How to Choose the Right Disinfectant to Prevent Health Care-Associated Infections

According to the CDC, 1 in 31 U.S. hospital patients will acquire an infection related to the care they receive. Also alarming is the CDC estimates that 380,000 residents in long-term care facilities die from similar infections yearly. These preventable health care-associated infections (pHAIs) are a significant cause of illness and death. pHAIs devastate patients’ physical, mental, emotional, and financial health. Additionally, they are a substantial burden on the US health care system, which spends tens of billions of dollars in direct medical costs related to pHAIs each year. Effective cleaning and disinfection are essential to reduce the spread of pathogens and pHAIs.

Disinfection of dirty, soiled surfaces is not achievable, so a precleaning step is often required before applying the disinfectant. In some cases, the EPA allows products to claim that they can “clean and disinfect in a single application,” provided the surface is visibly clean. Products that can clean and disinfect in 1 application will be labeled as such. Disinfection of Clostridiodies difficile, candida auris, biofilm, and Occupational Safety and Health Administration (OSHA) bloodborne pathogens requires surfaces to be precleaned. Crucial to infection control and prevention in hospitals and other health care facilities is choosing the proper disinfectant to kill bacteria, fungi, and inactivated viruses that cause pHAIs.

Over 10,000 disinfectants are registered with the Environmental Protection Agency (EPA). Of all these products, only 3 chemistries–bleach, peracetic acid, and sodium di-chloro-iso-cyanurate–are effective against endospore-forming bacteria such as C difficile. A handful of large manufacturers produce these basic chemistries, which then are private-labeled by scores of companies.

Given the sheer volume available, choosing the proper disinfectant might seem daunting. With the following guidelines, infection preventionists, environmental services (EVS), and hospital facilities managers can ensure they use the appropriate disinfectant to optimize infection prevention and control in their health care facilities.

• Start with the EPA lists.

Start with the EPA lists. The EPA’s 15 registered disinfectant lists deliver crucial information about effective products against bacterial, viral, and fungal pathogens. The EPA lists include all effective products against C difficile endospores, Candida auris, biofilm, methicillin-resistant Staphylococcus aureus (MRSA, SARS-CoV-2, hepatitis, norovirus, and more.

• Read the instructions

Every EPA-registered product has an EPA master label stating everything the product seller can claim regarding killing specific pathogens, including detailed instructions on how the disinfectant must be applied. Using a product other than what is indicated on that label is against the law.

Start by ensuring the disinfectant addresses the organisms of concern (eg, C difficile, MRSA, Candida auris, biofilm, norovirus, etc). If it is not listed on the master label, the disinfectant is ineffective against that particular pathogen. Then, look at dwell time, determining how long the surface must stay wet to kill the specific pathogen. Make sure that the dwell time is achievable. Next, review the directions for applying the disinfectant. For example, some products stipulate they must be used only via a spray versus a wipe–if wiped, the disinfectant is ineffective. Finally, ensure the disinfectant meets your operational policies and procedures for infection prevention. For example, a spray disinfectant should not be used when a patient is in the room.

• Ensure it is Broad-Spectrum

You won’t always know what organisms you’re contending with, especially in a health care setting, where you’ll likely deal with many. Broad-Spectrum means it kills various bacteria, viruses, and fungi, including the harder-to-kill species. Ideally, you’ll identify 1 product that handles all pathogens, including C auris, C difficile, MRSA, and biofilm.

• Ensure the chemistry is effective against biofilm

More than 80% of bacteria live in biofilms, a collection of microorganisms that have produced an extracellular polymeric coating to protect pathogens against environmental stressors, making them highly resistant to many disinfectants. If your disinfectant doesn’t kill bacteria in biofilm, you’re not disinfecting. As of this writing, there are only 3 EPA-registered products with kill claims for bacteria in biofilm. Ideally, you’ll select a disinfectant that eliminates all dangerous pathogens and those found in biofilm.

• Review safety warnings

Understand that disinfectants are hazardous by definition–they’re designed to kill. However, some are more hazardous than others. OSHA indicates that some disinfectants can irritate the skin and cause rashes. More corrosive disinfectants can cause severe burns if splashed on the skin or in the eyes. Mists, vapors, and gases from chemicals can irritate the eyes, nose, throat, and lungs.

In health care facilities, you’re dealing with ill people, so you want to choose safe products. Many disinfectants, particularly legacy products, are highly hazardous to the people applying them, the patients, and the staff. Look for the least hazardous disinfectant with the highest efficacy. Find a disinfectant with a safe pH range to ensure it is not hazardous to skin, lungs, or eyes. Ensure the product is non-carcinogenic.

Start with the product’s Hazardous Material Identification System (HMIS) rating, which is a scale of zero (safest) to four (most hazardous). The HMIS rating will have 3 numbers associated with health, fire, and instability risk. The ideal product will have an HMIS of 0/0/0, although many disinfectants are eye irritants, indicating an HMIS of 1/0/0. If you use a disinfectant delivered in concentrate form for dilution on site, evaluate the HMIS of both the concentrate and diluted products.

• Choose 1 disinfectant

Historically, health care disinfection meant using 1 product for most tasks and then switching to more hazardous chemicals for other, more difficult pathogens (eg, C difficile). This meant more training of staff and an increased chance that something could go wrong, such as mixing incompatible chemicals. Today, safer, broad-spectrum products are available. If you pick the proper disinfectant, you should need only 1 product throughout your health care facility. With 1 effective broad-spectrum disinfectant, infection preventionists, EVS directors, and health care facility managers can decrease the training required and significantly reduce pHAIs, risk, and costs.

• Consider environmental implications

Look at the environmental impact of your disinfectant. For example, are you paying to ship water? Many ready-to-use (RTU) disinfectants are 99% water and packaged in individual plastic bottles that end up in landfills. The implications are higher shipping, packaging, and storage costs, resulting in a significant carbon footprint.

What are you going to do with unused disinfectant products? Some highly acidic (low pH) disinfectants cannot be disposed of down the drain and sewer system. Some highly caustic (high pH) products can damage sewer lines. Concentrated, safer disinfectants will cut shipping and storage costs while reducing your environmental footprint via less packaging, more efficient shipping, and safer disposal.

Another consideration is the selected disinfectant's impact on medical equipment, mattresses, furniture, and floor finishes. Disinfectants with low pH (acidic) and higher pH (alkaline) can cause severe damage, resulting in significant replacement costs.

• Don’t forget about training!

In addition to choosing the proper EPA-registered disinfectant, regular training of hygiene specialists and other EVS staff is critical for appropriate cleaning and disinfection. Ensure all staff members understand why a particular disinfectant was chosen. Explain the importance of following all instructions on the master label, including proper use, dwell time, and key safety precautions. Doing so will ensure that EVS staff use the disinfectant safely and per the EPA master label instructions. By providing all staff understanding of best practice protocols and processes, health care facilities can eliminate the risk of cross-contamination and decrease pHAIs.

The proper disinfectant plays a key role in reducing the cost and burden of pHAIs on all types of health care facilities and society. When selecting the best disinfectant for your health care facility, follow the above criteria to help ensure a safe and hygienic environment for patients and staff.