Thursday, January 31, 2013

Sterilization and Disinfection


The Physical Method of Sterilization:

 Sterilization is defined as the process where all the living microorganisms, including bacterial spores are killed. Sterilization can be achieved by physical, chemical and physiochemical means. Chemicals used as sterilizing agents are called chemisterilants. 
Disinfection is the process of elimination of most pathogenic microorganisms (excluding bacterial spores) on inanimate objects. Disinfection can be achieved by physical or chemical methods. Chemicals used in disinfection are called disinfectants. Different disinfectants have different target ranges, not all disinfectants can kill all microorganisms. Some methods of disinfection such as filtration do not kill bacteria, they separate them out. Sterilization is an absolute condition while disinfection is not. The two are not synonymous.
Decontamination is the process of removal of contaminating pathogenic microorganisms from the articles by a process of sterilization or disinfection. It is the use of physical or chemical means to remove, inactivate, or destroy living organisms on a surface so that the organisms are no longer infectious.
Sanitization is the process of chemical or mechanical cleansing, applicable in public health systems. Usually used by the food industry. It reduces microbes on eating utensils to safe, acceptable levels for public health.
Asepsis is the employment of techniques (such as usage of gloves, air filters, uv rays etc) to achieve microbe-free environment. 
Antisepsis is the use of chemicals (antiseptics) to make skin or mucus membranes devoid of pathogenic microorganisms.
Bacteriostasis is a condition where the multiplication of the bacteria is inhibited without killing them.
Bactericidal is that chemical that can kill or inactivate bacteria. Such chemicals may be called variously depending on the spectrum of activity, such as bactericidal, virucidal, fungicidal, microbicidal, sporicidal, tuberculocidal or germicidal.
Antibiotics are substances produced by one microbe that inhibits or kills another microbe. Often the term is used more generally to include synthetic and semi-synthetic antimicrobial agents.
PHYSICAL METHODS OF STERILIZATION:
Sunlight: The microbicidal activity of sunlight is mainly due to the presence of ultra violet rays in it. It is responsible for spontaneous sterilization in natural conditions. In tropical countries, the sunlight is more effective in killing germs due to combination of ultraviolet rays and heat. By killing bacteria suspended in water, sunlight provides natural method of disinfection of water bodies such as tanks and lakes. Sunlight is not sporicidal, hence it does not sterilize.
Heat: Heat is considered to be most reliable method of sterilization of articles that can withstand heat. Heat acts by oxidative effects as well as denaturation and coagulation of proteins. Those articles that cannot withstand high temperatures can still be sterilized at lower temperature by prolonging the duration of exposure.
Factors affecting sterilization by heat are:
a.                  Nature of heat: Moist heat is more effective than dry heat
b.                  Temperature and time: temperature and time are inversely proportional. As temperature increases the time taken decreases.
c.                   Number of microorganisms: More the number of microorganisms, higher the temperature or longer the duration required.
d.                  Nature of microorganism: Depends on species and strain of microorganism, sensitivity to heat may vary. Spores are highly resistant to heat.
e.                  Type of material: Articles that are heavily contaminated require higher temperature or prolonged exposure. Certain heat sensitive articles must be sterilized at lower temperature.
f.                    Presence of organic material: Organic materials such as protein, sugars, oils and fats increase the time required.


Action of heat:
Dry heat acts by protein denaturation, oxidative damage and toxic effects of elevated levels of electrolytes. The moist heat acts by coagulation and denaturation of proteins. Moist heat is superior to dry heat in action. Temperature required to kill microbe by dry heat is more than the moist heat. Thermal death time is the minimum time required to kill a suspension of organisms at a predetermined temperature in a specified environment. 

DRY HEAT:
Red heat: Articles such as bacteriological loops, straight wires, tips of forceps and searing spatulas are sterilized by holding them in Bunsen flame till they become red hot. This is a simple method for effective sterilization of such articles, but is limited to those articles that can be heated to redness in flame.

Flaming: This is a method of passing the article over a Bunsen flame, but not heating it to redness. Articles such as scalpels, mouth of test tubes, flasks, glass slides and cover slips are passed through the flame a few times. Even though most vegetative cells are killed, there is no guarantee that spores too would die on such short exposure. This method too is limited to those articles that can be exposed to flame. Cracking of the glassware may occur. 

Incineration: This is a method of destroying contaminated material by burning them in incinerator. Articles such as soiled dressings; animal carcasses, pathological material and bedding etc should be subjected to incineration. This technique results in the loss of the article, hence is suitable only for those articles that have to be disposed. Burning of polystyrene materials emits dense smoke, and hence they should not be incinerated. 

Hot air oven:
This method was introduced by Louis Pasteur. Articles to be sterilized are exposed to high temperature (160o C) for duration of one hour in an electrically heated oven. Since air is poor conductor of heat, even distribution of heat throughout the chamber is achieved by a fan. The heat is transferred to the article by radiation, conduction and convection. The oven should be fitted with a thermostat control, temperature indicator, meshed shelves and must have adequate insulation.
Articles sterilized: Metallic instruments (like forceps, scalpels, scissors), glasswares (such as petri-dishes, pipettes, flasks, all-glass syringes), swabs, oils, grease, petroleum jelly and some pharmaceutical products.
Sterilization process: Articles to be sterilized must be perfectly dry before placing them inside to avoid breakage. Articles must be placed at sufficient distance so as to allow free circulation of air in between. Mouths of flasks, test tubes and both ends of pipettes must be plugged with cotton wool. Articles such as petri dishes and pipettes may be arranged inside metal canisters and then placed. Individual glass articles must be wrapped in kraft paper or aluminum foils.
Sterilization cycle: This takes into consideration the time taken for the articles to reach the sterilizing temperature, maintenance of the sterilizing temperature for a defined period (holding time) and the time taken for the articles to cool down. Different temperature-time relations for holding time are 60 minutes at 160oC, 40 minutes at 170oC and 20 minutes at 180oC. Increasing temperature by 10 degrees shortens the sterilizing time by 50 percent. The hot air oven must not be opened until the temperature inside has fallen below 60oC to prevent breakage of glasswares.
Sterilization control: Three methods exist to check the efficacy of sterilization process, namely physical, chemical
and biological.

•        Physical: Temperature chart recorder and thermocouple.
•        Chemical: Browne’s tube No.3 (green spot, color changes from red to green)
•        Biological: 106 spores of Bacillus subtilis var niger or Clostridium tetani on paper strips are placed inside envelopes and then placed inside the hot air oven. Upon completion of sterilization cycle, the strips are removed and inoculated into thioglycollate broth or cooked meat medium and incubated at 37oC for 3-5 days. Proper sterilization should kill the spores and there should not be any growth.

Advantages: It is an effective method of sterilization of heat stable articles. The articles remain dry after sterilization. This is the only method of sterilizing oils and powders.

Disadvantages:

•    Since air is poor conductor of heat, hot air has poor penetration. 
•    Cotton wool and paper may get slightly charred. 
•    Glasses may become smoky. 
•    Takes longer time compared to autoclave.

Infra red rays: Infrared rays bring about sterilization by generation of heat. Articles to be sterilized are placed in a moving conveyer belt and passed through a tunnel that is heated by infrared radiators to a temperature of 180oC. The articles are exposed to that temperature for a period of 7.5 minutes. Articles sterilized included metallic instruments and glassware. It is mainly used in central sterile supply department. It requires special equipments, hence is not applicable in diagnostic laboratory. Efficiency can be checked using Browne’s tube No.4 (blue spot).


MOIST HEAT:
Moist heat acts by coagulation and denaturation of proteins.
At temperature below 100oC:
Pasteurization: This process was originally employed by Louis Pasteur. Currently this procedure is employed in food and dairy industry. There are two methods of pasteurization, the holder method (heated at 63oC for 30 minutes) and flash method (heated at 72oC for 15 seconds) followed by quickly cooling to 13oC. Other pasteurization methods include Ultra-High Temperature (UHT), 140oC for 15 sec and 149oC for 0.5 sec. This method is suitable to destroy most milk borne pathogens like Salmonella, Mycobacteria, Streptococci, Staphylococci and Brucella, however Coxiella may survive pasteurization. Efficacy is tested by phosphatase test and methylene blue test.
Vaccine bath: The contaminating bacteria in a vaccine preparation can be inactivated by heating in a water bath at 60oC for one hour. Only vegetative bacteria are killed and spores survive.
Serum bath: The contaminating bacteria in a serum preparation can be inactivated by heating in a water bath at 56oC for one hour on several successive days. Proteins in the serum will coagulate at higher temperature. Only vegetative bacteria are killed and spores survive.
Inspissation: This is a technique to solidify as well as disinfect egg and serum containing media. The medium containing serum or egg are placed in the slopes of an inspissator and heated at 80-85oC for 30 minutes on three successive days. On the first day, the vegetative bacteria would die and those spores that germinate by next day are then killed the following day. The process depends on germination of spores in between inspissation. If the spores fail to germinate then this technique cannot be considered sterilization.


At temperature 100oC:
Boiling: Boiling water (100oC) kills most vegetative bacteria and viruses immediately. Certain bacterial toxins such as Staphylococcal enterotoxin are also heat resistant. Some bacterial spores are resistant to boiling and survive; hence this is not a substitute for sterilization. The killing activity can be enhanced by addition of 2% sodium bicarbonate. When absolute sterility is not required, certain metal articles and glasswares can be disinfected by placing them in boiling water for 10-20 minutes. The lid of the boiler must not be opened during the period. 
Steam at 100oC: Instead of keeping the articles in boiling water, they are subjected to free steam at 100oC. Traditionally Arnold’s and Koch’s steamers were used. An autoclave (with discharge tap open) can also serve the same purpose. A steamer is a metal cabinet with perforated trays to hold the articles and a conical lid. The bottom of steamer is filled with water and heated. The steam that is generated sterilizes the articles when exposed for a period of 90 minutes. Media such as TCBS, DCA and selenite broth are sterilized by steaming. Sugar and gelatin in medium may get decomposed on autoclaving, hence they are exposed to free steaming for 20 minutes for three successive days. This process is known as tyndallisation (after John Tyndall) or fractional sterilization or intermittent sterilization. The vegetative bacteria are killed in the first exposure and the spores that germinate by next day are killed in subsequent days. The success of process depends on the germination of spores.


At temperature above 100oC:
Autoclave: Sterilization can be effectively achieved at a temperature above 100oC using an autoclave. Water boils at 100oC at atmospheric pressure, but if pressure is raised, the temperature at which the water boils also increases. In an autoclave the water is boiled in a closed chamber. As the pressure rises, the boiling point of water also raises. At a pressure of 15 lbs inside the autoclave, the temperature is said to be 121oC. Exposure of articles to this temperature for 15 minutes sterilizes them. To destroy the infective agents associated with spongiform encephalopathies (prions), higher temperatures or longer times are used; 135oC or 121oC for at least one hour are recommended. 
Advantages of steam: It has more penetrative power than dry air, it moistens the spores (moisture is essential for coagulation of proteins), condensation of steam on cooler surface releases latent heat, and condensation of steam draws in fresh steam.
Different types of autoclave: Simple “pressure-cooker type” laboratory autoclave, Steam jacketed downward displacement laboratory autoclave and high pressure pre-vacuum autoclave


Construction And Operation Of Autoclave:

A simple autoclave has vertical or horizontal cylindrical body with a heating element, a perforated try to keep the articles, a lid that can be fastened by screw clamps, a pressure gauge, a safety valve and a discharge tap. The articles to be sterilized must not be tightly packed. The screw caps and cotton plugs must be loosely fitted. The lid is closed but the discharge tap is kept open and the water is heated. As the water starts boiling, the steam drives air out of the discharge tap. When all the air is displaced and steam start appearing through the discharge tap, the tap is closed. The pressure inside is allowed to rise upto 15 lbs per square inch. At this pressure the articles are held for 15 minutes, after which the heating is stopped and the autoclave is allowed to cool. Once the pressure gauge shows the pressure equal to atmospheric pressure, the discharge tap is opened to let the air in. The lid is then opened and articles removed.  Articles sterilized: Culture media, dressings, certain equipment, linen etc. Precautions: Articles should not be tightly packed, the autoclave must not be overloaded, air discharge must be complete and there should not be any residual air trapped inside, caps of bottles and flasks should not be tight, autoclave must not be opened until the pressure has fallen or else the contents will boil over, articles must be wrapped in paper to prevent drenching, bottles must not be overfilled. Advantage: Very effective way of sterilization, quicker than hot air oven. Disadvantages: Drenching and wetting or articles may occur, trapped air may reduce the efficacy, takes long time to cool
Sterilization control: Physical method includes automatic process control, thermocouple and temperature chart recorder. Chemical method includes Browne’s tube No.1 (black spot) and succinic acid (whose melting point is 121oC) and Bowie Dick tape. Bowie Dick tape is applied to articles being autoclaved. If the process has been satisfactory, dark brown stripes will appear across the tape. Biological method includes a paper strip containing 106 spores of Geobacillus stearothermophilus.
RADIATION: Two types of radiation are used, ionizing and non-ionizing. Non-ionizing rays are low energy rays with poor penetrative power while ionizing rays are high-energy rays with good penetrative power. Since radiation does not generate heat, it is termed "cold sterilization". In some parts of Europe, fruits and vegetables are irradiated to increase their shelf life up to 500 percent.
Non-ionizing rays: Rays of wavelength longer than the visible light are non-ionizing. Microbicidal wavelength of UV rays lie in the range of 200-280 nm, with 260 nm being most effective. UV rays are generated using a high-pressure mercury vapor lamp. It is at this wavelength that the absorption by the microorganisms is at its maximum, which results in the germicidal effect. UV rays induce formation of thymine-thymine dimers, which ultimately inhibits DNA replication. UV readily induces mutations in cells irradiated with a non-lethal dose. Microorganisms such as bacteria, viruses, yeast, etc. that are exposed to the effective UV radiation are inactivated within seconds. Since UV rays don’t kill spores, they are considered to be of use in surface disinfection. UV rays are employed to disinfect hospital wards, operation theatres, virus laboratories, corridors, etc. Disadvantages of using uv rays include low penetrative power, limited life of the uv bulb, some bacteria have DNA repair enzymes that can overcome damage caused by uv rays, organic matter and dust prevents its reach, rays are harmful to skin and eyes. It doesn't penetrate glass, paper or plastic.
Ionizing rays: Ionizing rays are of two types, particulate and electromagnetic rays. 
a.      Electron beams are particulate in nature while gamma rays are electromagnetic in nature. High-speed electrons are produced by a linear accelerator from a heated cathode. Electron beams are employed to sterilize articles like syringes, gloves, dressing packs, foods and pharmaceuticals. Sterilization is accomplished in few seconds. Unlike electromagnetic rays, the instruments can be switched off. Disadvantage includes poor penetrative power and requirement of sophisticated equipment. 
b.      Electromagnetic rays such as gamma rays emanate from nuclear disintegration of certain radioactive isotopes (Co60, Cs137). They have more penetrative power than electron beam but require longer time of exposure. These high-energy radiations damage the nucleic acid of the microorganism. A dosage of 2.5 megarads kills all bacteria, fungi, viruses and spores. It is used commercially to sterilize disposable petri dishes, plastic syringes, antibiotics, vitamins, hormones, glasswares and fabrics. Disadvantages include; unlike electron beams, they can’t be switched off, glasswares tend to become brownish, loss of tensile strength in fabric. Gamma irradiation impairs the flavour of certain foods. Bacillus pumilus E601 is used to evaluate sterilization process.


FILTRATION:
Filtration does not kill microbes, it separates them out. Membrane filters with pore sizes between 0.2-0.45 µm are commonly used to remove particles from solutions that can't be autoclaved. It is used to remove microbes from heat labile liquids such as serum, antibiotic solutions, sugar solutions, urea solution. Various applications of filtration include removing bacteria from ingredients of culture media, preparing suspensions of viruses and phages free of bacteria, measuring sizes of viruses, separating toxins from culture filtrates, counting bacteria, clarifying fluids and purifying hydatid fluid. Filtration is aided by using either positive or negative pressure using vacuum pumps. The older filters made of earthenware or asbestos are called depth filters.


Different types of filters are:
1.      Earthenware filters: These filters are made up of diatomaceous earth or porcelain. They are usually baked into the shape of candle. Different types of earthenware filters are:
a.      Pasteur-Chamberland filter: These candle filters are from France and are made up of porcelain (sand and kaolin). Similar filter from Britain is Doulton. Chamberland filters are made with various porosities, which are graded as L1, L1a, L2, L3, L5, L7, L9 and L11. Doulton filters are P2, P5 and P11.
b.      Berkefeld filter: These are made of Kieselguhr, a fossilized diatomaceous earth found in Germany. They are available in three grades depending on their porosity (pore size); they are V (veil), N (normal) and W (wenig). Quality of V grade filter is checked using culture suspension of Serrtia marcescens (0.75 µm).
c.       Mandler filter: This filter from America is made of kieselguhr, asbestos and plaster of Paris.

2.      Asbestos filters: These filters are made from chrysotile type of asbestos, chemically composed of magnesium silicate. They are pressed to form disc, which are to be used only once. The disc is held inside a metal mount, which is sterilized by autoclaving. They are available in following grades; HP/PYR (for removal of pyrogens), HP/EKS (for absolute sterility) and HP/EK (for claryfying).
3.      Sintered glass filters: These are made from finely ground glass that are fused sufficiently to make small particles adhere to each other. They are usually available in the form of disc fused into a glass funnel. Filters of Grade 5 have average pore diameter of 1-1.5 µm. They are washed in running water in reverse direction and cleaned with warm concentrated H2SO4 and sterilized by autoclaving.
4.      Membrane filters: These filters are made from a variety of polymeric materials such as cellulose nitrate, cellulose diacetate, polycarbonate and polyester. The older type of membrane, called gradocol (graded colloidion) membrane was composed of cellulose nitrate. Gradocol membranes have average pore diameter of 3-10 µm. The newer ones are composed of cellulose diacetate. These membranes have a pore diameter ranging from 0.015 µm to 12 µm. These filters are sterilized by autoclaving. Membrane filters are made in two ways, the capillary pore membranes have pores produced by radiation while the labyrinthine pore membranes are produced by forced evaporation of solvents from cellulose esters.

The disadvantages of depth filters are migration of filter material into the filtrate, absorption or retention of certain volume of liquid by the filters, pore sizes are not definite and viruses and mycoplasma could pass through. The advantages of membrane filters are known porosity, no retention of fluids, reusable after autoclaving and compatible with many chemicals. However, membrane filters have little loading capacity and are fragile.
Air Filters: Air can be filtered using HEPA (High Efficiency Particle Air) filters. They are usually used in biological safety cabinets. HEPA filters are at least 99.97% efficient for removing particles >0.3 µm in diameter. Examples of areas where HEPA filters are used include rooms housing severely neutropenic patients and those operating rooms designated for orthopedic implant procedures. HEPA filter efficiency is monitored with the dioctylphthalate (DOP) particle test using particles that are 0.3 µm in diameter.
SONIC AND ULTRASONIC VIBRATIONS: Sound waves of frequency >20,000 cycle/second kills bacteria and some viruses on exposing for one hour. Microwaves are not particularly antimicrobial in themselves, rather the killing effect of microwaves are largely due to the heat that they generate. High frequency sound waves disrupt cells. They are used to clean and disinfect instruments as well as to reduce microbial load. This method is not reliable since many viruses and phages are not affected by these waves.


Source: Sridhar Rao PN, Assistant Professor, Department of Microbiology, JJMMC, Davangere (www.microrao.com), Thank you very much to DR. Rao.
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