Surface Cleaning and Disinfection — What to use?

What product to choose for cleaning in the Healthcare Environment?

A clean healthcare environment is an important part of an infection prevention and control (IPC) programme¹. A growing body of evidence suggests that the transmission of pathogens whilst being treated in a healthcare facility, from environmental surfaces and equipment in the patient’s surroundings contributes to the increasing problem of healthcare associated infection (HAI)². A wide range of decontamination technology, methods and products are currently available³; however, there is much debate as to what is best practice and this is demonstrated in the diverse application and acceptance of methods and cleaning and disinfection agents. Here we will explore the use of a neutral detergent and separate disinfectant for surface cleaning and disinfection as part of a two step decontamination process.

Factors that influence successful removal of pathogens from surfaces

The increase in resistant organisms, novel pathogens and emerging infectious diseases has led to a growth in research looking at the efficacy of environmental decontamination in the healthcare setting. This has been further accelerated by the COVID pandemic which has seen a rapid shift in environmental cleaning and disinfection protocols as both awareness and understanding of transmission pathways became more apparent. Factors that can determine the effectiveness of an environmental cleaning program and subsequent reduction in surface based transmission rates include the following:

• Cleaning and disinfection agents, type and efficacy
• Level of training provided to cleaning personnel
• Variation in cleaning personnel performance and consistency of process
• Monitoring of cleaning practices
• Bio-burden (Biofilm) of the surface
• Properties of surface being cleaned
• Frequency the surface is touched e.g. high-touch surfaces or low-touch
• Adherence to manufacturer recommendations for correct product use and appropriate application of suitable contact time
• Resistance of pathogens to routine cleaning and/or disinfection
   

What most studies have concluded is that human factors play the most important part in effective decontamination of the environment if all other factors are equal and effective adherence to suitable process is essential for optimum outcomes.

Choosing a neutral detergent or disinfectant

The choice of cleaning agent is very much an independent one and relevant to the facility, local risks, environmental surfaces and equipment in use. Different products may be suitable for different situations within the same facility; for example, some facilities may use a neutral detergent for everyday routine cleaning but change to a disinfectant in the event of an outbreak. As a result of the pandemic we have seen changes to traditional protocols with a significant increase in active disinfectant application, adjustment to the frequency of cleaning and disinfection in order to prevent transmission from surfaces.

Broadly the difference between cleaning and disinfection is simple.

Cleaning is the removal of soil and contaminants from surfaces, whereas Disinfection relates to the inactivation, neutralisation or killing of pathogens by use of a chemical disinfectant.

The topic of whether routine environmental cleaning should be undertaken with a neutral detergent or a disinfectant remains controversial as the ongoing concern that overuse of disinfectants may lead to additional micro-organism mutation resulting in a possible rise in antimicrobial resistant organisms, clostridium difficile infections and other outbreaks associated with an environmental source.

Neutral detergent

For regular, everyday cleaning of healthcare surfaces, a neutral detergent product is a good cleaning agent to choose and provide a cost-effective solution. Additionally, by virtue of the cleaning process and the removal of dirt and contaminants that can harbor pathogens, the process will minimize pathogens and micro-organisms in the environment. Use of the detergent and regular removal of dirt and dust should minimise the build-up of bacteria and viruses and the formation of a biofilm. It has been found though that bulk detergent solutions that are then diluted for broader application have been known to become contaminated with bacteria if not changed frequently. This can result in the cleaning process contributing to the spread of pathogens around the environment instead of removing them. This can also occur if you re-use a cloth or wipe on multiple surfaces. Without a disinfectant this can result in further spread.

This risk can be minimised by using pre-moistened wipes, that are single use only and disposed of as per manufacturer recommendations. Recommended process for use of wipes is as follows:

• Use an S shaped motion to reduce cross contamination
• Clean Equipment and surfaces from the Top to the Bottom
• Wipe from Clean to Dirty to stop re contamination of clean areas
• Ensure contact times are as per instruction to ensure effective disinfection
• Use one wipe per surface /equipment — minimise the risk of cross contamination
   

There is also a reduced environmental impact to a broader use of disinfectant wipes instead of disinfectant products due to the reduction in overall chemical use. They are also non toxic and pose significant less risk of reactions and exposure to potentially toxic ingredients. Care should always be taken for users of products to take the relevant protective measures when using any product. Disinfectants by definition are chemicals that kill or render inactive pathogens at a cellular level, so a detergent will nearly always be less toxic than a disinfectant.

Disinfectants

There are several indications when a disinfectant would be the product of choice, primarily in situations of high levels of contamination. Disinfectants reduce higher bacterial counts than detergents but the product still relies on the removal of organic soil to be effective. It should be noted that many disinfectant compounds can be inhibited by dirt and soil and the presence of which may significantly reduce the relevant efficacy. It is for this reason that it has been widely accepted that a surface should be cleaned first prior to the use of a disinfectant.

It is recommended to use a disinfectant to decontaminate the room after the discharge of a patient who had been colonised or infected with MRO or other infectious disease. Multiple studies have demonstrated that a patient is at a higher risk of MRO acquisition if they were admitted to a room previously occupied by a patient positive for MRO. A disinfectant product is also used when there is persistent contamination with a pathogen, such as during an outbreak or when the area has endemic rates of disease. Additionally, there are some pathogens which have potential resistance to detergent-based cleaning including C. difficile, MROs, and norovirus.

Aside from the potential environmental toxicity issues, one of the draw-backs of disinfectants is that they require a minimum contact time to kill the pathogens. Having a robust process that facilitates the adherence to the contact time is essential in the optimal disinfection outcome. Contact time can be defined as the minimum time a pathogen needs to be exposed to the active ingredient in order for it to be killed or rendered inactive. In practice this is effectively wet exposure time so a surface needs to be wet with disinfectant for 60 seconds in order to achieve a 60 second contact time. It should be noted that contact time can change from product to product and pathogen to pathogen.

More recently there is an increase in combination detergent and disinfectant products that use the latest generation disinfectant active ingredients combined with detergent surfactants. The active ingredients in these are typically less affected by dirt and soil and will clean and disinfect the surface. For best outcomes it is still recommended that two wipes are used on any surface, the first to clean and the second to disinfect. These products should be treated with the same precautions as any other disinfectant.

Surface compatibility

Important to note that detergents and disinfectants have different material compatibility profiles that will differ from product to product. Care should be taken to assess the surfaces that the products will be applied to for compatibility prior to use. Of particular importance are surfaces and materials on pieces of medical equipment. These can be comprised of a variety of materials including metals, alloys, plastics, polymers and glass. All of these may react differently to cleaning and disinfection ingredients and you should always consult with the equipment manufacturer for guidance. Use of the correct products will ensure the lifespan of the surface or equipment is not unduly compromised by the environmental cleaning protocol.

Summary

In summary, there are positive and negative aspects to using both detergents and disinfectants. The end users need to consider the environment, current HAI and pathogen risks, existing protocols and processes, staff competence and choose their products appropriately. The process and effective application of any environmental cleaning and disinfection protocol is essential in achieving the very best outcomes. Remember you can have the best product available but if it is not used correctly it is not going to achieve the desired end state and if you do not adhere to contact times for disinfection you may as well use water as you will not achieve effective disinfection at all.

References

^{1. Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2017.}

^{2. Weber DJ, Rutala WA, Miller MB, Huslage K, Sickbert-Bennett E. Role of hospital surfaces in the transmission of emerging health care associated pathogens: norovirus, Clostridium difficile, and Acinetobacter species. Am J Infect Control 2010; 38(suppl): S25-S33.}

^{3. Boyce JM. Modern technologies for improving cleaning and disinfection of environmental surfaces in hospitals. Antimicrobial Resistance & Infection Control. 2016;5(1):10.}