Infection, infection control, and disinfectants in a challenging infection era
Health care-associated infections inflict a huge clinical and economic burden on public health worldwide. Bacterial resistance to antibiotics continues to escalate, and antimicrobial stewardship initiatives have yet to make a major impact. Additionally, the ability of bacteria to evade environmental threats by living within a self-produced protective biofilm and/or producing resistant spores further challenges effective infection control. The current severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has also amplified the burden significantly. Amidst a particularly challenging infection era, the demand for meticulous infection control and prevention practices is paramount, a key component of which is the use of appropriate disinfectants that can combat a wide variety of microbial pathogens, including diverse forms of viruses and bacteria, particularly highly tolerant spore-forming and biofilm-forming microorganisms. This review addresses the advantages and disadvantages of commonly used disinfectants such as alcohols, hypochlorite, and quaternary ammonium compounds, together with oxidizing agents such as chlorine dioxide and peracetic acid, which are gaining increasing acceptance in routine infection control practices today. Given the increasing requirements for rapid-acting disinfectants that are effective against the toughest of microorganisms (e.g. spores and biofilm), are environmentally friendly, and remain active under diverse environmental conditions, emerging oxidizing agents warrant further consideration, particularly chlorine dioxide, which offers most requirements for an ideal disinfectant, including retention of activity over a broad pH range. Given the critical importance of infection control and antimicrobial stewardship in public health and health care facilities today, consideration of chlorine dioxide as a safe, selective, highly effective, and environmentally friendly disinfectant is warranted.
Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US Health Care System. JAMA Intern Med 2013; 173: 2039–46. doi: 10.1001/jamainternmed.2013.9763
Health Protection Agency. English national point prevalence survey on healthcare-associated infections and antimicrobial use, preliminary data. 2011. Available from: http://webarchive.nationalarchives.gov.uk/20140714085429tf [cited May 2012].
Guest JF, Keating T, Gould D, Wigglesworth N. Modelling the annual NHS costs and outcomes attributable to healthcare-associated infections in England. BMJ Open 2020; 10: e033367. doi: 10.1136/bmjopen-2019-033367
Flemming H-C, Wuertz S. Bacteria and archaea on Earth and their abundance in biofilms. Nat Rev Microbiol 2019; 17: 247–60. doi: 10.1038/s41579-019-0158-9
Wolcott RD. Biofilms cause chronic infections. J Wound Care 2017; 26: 423–5. doi: 10.12968/jowc.2017.26.8.423
Bowler PG. Antibiotic resistance and biofilm tolerance: a combined threat in the treatment of chronic infections. J Wound Care 2018; 27: 273–7. doi: 10.12968/jowc.2018.27.5.273
National Institutes of Health Guide: research on microbial biofilms. 2002. Available from: https://grants.nih.gov/grants/guide/pa-files/PA-03-047.html [cited December 2002].
Høiby N, Ciofu O, Johansen HK, Song Z-J, Moser C, Jensen PØ, et al. The clinical impact of bacterial biofilms. Int J Oral Sci 2011; 3: 55–65. doi: 10.4248/IJOS11026
Payne AT, Davidson AJ, Kan J, Peipoch M, Bier R, Williamson K. Widespread cryptic viral infections in lotic biofilms. Biofilm 2020; 2: 100016. doi: 10.1016/j.bioflm.2019.100016
Voigt AM, Faerber HA, Wilbring G, Skutlarek D, Felder C, Mahn R, et al. The occurrence of antimicrobial substances in toilet, sink and shower drainpipes of clinical units: a neglected source of antibiotic residues. Int J Hyg Environ Health 2019; 333: 455–67. doi: 10.1016/j.ijheh.2018.12.013
Flemming H-C, Wingender J, Szewwzyk U, Steinberg P, Rice SA, Kjelleberg S. Biofilms: an emergent form of bacterial life. Nat Rev Microbiol 2016; 14: 563–75. doi: 10.1038/nrmicro.2016.94
Bowler PG, Murphy C, Wolcott RD. Biofilm exacerbates antimicrobial resistance: is this a current oversight in antimicrobial stewardship? Antimicrob Resist Infect Control 2020; 9: 162. doi: 10.1186/s13756-020-00830-6
Hu H, Johani K, Gosbell IB, Jacombs AS, Almatroudi A, Whiteley GS, et al. Intensive care unit environmental surfaces are contaminated by multidrug-resistant bacteria in biofilms: combined results of conventional culture, pyrosequencing, scanning electron microscopy, and confocal laser microscopy. J Hosp Infect 2015; 91: 35–44. doi: 10.1016/j.jhin.2015.05.016
Ledwoch K, Dancer SJ, Otter JA, Kerr K, Roposte D, Rushton L, et al. Beware biofilm! Dry biofilms containing bacterial pathogens on multiple healthcare surfaces; a multicentre study. J Hosp Infect 2018; 100: e47–56. doi: 10.1016/j.jhin.2018.06.028
Centers for Disease Control and Prevention and Infection Control Africa Network. Best practices for environmental cleaning in healthcare facilities in resource-limited settings. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; Cape Town, South Africa: Infection Control Africa Network; 2019. Available from: https://www.cdc.gov/hai/pdfs/resource-limited/environmental-cleaning-RLS-H.pdf and http://www.icanetwork.co.za/icanguideline2019/.
Simpson GD, Miller RF, Laxton GD, Clements WR. A focus on chlorine dioxide: the ‘ideal’ biocide. Corrosion 93. New Orleans, LA; March 1993. Available from: http://www.clo2.gr/en/pdf/secure/chlorinedioxideidealbiocide.pdf. [cited March 1993].
Rutala WA, Weber DJ. Disinfection and sterilization in healthcare facilities. Infect Dis Clin N Am 2016; 30: 609–37. doi: 10.1016/j.idc.2016.04.002
Luther K, Bilida S, Mermel LA, LaPlante KL. Ethanol and isopropyl alcohol exposure increase biofilm formation in Staphylococcus aureus and Staphylococcus epidermidis. Infect Dis Ther 2015; 4: 219–26. doi: 10.1007/s40121-015-0065-y
Noszticzius Z, Wittmann M, Kály-Kullai K, Beregvári Z, Kiss I, Rosivall L, et al. Chlorine dioxide is a size-selective antimicrobial agent. PLoS One 2013; 8: e79157. doi: 10.1371/journal.pone.0079157
Performacide: the advantage of chlorine dioxide – performacide. 2021. https://www.performacide.com/the-science.
Nam H, Seo H-S, Bang J, Kim H, Beuchat LR, Ryo J-H. Efficacy of gaseous chlorine dioxide in inactivating Bacillus cereus spores attached to and in a biofilm on stainless steel. Int J Food Microbiol 2014; 188: 122–7. doi: 10.1016/j.ijfoodmicro.2014.07.009
Dunkin N, Coulter C, Weng SC, Jacangelo JG, Schwab KJ. Effects of pH variability on peracetic acid reduction of human norovirus GI, GII RNA, and infectivity plus RNA reduction of selected surrogates. Food Environ Virol 2019; 11: 76–89. doi: 10.1007/s12560-018-9359-z
McFadden M, Loconsole J, Schockling AJ, Nerenberg R, Pavissich JP. Comparing peracetic acid and hypochlorite for disinfection of combined sewer overflows: effects of suspended-solids and pH. Sci Tot Environ 2017; 599–600: 533–9. doi: 10.1016/j.scitotenv.2017.04.179
Kim J, Huang C-H. Reactivity of peracetic acid with organic compounds: a critical review. ACS EST Water 2021; 1: 15−33. doi: 10.1021/acsestwater.0c00029
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