclaves, steam is
introduced at the top of the chamber to purge out the
cooler and denser air-steam mixture from the bottom of
the chamber. The exhaust valve closes when all the air has
been removed, thus allowing the pressure to build and
temperature to rise.

• Such autoclaves are used for sterilising liquids and items in

wraps that steam can penetrate. The sterilisation step
itself normally lasts about 15 minutes at 121°C at 103.4
kilopascal (15 pounds/square inch).
 High-Vacuum Autoclaves

• Air is first vacuumed out and then

steam introduced
• Faster and better penetration
throughout the load
• Pressure and temperature higher;
134°C at about at 30 pounds/inch2
• Processing time about three minutes
• Not suited for liquids due to need for
vacuum
• In high-vacuum autoclaves, the air from the
steriliser chamber is first vacuumed out and
then steam is introduced allowing faster and
better penetration throughout the entire load.
The pressure and temperature rise quickly
allowing process times of three minutes at
134°C at about 206.8 kilopascal (30
pounds/square inch).
 Flash Sterilisation
• Only to process a critical surgical item:
a) in an emergency
b) when accidentally contaminated, or
c) when other means of sterilisation unavailable
• Never to be used for implantable items or to
compensate for shortage of key instruments

December 1, 2013 47
In a Flash steriliser, steam is used to process surgical items for use when a critical item has
become accidentally contaminated during an operation or when no other means of sterilisation
are available. It should never be used for implantable items or to compensate for a shortage of
essential instruments. Either a gravity-displacement or pre-vacuum autoclave can be used for
flash sterilisation of porous or non-porous items without wrapping or with a single wrap.
Waiting to read any included BIs is not possible due to the rapid turn-around needed for flash-
sterilised items. Unless suitable containers are used, there is a high risk of recontamination of
the processed items and also thermal injury to personnel during transportation to the point-of-
use. Flash Sterilisation is not accepted in all regions.

• ‘Flash’ sterilisation recommendations

• restrict use to emergencies, such as unexpected surgery, or dropped instruments. ‘In most
emergency situations, the risk/benefit ratio is low enough that the use of flash sterilized
objects is justifiable. In non-emergency situations, however, the risk/benefit ratio is higher,
particularly when implantable devices are involved’
• ‘flash’ sterilizers must never be used for implantables, suction tubing or cannulars or any other
product not specifically validated for the “flash” process
B. Moist heat
Causes denaturation and coagulation of proteins.

1. Pasteurization :
The temperature employed is either 630C for 30mins (Holder method) or
720C for 15-20 seconds (Flash method) followed by cooling quickly to 130C.
Method is used for heat sensitive liquid and pharmaceutical products.

2. Tyndallisation :
Named after John Tyndall.
Exposure of 1000C for 20 min for 3 successive day.
Principle: 1st exposure kills all vegetative bacteria & spores, since they are
in a favorable medium, will germinate and be killed on subsequent
occasions.
 Pasteurisation and Boiling
• Semi-critical items can be pasteurised
– 65-77°C, 30 min
– Example: respiratory therapy equipment
• Must be retrieved carefully for safe
transport and storage
Semi-critical items, such as respiratory therapy and anaesthesia
equipment, can be pasteurised by heating in water. All their parts
must remain well-immersed throughout; holding the heat at about 65-
77°C for 30 minutes is sufficient. Locations at higher elevations require
a longer time because the boiling point of water gets lower the higher
one gets from sea-level.

Immersion of heat-resistant items in boiling water for about 10

minutes can substantially reduce the pathogen load, but must never
be regarded as ‘sterilisation’. Pasteurisation and boiling are thus low-
tech and chemical-free methods (as long as the water is pure); treated
items must be retrieved carefully for safe transport and storage.
Sterilisation Process Monitoring
Recommended practices state that both
biological and chemical indicators shall be used
to monitor the sterilisation process
• Mechanical monitoring
• Chemical monitoring
• Biological monitoring

53
 Sterilization control of the moist heat

Physical Indicator- an alloy designed to melt only after being subjected to

relevant holding time.

Chemical indicator- Strips or tapes that change color once the correct
conditions have been met.

Biological indicator- Spores of Geobacillus stearothermophilus are used as the

test organisms as it is toughest organism for an autoclave to destroy.
Its spores require an exposure of 15 mins at 1210c to be destroyed.
For the high vacuum process, steam penetration of the load depends on adequate air removal. This
can be monitored in two ways – firstly by a ‘leak test’ - can the vacuum be maintained or will air leak
in (often around the door) - and secondly by the ability of steam to penetrate a small pack of towels
used in the ‘Bowie Dick’ test. If these tests are satisfactory then an alternative monitoring approach
is ‘parametric release’. This system relies on ensuring that the autoclave cycle has fulfilled all
specifications with regard to temperature, pressure and time using calibrated instruments in addition
to, or in place of, BIs. Since this approach is based on measurable data and calibrated equipment, the
results tend to be more reliable and much more rapid than the use of BIs.

Parametric release – the release of sterile items based on the compliance with defined critical
parameters of sterilisation without having to perform sterility tests (biological monitoring).
Traditionally, Biological Indicators (BI’s) are used as an integral part of the
release process for sterilised products. Parametric release can be used if the data
demonstrating correct processing of a batch provides sufficient assurance, on its own, that the
process designed and validated to ensure the sterility of the product has been delivered. Sterilisation
methods using steam, dry heat and ionising radiation may be considered for parametric release.
 Practical Tips
• A wide range of sterilisers is available
• Always sterilise items for the correct time
using a clock or timer
• Air in the steriliser and load results in
inadequate steam penetration
• Never sterilise single use items
• Always follow the manufacturer’s instructions for the type of steriliser that you are using.

• Air in the steriliser and load results in inadequate steam penetration and incomplete drying of the load. This
is because air acts as an insulator for heat and prevents steam reaching the surface of items to be sterilised.
Steam purging by opening and closing the valve, removes air and improves the steriliser's performance.

• Standard combinations of time and temperature for sterilisation are: 121°C for 15 minutes and 134°C for 3
minutes. You need to know the operating pressure of the autoclave and altitude of your health facility to
determine correct sterilising time. If you cannot change the operating pressure then you need to extend the
sterilising time.

• Because it is difficult to keep items sterile (items are contaminated by contact in the air), carry out
sterilisation on the day of use (but not immediately before use as you need to allow time for items to cool
down). Replace safety valve and gaskets (rubber seals that seal the junction of metal surfaces) immediately if
they are damaged or worn.

• From WHO:
http://www.who.int/management/resources/procurement/MedicalSuppliesforPHC(2)Procurement&Manage
ment.pdf
 Ethylene Oxide (EO)
• Colourless, flammable, explosive and toxic gas
• Processing cycles overnight or longer
• Parametric release is not possible
– EO and relative humidity cannot readily be measured
• Spores of Bacillus atrophaeus used as biological
indicators to monitor process
 Ethylene Oxide Sterilization (ETO)

Used almost exclusively to sterilize

medical products that cannot be steam
sterilized or sensitive to radiation.
Mechanism of action: It destroys
micro-organisms by alkylation and
cause denaturation of nucleic acids of
micro-organisms.
At 30 °C - 60°C with relative humidity
above 30 % and gas conc. between 200
and 800 mg/l for at least 3 hours.
• Ethylene oxide (EO) is used to sterilise items that are sensitive to heat, pressure, or
moisture. EO is a colourless gas that is flammable, explosive, and toxic to humans.
Two EO gas mixtures are available, one with hydrochlorofluorocarbons (HCFC) the
other a mixture of 8.5% EO and 91.5% carbon dioxide; the latter mixture is less
expensive.
•
• EO concentration, temperature, relative humidity (RH), and exposure time must all
be maintained at the right levels during the process to ensure sterilisation. Gas
concentration should be 450 to 1200 mg/l, temperature ranges from 37 to 63 oC, RH
from 40% to 80%, and exposure times from one to six hours.

• Parametric release is not possible since gas concentrations and RH cannot readily
be measured; a BI should be included with each load. The recommended BI is
Bacillus atrophaeus; loads should be quarantined until the incubation time of the BI
is complete.
Ethylene oxide is a colorless liquid with a boiling
point of 10.7 °C.
 Highly penetrating gas with sweet ethereal smell.
Highly inflammable & in conc. greater than 3%, highly
explosive.
By mixing with inert gases such as CFC or CO2,
explosive tendency is eliminated.
Plastics, rubber & photographic equipments can be
sterilized by this method.
Also used for mass sterilization of disposable items,
plastic syringes,needles,catheters,blades etc.
Ethylene Oxide (EO) Gas
Sterilisation
• Used for heat or moisture sensitive
items
• Prevents normal cellular metabolism
and replication

64
• Disadvantages
– Lengthy cycle time
– Cost
– Potential hazards to patients & staff

• Advantage:
Can sterilize heat or moisture sensitive
medical equipments.
 EO Sterilisation
Advantages Disadvantages
• Items not damaged by • Cost
heat or moisture • Toxic properties of
• Not corrosive, not ethylene oxide
damaging to delicate • Aeration required
instruments, scopes • Longer process
• Permeates porous
materials
• Dissipates from material
• The main disadvantages
of EO sterilisation are the
long cycle times and high
cost. Sterilised items must
be aerated well after
processing to remove all
residues of EO. Risk of
personnel exposure to
ethylene oxide demands
environmental control
equipment be in place.
 Low-Temperature
• Mixture of steam (50-80°C) and
formaldehyde vapour
• To process heat-resistant or heat-
sensitive medical devices in specialised
equipment
• Devices pre-cleaned and wrapped in
standard material and processed in a
three-hour cycle
• Cannot be used for liquids
• Formaldehyde must be purged/
neutralised well
In the low-temperature steam-formaldehyde (LTSF) process,
steam (50-80°C) is used with vapourised formaldehyde to
sterilise heat-sensitive medical devices (even those with narrow
lumens). As usual, devices are cleaned and then processed.

First, a vacuum is created; steam is introduced in several pulses

followed by vapourisation of formaldehyde. At the end of the
cycle, the formaldehyde is evacuated and completely purged out
with several pulses of steam and high vacuum. Chemical and
biological indicators are used to monitor the steriliser
performance. It cannot be used with liquids and the potential
toxicity of formaldehyde remains a concern.
 Hydrogen Peroxide Gas Plasma
• Highly reactive/charged particles from
hydrogen peroxide generated under
vacuum
• Can be used to sterilise heat- and
moisture-sensitive items
– Some plastics, electrical/electronic devices,
and corrosion-susceptible metal alloys
• Not compatible with cellulose (linen,
paper), devices with dead-end lumens,
powders and liquids
• Special wrapping required
• Gas plasmas are generated in an enclosed chamber under deep vacuum
using radio frequency or microwave energy to excite hydrogen peroxide gas
molecules and produce charged particles, many of which are highly
reactive free radicals. Gas-plasma can be used to sterilise heat- and
moisture-sensitive items, such as some plastics, electrical/electronic
devices, and corrosion-susceptible metal alloys. The spores of G.
stearothermophilus are used as BIs.
•
• This is a safe process, and, as no aeration is needed, sterilised items are
available for immediate use or storage. However, It is not suitable for
devices with dead-end lumens, powders, or liquids. Other disadvantages
include the high cost and need for special packaging material since paper
or linen cannot be used. In addition, any liquid or organic residues present
interfere with the process.
 Fumigation
• For rooms contaminated with some pathogens
– Such as MRSA and Clostridium difficile
• Release of hydrogen peroxide, chlorine dioxide gas or
possibly ozone in sealed rooms
• Spore strips (biological indicators) placed strategically
to monitor process
• Special equipment required
• Risk of damage to sensitive items

December 1, 2013 74
• Recently, there has been much interest in using fumigants to deal with healthcare-associated pathogens
such as methicillin-resistant S. aureus and C. difficile in the environment. Several devices are available
which vary in cost, the process used, and the degree of field testing they have undergone.

• A common process is to vaporise a solution of hydrogen peroxide into a sealed room, such as a patient
room, for surface decontamination. No post-treatment aeration is necessary because hydrogen peroxide
readily breaks down into oxygen and water. Spore strips are strategically placed throughout the room and
retrieved later to monitor the effectiveness of the process. Disadvantages include incompatibility with
cellulosic materials and potential corrosion of electronic devices.
•
• Chlorine dioxide generated on-site may be released as a gas for room decontamination. The rooms must
not only be sealed but also darkened to prevent daylight accelerating the breakdown of the gas. Like
hydrogen peroxide, chlorine dioxide naturally breaks down into innocuous by-products.
•
• Ozone can decontaminate surfaces in enclosed spaces, however it is highly unstable and potentially
damaging to a variety of the materials common in health care facilities. However, an ozone-based medical
device steriliser is available. It generates the gas from oxygen and at the end of the cycle converts it to
oxygen and water by catalysis. The machine claims wide materials compatibility and the ability to handle
narrow-lumened devices.
 FUMIGATION OF OPERATION THEATRE

- Fumigation of the operation theatre is achieved by

fumigator and potassium permanganate reaction
technique.
- The chemical used is 40% formaline.
Factors influencing the fumigation of the theatre :
1. Relative humidity
Relative humidity plays a major role in fumigation. A
minimum of 70% is essential. Water used in fumigator
with fumigant helps to achieve and maintain humidity.
2. Temperature
temperature for effective fumigation is 300-400C.
3. Formaldehyde levels in the Air in the operation theatre
The dose of formaline is usually decided by the size of
the room. As a rule, 180 ml is used for a room of the size
1000 cubic feet.
 Microwaves
• Heating from rapid rotation of water molecules
• Limited use except for disinfecting soft contact lenses
and urinary catheters for intermittent self-
catheterisation
• May be used in emergencies to treat water for
drinking or to ‘disinfect’ small water-immersible
plastic or glass items

December 1, 2013 80
• Exposure of water-containing items to microwaves
generates heat due to friction from rapid rotation of
water molecules. Thus far this process has only been
used for disinfecting soft contact lenses and urinary
catheters for intermittent self-catheterisation.
However, small volumes of water could possibly be
made safe for drinking by microwaving in a glass or
plastic container. Similarly, small glass or plastic
objects could be immersed in water and ‘disinfected’
in a microwave oven.
 Filtration
• Removal of microbes from air or
heat-sensitive liquids
• Disinfectant-impregnated filters may
inactivate trapped microorganisms
• Example: High-efficiency particulate
air (HEPA) filters
• All filters must be checked for
integrity and replaced as necessary

December 1, 2013 83
 FILTRATION
• Help to remove bacteria from heat labile
liquids.
• As viruses pass through ordinary filters, it can
be used to obtain bacteria free filtrates of virus
isolation.
• TYPES:
– Candle filter
– Asbestos filter
– Sintered glass filter
– Membrane filter
• A simple means of removing microbes from air or heat-sensitive liquids is by passage through
membrane or cartridge filters. This process retains physical microorganisms based on their size,
without killing them unless the filter matrix is impregnated with or exposed to a microbicidal agent.

• High efficiency particulate air (HEPA) filters are frequently used to remove microbial contamination
from air in surgical theatres, microbiology laboratories, and for sterile manufacturing of
pharmaceuticals. Their use in hospital wards and waiting rooms is also increasing to reduce the risk
of spread of airborne pathogens. HEPA filters must be checked for integrity after installation and
have a scheduled maintenance programme. Cartridge filters may be used on air-supply lines to
remove microbial contamination.
•
• Membrane and cartridge filters with a nominal pore diameter of 0.2 µm are quite commonly used
in the manufacture of a variety of heat-sensitive biologicals and injectables. Such filters cannot
remove viruses due to their much smaller size. Cartridge filters are also common on taps for
potable water and inside automatic endoscope reprocessors to protect processed devices from
recontamination with bacteria in rinse water. Liquids passed through such filters are often referred
to as ‘sterile’, although this is not strictly true.
 IRRADIATION
Radiation used for sterilization is of two types
1. Ionizing radiation, e.g., X-rays, gamma rays, and high
speed electrons .
2. Non-ionizing radiation, e.g. ultraviolet light, and infrared
light.
These forms of radiation can be used to kill or inactivate
microorganisms.
1. Ionizing Radiation
X-rays, gamma rays and cosmic rays are highly lethal to DNA and other vital
constituents.
They have high penetration power.
There is no appreciable increase in temperature, thus referred to as cold sterilization.
Commercial plants use gamma radiation for sterilizing plastics, syringes, swabs,
catheters etc.

.
2. Non-ionizing radiation
Two types of non-ionizing radiations are used for sterilization:-

• A. Ultraviolet -
Short range UV(UVC) is considered “germicidal UV”.
At a wavelength of 2537 Angstroms UV will destroy
micro-organismal DNA.
Used mainly for air purification and water purification in
hospitals.

• B. Infrared –
It is most commonly used to purify air, such as in the
operating room. Infrared is effective, however, it has no
penetrating ability.
 Ultraviolet (UV) Light
• UV lamps useful for chemical-free disinfection of air
and water and also possibly for decontamination of
environmental surfaces
• Broad-spectrum microbicidal action
• Require regular cleaning and periodic replacement

December 1, 2013 90
• Recent advances in ultraviolet (UV) lamp technology make the
microbicidal potential of short-wave UV radiation viable for a variety of
uses. UV lamps are increasingly popular for disinfection of water and
wastewater in some regions. UV-based devices are being marketed for
the disinfection of air in hospitals and clinics to reduce the spread of
airborne pathogens. Devices are being marketed for the disinfection of
environmental surfaces in hospitals as well in some regions.
•
• UV radiation does not add any chemicals to the water and air being
treated, except for the generation of low levels of ozone. However, it
cannot penetrate through dirt, and items require direct exposure to the
radiation. Such lamps require regular cleaning and periodic replacement;
they can still emit visible light even after the UV radiation has diminished.
 Chemical Indicators
• External Chemical Indicator
• process indicator - autoclave tape
• distinguishes processed from unprocessed medical
devices
• secures pack
• labels pack
• Check external indicator to ensure it has changed
color before using any package
• If the indicator did not change, do not use

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Chemical indicators (CI) are used to assess if the required time and temperature were
attained during the sterilisation process. One type of CI is an autoclave tape that can be
affixed to the outside of a package; it shows a colour change if the package was exposed
to heat. Though CIs are not meant to indicate that a product has been sterilised, they
can help to detect equipment malfunctions and identify procedural errors.

• Indicator strips, such as TST (TimeSteamTemperature), should be used –

ideally during every sterilisation cycle or at least once a week – to make sure
sterilisation has been satisfactorily carried out.

• Class 5 chemical indicator:  Is an integrating indicator.  This chemical indicator reacts

to all three parameters of sterilisation which include proper amount of time,
temperature and pressure of the sterilizer.  They have been correlated to the
performance of a biological indicator when used according to the manufacturers
conditions noted on the label.
 Biological Indicators
• Requires routine monitoring daily
• Test must be dated and labeled
• Once removed from the steriliser the test pack
opened, BI labeled, crushed and incubated in the
incubator
• Records of time, date of incubation and staff initials is
required and then time and date and initials of the
staff reading the final BI result

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Biological indicators (BI) contain the spores of the
bacterium Geobacillus stearothermophilus.
Commercially-available spore strips or vials containing
the spores are strategically placed in the load to be
sterilised. After a cycle, the BI are cultured or
evaluated for growth and they must all indicate no
growth to declare the sterilisation process a success.

In Europe- not daily – every 400 charges or every 6

months. Validation of sterilsers used instead.
 Biological Monitoring
• SteamGeobacillus stearothermophilus
• Dry heat B.atrophaeus (formerly B.subtilis)
• EO B.atrophaeus
• New low temperature sterilisation technologies
• Plasma sterilisation (Sterrad) B.atrophaeus
• Peracetic acid - Geobacillus stearothermophilus

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 Key Points

• Cleaning , disinfection and sterilisation are the backbone of

infection prevention and control.
• Proper cleaning essential before any disinfection or
sterilisation process.
• Failure to sterilise or disinfect reusable medical devices
properly may spread to infections.
• The type and level of device decontamination depends upon
the nature of the item and its intended use.
• Steam sterilisation effective only when preceded by through
pre-cleaning , proper packaging/ loading , and careful
monitoring of autoclaves.
• Chemical disinfectants must be selected , used and discarded
to minimise harm.
• Those responsible for processing contaminated items must be
fully trained and wear protective clothing when necessary.
• Clearly written policies and procedures must be available on-
site for training personnel and for monitoring their
performance.