CLEANING DISINFECTION AND STERILIZATION

APRIL 21, 2025

VINCENT
Kerron Solutions
Hello everyone, Good morning! Oh, hello everyone, good morning this morning.

All right guys, today's been really information-happy, so there's a lot of information to cover. This is a
really important chapter where we're going to be going over Chapter 31, which is Clean, Disinfection,
Sterilization.

Cleaning, disinfection, and sterilization is a really important chapter. Now, I know I say this about a lot of
chapters. I know that, um, I tell you there's a lot of really important information. That is because there
is! The CIC requires a tremendous amount of study.

Now, I do think that you would be more than able to prepare within a six-week time frame, but it has to
be six weeks.

I'm having trouble hearing you; it sounds like you're in a tunnel. Okay, do I sound like I'm in a tunnel for
anybody else? I sound like I'm in a tunnel? What? That's not cute. Okay, give me one second.

Is this any better? Not really? Okay, so there's an echo. Okay, I fixed it! Everybody can hear me? Okay!
Hey, and I didn't have to call I.T., I didn't have to call for backup—figured it out. Okay, so we have a win
already! Okay, perfect.

So, um, I know you guys—you guys see me on the struggle bus every time with technology, so I
appreciate the patience. But back to Chapter 31, now that I am live and in stereo.

This one is an important one. It's a long chapter, there's a lot of information, and I really recommend
that you read through it multiple times. Same thing with Chapter 13. There are just going to be a couple
of really key chapters where the information is going to continuously come up throughout the test, and
this is one of them.

Another thing is, if you don't work in healthcare—so specifically if you are one of my healthcare
epidemiologists or just an epi—this section might also be a little bit more difficult for you because it's
harder for you to get hands-on experience with a, um, with an SPD department.

Okay, so: Cleaning, Disinfection, and Sterilization—basic definitions.

So, we have three primary categories that medical devices fall under depending on what type of tissue
that item is going to come into contact with.

So, items that contact sterile tissue, such as surgical instruments, would fall under what category?

Critical! Thank you. Next one—items that contact mucous membranes, such as endoscopes?

Semi-critical! Great.

And then the very last one is devices that contact only intact skin, such as stethoscopes?

Non-critical. Perfect.

So, the blank divides medical equipment into three categories based on risk and continues to be the
primary principle that guides disinfection and sterilization processes. What is that called?

Spalding Classification System! Great.

Do you guys know what Spalding's first name was? Everybody knows Spalding Classification... Sanjosa?
Earl?

I know, yes—his name was Earl. I don't know why, but I just wasn't expecting it when I, um, when I
looked it up. I was like, it's Earl? Okay. Just—it didn't seem to match. But yes, Earl Spalding. So that's
where we get the Spalding Classification from, and, um, it's pretty fantastic. We're still using it to this
day, which is exciting.

Environmental decontamination plays an important role in decreasing bioburden, which may help lower
rates of healthcare-associated infections. Environmental surfaces include non-critical items, as
designated by the Spalding Classification System, as well as high-touch surfaces such as countertops,
bed rails, and tray tables.

Alright, this chart right here—you need to know these definitions. These definitions are the definitions
that are going to be on the test. So whenever you read them, you need to be able to link them back to
their specific—to that specific word.

So for Sterilization, it destroys all microorganisms, including bacterial spores. Here you have the method
examples with processing time and your healthcare application.

Now, all of this is important, but most important by far are these definitions right here. You have to
know them. There's just—there's no way around it. You have to know it.

High-level disinfection destroys all microorganisms except high numbers of bacterial spores.

Intermediate-level disinfection destroys vegetative bacteria, mycobacteria, most viruses, most fungi, and
—not—but sorry—but not bacterial spores.

And then your low-level disinfection destroys vegetative bacteria, some fungi and viruses, but not
mycobacteria or spores.

So now that we went over that: first one—destroys all microorganisms except high numbers of bacterial
spores. What is that?

Now in this specific example, in this slide, you can see all of the different classifications, right? And you
know that sterilization, high-level disinfection, intermediate-level, and low-level are going to match with
one of them. When you're taking the test, you're not going to have that, so you need to make sure that
you're able to pick it out—pick out which one it is.

Okay, so I'm getting a ton of high-level disinfection, which is correct! Good job—five stars!

All right, next one. Next one—destroys all microorganisms including bacterial spores. We're on this one:
it destroys all microorganisms including bacterial spores.

Sterilization is correct. Getting a lot of sterilization—good.

Next one—destroys vegetative bacteria, some fungi and viruses, but not mycobacteria or spores. You
have two options left, so it's either intermediate or low-level. And I'm getting a lot of intermediate—
however, that is incorrect. It's going to be low-level disinfection.
Low-level disinfection destroys vegetative bacteria, some fungi and viruses, but not mycobacterium or
spores.

And then the last one—destroys vegetative bacteria, mycobacteria, most viruses, most fungi, but not
bacterial spores. That's going to be intermediate-level disinfection. So you have to know your definitions.

All right, so this presentation focuses a lot of information, and there is a lot of reading from the slides.
For those of you who are auditory learners, this is going to be really helpful. Um, for those of you who
are visual—hopefully helpful. But for people who really appreciate our lessons where there's a lot of
questions, that's definitely not this type of PowerPoint, because we have a lot of basic information that
we need to cover.

All right, so—cleaning.

The cleaning process for critical and semi-critical devices should begin as soon as possible after use.
Gross debris should be removed by wiping or irrigation as indicated by the instrument manufacturer's
instructions for use—the IFUs. Removal of gross contamination prevents the drying of blood and tissue,
reduces the bio burden and nutrient material on medical instruments, and reduces the possibility of
spillage or aerosolizing of contaminants into the environment.

Now, this is extremely important. Currently at our facility, one thing that one of our infection
preventionists—Charles—is working on is on getting that point-of-use cleaning in the ORs to happen
consistently.

Now, ideally, you're going to have techs who do a really good job at ensuring that things are staying
clean throughout a procedure. But we do have a lack of standardization, and there need to be some
improvements.

So, one thing that I recommend that you do if you're an IP and you have a facility is to go spend some
time in your sterile processing department.

So, one of the things that Charles is currently doing is—with our OR educator—they go stand together in
sterile processing, decotam—in their decontamination department. And when people are dropping off
their trays, they're literally having them open their trays and they're taking a look to see the condition
that their trays are in.

Because we have this misconception in healthcare sometimes where—"Oh no, that's EVS, takes care of
that." "Uh, SPD takes care of that." "Um, nursing takes care of that." Where you get siloed, and you get
separated, and you can't really see the bigger picture.

And that's one of the responsibilities that infection prevention has—where we have to bring people
together, and we have to bring departments together, and we have to help them understand that this is
bigger than you, right? This is bigger than you. This is bigger than department.

Um, this is about patient safety, staff safety—all of the above.

So, point-of-use cleaning—and cleaning—is the absolutely most important thing when it comes to
cleaning, disinfection, sterilization.
You cannot disinfect an item if it's not clean. You cannot sterilize an item if it has not been properly
cleaned.

Now, you need to spend—spend time in your SPD department. It's really important. I'll dive into why it's
so important for you to set time aside—if not on a weekly basis, then at least once, twice a month—
because you need to know what's going on in that department.

If soiled materials become dried or baked onto the instruments, the removal process becomes more
difficult, and the disinfection or sterilization process becomes less effective or ineffective.

Instruments should be kept moist after the initial removal of gross contamination and prior to transport
for additional cleaning, disinfection, and sterilization.

Another reason why it's really important to spend time in SPD, in your ORs, is because you're going to
have procedures that vary in length. And depending on the length of a procedure, you could be in an
operating room for four hours, for five hours, for six hours, for seven hours.

And if you have—if you have, um, staff who are not doing a good job of keeping those instruments, um,
moist, it's going to be an issue. Right?

"Oh, I—I start my procedure at one, and I use this instrument, never cleaned it off, never used it again
after I touched it that first time, and it's been seven hours. And that blood and tissue is nice and dried,
hard as a rock on that thing."

That's a problem. Because when it gets back to SPD, they're going to have to make sure that that
instrument gets cleaned. And it makes their job way more difficult, and it's not a best practice.

So, soiled materials need to remain moist. This can be accomplished by using special instruments—
sorry, by special containers, a pre-treatment product, or towels moistened with water.

So why can we use sterile water but not saline on—

Our instruments—what’s the limitation with saline?

Okay, so I have: saline causes rust, corrodes instruments, it’s corrosive, it could possibly damage—yes,
okay, all of these are perfect.

So, quick tip: when you are learning—when you are at—okay, my words—I was thinking three different
things and they were all coming out at once. When you’re taking your test and they’re talking about
cleaning, disinfection, and sterilization, if they have the use of saline as one of their answer choices—
specifically relating to surgical instruments, etc.—your ears should like prickle up a little bit and be like,
“Wait, wait a minute, why are they talking about saline?”

Because most of the times you’re going to be able to cross those out, right? And say, “Uh, yeah no, nice
try, you’re not going to get me this time because I know that I shouldn’t be using saline on those
instruments.”

Cleaning and rinsing is the most important step. It is bolded and underlined because it’s not enough to
just bold, it’s not enough to just underline, and honestly maybe I should highlight it as well because it’s
so important. It is the most important step in the reusable medical equipment process.
Cleaning reduces the bioburden and removes foreign material, organic residue, and inorganic salts that
interfere with the sterilization process by acting as a barrier to the sterilization agent.

It—it really sucks, and I can say this from experience—to be working on a tray, have all of your
instruments separated out, and for you to get down to some Adsons, or you know, they look kind of like
little tweezers—and there's fine tissue on them. Because you know what that means? That means the
whole tray has got to go back.

So cleaning is important. Go spend some time in decontam. Learn from your decontamination team.
Spend time in SPD. There is so much to learn from that department.

Decontamination

Reusable items should be transported from the point of use to the reprocessing area in a closable,
puncture-resistant, leak-proof container—sorry, leak-proof containers—that are properly marked as
biohazard.

Standard precautions should always be adhered to when handling contaminated medical equipment.
Contaminated items should be transported to a decontamination area where they must be thoroughly
cleaned and decontaminated using water with detergents or enzymatic cleaners.

Quick polling question for those of you who are in hospitals: how many of you spray your enzymatic
solutions in the OR, and then how many of you spray it when it gets to SPD?

So, I’m getting a lot of people saying, “We spray in the OR, we spray in the OR.” I do have somebody
saying that they spray in SPD, but mostly everybody’s saying the operating room.

Yeah, and you know that’s also another thing that you need to keep in mind. Um, when are your
instruments getting their—and you know, different departments—or different—not departments—
different facilities may be using different things? There's some where there’s a gel, there’s some where
there’s a foam, etc.

So yeah, but the majority of you are spraying in the OR.

Okay, remember to pre-clean at the point of care. Yeah, and that’s something that—that we’re definitely
working on. But I really recommend you go spend some time looking at your instruments and seeing
what they look like when they arrive to SPD.

So, instrument cleaning manually— the two essential components are friction and fluidics.

Using friction—so rubbing, scrubbing the soiled area with a brush—is an old and dependable method.
And that is most definitely what we do and what I do when I’m in decontam.

Fluidics, which is fluids under pressure—okay, let me tell you guys about—so when I was first getting
trained in decontamination and spending time with SPD, they operate a lot of their equipment with
pedals—like foot pedals, like on the ground.

And so when I was—they have this like highly pressurized water that you use to flush, you know, all
different types of—like your lumens, instruments, anything within the sink. But that thing is like so
powerful—you have to be really careful that you don’t—that it’s not, um, outside of the water. So that
it’s underneath the water when you’re spraying it. Because otherwise it can literally go everywhere.
Um, so yes—fluids under pressure. Fluidics is used to remove soil and debris from internal channels after
brushing, and when the design does not allow the passage of a brush through a channel. In instances
when it may not allow the passage of a brush through a channel, that’s why you have to use that high
pressure—because a brush may be too big in order to, um, to fit into those really, really, really tiny
channels.

I’m trying to remember—I think it’s a Frazier suction? Sorry, I’m not as good with my instruments as I
should be, but they have these really, really, really tiny, tiny lumens—like you can only clean them with,
um, it’s almost like a kind of a long needle-type of thing. It’s not even a brush.

But that’s one of the reasons why you need to make sure that you’re paying attention to how things are
being cleaned—whether they’re using brushes or those fluids under pressure.

Next is mechanical units. So these are going to be your ultrasonic cleaners or your washer disinfectors,
and this is where equipment is going to go—your instruments are going to go—once you’re done with
the actual manual cleaning.

When using a washer disinfector, care should be taken as to the method of loading instruments. Also
lids—you have to pay attention. Like, does my lid have a bottom? Because if there’s a bottom, what does
that mean? What—my washer disinfector—for what does that mean for my washer disinfector?

That means that water isn’t going to be able to actually thoroughly clean the equipment.

I need to take some pictures now that I’m realizing—so we’re going to come back. We’re—we’re going
to have to do like a follow-up to this one, because I feel like, um—well, we actually do a follow-up at the
end for cleaning, disinfection, and sterilization.

I want to really show you guys some pictures—for those of you who can’t get into an SPD department—
of what these things look like. And maybe even, you know what, I might be bold and make a little
YouTube montage or something. I’m a little artistic, I have a little bit of creativity in me, so who knows!
I’m writing down ideas just because I want you guys to be able to really see this. I want it to be more
than just words on a slide or on a piece of paper.

So, hinge instruments should be opened fully to allow adequate contact with the detergent solution.
The stacking of instruments in washers should be avoided. Instruments should be disassembled as much
as possible.

Your hinged instruments—they need—everything needs to be open. You need to ensure that all of your
stuff, all of your instruments are open so that when they’re in the washer disinfector, it can get into all
those nooks and crannies and crevices and clean everything out real good.

Now it’s important to note that even though we have all of these things in place, instruments can still
get to the clean side not thoroughly cleaned—and that’s why that manual inspection process when
you’re getting ready to set up a tray is so important.

Next, let’s talk about mechanical or automatic cleaners.

So, ultrasonic cleaning removes soil by a process called cavitation—an implosion in which waves of
acoustic energy are propagated in aqueous solutions to disrupt the bonds that hold particulate matter to
surfaces.

That’s like a beautiful sentence—but the way I think about it? It’s like all these little bubbles. There’s all
of these little bubbles just popping while it’s in the ultrasonic cleaner and like, getting rid of dirt.

You know those Dawn soap commercials where they show you like the little bubble that like scoops up
all the dirt and then takes it away? That’s what these things do, like in plain terms. But there is beautiful
scientific language to thoroughly explain how they do it. But that’s what I think about—that’s the little
image that comes to my head when I think of ultrasonic cleaners.

Users of ultrasonic cleaners should be aware that the cleaning fluid could result in an endotoxin
contamination of surgical instruments that could cause severe inflammatory reactions.

Next, your washer decontaminators and disinfectors act like a dishwasher. They are—they’re like a
dishwasher. When you see them through the window, they use a combination of water circulation and
detergents to remove soil.

These units sometimes have a cycle that subjects the instruments to a heat process of 93 degrees
Celsius for 10 minutes. And this is—okay, so the ones that we have—you can actually see through them.
So they’re, um, this like thick, uh, glass—well, I don’t know if it’s glass—but it’s see-through. You can
see, as the machine is working, all of the washing and the water and everything inside the machine.

Washer sterilizers are modified steam sterilizers that clean by filling the chamber with water and
detergent, through which steam is passed to provide agitation. Instruments are subsequently rinsed and
subjected to a short steam sterilization cycle.

Another washer sterilizer employs rotating spray arms for a wash cycle, followed by a steam sterilization
cycle at 285 degrees Celsius.

Washer pasteurizers expose instruments to hot water for 30 minutes at a temperature of 70 degrees
Celsius, and are typically used in the reprocessing of respiratory therapy equipment.

In the exam, a lot of the times when they’re going to talk about your washer pasteurizers, they’re going
to link it back to respiratory therapy equipment—so you need to remember that.

So why is it 70 degrees Celsius? Why is the temperature 70 degrees Celsius for a washer pasteurizer?

You can take a guess—Crystal?

Yes—to not damage plastics. Perfect.

So it’s less than the temperature that typically damages plastics, right? Oh, so very good.
So 70 degrees Celsius is about 158 degrees Fahrenheit, and some plastics have a melting point as low as
165 degrees Fahrenheit. So yes, absolutely.

Critical items.

So critical items are objects or instruments that must be free of any microorganisms, including bacterial
spores, when they enter sterile tissue, bone, or the vascular system, in order not to introduce
microorganisms into the site—resulting in an infection or disease.

This category includes:

 surgical instruments,

 cardiac and urinary catheters,

 implants, and

 ultrasound probes used in sterile body cavities.

The items in this category should be purchased as sterile or be steam sterilized prior to use.

Steam sterilization under pressure is one of the oldest and most effective methods for sterilization and
is the preferred method for the sterilization of critical medical equipment.

This last bullet point is very important—steam sterilization is going to be our preferred method.

However, we have all different sorts of instruments and equipment that cannot handle steam
sterilization—they are heat sensitive.

And so, you have to have other methods to achieve sterilization—and that is what they’re going to ask
you a lot of questions about on the test: your different sterilization processes.

They can get into specifics about temperatures when it comes to sterilization. If you’re good with
numbers, if that’s something that is very easy for you to remember—those questions will be very easy.

Those were a bit challenging for me because if you’re not doing this all the time, if that’s not—you
know, if you’re not working in SPD all the time, it can be really easy to forget what temperature goes
with each type of—what—with each type of sterilization.

So, critical item—if the item is heat sensitive and cannot be steam sterilized, the object may be sterilized
with:
  ethylene oxide,

 hydrogen peroxide gas plasma,

 ozone,

 vaporized hydrogen peroxide, or

 liquid chemical sterils.

So, liquid chemical sterils—with the exception of 0.2% peracetic acid (12 minutes at 50 to 56 degrees
Celsius)—have indicated exposure times that range from 3 to 12 hours.

So for our liquid chemical sterils, we’re looking at an exposure time of 3 to 12 hours, except for
peracetic acid.

That’s a pretty long time. That’s a pretty long time for a liquid chemical steril.

Another thing that you need to know for liquid chemical sterils are going to be some of your limitations
—and that’s what they’re going to ask you on the test:

What are your limitations with liquid chemical sterils?

One limitation is that the device cannot be wrapped during processing, creating a challenge for
maintaining sterility.

After processing and during storage, devices require rinsing following processing with liquid chemical
sterilants. The type of water—either sterile or filtered—should be determined by the manufacturer’s
instructions for use (IFU) for both the device and the liquid chemical being used.

Due to the inherent limitations of using liquid chemical sterilants for sterilization, their use should be
restricted to reprocessing critical devices that are heat-sensitive and incompatible with other
sterilization methods.

Key takeaway:
You only want to use liquid chemical sterilants if absolutely necessary and no other method can be
used—because there are so many limitations to ensuring sterility, and that’s the real problem.

Semi-Critical Items

Let’s talk about semi-critical items. These are items that come in contact with mucous membranes or
non-intact skin. This category includes:

 Respiratory therapy and anesthesia equipment

 Gastrointestinal endoscopes

 Bronchoscopes

 Laryngoscopes

 Esophageal manometry probes

 Anorectal manometry catheters

  Endocavitary probes (rectal and vaginal)

 Prostate biopsy probes

 Infrared coagulation devices

 Diaphragm fitting rings

Semi-critical items are my favorite—they really are.

But they give you the most headaches out of all three classifications.

There’s going to be a lot of research coming out in the next few years about these devices because this
is the highest-risk category for problems. By far.

You need to know your devices and their classifications.

And you need to know that if you have a semi-critical item, then it must undergo high-level
disinfection.

One tip I have for you:

Make flashcards. Write down examples of non-critical, semi-critical, and critical items and make sure
you know what category each one belongs to.

It will be on the test.

I repeat: It. Will. Be. On. The. Test.
Hopefully you’ll remember either by seeing a slide, recalling a chapter—or hearing my voice in your
head. Whatever works!

You should also know the locations in your facility where semi-critical items are used. These devices
should be free of all microorganisms—including:

 Mycobacteria

 Fungi

 Viruses

 Bacteria

Although small numbers of bacterial spores may still be present, intact mucous membranes (like those
of the lungs or GI tract) are generally resistant to infection from spores—but they are susceptible to
other pathogens.

Disinfection of Semi-Critical Items

Semi-critical items require high-level disinfection using chemical disinfectants. Common examples
include:

 Glutaraldehyde

 Hydrogen peroxide

 Ortho-phthalaldehyde (OPA)
  Improved hydrogen peroxide

 Peracetic acid with hydrogen peroxide

 Chlorine-based products

These are cleared by the U.S. FDA and are dependable high-level disinfectants, provided the correct
time and temperature parameters are met.

Know This Chart (Table 31.2)

Let me pull up this chart really quick—this will be on the test.

In your APIC text, look for:

Table 31.2 – Summary of Advantages and Disadvantages of Chemical Agents Used as Chemical
Sterilants or High-Level Disinfectants

For example:

 With OPA, a common test reference is anaphylactic reactions in bladder cancer patients after
repeated exposure through cystoscopy.

 The disadvantages of each chemical method are lengthy—lots of bullet points.

You’ll want to know:

 Peracetic acid

 Hydrogen peroxide

What are the advantages?

What are the disadvantages?

Some are:

 More expensive

 Cause skin or eye irritation

 Have material compatibility issues (e.g., with brass, zinc, copper, nickel, or silver plating)

I highly recommend you:

 Read this chart

 Make flashcards

 Study the pro/con details

Audits & Competency

Audits of reprocessing for semi-critical devices are essential.

  Staff should receive competency training and evaluation on the safe use and reprocessing of
equipment.

 Infection prevention (IP) rounds or audits should be conducted at least annually in all clinical
areas that reprocess critical and semi-critical devices.

 Results of these rounds should be provided to unit managers.

 Deficiencies should be corrected quickly and documented to Infection Prevention, per policy.

The message here: You need to be out there. You need to be observing. You need to be involved.

And yes, I know—it’s hard. There’s already so much on every IP’s plate, especially during a pandemic.

But I’ll tell you this—when I’ve done audits, I often find that staff can verbalize exactly what they’re
supposed to do… but when you observe?

That’s when you really see what’s happening.

When I do audits, I:

1. Introduce myself to the patient:

“Hi, I’m with the Infection Prevention Department. This is one of the ways we ensure your safety
and the safety of all patients. Is it okay if I observe your visit?”

2. They can say yes or no.

3. But this gives me the opportunity to see what happens:

o In the room

o After the patient leaves

o How the devices are handled and cleaned

Highly recommend doing this.

Not only because APIC recommends it, but because it’s the right thing to do.

Local vs Central Reprocessing

 Central processing areas offer:

o Validated, specialized reprocessing equipment

o Staff who are experts in reprocessing

 Local reprocessing offers:

o Faster instrument turnaround

o Less instrument loss

o Lower instrument inventory

In one study, instruments reprocessed by the central decontamination unit had significantly less
residual protein than instruments reprocessed by the local decontamination unit. Periodic
inspection for quality and infection prevention purposes are recommended for all areas where
equipment is reprocessed, and this is essentially about where central reprocessing in your sterile
processing department is housed. Do you have a central department where everything that needs
to be sterilized is coming over to them, or do you have a central or do you have a local approach
where it's being done at that specific, in that specific department, in that specific outpatient
surgery center, etc.? From the apic text, their recommendation is most definitely central
processing. You want to have a central processing area because that's where you're going to have
your most highly skilled, most highly trained access to better equipment in that central, in that
central processing area. I can tell you from my time at the health department that there are some,
there are some really questionable practices happening in reprocessing departments that are
outside of hospitals, and even within hospitals, there are also some really questionable things.

So paying attention, being involved, and having relationships with this department is extremely
important. And Mona says it's kind of scary. It is. It is frightening because you have to think
about the frequency in which some of these outpatient sites are getting visits, right? Think about
how often an infection preventionist is going out to outpatient sites to look at their process, to
look at what their, what their departments look like, the things that they're doing. I mean, I
obviously can't talk about any specifics, but if you are responsible for outpatient areas, you really
need to ensure that you're putting them on your radar because those are the, those are the types of
places that end up on the news, right?

You need to make sure you're getting out to your, to your designated areas because you don't
want the health department to be the people coming in and asking you, "Wait, what? You're,
you're doing this here? Absolutely not." I mean, I've had to do that before where it's like, "No,
you can no longer reprocess here, effective immediately." Right? And as the health department,
you're not regulatory, but you can give very strong recommendations, and if a facility is not
willing to comply, you can get aca involvement, you know? Your processes are not up to
standards, and you're putting patients at risk, therefore we need to red flag, right? It's a, it's a,
there's no yellow card, it's like, it's red card, come on, we gotta stop. So now, trying to scare
anybody, I'm just letting you know that this is important, and you need to get out there, and you
need to see what you're responsible for and ensure that things are getting done.

Biofilms, biofilms are like one of my favorite things. I just, biofilms are, they're terrifying,
they're fantastic, it's one of the most, I think, exciting aspects of the future of infection
prevention, just the things that we're going to continue to learn about how biofilms and water,
water management programs, sinks, drains, showers, the type of role that they play in the spread
of infection, like it's just fantastic. So biofilms are microbial masses attached to surfaces that are
immersed in liquids. Once these masses are formed, microbes may be resistant to the
disinfectants by multiple mechanisms, including higher resistance of older biofilms, genotypic
variation of the bacteria, microbial production of neutralizing enzymes, and physiologic
gradients within the biofilm. Bacteria within biofilms are up to a thousand, a thousand times
more resistant to antimicrobials than the same bacteria in suspension.
So you have these like, just, I don't even know, mutant ninja turtles type of bacteria that are, that
are within biofilms in the sink drains, and you guys need to learn about this, okay? I can't even
explain everything to you, but you need to listen to Amy Mathers, Dr. Tara Palmer with the NIH,
you have to go out and seek this information, because it's absolutely fascinating. Biofilms have
been found in whirlpools, dental unit water lines, and numerous medical devices, contact lenses,
pacemakers, hemodialysis systems, urinary catheters, central venous catheters, endoscopes. So,
biofilms are in places where you don't even know that they're there, right? But they're there,
they're there. So that's why you're cleaning that point of use, cleaning, ensuring that you're not
getting those instruments caked on in any type of biofilm forming on them is really important.

This is Dr. Tara Palmer's lecture on multi-drug resistant organisms in hospital drains. It's one of
my favorite, absolute favorite lectures. One place you can watch it on is on my YouTube
channel, CIC Epidemiologist, or you can also find it in one of our links in the excel file. You
have multiple methods of learning more about her. One of my goals is to have Dr. Amy Mathers,
who's one of the key, I mean, she's, she's amazing, but she works with the sync lab at the
University of Virginia, is for her to like come on this group and talk about biofilm, because that
would be just the most fantastic day ever. I'm a big fan, a big fan, huge fan, it would be fantastic.
So, there's a lot of really great resources, you need to know about biofilm. Honestly, we should
just have a whole lecture on biofilm, because it's just so fun.

So here's your biofilm growth: You have your, your colonizer, your single little free-floating
bacteria that starts it all, that starts the process, the snowball situation, the partying in the drains.
So here it is, single free-floating bacteria on the surface, bacterial cells then aggregate and attach,
then you have growth and division of bacteria for biofilm formation, formation, then you have
mature biofilm, and then number five, part of the biofilm disperses to release free-floating
bacteria for further colonization, which means you have these little blobs of bacteria making
their way down the piping system and finding another little home to start creating their own
massive empire of biofilm, and then guess what they do? They just party it up in the pipes, they
party it up in the drains, and guess what we do? We do nothing but feed them. Think about
juices, Coca-Cola, dextrose. Think about, think about the things that you are putting down that
drain, and you're just, you're just making them stronger, feeding them.

So, okay, sorry, I'm getting a little passionate about biofilm because it's just so fantastic. Let me
calm down. So toxic anterior segment syndrome, T-A-S-S, can I, is a tissue, is a task, can I say
either? Does anybody know? I'm not sure, I'm not getting any answers. Okay, so toxic anterior
segment syndrome is an acute infectious inflammatory reaction of the interior chamber of
segment of the eye that typically occurs 12 to 48 hours after an uneventful cataract surgery.
Common symptoms include blurry vision, redness of the eye, ocular pain, corneal edema, and
severe inflammation that is limited to the anterior segment. Symptoms often mimic those of
infectious bacterial endophthalmitis. However, TASS symptoms improve after the administration
of topical or oral steroids, and we did cover this, and I think, is it chapter 68?

I think we covered this in chapter 68 recently, where we kind of touched on this a little bit,
specifically relating to our ophthalmoscopes. Spaulding classification of ophthalmoscopes: What
is it? What is the classification of ophthalmoscopes? Is it critical, semi-critical, or non-critical?
Okay, everyone's saying semi. Good, good, good! I'm actually getting some engagement. Last
time I asked this question, I was getting all sorts of answers, so I'm glad I'm seeing something.
Critical surgery and TASS: A variety of substances that can enter the eye during or after surgery,
as well as breaches in sterilization and disinfection of intraocular surgical instruments, have been
implicated as causes of toxic anterior segment syndrome. These substances include detergent
residues, topical ophthalmic ointments, and salt solutions, antiseptic agents, talc from gloves,
water bath contaminants, impurities of autoclave steam, heat-stable endotoxins, and irritants on
the surface of intraocular surgical instruments.

Early identification of TASS for single cases, as well as outbreaks, requires the implementation
of surveillance systems involving surgical staff, infection prevention, and cleaning and
sterilization personnel.

Now, human papillomavirus (HPV) is an extremely common sexually acquired infection and is
considered the cause of cervical cancer, with approximately 70% of cervical cancers being
attributed to two types: HPV 16 and HPV 18. A recent study showed that a considerable number
of endovaginal ultrasound probes were contaminated with HPV—28% pre-examination. That
means 28% of the vaginal probes had human papillomavirus on them before being used. That's
for anybody who is wondering, "What does 28% pre-examination mean?" That's exactly what
that means. Endovaginal ultrasound probes are semi-critical items, even if covered with a sheath
or probe cover, and require high-level disinfection. HPV contamination of endovaginal probes
can occur regardless of sheath or probe cover usage.

So let me tell you what I did after I found out this really fantastic information. I'm a lady, right? I
have a lady doctor. I called and I asked the office, "Do you guys have a Trophon? What type,
you know, what are you using for the high-level disinfection of your probes?" Because I could
not continue my life without knowing what type of equipment the office was using. They were
not using a Trophon. Needless to say, I have another lady doctor now, but this is important,
right? You need to know how your high-level disinfection is happening in your facilities.

And then for those of you who have no idea what I'm talking about, we use Trophons. Let me
pull up a Trophon. How many of you guys use Trophons in your facilities? Okay, Krista is
saying we do. Alright, so this is what it looks like. Ah, that picture's not that big, but okay. So
here's your Trophon machine, which does your high-level disinfection of your probes, and you
can see that she's placing the probe in there. You lock that thing up. Obviously, there is pre-
cleaning that needs to happen before you put it into the Trophon. You can't just be like, "Here we
go," but this is what it looks like and this is what we use.

So yes, important. Remember, your vaginal probes are going to be semi-critical devices, which
means they require high-level disinfection.

Alright, inactivation of Creutzfeldt-Jakob disease (CJD). Since the CJD agent is not readily
inactivated by conventional disinfection and sterilization procedures, and because of the
invariably fatal outcome of CJD, the procedures for disinfection and sterilization of the CJD
prion have been conservative and controversial for many years. On the basis of scientific data
only, critical surgical instruments and semi-critical devices contaminated with high-risk tissue—
and okay, this little parenthesis here: brain, spinal cord, and eye tissue—important to know.
High-risk tissue, the way they can pose the question to you is, "What would be considered high-
risk tissue for Creutzfeldt-Jakob disease?" This is what you're going to think about: brain, spinal
cord, and eye tissue. I know it's in parentheses and you're like, "Oh, okay, it's in parentheses." It's
an important parenthesis to pay attention to.

From high-risk patients, known or suspected infection with CJD or other prion disease requires
special prion reprocessing. A moist environment post-contamination reduces the attachment of
both protein and prion amyloid to the stainless-steel surface. So, maintaining moist conditions at
the point of use is critical.

Okay, so inactivation of Creutzfeldt-Jakob disease. After the device is clean, it should be

sterilized by either steam sterilization or using a combination of sodium hydroxide and
autoclaving using one of the following options. So, you have four different options of things that
you can use. If you're good at remembering numbers and time frames, great, but I can tell you it
would be very difficult for me to remember this. I just— a lot of infection prevention, what it is,
is knowing where to find answers to your questions. Right? So knowing, "Hey, oh yeah, I know I
can find that in CDC guidelines that were published in 2007, updated in 2019. I know I can find
this in the CDC environmental chapter. Oh, this was mentioned in the APIC text. I know exactly
where to go." That's where that's—that’s how a lot of issues and problems are solved with
infection prevention.

So when you get an email asking you about pharmacy and, "Hey, I have filamentous fungi
growing in pharmacy. What am I going to do?" I get that phone call. "What are you going to
do?" You should know, "Okay, well, these are my resources. This is where I can go and this is
what I can find." And I think that for this test, they want you to have an understanding of
infection prevention and for you to feel comfortable with a lot of the big major topics of our
field.

So, if you struggle with remembering specifics like temperatures, try your best, but not all
questions are going to be, you know, expecting for you to have things like this memorized. Like,
"Oh, I need to steam sterilize at 134 degrees Celsius for 18 minutes." Because, yes, you may
remember that for the test, but you might forget it right after. Right?

And then reprocessing of endoscopes: So the reprocessing of endoscopes is a whole situation

where we don't have enough time to cover it because we're at the end. I wanted to give you guys
some time for questions. Does anybody have any questions? We are halfway through the group.
We're lit, we're halfway through. That means you should be signing up for your test within the
next two weeks if you're planning on finishing it out with us. The only thing that's really going to
push you to take your exam is to sign up, right? You have to make that commitment. You can
continue to come and listen and review and read, but until you really—after you really commit
and sign up for a date, that's when it gets real. That's when the pressure is on and you feel like,
"Oh, okay, I have to get serious. Like, it's happening."

So one of our international friends said that the Dubai centre is fully booked. Dang, that's
bananas. It's fully booked. Yeah. We have a question. "Has anyone tried the proctor exam? Is
there any feedback?" I don't know if we have anybody on who's recently taken it, so I don't know
if we have any feedback.

Okay, I'm not getting any more questions at this moment in time. So I will see you guys next
Friday. Make sure you do your readings. Next week, let me pull up next week. Next week we're
starting employee and occupational health, but we're halfway through. So, it's a lot of chapters.
There's a lot of chapters. I need to break this up for future people because this is a lot of pages.
So yeah, we're starting employee and occupational health next week. Thank you guys and I will
see you next Friday.