1. Sterilization
It is the process that destroys all microorganisms (including bacterial microspores).
The skin could never be sterilized without its own destruction.

2. Disinfection
A process which destroys only the vegetative forms of organisms =basically clean.
A disinfectant (germicide, antiseptic): any chemical substance with either a bactericidal or a bacteriostatic action.
Antiseptic -- Agent applied to living tissue
Disinfectant -- Agent applied to inanimate surface

3. Surgical Disinfection
This is an essential part of a programme for the control of infection.
High Risk Items: as they come in close contact with broken skin or those that breach mucous membranes or are introduced into a sterile cavity.

4. Requirements for decontamination practice
The basic requirements for good decontamination practice are:
A Management control system;
Appropriate facilities;
Appropriate equipment;
Properly trained and supervised staff;
Ensuring that single use medical devices are not reused;
Records of decontamination are kept.

5. Methods of Disinfection
Physical: The most important as they can be relied on to ensure the sterilization of articles used in the treatment of patients:
Thermal: Heat or Steam
Radiation: infra-red radiation, - rays,  particles
Filtration:utilizing filters capable of screening out microorganisms
Chemical: Less effective, used for personnel
Organic
Inorganic
Gaseous disinfectants: very efficient, not routine
Formaldehyde gas
Ethylene oxide

6. MANUAL CLEANING
Cleaning is vital prior to any decontamination procedure.
‘Detergent’ removes the nutritive material on which bacterial survival and multiplication may take place.
This reduces the number to a level which is not harmful for health.

7. MANUAL CLEANING
Effective cleaning to remove protein from medical devices is paramount (agents such as CJD are not inactivated by heat).
Dismantle or Open the instrument to be cleaned
Friction for 2-3 minutes
Brush, Wipe, Agitate, Irrigate, jet wash or hand spray the item to dislodge and remove all visible soil
Rinse the item thoroughly with clean water
Drying

8. Physical Methods of Disinfection HEAT
DRY HEAT
Kills by Destructive oxidation of cell constituents
Surest incineration
Hot-air oven:
inefficient, poor conductor of heat, penetrates feebly.
160°C for 1 hour: damages fabrics, melts rubber
Used for: Glassware, oily fluids, powders

9. Physical Methods of Disinfection HEAT
MOIST HEAT
Effective at low temperature, in a shorter period of time
Boiling: 100°C for 30 minutes
Pasteurisation: 63°C for 30 minutes
Tyndallisation: steaming for 20 minutes for 3 successive days
Steaming under pressure= Autoclaving

10. Advantages of steam
Kills by denaturing & coagulating enzymes & proteins
More rapid (maximum needed time 45mn) & at lower temperature
Condensation of steam leads to liberation of latent heat which raises the temperature, and gives more penetration
Half dense as air, so has better penetration

11. Steam Sterilization: Autoclave
Principle: An autoclave is a self locking machine that sterilizes with the high temperature that steam under pressure can reach.
High-vacuum pumps remove as much as possible air before the steam is admitted, so the required temperature is reached very rapidly.

12. Steam criteria Dry: no suspended droplets of water
Close to its point of condensation: not superheated
Free from air: as it decreases the temperature and the penetration
Temperature
121°C: 15mn-30mn
134°C: 4-7mn Flashing

13. Steps of autoclaving
Water in the surrounding container full and heated
Articles in cabinet, doors bolted
Vacuum to evacuate as much air as possible
Steam is admitted at a high pressure of and when the thermometre reaches the required temperature, sterilisation begins
Sterilisation is continued for the required time and then the steam is turned off.
Drying is carried-out by reapplying a vacuum to evacuate the steam, introducing dry filtered air into the cabinet (for 15 minutes).

14. Efficient Autoclaving
All instruments must be double wrapped in linen or special paper or placed in a special metal box equipped with a filter before sterilization.
The white stripes on the tape change to black when the appropriate conditions (temperature) have been met.
Expiration dates should be printed on all equipment packs.
There should be a uniform development of bars throughout the length of the strips.
Ready made plastic bags with strips printed with a sensitive ink.

15. Control of autoclave efficiency
Bowie-Dick test: Used for high-vacuum autoclaves, Done every day:
In the middle of a test pack of towel, a paper on to which a strip of a specific tape is put, for testing.
Uniform development of dark color indicates that the steam has passed freely and rapidly to the center of the load.
Biological sterilization indicators: Spores of a non-pathogenic organism: Done weekly
They are killed at 121°C after 15 minutes.
Attempts to culture them is subsequently made

16. RADIATION DISINFECTION
High energy ionizing radiation destroys microorganisms and is used to sterilize prepacked, Single-use, surgical equipment by manufacturers
Common sources of radiation include electron beam and Cobalt-60

17. CHEMICAL DISINFECTION
A SATISFACTORY AGENT SHOULD:
Be active against a wide range of organisms and spores. Only few are truly sterilizer
Have a rapid action
Should not be toxic or irritant to the skin
Should be Persistent
There is no one disinfectant which can be used to kill all micro-organisms in all situations.

18. Types of Chemical disinfectants
Inorganic:
Iodine
Chlorine
Organic:
Alcohols
Aldehydes
Phenols
Cationic surface-active agents

19. Inorganic disinfectants
The halogens: Chlorine and Iodine
Have a rapid action against vegetative organisms and spores= true sterilizers
Their action is annulled by foreign organic material

20. Iodine disinfectants
The broadest spectrum of all topical anti-infectives, with action against bacteria, fungi, viruses, spores, protozoa, and yeasts.
Tincture iodine:
2.5% iodine & 2.5% potassium iodide in 90% ethanol.
Best skin disinfectant
Irritating to raw surfaces: due to its alcoholic component
Allergic dermatitis
Iodophors: Solutions of iodine in non-ionic detergents= Povidone iodine= Betadine
Less irritating and less staining
Less disinfectant than tincture

21. Chlorine disinfectants
Powerful, Disinfect water
Particularly active against viruses
Concentrated solutions too corrosive
Usually diluted with a compatible detergent

22. Organic Disinfectants
Alcohols: bactericidal: 50-70% ethanol
Aldehydes:
Formalin: irritant, powerful=sterilizer
Glutaraldehyde: less irritant, not volatile, more rapid action.
Phenols: continued activity in organic matter as human excreta.
Phenol: Toxic, expensive
Cresols: Lysol
Chloroxylenol: Dettol
Chlorhexidine: Hibitane- Alkanol
Hexachlorophane
Cationic surface-active agents:
Cetrimide: Cetavlon

23. Alcohol Isopropyl Alcohol 70% (or Ethyl Alcohol 90%) ADVANTAGES:
Causes protein denaturation, cell lysis, and metabolic interruption.
Degreases the skin.
DISADVANTAGES:
Ineffective against bacterial spores and poorly effective against viruses and fungi.

24. Glutaraldehyde (Cidex)
Cold Sterilization:
Instruments must be dry before immersion.
Glutaraldehyde is bactericidal, fungicidal, viricidal, and sporicidal
Sterilization: a 10 hour immersion. This prolonged chemical action can be more detrimental to surgical instruments.
3 hours exposure time is needed to destroy spores.
If the instruments need to be "disinfected" only, cold sterilization is okay as disinfection will take place in only 10 minutes.

25. Lysoformin Formaldehyde & glutaral
Lysoformin: liquid concentrate with which any dilution required can be made by simply adding water (20ml + 4-8L)
The timing depends on the concentration used:
flexible endoscopes
deactivation of HBV & HIV
Used for heat labile instruments and cleaning
Does not harm metal instruments
1.5 % - 30 min 2.0 % - 15 min

26. Chlorhexidine Gluconate Hibitane vs Alkanol
Broadest spectrum
Better residual activity than iodophors
Occasional skin sensitivity
ADVANTAGES:
Rapid action
Residual activity is enhanced by repeated use
Less susceptible to organic inactivation than povidone iodine
DISADVANTAGES:
Occasional skin sensitivity.
Inactive against bacterial spores
Activity against viruses and fungi is variable and inconsistent
May harm metal instruments

27. Gaseous Disinfection Ethylene Oxide Sterilization: EO Gas
Colorless gas, available as cartridges
Toxic and flammable, Odor similar to ether
Has an extremely well penetration, even through plastics
Microorganism destruction is caused by a chemical reaction
Effective sterilization is dependent on concentration of gas, exposure time, temperature, and relative humidity
Powerful sterilizer: Kills all known viruses, bacteria (including spores), and fungi

28. EO Gas Sterilizer
Is used in large hospitals, as it is expensive, dangerous, needs more expertise.
Used for heat sensitive instruments: fabrics, plastics, suture material, lenses, endoscopes, electrical equipment and finely sharpened instruments.
At 20°C-25°C: sterilization takes 18hours
At 50°C-60°C: sterilization takes 4 hours
In Demerdash: The average of the cycle is 8-14 hours

29. Sterility Check List
Before assuming a pack is sterile, always evaluate the following before opening the pack:
Expiration date
Indicator color change
General condition of wrapper and how it had been stored
Always check for holes or moisture damage

30. Standards for Surgical Scrubbing, Gowning and Gloving
The pre-surgical practice of scrubbing, gowning and gloving is integral to the minimization of risk of infection from micro-organisms present in the wound at the time of surgery.

31. Accessing to the operating theatre
Wear prescribed operating suite attire
Remove jewellery
Keep fingernails short, clean, healthy
Wear appropriate protective attire: masks, head, overshoes..

32. REMEMBER What went inside the machines is the STERILISED material
Personnel are only DISINFECTED

33. Surgical Hand scrub No touch: infrared robinets, with your elbow, leg…
Use brush??
The ideal duration of the scrub is not agreed.
Accepted time is 5 minutes: appears safe
Some surgeons do not rinse off the chlorhexidine or Betadine in order to enhance residual activity.
Alternative: Two-stage surgical scrub:
an initial 1- or 2-minutes scrub with 4% chlorhexidine gluconate or povidone-iodine followed by application of an alcohol-based product

34. Surgical Hand scrub
Trim fingernails and Wash for seconds with surgical scrub.
Scrub fingers with a sterile scrub brush
Make sure to scrub all sides of each finger, including the area between fingers.

35. Surgical Hand scrub
Scrub hands and arms with a sterile scrub brush. Make sure to scrub each surface of each hand and arm
An accepted contact time is 10 brush strokes per surface
During scrubbing, rinsing and drying, hands are held above elbows. This is done so that water will not be dripping from upper arms onto lower arms and hands

36. Drying Hands A sterile towel is included within the sterile gown pack.
One hand and forearm are dried by one side of the towel.
Always dry in the direction of hand to elbow so that contamination of the upper arm is not spread by the towel to the surgeon's hand.

37. Gowning
All gowns are folded and packaged for sterilization, with the inside exposed so that the surgeon may handle the gown without contaminating the outside of the gown.
Grasp the exposed inside of the gown and lift the gown away from the table.
Your hands are disinfected and the gown is sterilized

38. Gowning
Unfold the gown by placing hands into the white arm holes. Continue placing hands and arms through the sleeves..

39. PLEASE: DO NOT DRY YOUR HANDS IN THE FRONT OF THE GOWN
Gowning
An assistant fastens the neck tie and the inside waist tie.
PLEASE: DO NOT DRY YOUR HANDS IN THE FRONT OF THE GOWN

40. Types of Gowns
Disposable Paper Gown: resistant to wetting so they are less permeable to bacteria, expensive. It is usually a wrap around gown. The ties "wrap around" the surgeon.
Linen (cloth): comfortable and reusable. When it becomes wet, bacteria can permeate. The cloth gown is also known as a front sterile gown. The gown is just tied in the back.

41. DO NOT ADJUST THE FIRST GLOVE BEFORE PUTTING
Gloving
Sterile surgical gloves can be worn by:
Open method:
The gloves are presented to enable the introduction of the hands on the inside surface directly
The nurse with her sterile glove opens the glove for the surgeon who introduces directly his hands on the inside surface of the glove
DO NOT ADJUST THE FIRST GLOVE BEFORE PUTTING
THE SECOND ONE !!!

42. Gloving Closed gloving:
This is the introduction of hands covered with the cuff of a sterile gown.
So, If you are planning on closed gloving, do not thrust hands through the cuffs.
This is usually performed by the first person to be sterilized= the nurse

43. Gloving: Closed method
An assistant opens the sterile pack of gloves and drops them into the sterile field.
The inside of the cuff of the glove is grasped by the opposite hand (still within the gown) until introduction

44. ??Remove the excess of the detergent
Patient Preparation
Sterilization is best done with a detergent followed by a disinfectant on a larger area of the surgical field. H&N??
Use Ample Detergent
Scrub roughly the skin in any direction for 2-3mn
??Remove the excess of the detergent
Apply the disinfectant first on the most clean area
Scrub in one direction only

45. Draping
Standard head drape: two towels, one under the shoulders and the other wrapped around the head
Better to suture the drapes to the skin to prevent shifting
Towels are used for lateral draping
Drapes should lie flat

46. Practical Sterilization Instruments sterilization
Metal Instruments: Avoid chemical sterilization
Autoclave
EO chamber
Formaldehyde beads or powder
Sharp-edged: avoid heating & wetting:

47. Practical Sterilization Instruments sterilization
Catheters, gloves,…: depend on pre-sterilized, disposable equipment
Radiation
EO chamber
Endoscopes: avoid heat
Cidex
Lysoformin
Autoclaving
Handles of drills:
Autoclave after washing and oiling

48. THANK YOU