Healthcare Cleaning: Are Disinfection Guidelines Outdated?

Guidelines from several government and professional organizations lead one to believe that the use of spray disinfectants in healthcare settings is “taboo”.  The primary rationale cited for this is concern for the production of aerosols and also for contaminated solutions. In true Infection Preventionist form, I decided to take a closer look at the evidence that informs these guidelines. The bottom line is that I could not find much evidence to support NOT using sprays disinfectants when appropriate, at least nothing current.  Let’s take a closer look.

The Evidence

What evidence was used to inform these guidelines? For their recommendations around use of spray disinfectants in healthcare settings, the Centers for Disease Control and Epidemiology (CDC) Guidelines cite four studies ranging from 21-49 years old with little relevance to spray disinfectants.¹ As I chased the evidence trail, the studies just got older and older. The most curious finding was the lack of relevance of these studies. The guideline authors are generalizing results from studies that looked at floor care and vacuuming with outdated and faulty equipment, construction activities, use of porous insulation in buildings as a source of pathogens, and prevention of opportunistic infections in stem cell transplant patients to support their stance on not using spray disinfectants.

As for the guidelines from the key professional organizations, most simply cite the CDC’s guidance. Take for example the Association for periOperative Registered Nurses (AORN) Perioperative Practice Guidelines which recommend against the use of spray bottles in the operating room.²  AORN cites the CDC guidelines and states that “sprayed disinfectants produce more aerosols compared to other formats”.² They also provide the rationale that “if the cleaning solution is contaminated, spraying may provide a route for airborne transmission which may contaminate the surgical wound, sterile supplies, or the sterile field”.²

With today’s pre-diluted, ready-to-use (RTU) sprays and liquids, the chance of contaminated product is virtually zero³. I would also like to call out that we should not be carrying out environmental cleaning tasks when the patient with a surgical wound or sterile supplies are present anyway - regardless of the disinfectant format used!

The Association for the Healthcare Environment (AHE) Practice Guidance provides no rationale or evidence for their recommendation to “apply chemicals using pour spouts, rather than sprayers”.⁴ Like AORN, AHE recommends “no spraying or misting bottles in the OR as they may aerosolize the disinfectant”.  The source for this guidance? AORNs guidelines which point to the CDC Guidance addressed above. As you can see, we are traversing quite the rabbit hole!

Most importantly, I could find no mention on use of spray disinfectants from the Association for Professionals in Infection Control & Epidemiology (APIC) or from the Centers for Medicare & Medicaid (CMS), the latter of which is a regulatory agency.

The basis for non-use of sprays largely centers on the concern of contaminated disinfectants made from concentrate. While this may be possible, the use of RTU sprays and refillable bottles, the risk can be decreased by emphasizing the need to clean and dry spray bottles rather than “topping off”.

Modern Day Sprays

Some of today's manufactures have engineered sprayers that create larger droplets rather than an aerosolized mist which would reduce the risk that spray bottles aerosolize microorganisms or pose an occupational hazard. So if we connect the dots of what we have learned so far, spray disinfectants do have a place for use in healthcare settings.

Think about conducting a risk assessment to determine when and where in your facility that the use of spray bottles might be appropriate. Some examples might include: vacant spaces such as operating rooms between patients or at end of the day, waiting rooms, public restrooms, conference rooms, and public spaces to list a few. When considering a spray disinfectant, include the following in your assessment:

1. The conditions in which it would be appropriate to use spray disinfectants.
2. Information provided in the Safety Data Sheet (SDS).
3. Product instructions for use (IFUs), including personal protective equipment (PPE).  

Summary

A reassessment of the evidence from past studies is needed. But in the meantime, we must remember that these are guidelines and not regulations and that healthcare facilities can conduct their own risk assessments and implement the appropriate use of spray disinfectants.

References

1. Centers for Disease Control & Prevention (CDC). (2003). Environmental infection Control Guidelines from https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html.
2. Association for periOperative Registered Nurses (AORN). (2020). Guidelines for periOperative Practice from https://www.aorn.org/guidelines/about-aorn-guidelines (subscription required).
3. Weber, D., Rutala, W., Sickbert-Bennett, E. (2007) Outbreaks Associated with Contaminated Antiseptics and Disinfectants. Antimicrobial Agents and Chemotherapy, p. 4217-4224.
4. Association for the Health Care Environment (AHE). (2020). Practice Guidance for Health Care Environmental Cleaning, 3^rd edition from https://www.ahe.org/ahe-publications-home (subscription required).