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Accessible version: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/

Guideline for Disinfection and

Sterilization in

Healthcare

Facilities

, 2008

Update: May 2019

William A. Rutala, Ph.D., M.P.H.

1,2 , David J. Weber, M.D., M.P.H. 1,2 , and the Healthcare

Infection Control Practices Advisory Committee

(HICPAC) 3 1

Hospital Epidemiology

University of North Carolina Health Care System

Chapel Hill, NC

27514
2

Division of Infectious Diseases

University of North Carolina School of Medicine

Chapel Hill, NC 27599-7030

Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)

Last update:

May 2019 2 of 163

3

HICPAC Members

Robert A. Weinstein, MD (Chair)

Cook County Hospital

Chicago, IL

Jane D. Siegel, MD (Co-Chair)

University of Texas Southwestern Medical Center

Dallas, TX

Michele L. Pearson, MD (Executive Secretary)

Centers for Disease Control and Prevention

Atlanta, GA

Raymond Y.W. Chinn, MD

Sharp Memorial Hospital

San Diego, CA

Alfred DeMaria, Jr,

MD

Massachusetts Department of Public Health

Jamaica Plain, MA

James T. Lee, MD, PhD

University of Minnesota

Minneapolis, MN

William A. Rutala, PhD, MPH

University of North Carolina Health Care System

Chapel Hill, NC

William E. Scheckler, MD

University of Wisconsin

Madison, WI

Beth H. Stover, RN

Kosair Children's Hospital

Louisville, KY

Marjorie A. Underwood, RN, BSN CIC

Mt. Diablo Medical Center

Concord, CA

This guideline discusses use of products by

healthcare personnel in healthcare settings such as hospitals, ambulatory care and home care; the recommendations are not intended for consumer use of the products discussed. Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)

Last update:

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Table of Contents

Executive Summary ...................................................................................................................................... 8

Introduction.................................................................................................................................................... 9

Methods......................................................................................................................................................... 9

Definition of Terms ........................................................................................................................................ 9

A Rational Approach to Disinfection and Sterilization ................................................................................. 11

Critical Items ......................................................................................................................................... 11

Semicritical Items.................................................................................................................................. 11

Noncritical Items ................................................................................................................................... 12

Changes in Disinfection and Sterilization Since 1981 .......................................................................... 13

Disinfection of Healthcare Equipment ......................................................................................................... 14

Concerns about Implementing the Spaulding Scheme ........................................................................ 14

Reprocessing of Endoscopes ............................................................................................................... 14

Laparoscopes and Arthroscopes .......................................................................................................... 18

Tonomete

rs, Cervical Diaphragm Fitting Rings, Cryosurgical Instruments, and Endocavitary

Probes ....................................................................................................................................... 19

Dental Instruments................................................................................................................................ 21

Disinfection of HBV-, HCV-, HIV- or TB-Contaminated Devices .......................................................... 22

Disinfection in the Hemodialysis Unit ................................................................................................... 22

Inactivation of

Clostridium difficile ........................................................................................................ 23

OSHA Bloodborne Pathogen Standard ................................................................................................ 24

Emerging Pathogens (Cryptosporidium, Helicobacter pylori, Escherichia coli O157:H7, Rotavirus, Human Papilloma Virus, Norovirus, Severe Acute Respiratory Syndrome

[SARS] Coronavirus) ................................................................................................................. 24

Inactivation of Bioterrorist Agents ......................................................................................................... 26

Toxicological, Environmental and Occupational Concerns .................................................................. 27

Disinfection in Ambulatory Care, Home Care, and the Home .............................................................. 28

Susceptibility of Antibiotic-Resistant Bacteria to Disinfectants ............................................................. 29

Surface Disinfection .............................................................................................................................. 30

Air Disinfection ...................................................................................................................................... 32

Microbial Contaminatio

n of Disinfectants ............................................................................................. 33

Factors Affecting the Efficacy of Disinfection and Sterilization .................................................................. 34

Number and Location of Microorganisms ............................................................................................. 34

Innate Resistance of Microorganisms .................................................................................................. 34

Concentration and Potency of Disinfectants ........................................................................................ 35

Physical and Chemical Factors ............................................................................................................ 35

Organic and Inorganic Matter ............................................................................................................... 35

Duration o

f Exposure ............................................................................................................................ 35

Biofilms ................................................................................................................................................. 36

Cleaning ...................................................................................................................................................... 37

Disinfection .................................................................................................................................................. 39

Chemical Disinfectants ......................................................................................................................... 39

Alcohol............................................................................................................................................ 39

Overview. ................................................................................................................................. 39

Mode of Action. ........................................................................................................................ 39

Microbicidal Activity. ................................................................................................................ 39

Uses. ........................................................................................................................................ 40

Chlorine and Chlorine Compounds ................................................................................................ 40

Overview. ................................................................................................................................. 40

Mode of Action. ........................................................................................................................ 42

Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)

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Microbicidal Activity. ................................................................................................................ 42

Uses. ........................................................................................................................................ 42

Formaldehyde ................................................................................................................................ 43

Overview. ................................................................................................................................. 43

Mode of Action. ........................................................................................................................ 44

Microbicidal Activity. ................................................................................................................ 44

Uses. ........................................................................................................................................ 44

Glutaraldehyde ............................................................................................................................... 44

Overview. ................................................................................................................................. 44

Mode of Action. ........................................................................................................................ 45

Microbicidal Activity. ................................................................................................................ 45

Uses. ........................................................................................................................................ 46

Hydrogen Peroxide ........................................................................................................................ 47

Overview. ................................................................................................................................. 47

Mode of Action. ........................................................................................................................ 47

Microbicidal Activity. ................................................................................................................ 47

Uses. ........................................................................................................................................ 48

Iodophors ....................................................................................................................................... 48

Overview. ................................................................................................................................. 48

Mode of Action. ........................................................................................................................ 49

Microbicidal Activity. ................................................................................................................ 49

Uses. ........................................................................................................................................ 49

Ortho-phthalaldehyde (OPA) ......................................................................................................... 49

Overview. ................................................................................................................................. 49

Mode of Action. ........................................................................................................................ 49

Microbicidal Activity. ................................................................................................................ 49

Uses. ........................................................................................................................................ 50

Peracetic Acid ................................................................................................................................ 51

Overview. ................................................................................................................................. 51

Mode of Action. ........................................................................................................................ 51

Microbicidal Activity. ................................................................................................................ 51

Uses. ........................................................................................................................................ 51

Peracetic Acid and Hydrogen Peroxide ......................................................................................... 51

Overview. ................................................................................................................................. 51

Microbicidal Activity. ................................................................................................................ 51

Uses. ........................................................................................................................................ 52

Phenolics ........................................................................................................................................ 52

Overview. ................................................................................................................................. 52

Mode of Action. ........................................................................................................................ 52

Microbicidal Activity. ................................................................................................................ 52

Uses. ........................................................................................................................................ 52

Quaternary Ammonium Compounds ............................................................................................. 53

Overview. ................................................................................................................................. 53

Mode of Action. ........................................................................................................................ 53

Microbicidal Activity. ................................................................................................................ 53

Uses. ........................................................................................................................................ 54

Miscellaneous Inactivating Agents ....................................................................................................... 55

Other Germicides ........................................................................................................................... 55

Metals as Microbicides ................................................................................................................... 55

Ultraviolet Radiation (UV)............................................................................................................... 55

Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)

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Pasteurization ................................................................................................................................ 56

Flushing

- and Washer-Disinfectors ................................................................................................ 56

The Regulatory Framework for Disinfectants and Sterilants ................................................................ 57

EPA and FDA ................................................................................................................................. 57

CDC................................................................................................................................................ 57

Test Methods ................................................................................................................................. 58

Neutralization of Germicides ................................................................................................... 58

Sterilization .................................................................................................................................................. 59

Steam Sterilization ................................................................................................................................ 59

Overview. ....................................................................................................................................... 59

Microbicidal Activity. ....................................................................................................................... 61

Mode of Action. .............................................................................................................................. 61

Uses. .............................................................................................................................................. 61

Flash Sterilization ................................................................................................................................. 61

Overview. ....................................................................................................................................... 61

Uses. .............................................................................................................................................. 62

Low-Temperature Sterilization Technologies ....................................................................................... 62

Ethylene Oxide "Gas" Sterilization ....................................................................................................... 63

Overview. ....................................................................................................................................... 63

Mode of Action. .............................................................................................................................. 64

Microbicidal Activity. ....................................................................................................................... 64

Uses. .............................................................................................................................................. 64

Hydrogen Peroxide Gas Plasma

.......................................................................................................... 64

Overview. ....................................................................................................................................... 64

Mode of Action. .............................................................................................................................. 65

Microbicidal Activity. ....................................................................................................................... 65

Uses. .............................................................................................................................................. 65

Peracetic Acid Sterilization ................................................................................................................... 65

Overview. ....................................................................................................................................... 65

Mode of Action. .............................................................................................................................. 66

Microbicidal Activity. ....................................................................................................................... 66

Uses. .............................................................................................................................................. 66

Microbicidal Activity of Low-Temperature Sterilization Technologies .................................................. 67

Bioburden of Surgical Devices ............................................................................................................. 68

Effect of Cleaning on Sterilization Efficacy ........................................................................................... 69

Other Sterilization Methods .................................................................................................................. 69

Ionizing Radiation. .......................................................................................................................... 69

Dry-Heat Sterilizers. ....................................................................................................................... 69

Liquid Chemicals. ........................................................................................................................... 70

Performic Acid. ............................................................................................................................... 70

Filtration. ........................................................................................................................................ 70

Microwave. ..................................................................................................................................... 71

Glass Bead "Sterilizer". .................................................................................................................. 71

Vaporized Hydrogen Peroxide (VHP). ........................................................................................ 71

Ozone. ............................................................................................................................................ 72

Formaldehyde Steam. .................................................................................................................... 72

Gaseous chlorine dioxide. .............................................................................................................. 73

Vaporized Peracetic Acid. .............................................................................................................. 73

Infrared rad

iation. ........................................................................................................................... 73

Sterilizing Practices .............................................................................................................................. 73

Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)

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Overview. ....................................................................................................................................... 73

Sterilization Cycle Verification. ....................................................................................................... 74

Physical Facilities. .......................................................................................................................... 74

Cleaning. ........................................................................................................................................ 74

Packaging. ..................................................................................................................................... 75

Loading. ......................................................................................................................................... 76

Storage. .......................................................................................................................................... 76

Monitoring. ..................................................................................................................................... 77

Reuse of Single

-Use Medical Devices ........................................................................................................ 81

Conclusion................................................................................................................................................... 82

Web-Based Disinfection and Sterilization Resources ................................................................................. 83

Recommendations for Disinfection and Sterilization in Healthcare Facilities ............................................. 84

A. Rationale

.......................................................................................................................................... 84

B. Rankings .......................................................................................................................................... 84

New Categorization Scheme for Updated Recommendations [November 2018] ................... 84

C. Recommendations ........................................................................................................................... 84

1. Occupational Health and Exposure ......................................................................................... 84

2. Cleaning of Patient-Care Devices ........................................................................................... 85

3. Indications for Sterilization, High-Level Disinfection, and Low-Level Disinfection .................. 85

4. Selection and Use of Low-Level Disinfectants for Noncritical Patient-Care Devices .............. 85

5. Cleaning and Disinfecting Environmental Surfaces in Healthcare Facilities ........................... 86

6. Disinfectant Fogging ................................................................................................................ 87

7. High-Level Disinfection of Endoscopes ................................................................................... 88

8. Management of Equipment and Surfaces in Dentistry ............................................................ 91

9. Processing Patient-Care Equipment Contaminated with Bloodborne Pathogens

(HBV, Hepatitis C Virus, HIV), Antibiotic-Resistant Bacteria (e.g., Vancomycin- Resistant Enterococci, Methicillin-Resistant Staphylococcus aureus, Multidrug Resistant Tuberculosis), or Emerging Pathogens (e.g., Cryptosporidium, Helicobacter pylori, Escherichia coli O157:H7, Clostridium difficile, Mycobacterium tuberculosis,

Severe Acute Re

spiratory Syndrome Coronavirus), or Bioterrorist Agents ............................ 91

10. Disinfection Strategies for Other Semicritical Devices ............................................................ 91

11. Disinfection by Healthcare Personnel in Ambulatory Care and Home Care ........................... 92

12. Microbial Contamination of Disinfectants ................................................................................ 92

13. Flash Sterilization .................................................................................................................... 92

14. Methods of Sterilization ........................................................................................................... 93

15. Packaging ................................................................................................................................ 93

16. Monitoring of Sterilizers ........................................................................................................... 93

17. Load Configuration. ................................................................................................................. 94

18. Storage of Sterile Items ........................................................................................................... 94

19. Quality Control ......................................................................................................................... 94

20. Reuse of Single-Use Medical Devices .................................................................................... 95

Performance Indicators ............................................................................................................................... 96

Acknowledgements ..................................................................................................................................... 97

Glossary ...................................................................................................................................................... 98

Tables and Figure ..................................................................................................................................... 106

Table 1. Methods of sterilization and disinfection ............................................................................... 106

Table 1A. Smooth, Hard Surface

1,4 .............................................................................................. 106

Table 1B. Rubber tubing and catheters

3,4 .................................................................................... 107

Table 1C. Polyethylene tubing and catheters

3,4,7 ......................................................................... 108

Table 1D. Lensed instruments

4

.................................................................................................... 109

Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)

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Table 1E. Thermometers (Oral and Rectal)

8 ............................................................................... 110

Table 1F. Hinged Instruments

4

.................................................................................................... 111

Table 2. Properties of an ideal disinfectant ........................................................................................ 113

Table 3. Epidemiologic evidence associated with the use of surface disinfectants or

detergents on noncritical environmental surfaces................................................................... 114

Figure 1. Decreasing order of resistance of microorganisms to disinfection and sterilization (with the

disinfection levels indicated) ..................................................................................... 115

Table 4. Comparison of the characteristics of selected chemicals used as high -level

disinfectants or chemical Sterilants ......................................................................................... 116

Table 5. Summary of advantages and disadvantages of chemical agents used as chemical sterilants 1

or as high-level disinfectants .................................................................................. 117

Table 6. Summary of advantages and disadvantages of commonly used sterilization

technologies ............................................................................................................................ 118

Table 7. Minimum cycle times for steam sterilization cycles .............................................................. 119

Table 8. Examples of flash steam sterilization parameters ................................................................ 120

Table 9. Characteristics of an ideal low-temperature sterilization process ........................................ 121

Table 10. Factors affecting the efficacy of sterilization....................................................................... 122

Table 11. Comparative evaluation of

the microbicidal activity of low-temperature sterilization

technology (based on tests of inoculated carriers in lab setting) ............................................ 123

Table 12. Suggested protocol for management of positive biological indicator in a steam

sterilizer ................................................................................................................................... 124

Disclosure of Financial Interests and

Relationships (2000

- July 2004) ................................................... 124

References ................................................................................................................................................ 125

Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)

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