Sterilisation,

Disinfection, and
Antisepsis
Learning outcomes
• Definition of key terms
• Define the three levels of disinfection and give examples
• Discuss methods of sterilization
• Give examples of disinfectants and their mode of action
An important aspect of the control of
infections is an understanding of the
principles of sterilization, disinfection and
antisepsis
Definitions
Sterilization
• Total destruction of all microbes, including the more resilient forms
such as bacterial spores, mycobacteria, non-enveloped viruses and
fungi.
• This can be accomplished using physical, gas vapour or chemical
sterilants.
Disinfection
• Microbes can be destroyed by disinfection procedures, although more
resilient organisms survive.
• The term disinfection and sterilization are used interchangeably.
• Disinfection processes have been categorized as high level,
intermediate level and low level.
• High level disinfection can approach sterilization in effectiveness,
whereas spore forms can survive intermediate level disinfection, and
many microbes can remain viable, when exposed to low-level
disinfection.
High level disinfectants
• Used for items involved with invasive procedures that cannot
withstand sterilization procedures (e.g.certain types of endospores
and surgical instruments with plastic or other components that
cannot be autoclaved)
• Disinfection of these and other itemsis most effective if cleaning the
surface to remove organic matter precedes treatment.
• Examples: treatment with moist heat and use of liquids such as
glutaldehyde, hydrogen peroxide, peractic acid and chlorine
compounds.
Intermediate level disinfectants
• Alcohols, iodophor compounds, phenolic compounds
• Are used to clean surfaces or instruments where contamination with
bacterial spores and other highly resilient organisms is unlikely.
• These have been refered to as semi-critical instruments and devices
and include flexible fiberoptic endoscopes, laryngoscopes, vagina
specula, anesthesia breathing circuits and other items.
Low-level disinfectants
• Quatenary ammonium compounds
• Used to treat non critical instruments and devices, such as blood
pressure cuffs, electrocardiogram electrodes, and stepthoscopes.
• Although these items come into contact with patients, they do not
penetrate through mucosal surfaces or into sterile tissues.
Disinfection
• The level of disinfection used for environmental surfaces is determined by
the relative risk these surfaces pose as reservoir for pathogenic organisms.
• For example, a high level of disinfectant should be used to clean the surface
of instruments contaminated with blood than tht used to clean surfaces that
are dirty such as floors, sinks and counter tops.
• The exception to this rule is if a particular surface has been implicated in a
nosocomial infection, such as a bathroom contaminated with clostridium
difficile (spore forming anaerobic bacterium) or a sink contaminated with
pseudomonas aeruginosa.
• In these cases, a disinfectant with appropriate activity against the implicated
pathogen should be selected.
Antisepsis
• Antisepsis agents are used to reduce the number of microbes on skin
surfaces.
• These compounds are selected for their safety and efficacy.
Antisepsis
• Alcohol has excellent activity against all groups of organisms, except
spores, and are non-toxic, although they tend to dry the skin surface
because they remove lipids.

• They also do not have residual activity and are inactivated by organic
matter. Thus the surface of the skin should be cleaned before alcohol
is applied.
Antisepsis
• Iodophors are also excellent skin antiepti agents, having a range of
activity similar to that of alcohols. They are slightly more toxic to the
skin than is alcohol, have limited residual activity, and are inactivated
by organic matter.
• Iodophors and iodine preparations are frequently used with alcohols
for disinfecting the skin surface.
• Chlorhexidine has broad antimicrobial activity, although it kills
organisms at a much slower rate than alcohol.
• Its activity persists although organic matter and high pH levels
decrease its effectiveness.
Antisepsis
• Chlorometaxylenol is limited primarily to gram-positive bacteria
• Because it is non toxic and has residual activity, it has been used in
handwashing products.
• Triclosan is active against bacteria but not against many other
organisms. It is a common antiseptic agent in deodorant soaps and
some toothpaste products.
Mechanisms of Action
Moist Heat
• Attempts to sterilize items using boiling water are inefficient, because only a
relatively low temperature (100C) can be maintained
• Indeed spore formation by a bacterium is commonly demonstrated by boiling a
solution of organisms and then subculturing the solution. Boiling vegetative
organisms kills them, but the spores remain viable.
• In contract, steam under pressure in an autoclave is a very effective form of
sterilization, the higher temperature causes denaturation of microbial proteins.
• The rate of killing organisms during the autoclave process is rapid but is influenced
by the temperature and duration of autoclaving, size of the autoclave, flow rate of
the steam, density and size of the load, and placement of the load in the chamber.
• Care must be taken to avoid creating air pockets, which inhibit penetration of the
steam into the load.
Moist heat
• Most autoclaves are operated at 121C to 132 C for 15mins or longer.
• Including commercial preparations of Bacillus stearo thermophilus
spores can help monitor the effectiveness of sterilization.
• An ampule of spores is placed in the center of the load, removed at
the end of the autoclave process, and incubated at 37C.
• If the sterilization process was successful, the spores are killed and
the organisms fail to grow.
Ethylene oxide
• Ethylene oxide(EO) is a colorless gas (soluble in water and common organic solvents)
that is used to sterilize heat sensitive items.
• Sterilization with ethylene oxide is optimal in a relative humidity of approx. 30%, with
decreased activity at higher or lower humidity.
• EO exerts its sporicidal activity through alkylation of terminal hydroxyl, carboxyl,
amino, and sulfhydryl groups. This process blocks reactive groups required for many
essential metabolic processes.
• Examples of other strong alkylating gases used as sterilants are formaldehyde and
betapropiolactone
• Because ethylene oxide can damage viable tissues, the gas must be dissipated before
the item can be used. This aeration period is generally16 hours or longer.
• The effectiveness of sterilisation is monitored with the bacillus subtilis spore test
Aldehydes
• As with ethylene oxide, aldehydes exert their effect through alkylation.
• The two best known aldehydes are formaldehyde and glutaraldehyde, both of which
can be used as sterilants or high level disinfectants.
• Formaldehyde can be dissolved in water (creating a solution called formalin) at a final
concentration of 37%.
• Stabilizers, such as methanol are added to formalin. Low concentrations of formalin
are bacteriostatic, whereas higher concentrations can kill all organisms.
• Combining formaldehyde with alcohol (e.g. 20% formalin in 70% alcohol)can enhance
this microbicidal activity. Exposure of skin or mucous membranes to formaldehyde can
be toxic.
• Glutaldehyde is more active at alkaline pH levels, is less toxic for viable tissues, but it
can cause burns on the skin or mucous membranes
Oxidizing agents
• Examples include ozone, peracetic acid, and hydrogen peroxide, with
the last used most commonly
• Hydrogen peroxide kills most bacteria at a concentration of 3% to 6%
and kills all organisms, including spores, at higher concentrations
(10% to 25%)
• Hydrogen peroxide is used to disinfect plastic implants, contact
lenses, and surgical prostheses
• The active oxidant is the free hydroxyl radical formed by
decomposition of hydrogen peroxide.
Halogens
• Halogens, such as compounds containing chlorine or iodine are used
extensively as disinfectants.
• Iodine compounds are the most effective halogens available for
disinfection. It is microbicidal against virtually all organisms, including
spore forming bacteria and mycobacteria. The efficiency of iodine is
increased in acid solutions
• However the activity of iodine can be reduced in the presence of
some organic and inorganic compounds including feaces,serum,
ascitic fluid, sputum, urine, ammonia etc.
Halogens
• Chlorine compounds are also used extensively as disinfectants.
• Aqueous solutions of chlorine are rapidly bactericidal, although there
mechanisms of action are not defined.
• Organic matter and alkaline detergents can reduce the effectiveness
of chlorine compounds. These compounds demonstrate good
germicidal activity , although spore forming organisms are 10-1000
fold more resistant to chlorine than are vegetative bacteria.
Phenolic compounds
• Phenolic compounds are rarely used as disinfectants.
• They are active against normally resilient mycobacteria, because the
cell wall of these organisms has a very high concentration of lipids.
Quaternary Ammonium
Compounds
• Examples include benzalkonium chloride, cetylpyridinium chloride
• They act by denaturing cell membranes to release the intracellular
components.
• They are bacteriostatic at low concentrations and bactericidal at
higher concentrations
• Organisms such as mycobacteria, pseudomonas, trichophyton are
resistant to these compounds.
Alcohols
• Two most commonly used alcohols are ethanol and propanol
• These alcohols are rapidly bactericidal against vegetative bacteria,
mycobacteria, some fungi and lipid containing viruses.
• Unfortunately alcohols have limited activity against bacterial spores,
some fungi and non-lipid containing viruses.
• Activity is greater in the presence of water.
• Alcohol is a common disinfectant for skin surfaces, thermometers