Feasibility of a combined carrier test for disinfectants: studies with a mixture of five types of microorganisms

Effects of Disinfectants on Bacterium Paenibacillus larvae in Laboratory Conditions

American foulbrood is an infectious disease of the honeybee brood that causes multiple types of damage to beekeeping. The causative agent of the disease is the bacterium Paenibacillus larvae, which forms resistant infective spores and is viable for decades. After the eradication measures have been implemented, in cases of clinically visible disease, it is necessary to conduct effective final disinfections of equipment and tools. This study aimed to determine the effect of ten commercially available and commonly used disinfectants on certified strains of P. larvae under laboratory conditions, as well as to compare the obtained results among individual genotypes of P. larvae. Selected products were tested by determining the zone of inhibition using an agar diffusion test, a suspension test for viable bacteria, a surface disinfectant test, and a sporicidal effect in the suspension test. Incidin OxyFoam S and Sekusept Aktiv are both effective against all examined genotypes of P. larvae. Despadac and Despadac Secure have a bactericidal effect, but their sporocidal effect is not as satisfactory as that of Genox. Genoll does not exhibit a sporicidal effect, and Ecocide S at 1%, Bee protect H forte, and Bee protect F did not exhibit a satisfactory sporocidal effect. Additionally, EM® PROBIOTIC FOR BEES did not exhibit any bactericidal effect. The effective application of control measures and proper application of final disinfection can reduce the reoccurrence of visible clinical signs of disease, whereas methods of early diagnosis can significantly reduce the incidence of the disease.

Disinfection, sterilization and antisepsis: An overview

BACKGROUND

Each year in the United States there are approximately 100,000,000 outpatient/inpatient surgical procedures. Each of these procedures involves contact by a medical device or surgical instrument with a patient's sterile tissue and/or mucous membrane. A major risk of all such procedures is the introduction of infection.

METHODS

We searched published literature for articles on the use and effectiveness of disinfectants, sterilization methods and antiseptics.

RESULTS

The level of disinfection is dependent on the intended use of the object: critical (items that contact sterile tissue such as surgical instruments), semicritical (items that contact mucous membrane such as endoscopes), and noncritical (devices that contact only intact skin such as stethoscopes) items require sterilization, high-level disinfection and low-level disinfection, respectively. Cleaning must always precede high-level disinfection and sterilization. Antiseptics are essential to infection prevention as part of a hand hygiene program as well as other uses such as surgical hand antisepsis and pre-operative patient skin preparation.

CONCLUSIONS

When properly used, disinfection and sterilization can ensure the safe use of invasive and non-invasive medical devices. Cleaning should always precede high-level disinfection and sterilization. Strict adherence to current disinfection and sterilization guidelines is essential to prevent patient infections and exposures to infectious agents.

Biocides in the Hospital Environment: Application and Tolerance Development

Hospital-acquired infections are a rising problem with consequences for patients, hospitals, and health care workers. Biocides can be employed to prevent these infections, contributing to eliminate or reduce microorganisms' concentrations at the hospital environment. These antimicrobials belong to several groups, each with distinct characteristics that need to be taken into account in their selection for specific applications. Moreover, their activity is influenced by many factors, such as compound concentration and the presence of organic matter. This article aims to review some of the chemical biocides available for hospital infection control, as well as the main factors that influence their efficacy and promote susceptibility decreases, with the purpose to contribute for reducing misusage and consequently for preventing the development of resistance to these antimicrobials.

Fungal Biodegradation of Polyurethanes

Polyurethanes (PURs) are versatile polymers used in a wide variety of fields, such as the medical, automotive, textile, thermal insulation, and coating industries as well as many everyday objects. Many PURs have applications that require a long service life, sometimes with exposure to aggressive conditions. They can undergo different types of physicochemical and biological degradation, but they are not compostable, and many of them constitute persistent waste in the environment. Although both bacteria and fungi can be involved in the degradation of PURs, fungi are often the main biodegradation agents. The chemical structure of PURs determines their degree of biodegradation. Fungal biodegradation of PURs is linked to the production of enzymes, mainly esterases and proteases, alongside laccases, peroxidases, and tyrosinases, which can modify the structure of polyurethane compounds by forming carbonyl groups. The experimental analysis of the biodegradation of PUR can be carried out by bringing the polymer into contact with a mold in pure culture or with a microbial consortium. Then, global measurements can be taken, such as weight loss, tensile tests, or the ability of microorganisms to grow in the presence of PUR as the sole carbon source. The analysis of the chemical structure of the polymer and its degradation products after fungal growth can confirm biodegradation and specify the mechanism. The main avenues of future research are directed towards the development of fully biodegradable PURs and, on the contrary, towards the development of PURs that are more resistant to degradation phenomena, in particular biodegradation, for applications where the material is in contact with living organisms.

A survey of current trends in root canal treatment: access cavity design and cleaning and shaping practices

The purpose of this study was to evaluate current trends in access cavity design and cleaning and shaping among endodontists. A survey was e-mailed to active members of the American Association of Endodontists. Data showed that most respondents used traditional (57%) or conservative (43%) access cavities; less than 1% reported using ultraconservative access cavities. A glide path was created by 93% of respondents; NaOCl was used as lubricant by 51% of respondents, while 28% used RC Prep, 9% used liquid EDTA, 7% used Glyde, and 2% did not use any lubricant. Most respondents used NaOCl at 5.25% or higher concentration. Smear layer was removed by 92% of endodontists. Apical gauging was mostly accomplished with hand files. Clinical preferences varied among surveyed endodontists and among different age groups. Currently, very few endodontists use ultraconservative access preparations. There was large variation among the respondents suggesting a possible need for quality guidelines.

Effect of sodium hypochlorite on conventional and heat-treated nickel-titanium endodontic rotary instruments - An in vitro study

Background/purpose

Sodium hypochlorite (NaOCl) is a highly alkaline solution which exhibits antimicrobial properties. However, it causes corrosion to endodontic rotary files. This study investigated the effect of NaOCl on the metal surface of five different unused endodontic rotary files in vitro.

Materials and methods

Two non-heat-treated nickel-titanium (NiTi) files, ProTaper, BioRace, and three heat-treated NiTi files, VortexBlue, TRUShape, and EdgeFile X7 files, were immersed in 4% NaOCl for 5, 10, and 20 min, and 1, 6 and 24 h. The corrosion susceptibility was evaluated by visual inspection and scanning electron microscopy (SEM).

Results

In the TRUShape group, the black particulate matter was mostly formed at the file's curvature and shaft. A large amount of precipitate accumulated in the EdgeFile group. The extent and prevalence of surface defects were found to be consistently higher in EdgeFile X7 instruments than in any other instruments. EdgeFile X7 and TRUShape files exhibited a greater corrosive tendency to NaOCl than BioRace, ProTaper, and VortexBlue not only under visual inspection, but also under SEM analysis after prolonged immersion (1, 6, 24 h) in 4% NaOCl. However, shorter immersion periods (5, 10, 20 min) showed little surface corrosion across all experimental groups.

Conclusion

Within the limitations of this study, EdgeFile X7 and TRUShape files exhibit greater corrosive tendencies to NaOCl in vitro than BioRace, ProTaper, and VortexBlue files after prolonged immersion in 4% NaOCl. However, shorter immersion periods, which more closely approximate clinical conditions during single root canal therapy, may not show surface corrosion across all experimental groups.

Best practices for disinfection of noncritical environmental surfaces and equipment in health care facilities: A bundle approach

Over the past decade, there is excellent evidence in the scientific literature that contaminated environmental surfaces and noncritical patient care items play an important role in the transmission of several key health care-associated pathogens including methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, Acinetobacter, norovirus, and Clostridium difficile. Thus, surface disinfection of noncritical environmental surfaces and medical devices is one of the infection prevention strategies to prevent pathogen transmission. This article will discuss a bundle approach to facilitate effective surface cleaning and disinfection in health care facilities. A bundle is a set of evidence-based practices, generally 3-5, that when performed collectively and reliably have been proven to improve patient outcomes. This bundle has 5 components and the science associated with each component will be addressed. These components are: creating evidence-based policies and procedures; selection of appropriate cleaning and disinfecting products; educating staff to include environmental services, patient equipment, and nursing; monitoring compliance (eg, thoroughness of cleaning, product use) with feedback (ie, just in time coaching); and implementing a "no touch" room decontamination technology and to ensure compliance for patients on contact and enteric precautions. This article will also discuss new technologies (eg, continuous room decontamination technology) that may enhance our infection prevention strategies in the future.

Disinfection, sterilization, and antisepsis: An overview

All invasive procedures involve contact by a medical device or surgical instrument with a patient's sterile tissue or mucous membranes. The level of disinfection or sterilization is dependent on the intended use of the object. Critical (items that contact sterile tissue, such as surgical instruments), semicritical (items that contact mucous membranes, such as endoscopes), and noncritical (devices that contact only intact skin, such as stethoscopes) items require sterilization, high-level disinfection, and low-level disinfection, respectively. Cleaning must always precede high-level disinfection and sterilization. Antiseptics are essential to infection prevention as part of a hand hygiene program, as well as other uses, such as surgical hand antisepsis and preoperative skin preparation.

The Effect of Sterilization Methods on the Structural and Chemical Properties of Fibrin Microthread Scaffolds

A challenge for the design of scaffolds in tissue engineering is to determine a terminal sterilization method that will retain the structural and biochemical properties of the materials. Since commonly used heat and ionizing energy-based sterilization methods have been shown to alter the material properties of protein-based scaffolds, the effects of ethanol and ethylene oxide (EtO) sterilization on the cellular compatibility and the structural, chemical, and mechanical properties of uncrosslinked, UV crosslinked, or 1-ethyl-3-(3-dimethylaminopropyl)carbodiimide (EDC) crosslinked fibrin microthreads in neutral (EDCn) or acidic (EDCa) buffers are evaluated. EtO sterilization significantly reduces the tensile strength of uncrosslinked microthreads. Surface chemistry analyses show that EtO sterilization induces alkylation of EDCa microthreads leading to a significant reduction in myoblast attachment. The material properties of EDCn microthreads do not appear to be affected by the sterilization method. These results significantly enhance the understanding of how sterilization or crosslinking techniques affect the material properties of protein scaffolds.

Quaternary ammonium biocides: efficacy in application

Quaternary ammonium compounds (QACs) are among the most commonly used disinfectants. There has been concern that their widespread use will lead to the development of resistant organisms, and it has been suggested that limits should be place on their use. While increases in tolerance to QACs have been observed, there is no clear evidence to support the development of resistance to QACs. Since efflux pumps are believe to account for at least some of the increased tolerance found in bacteria, there has been concern that this will enhance the resistance of bacteria to certain antibiotics. QACs are membrane-active agents interacting with the cytoplasmic membrane of bacteria and lipids of viruses. The wide variety of chemical structures possible has seen an evolution in their effectiveness and expansion of applications over the last century, including non-lipid-containing viruses (i.e., noroviruses). Selection of formulations and methods of application have been shown to affect the efficacy of QACs. While numerous laboratory studies on the efficacy of QACs are available, relatively few studies have been conducted to assess their efficacy in practice. Better standardized tests for assessing and defining the differences between increases in tolerance versus resistance are needed. The ecological dynamics of microbial communities where QACs are a main line of defense against exposure to pathogens need to be better understood in terms of sublethal doses and antibiotic resistance.

Inactivation of coxsackievirus B4, feline calicivirus and herpes simplex virus type 1: unexpected virucidal effect of a disinfectant on a non-enveloped virus applied onto a surface

OBJECTIVE

To evaluate the effect of a disinfectant onto viruses in suspension on the one hand and applied onto a surface on the other.

METHODS

A system combining flocked swabs to recover viruses dried onto stainless steel carriers and gel filtration to eliminate cytotoxic products has been developed to study the virucidal effect of a quaternary ammonium-based disinfectant towards herpes simplex virus type 1 (HSV-1), coxsackievirus B4 (CVB4) and feline calicivirus F9 (FCV). The recovery of FCV has been estimated by RT real-time PCR.

RESULTS

HSV-1, CVB4 and FCV had a titer over 10(4) TCID50 · ml(-1) after 2 h drying and were recovered from the carriers using flocked swabs. HSV-1 was inactivated in suspension and on stainless steel carriers by the disinfectant (a reduction factor of 4 and 2.83 log, respectively) whereas CVB4 was resistant. The reduction of infectious titer was moderate, 1.5 log in 30 min, when FCV was in suspension, whereas it was up to 4 log in 10 min when the virus was dried on a carrier. Dried FCV was efficiently recovered from carriers as demonstrated by RT real-time PCR.

CONCLUSION

A non-enveloped virus, FCV, applied on a surface, but not in suspension, was inactivated by a quaternary ammonium-based disinfectant. The resistance of viruses applied onto a surface to the effect of disinfectants should be investigated further.

Assessment of stability of surface anchors for antibacterial coatings and immobilized growth factors on titanium

Titanium (Ti) has been functionalized with biomolecules for biomedical purposes. However, there is very limited information on the stability of such functionalities. Ti surface functionalized with carboxymethyl chitosan (CMCS) and bone morphogenetic protein 2 (BMP-2) has been reported to inhibit bacterial colonization while at the same time enhances osteoblast functions. In this work, three types of anchoring molecules, (3-aminopropyl) triethoxysilane (Silane), dopamine (DA), and polydopamine (PDA), were used for immobilizing the CMCS on Ti. The CMCS-modified surfaces were subjected to 70% ethanol treatment, autoclaving, and prolonged immersion in phosphate buffered saline (PBS). After the treatment procedures, the ability of the CMCS-modified substrates to inhibit colonization by Staphylococcus epidermidis (S. epidermidis) was assessed to evaluate the stability of the immobilized CMCS. The bacterial adhesion assays showed that the CMCS-DA- and CMCS-PDA-modified Ti remained stable after 70% ethanol treatment, autoclaving, and prolonged immersion in PBS, whereas the CMCS-Silane-modified Ti was less stable after autoclaving and prolonged immersion in PBS. The CMCS-DA- and CMCS-PDA-modified Ti substrates were functionalized with BMP-2 and used to support osteoblast growth. Evaluation of alkaline phosphatase (ALP) activity and calcium deposition from osteoblasts cultured on these substrates, which have been treated with 70% ethanol, or subjected to autoclaving, and prolonged immersion in PBS indicated that the immobilized BMP-2 on these surfaces retained its bioactivity.

Topical antibacterial agents

Decreased systemic toxicity, ease of application, and increased concentrations at the target site are some of the important advantages topical antibacterial agents offer. This article reviews the literature on selected indications for these agents and provides in-depth examination of specific agents for the prophylaxis and treatment of skin and wound infections.

The effect of sterilization methods on the physical properties of silk sericin scaffolds

Protein-based biomaterials respond differently to sterilization methods. Since protein is a complex structure, heat, or irradiation may result in the loss of its physical or biological properties. Recent investigations have shown that sericin, a degumming silk protein, can be successfully formed into a 3-D scaffolds after mixing with other polymers which can be applied in skin tissue engineering. The objective of this study was to investigate the effectiveness of ethanol, ethylene oxide (EtO) and gamma irradiation on the sterilization of sericin scaffolds. The influence of these sterilization methods on the physical properties such as pore size, scaffold dimensions, swelling and mechanical properties, as well as the amount of sericin released from sericin/polyvinyl alcohol/glycerin scaffolds, were also investigated. Ethanol treatment was ineffective for sericin scaffold sterilization whereas gamma irradiation was the most effective technique for scaffold sterilization. Moreover, ethanol also caused significant changes in pore size resulting from shrinkage of the scaffold. Gamma-irradiated samples exhibited the highest swelling property, but they also lost the greatest amount of weight after immersion for 24 h compared with scaffolds obtained from other sterilization methods. The results of the maximum stress test and Young's modulus showed that gamma-irradiated and ethanol-treated scaffolds are more flexible than the EtO-treated and untreated scaffolds. The amount of sericin released, which was related to its collagen promoting effect, was highest from the gamma-irradiated scaffold. The results of this study indicate that gamma irradiation should have the greatest potential for sterilizing sericin scaffolds for skin tissue engineering.

Topical antibacterial agents

Decreased systemic toxicity, ease of application, and increased concentrations at the target site are some of the important advantages topical antibacterial agents offer. This article reviews the literature on selected indications for these agents and provides in-depth examination of specific agents for the prophylaxis and treatment of skin and wound infections.

Antimicrobial efficacy in vivo of a new formulation of 2-butanone peroxide in n-propanol: comparison with commercial products in a cross-over trial

The use of hand rub to obtain maximum decrease in bacterial load is important because the reduction needed to avoid transmission is unknown. The monomer of 2-butanone peroxide is a peroxygen derivative with potential biocidal use in hospitals. The aim of this study was to compare the efficacy of hand rub with an alcoholic solution of peroxide 2-butanone versus five antiseptic products, against E. coli K12 (CECT 433) transient flora acquired by hand immersion in a broth culture following the UNE-EN-1500 standard. Isopropanol 60% (control) obtained 99.99% reductions, driving down the bacterial load from 10(6) cfu/mL in the initial inocula to <100 cfu/mL. Products A, B and C (different alcoholic solutions ranging from 65% to 75% with low amounts of biguanidines and/or quaternary ammonium compounds) resulted in significantly lower amounts, reducing initial inocula to approximately 500 cfu/mL. Products D and E (70-75% alcohol solutions containing higher amounts of different quaternary ammonium compounds and triclosan in the case of product E) produced reductions similar to that of isopropanol, with significantly larger reductions than products A, B and C. The product with the solution of 2-butanone peroxide produced the same effect as products D and E with mean reductions of approximately 4log(10) (99.99%), driving the initial inocula down to < or = 100 cfu/mL, despite the low concentration (35%) of propanol in the solution. This novel peroxygen biocide offers high in-vivo cidal activity against acquired E. coli transient flora, offering an alternative to products with higher alcohol concentrations.

Influence of sodium hypochlorite on fracture properties and corrosion of ProTaper Rotary instruments

AIM

To evaluate the influence of immersion in NaOCl on resistance to cyclic fatigue fracture and corrosion of ProTaper NiTi Rotary instruments.

METHODOLOGY

A total of 120 new ProTaper NiTi Rotary files (F2) were randomized and assigned to three different groups of 40 each. Group 1 was the control group; 20 mm (excluding the shaft) of group 2 instruments were immersed in 5% NaOCl at 50 degrees C for 5 min; instruments in group 3 were completely immersed in 5% NaOCl at 50 degrees C for 5 min. All instruments were then tested for cyclic fatigue, recording the time in seconds to fracture. Data were analysed by the Kruskall-Wallis test and post-hoc multiple comparisons (P < 0.05). Micromorphological and microchemical analyses were also completed by means of a field emission scanning electron microscopy (SEM) on those instruments in group 3 that had undergone early fracture.

RESULTS

Instruments in group 3 had a significantly lower resistance to fracture because of cyclic fatigue than those in groups 1 and 2 (P < 0.001). In some instruments in group 3, early fracture occurred after only a few seconds of fatigue testing. SEM observations revealed evident signs of corrosion of the fractured instruments.

CONCLUSION

Group 3 had significantly reduced resistance to cyclic fatigue compared with instruments in groups 1 and 2. The phenomenon of early fracture may be attributed to galvanic corrosion induced by the presence of dissimilar metals, where one acts as the cathode of a galvanic couple, established when the instrument is immersed in NaOCl solution. The NiTi alloy may acts as the anode and thus undergoes corrosion.

Value of the chlorhexidine decontamination method for recovery of nontuberculous mycobacteria from sputum samples of patients with cystic fibrosis

The chlorhexidine method was compared to the N-acetyl-l-cysteine-NaOH-oxalic acid decontamination method currently recommended for the recovery of nontuberculous mycobacteria (NTM) from patients with cystic fibrosis. Sputum samples (n = 827) treated with chlorhexidine yielded twice as many NTM-positive cultures as those treated by the reference method (54 [6.50%] versus 27 [3.25%]; P < 0.0001) despite a higher contamination rate (20% versus 14.2%; P = 0.0017).

Broad-spectrum microbicidal activity, toxicologic assessment, and materials compatibility of a new generation of accelerated hydrogen peroxide-based environmental surface disinfectant

Background

Concerns on human and environmental safety and label claims of many microbicides point to the need for safer, faster acting, and broad-spectrum substitutes. ACCEL TB, a 0.5% accelerated H₂O₂ (AHP)-based disinfectant described here, is a potential candidate.

Methods

ACCEL TB was tested for its broad-spectrum microbicidal activity, safety and materials compatibility using internationally accepted protocols. Activity against bacteria (Staphylococcus aureus, Escherichia coli, Acinetobacter baumannii, Pseudomonas aeruginosa, vancomycin-resistant Enterococcus faecalis, methicillin-resistant Staphylococcus aureus, and Salmonella choleraesuis) was tested with the AOAC use-dilution method and the first tier of a quantitative carrier test (QCT-1). Mycobactericidal activity was tested against Mycobacterium bovis and Mycobacterium terrae using a quantitative suspension test (QST) and QCT-1, respectively. Fungicidal activity (Trichophyton mentagrophytes) was determined with the AOAC test and QCT-1. Activity against several enveloped and nonenveloped viruses was evaluated using the American Society for Testing and Materials (ASTM) method No. E-1053. Sanitizing action was tested against 7 types of vegetative bacteria with method No. DIS/TSS-10. All microbicidal tests contained an added soil load; in all AOAC tests, it was 5% fetal bovine serum, and, in QCT-1, a mixture of 3 types of proteins in phosphate buffer was used instead. The methods to test for acute oral, dermal, inhalation toxicities, and dermal and eye irritation as well as skin sensitization complied with the requirements of the Organization for Economic Cooperation and Development and the US Environmental Protection Agency (OPPTS 870). Standard methods were also used to test compatibility with metals and plastics.

Results

At 20°C, the full-strength product was bactericidal and virucidal in 1 minute and mycobactericidal and fungicidal in 5 minutes. It was nonirritating to skin and eyes. The acute oral LD₅₀ (lethal dose 50%) was >5000 mg/kg. It was compatible with 12 types of plastic and 3 out of 4 metals.

Conclusion

The tested formulation showed a high safety and materials compatibility profile in addition to being a fast acting, intermediate-level disinfectant.

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Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs

The etiology of nosocomial infections, the frequency of contaminated hands with the different nosocomial pathogens, and the role of health care workers' hands during outbreaks suggest that a hand hygiene preparation should at least have activity against bacteria, yeasts, and coated viruses. The importance of efficacy in choosing the right hand hygiene product is reflected in the new Centers for Disease Control and Prevention guideline on hand hygiene (J. M. Boyce and D. Pittet, Morb. Mortal. Wkly. Rep. 51:1-45, 2002). The best antimicrobial efficacy can be achieved with ethanol (60 to 85%), isopropanol (60 to 80%), and n-propanol (60 to 80%). The activity is broad and immediate. Ethanol at high concentrations (e.g., 95%) is the most effective treatment against naked viruses, whereas n-propanol seems to be more effective against the resident bacterial flora. The combination of alcohols may have a synergistic effect. The antimicrobial efficacy of chlorhexidine (2 to 4%) and triclosan (1 to 2%) is both lower and slower. Additionally, both agents have a risk of bacterial resistance, which is higher for chlorhexidine than triclosan. Their activity is often supported by the mechanical removal of pathogens during hand washing. Taking the antimicrobial efficacy and the mechanical removal together, they are still less effective than the alcohols. Plain soap and water has the lowest efficacy of all. In the new Centers for Disease Control and Prevention guideline, promotion of alcohol-based hand rubs containing various emollients instead of irritating soaps and detergents is one strategy to reduce skin damage, dryness, and irritation. Irritant contact dermatitis is highest with preparations containing 4% chlorhexidine gluconate, less frequent with nonantimicrobial soaps and preparations containing lower concentrations of chlorhexidine gluconate, and lowest with well-formulated alcohol-based hand rubs containing emollients and other skin conditioners. Too few published data from comparative trials are available to reliably rank triclosan. Personnel should be reminded that it is neither necessary nor recommended to routinely wash hands after each application of an alcohol-based hand rub. Long-lasting improvement of compliance with hand hygiene protocols can be successful if an effective and accessible alcohol-based hand rub with a proven dermal tolerance and an excellent user acceptability is supplied, accompanied by education of health care workers and promotion of the use of the product.

Topical antibacterial agents

Decreased systemic toxicity, ease of application, and increased concentration at the target site are some of the important advantages topical antibacterial agents offer. This article reviews the literature on selected indications of these agents and provides in-depth examination of specific agents for the prophylaxis and treatment of skin and wound infections.

Reprocessing endoscopes: United States perspective

Endoscopes are used frequently for the diagnosis and therapy of medical disorders. For example, greater than 10000000 gastrointestinal endoscopic procedures are performed each year in the United States. Failure to employ appropriate cleaning and disinfection/sterilization of endoscopes has been responsible for multiple nosocomial outbreaks and serious, sometimes life-threatening, infections. Flexible endoscopes, by virtue of the site of use, have a high bioburden of microorganisms after use. The bioburden found on flexible gastrointestinal endoscopes following use has ranged from 10(5) to 10(10)CFU/ml, with the highest levels being found in the suction channels. Cleaning dramatically reduces the bioburden on endoscopes. Several investigators have shown a mean log(10) reduction factor of 4 (99.99%) in the microbial contaminants with cleaning alone. Cleaning should be done promptly following each use of an endoscope to prevent drying of secretions, allow removal of organic material, and decrease the number of microbial pathogens. Because the endoscope comes into intimate contact with mucous membranes, high-level disinfection is the reprocessing standard after each patient use. High-level disinfection refers to the use of a disinfectant (e.g., FDA-cleared chemical sterilant or high-level disinfectant) that inactivates all microorganisms (i.e., bacteria, viruses, fungi, mycobacteria) but not high levels of bacterial spores. The disinfection process requires immersion of the endoscope in the high-level disinfectant and ensuring all channels are perfused for the approved contact time (e.g., for ortho-phthaladehyde this is 12 min in the US). Following disinfection, the endoscope and channels are rinsed with sterile water, filtered water, or tapwater. The channels are then flushed with alcohol and dried using forced air. The endoscope should be stored in a manner that prevents recontamination. A protocol that describes the meticulous manual cleaning process, the appropriate training and evaluation of the reprocessing personnel, and a quality assurance program for endoscopes should be adopted and enforced by each unit performing endoscopic reprocessing.

The effect of cleaning procedures on fracture properties and corrosion of NiTi files

AIM

To evaluate the effect of repeated cleaning procedures on fracture properties and corrosion of nickel-titanium (NiTi) files.

METHODOLOGY

New NiTi instruments were subjected to 2, 5 and 10 cleaning cycles with the use of either diluted bleach (1% NaOCl) or Milton's solution (1% NaOCl plus 19% NaCl) as disinfectant. Each cleaning cycle consisted of scrubbing, rinsing and immersing in NaOCl for 10 min followed by 5 min of ultrasonication. Files were then tested for torsional failure and flexural fatigue, and observed for evidence of corrosion using scanning electron microscope (SEM). Four brands of NiTi files were immersed in either Milton's solution or diluted bleach overnight and evaluated for corrosion.

RESULTS

Up to 10 cleaning cycles did not significantly reduce the torque at fracture or number of revolutions to flexural fatigue (P > 0.05, two-way anova), although decreasing values were noted with increasing number of cleaning cycles using Milton's solution. No corrosion was detected on the surface of these files. Files immersed in 1% NaOCl overnight displayed a variety of corrosion patterns. The extent of corrosion was variable amongst different brands of files and amongst files in each brand. Overall, Milton's solution was much more corrosive than diluted bleach. Corrosion of file handles was often extreme.

CONCLUSIONS

Files can be cleaned up to 10 times without affecting fracture susceptibility or corrosion, but should not be immersed in NaOCl overnight. Milton's solution is much more corrosive than bleach with the same NaOCl concentration.

Multi-society guideline for reprocessing flexible gastrointestinal endoscopes. Society for Healthcare Epidemiology of America

Flexible gastrointestinal endoscopy is a valuable diagnostic and therapeutic tool for the care of patients with gastrointestinal and pancreaticobiliary disorders. Compliance with accepted guidelines for the reprocessing of gastrointestinal endoscopes between patients is critical to the safety and success of their use. When these guidelines are followed, pathogen transmission can be effectively prevented. Increased efforts and resources should be directed to improve compliance with these guidelines. Further research in the area of gastrointestinal endoscope reprocessing should be encouraged. The organizations that endorsed this guideline are committed to assisting the FDA and manufacturers in addressing critical infection control issues in gastrointestinal device reprocessing.

In-vitro evaluation of Perasafe compared with 2% alkaline glutaraldehyde against Mycobacterium spp

Quantitative suspension and carrier tests were used to compare the activity of Perasafe and Cidex against Mycobacterium tuberculosis, Mycobacterium avium-intracellulare, Mycobacterium fortuitum, and Mycobacterium chelonae. The interference of an organic load, and of hard water was also considered. Both agents achieved reductions exceeding 10(5)-fold within 20 and 30 min for all the strains tested. Perasafe is thus mycobactericidal and a viable alternative to Cidex for intermediate or high-level disinfection.

A survey of sodium hypochlorite use by general dental practitioners and endodontists in Australia

BACKGROUND

Sodium hypochlorite is used commonly as an endodontic irrigant, but there are no published reports that provide details of its use. This survey sought to determine the percentage of Australian dentists who practiced endodontics, whether they used sodium hypochlorite for irrigation, and the manner of dilution, storage and dispensing sodium hypochlorite used by both dentists and endodontists.

METHODS

All Australian endodontists and a stratified random sample of 200 general dentists in Australia were surveyed to address the issues identified above.

RESULTS

Almost 98 per cent of dentists surveyed performed endodontic treatment. Among endodontists, nearly 94 per cent used sodium hypochlorite for irrigation compared with just under 75 per cent of general dentists. Sodium hypochlorite use by general dentists was more common in Victoria and South Australia than in other States. An infant sanitizer (Milton or Johnson's Antibacterial Solution) was used by just over 92 per cent of general practitioners and by more than 67 per cent of endodontists. All other respondents used domestic bleach. One hundred and sixty four of the respondents (80 per cent of endodontists and over 90 per cent of general dentists) used a 1 per cent w/v solution. Ten practitioners used a 4 per cent w/v solution, five used a 2 per cent w/v solution and four used a 1.5 per cent w/v solution. Eighty per cent of the practitioners who diluted their sodium hypochlorite before use, used demineralized water for this purpose. The remainder used tap water. Only four practitioners stored sodium hypochlorite in a manner which risked light exposure and loss of available chlorine content.

CONCLUSIONS

Sodium hypochlorite is commonly used as an endodontic irrigant and Australian dentists generally stored the material correctly.

The role of the home environment in the transmission of infectious diseases

The purpose of this paper is to examine current health care literature (1980-2000) regarding the microbiology of the home environment, to summarize evidence of transmission within the home, and to assess effectiveness of cleaning practices and products. The home environment, particularly the kitchen and bathroom, serves as a reservoir of large numbers of microorganisms, particularly Enterobacteriacae, and infectious disease transmission has been demonstrated to occur in 6-60% of households in which one member is ill. Current food preparation and cleaning practices provide multiple opportunities for intra-household member spread. Routine cleaning is often sufficient, but in cases of household infection, may not adequately reduce environmental contamination. The effectiveness of disinfectants varies considerably and depends on how they are used as well as their intrinsic efficacy. The behavioral aspects of infection prevention in the home (e.g., foodhandling and cleaning practices) warrant increased public attention and education.

The shelf-life of sodium hypochlorite irrigating solutions

BACKGROUND

Sodium hypochlorite (bleach) solutions are widely used as irrigants in endodontics. Their tendency to deteriorate is worsened by environmental influences which could cause loss of available chlorine content.

METHODS

This study measured the loss of available chlorine concentration in a range of sodium hypochlorite solutions under conditions which mimic clinical usage and storage. Domestic bleach, both undiluted and diluted with demineralised water or hard water, was tested, along with Milton, for initial concentration of available chlorine, and then retested after varying periods and modes of storage to measure loss of chlorine concentration. The types of storage were: (1) in closed plastic bottles which were opened daily and agitated; (2) in open plastic bottles; (3) in syringes exposed to sunlight; (4) in syringes kept in the dark; (5) in open stainless steel bowls; (6) in closed stainless steel bowls; and (7) when heated to 50 degrees C. Not all solutions were tested under all storage conditions.

RESULTS

Of the solutions opened daily, undiluted domestic bleach was the most stable and Milton was the least stable. Initially, diluted bleach left open deteriorated rapidly but deterioration slowed with time. Solutions in syringes exposed to sunlight showed the most rapid loss of chlorine content. Heated bleach lost nearly 5 per cent of its strength in six hours. Diluted bleach surprisingly, increased its chlorine concentration in open bowls probably due to evaporation of water. Dilution of bleach with hard tap water did not significantly affect shelf-life. Preloading of diluted bleach into syringes appears to be a sound technique if the syringes are stored away from light.

CONCLUSIONS

This study reinforces the need for sodium hypochlorite to be stored in closed opaque containers. Constant opening of containers appears to cause greater loss in chlorine concentration of diluted bleach solutions, perhaps because a lower concentration of sodium hydroxide allows the pH to drop more rapidly.

Preventing the spread of hepatitis B and C viruses: where are germicides relevant?

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are the most prevalent bloodborne pathogens. Infections caused by these organisms can become chronic and may lead to liver cirrhosis and carcinoma. Limited chemotherapy is now available, but only HBV can be prevented through vaccination. Both viruses are enveloped and relatively sensitive to many physical and chemical agents; their ability to survive in the environment may not be as high as often believed. As a result, their spread occurs mainly through direct parenteral or percutaneous exposure to tainted body fluids and tissues. Careful screening of and avoiding contact with such materials remain the most effective means of protection. Nevertheless, the indirect spread of these viruses, although much less common, can occur when objects that are freshly contaminated with tainted blood enter the body or contact damaged skin. Germicidal chemicals are important in the prevention of HBV and HCV spread through shared injection devices, sharps used in personal services (such as tattooing and body piercing), and heat-sensitive medical/dental devices (such as flexible endoscopes) and in the cleanup of blood spills. Microbicides in vaginal gels may also interrupt their transmission. General-purpose environmental disinfection is unlikely to play a significant role in the prevention of the transmission of these viruses. Testing of low-level disinfectants and label claims for such products against HBV and HCV should be discouraged. Both viruses remain difficult to work with in the laboratory, but closely related animal viruses (such as the duck HBV) and the bovine viral diarrhea virus show considerable promise as surrogates for HBV and HCV, respectively. Although progress in the culturing of HBV and HCV is still underway, critical issues on virus survival and inactivation should be addressed with the use of these surrogates.

Rapid screening method for Mycobactericidal activity of chemical germicides that uses Mycobacterium terrae expressing a green fluorescent protein gene

The slow growth of mycobacteria in conventional culture methods impedes the testing of chemicals for mycobactericidal activity. An assay based on expression of the green fluorescent protein (GFP) by mycobacteria was developed as a rapid alternative. Plasmid pBEN, containing the gene encoding a red-shifted, high-intensity GFP mutant, was incorporated into Mycobacterium terrae (ATCC 15755), and GFP expression was observed by epifluorescence microscopy. Mycobactericidal activity was assessed by separately exposing a suspension of M. terrae(pBEN) to several dilutions of test germicides based on 7.5% hydrogen peroxide, 2.4% alkaline glutaraldehyde, 10% acid glutaraldehyde, and 15.5% of a phenolic agent for contact times ranging from 10 to 20 min (22 degrees C), followed by culture of the exposed cells in broth (Middlebrook 7H9) and measurement of fluorescence every 24 h. When the fluorescence was to be compared with CFU, the samples were plated on Middlebrook 7H11 agar and incubated for 4 weeks. No increase in fluorescence or CFU occurred in cultures in which the cells had been inactivated by the germicide concentrations tested. Where the test bacterium was exposed to ineffective levels of the germicides, fluorescence increased after a lag period of 1 to 7 days, corresponding to the level of bacterial inactivation. In untreated controls, fluorescence increased rapidly to reach a peak in 2 to 4 days. A good Pearson correlation coefficient (r > or =0.85) was observed between the intensity of fluorescence and the number of CFU. The GFP-based fluorescence assay reduced the turnaround time in the screening of chemical germicides for mycobactericidal activity to < or =7 days.

Assessment of in-vitro efficacy of 1% Virkon against bacteria, fungi, viruses and spores by means of AFNOR guidelines

Peroxygenic acid, under the brand name Virkon, has unleashed great debate following contradictory reports of its efficacy and spectrum of activity. The aim of this study was to test the biocidal activity of the compound against 10 different micro-organisms, following standard in-vitro test procedures. Bactericidal, fungicidal and sporicidal activities were determined using quantitative suspension and germ carrier tests and virucidal activity was assessed using a simple dilution suspension test, following the Association Française de Normalisation (AFNOR) guidelines. One percent Virkon demonstrated bactericidal activity against Pseudomonas aeruginosa, Escherichia coli, Staphylococcus aureus, Enterococcus hirae and Mycobacterium smegmatis in the suspension test and against P. aeruginosa, E. coli, S. aureus and E. hirae in the carrier test. One percent Virkon showed virucidal activity against poliovirus in the suspension test. However, this concentration did not comply with sporicidal and fungicidal activity guidelines. In conclusion, 1% Virkon is effective only against vegetative bacteria, yeasts and viruses, and should therefore be considered a low-level disinfectant.

Antiseptics and disinfectants: activity, action, and resistance

Antiseptics and disinfectants are extensively used in hospitals and other health care settings for a variety of topical and hard-surface applications. A wide variety of active chemical agents (biocides) are found in these products, many of which have been used for hundreds of years, including alcohols, phenols, iodine, and chlorine. Most of these active agents demonstrate broad-spectrum antimicrobial activity; however, little is known about the mode of action of these agents in comparison to antibiotics. This review considers what is known about the mode of action and spectrum of activity of antiseptics and disinfectants. The widespread use of these products has prompted some speculation on the development of microbial resistance, in particular whether antibiotic resistance is induced by antiseptics or disinfectants. Known mechanisms of microbial resistance (both intrinsic and acquired) to biocides are reviewed, with emphasis on the clinical implications of these reports.

Efficacy and mechanisms of action of sodium hypochlorite on Pseudomonas aeruginosa PAO1 phage F116

The Pseudomonas aeruginosa PAO1 phage F116 was used to investigate the viricidal activity and the mechanism of action of sodium hypochlorite. The bacteriophage was inactivated with a low concentration (0.0005% available chlorine) of the biocide prepared in tap water but it was less sensitive to a sodium hypochlorite solution prepared in ultra-pure water (0.0075% available chlorine). For all the effective concentrations of sodium hypochlorite (i.e. producing at least 4 log reduction in phage titre), F116 was readily inactivated within 30 s. Electron microscopical investigations of the phage particles challenged with sodium hypochlorite showed a wide variety of deleterious effects, some of which have not been previously observed with other biocides. The wide range of structural alterations observed suggested that sodium hypochlorite has multiple target sites against F116 bacteriophage. A 30 s exposure to sodium hypochlorite (0.001% available chlorine) produced severe damage, the number and severity of which increased with a higher concentration (0.0075% available chlorine) and with a longer contact time. These observations suggested that sodium hypochlorite inactivated F116 bacteriophage by causing structural alterations to the phage head, tail and overall structure, hence possibly releasing the viral genome from damaged capsids in the surrounding media.

Sodium hypochlorite and its use as an endodontic irrigant

Sodium hypochlorite has been used as an endodontic irrigant for more than 70 years, and is now one of the most common solutions for this purpose. The chemical properties and production of commercial sodium hypochlorite are reviewed. Domestic bleaches and an infant sanitizer are compared from the point of view of cost and ease of use--Milton being recommended where a 1% solution is required. The cost of syringes and needles for endodontic irrigation is many times greater than the hypochlorite they contain, and total annual practice costs for hypochlorite are low. Brief guidelines for clinical use, storage, handling and disposal are included.

Mycobactericidal testing of disinfectants: an update

Tuberculosis, a major killer in developing countries, is on the rise again in industrialized nations. AIDS, increased use of immunosuppression and the emergence of multiple drug-resistant Mycobacterium tuberculosis (MDR-TB) have further enhanced its significance. TB is projected to cause 3.5 million deaths per year by 2000. Also, other types of mycobacteria are being incriminated in human infections with increasing frequency. Thus, the enhanced risk of nosocomial and iatrogenic spread of mycobacteria is forcing a review of infection control in general and claims of mycobactericidal activity of disinfectants in particular. Mycobacteria are more resistant to disinfection than enveloped viruses and other types of vegetative bacteria, but a proper comparison with non-enveloped viruses requires more data. Flaws in currently used protocols for mycobacterial activity are: (i) a lack of proper quantitation; (ii) unrealistically long contact times at higher than ambient temperatures; (iii) absence of a suitable organic load; (iv) ineffective neutralizers; (v) unsuitable surrogates for M. tuberculosis; (vi) improper recovery media; and (vii) inappropriate types of carriers. Furthermore, we have recently found a product meant for 14 day reuse to become non-mycobactericidal after only a week under actual use in an endoscopy unit. These considerations make the available data on product efficacy unreliable, especially in view of the increasing threat from MDR-TB. Recent findings suggest that the use of Mycobacterium terrae as a surrogate, better recovery media, flat surfaces as carriers, elimination of neutralizers, proper removal of cell clumps and a required > or = 4 log10 reduction in the number of colony forming units of the test bacterium after disinfectant treatment should make mycobacteridal tests more precise and reliable, thus making product registration and selection easier. There is also an urgent need to develop standardized protocols to determine the mycobactericidal activity of disinfectants under conditions of reuse.