INF ECTION P R EVENTION
a great range of fomites without damaging or degrading them. Those items regularly touched by staff and patients should be disinfected most often (the aforementioned ‘hot touch’ items). QACs can also be applied following maintenance work, as covered by an infection control risk assessment. The latter should be conducted before initiating repairs, demolition, construction, or renovation activities to identify potential exposures of susceptible patients to dust and moisture, and to determine the need for dust and moisture containment measures. Another area of application, as described, is as a hand sanitisation agent in a more dilute form.
Overcoming technical challenges and usage issues To be effective, QACs – along with other disinfectants – need to be applied correctly, ensuring wiping of the application, and observing the manufacturer’s recommended contact time. It is important there are clear protocols that adequately define ward disinfection procedures in accordance with national standards. This extends to residues as well. A residue accumulate effect arises with disinfectant use, although for a QAC this is often less than other cleanroom broad spectrum biocides and so less rinsing will be required.
In-use, quaternary ammonium
compounds can become contaminated, with a particular risk arising from Gram-negative bacteria.42
To guard against this, for different presentations, trigger spray systems need to be evaluated to ensure that the ingress of air is minimised, and an expiry time should be assigned to solutions prepared in buckets. The disinfectants are suitable against most surface types, although like most liquid disinfectants, materials such as cotton and gauze pads prove challenging to disinfect due to the absorption of the active ingredient.43
This also makes the selection
of cloths used for wiping an important consideration.44 Quaternary ammonium are good cleaning
agents (lowering the surface tension between a liquid and a surface or between two liquids), but their efficacy can be affected by water hardness.45
This concern can be
addressed by using ready-made preparations or ensuring that water that has undergone a water purification process is used to dilute a concentrate (as well as ensuing correct dilution, to avoid over-dilution or under- dilution of the end-use product and hence avoid any loss of efficacy).
Once used, a safe means of disposal must be considered since QACs are biologically active compounds. While many QACs are readily biodegraded in sewage treatment and in receiving waters, there remain appropriate environmental impacts that need to be considered to ensure that
safe disposal takes place.46 It is also necessary to ensure that the product has been listed as safe by a national regulatory body (such as the Health and Safety Executive in the UK, the European Biocidal Products Directive 98/8/EC, or the US Environmental Protection Agency) and that personal protective equipment is worn, in particular suitable gloves and eye protection.
Summary
There is considerable evidence that contaminated surfaces and the untreated hands of healthcare professionals contribute to the spread of nosocomial pathogens within the hospital setting. For these reasons, environmental disinfection and skin antisepsis are necessary to contain the severity and likelihood of infection transmission to the individual patient and to minimise the potential for a ward-level outbreak situation emerging. The application of QACs must be used in relation to defined infection-control strategies which will set out preparation, methods of application, frequency of application, and contact times. Such strategies must be consistently implemented in order to prevent opportunistic, environment-related infections in immunocompromised populations. Hence, for every infection control strategy, disinfectant selection is a very important component and essential for achieving effective microbial kill. Disinfectant use needs to be supported with effective training of healthcare personnel. While there are an array of different disinfectant products available, in varying formats, it remains that one of the most effective types of disinfectants available to healthcare are the QACs. As this article has presented, these broad spectrum disinfectants are effective against the common hospital related infectious agents. Furthermore, as well as being relatively safe, QACs come with the added benefit of possessing some effective cleaning properties, in addition to possessing a strong biocidal kill.
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Therefore, the inclusion of a QAC disinfectant represents a very important part of infection control measures.
References 1. Sandle, T. (2016) Application of disinfectants and detergents in the pharmaceutical sector. The CDC Handbook: A guide to cleaning and disinfecting cleanrooms, 2nd edition, Grosvenor House Publishing: Surrey, UK, pp168-197
2. Rutala WA and Weber DJ. (2014) Selection of the ideal disinfectant. Infect Control Hosp Epidemiol. 35:855-865
3. Rutala, W. and Weber, D. (2008) Guideline for Disinfection and Sterilization in Healthcare Facilities, U.S. Centers for Disease Control and Prevention at:
https://www.cdc.gov/ infectioncontrol/guidelines/disinfection/
index.html
4. Rutala WA, White MS, Gergen MF, Weber DJ. (2006) Bacterial contamination of keyboards: Efficacy and functional impact of disinfectants. Infect Control Hosp Epidemiol:372-7
5. Vijayakumar, R., Kannan, V.V., Sandle, T., and Manoharan, C. (2012) In vitro Antifungal Efficacy of Biguanides and Quaternary Ammonium Compounds against Cleanroom Fungal Isolates, PDA Journal of Pharmaceutical Science and Technology, 66 (3): 236-242
6. Weber DJ, SL Barbee, MD Sobsey, WA Rutala. (1999) The effect of blood on the antiviral activity of sodium hypochlorite, a phenolic, and a quaternary ammonium compound. Infect. Control Hosp. Epidemiol. 20:821-827
6. Otter JA, Yezli S, French GL. (2011) The role played by contaminated surfaces in the transmission of nosocomial pathogens. Infect Control Hosp Epidemiol. Jul;32(7):687–699
7. Abbas, S. and Stevens, M. (2018) Guide to infection control in the healthcare setting: Horizontal vs vertical infection control strategies, International Society for Infectious Diseases:
https://isid.org/wp-content/uploads/2019/06/ ISID_GUIDE_HORIZONTAL.pdf
8. United States Environmental Protection Agency. List N: Disinfectants for Use Against SARS-CoV-2
https://www.epa.gov/pesticide-registration/list-n- disinfectants-use-against-sars-cov-2
9. Zinchenko AA, Sergeyev VG, Yamabe K, Murata S, DECEMBER 2021
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