INFECTION CONTROL

[Drsumitra]

 Question 1. There have been a number of waterless, alcohol-based hand antiseptics marketed in recent years. I hear from colleagues they are recommended over hand washing for routine use in clinical settings. Does this mean that hand washing is no longer considered effective or acceptable?

You have several acceptable choices for accomplishing effective hand hygiene in your practice. These alternatives are included in the comprehensive 2003 Centers for Disease Control and Prevention (CDC) infection control recommendations for dentistry. Either plain soap or an antimicrobial soap and water can be used for nonsurgical dental procedures, such as examinations, preventive procedures, restorative dentistry, orthodontics, and endodontic procedures. If hands are not visibly soiled or contaminated with blood or other potentially infectious material (ie, saliva, bloody saliva), use of a waterless, alcohol-based hand rub is also acceptable. It is important to note the specific wording of the recommendation: “If hands are not visibly soiled, an alcohol-based hand rub can also be used.” 
While the use of an antiseptic agent provides effective antimicrobial activity against overgrowth of normal, commensal, and transient microflora; the basic tenet of hand washing is to clean hands. Several factors must be considered when deciding what approach will be used. These factors include the type of procedures performed in the clinical facility, degree of anticipated contamination during patient treatment, and whether or not residual or persistent antimicrobial activity is needed after hand hygiene procedures. Thus, you can choose to routinely use a liquid soap or antimicrobial antiseptic and water. Use of plain soap is appropriate for removing skin debris and microbial contamination. Since intact skin is a primary barrier, any non-antimicrobial soap considered should contain ingredients to prevent skin irritation and dryness to help preserve epithelial integrity. Optimal properties for use of an antimicrobial antiseptic with water should include broad antimicrobial spectrum of activity, ability to act fast, and a residual, persistent effectiveness. 
The key for use of whatever hand hygiene agent that you decide upon is compliance. Several clinical reports published in the medical literature have indicated that the incidence of healthcare-associated infections decreased as healthcare workers (HCW) demonstrated improved hand hygiene practices. Other studies have also shown that compliance increased with use of alcohol-based hand rubs. As such, the 2002 CDC guidelines for hand hygiene in healthcare settings that served as the basis for the 2003 dental recommendations, advocated a combined protocol of hand washing and alcohol-based agents for routine hand antisepsis.

Question 2. Are there any recommendations for the use of hand lotion in clinical settings?
Lotions are recommended to reduce drying of hands and possible dermatitis from glove use. Use of lotions is especially important in healthcare where HCW frequently wash their hands 20 or more times a day, thereby leading to an increased potential for chronic irritation dermatitis. Previously, the overwhelming majority of commercial lotions were petroleum-based. While they can lubricate and replenish keratinized epithelial tissues, these formulations also unfortunately react with gloves being worn (primarily latex gloves) and increase their permeability. Basically, the gloves can become tacky, and thus do not provide the appropriate dexterity needed during treatment. Water-based lotions are far more compatible with gloves, can be absorbed into the skin more rapidly, and have become increasingly available in both the healthcare and public marketplaces. When deciding which lotion to use, consider the possible interaction of the glove type, dental materials, and antimicrobial hand hygiene products with the lotion.

Question 3. What are some of the common errors that can lead to sterilization failure? 
There are multiple factors that can adversely affect sterilization cycles in an autoclave, dry heat, or unsaturated chemical vapor sterilizer. Problems that apply to each of these heat sterilizers include the following 6 issues:
1. Improper cleaning of instruments. Cleaning is the basic, critical step in instrument processing because it involves removal of contaminating debris and organic material from an instrument before sterilization. If blood, saliva, and other contamination remain, they can shield adherent microorganisms and potentially compromise the sterilization process.
2. Improper packaging. This factor includes using the wrong type of packaging material for method of sterilization, placing too many instruments in a package, and wrapping items in excessive amounts of packing wrap. If the material used to package instruments is not compatible, or excessive wrap is used, the sterilizing agent (ie, moist heat under pressure, dry heat, unsaturated chemical vapor under pressure) may not be able to appropriately contact instrument surfaces, thereby resulting in a sterilization failure. Also, if the packaging material cannot withstand the high temperatures required for dry heat sterilizers, it may melt and create additional problems with the unit.
3. Overloading the sterilizer. Overloading the chamber can result in prolonged warm-up times needed to reach sterilization conditions, and may also prevent thorough contact of the sterilizing agent with all items in the unit. Not spacing wrapped instrument packages adequately is a common problem observed with sterilization failures. Most sterilizers sold in recent years are provided with racks or trays, which allow a maximal capacity of instrument packages and effective sterilization with prescribed cycles. A number of older units can also be fitted with available racks or trays. 
4. Inappropriate sterilization time, temperature, and/or pressure. Issues to consider here include use of inadequate temperature or time during the sterilization cycle and interrupting the total cycle. Human error plays a role here if the sterilizer door is opened during the cycle or timers are incorrectly set, thereby resulting in incomplete sterilization. 
5. Inadequate maintenance of sterilization equipment. Routine maintenance as recommended by the manufacturer is critical to the whole instrument processing protocol. Examples of problem areas here are defective control gauges, which may give erroneous readings of conditions inside the chamber and worn door gaskets and seals. 
6. Use of improper equipment for sterilization. This potential problem is clearly addressed in the CDC Guidelines for Infection Control in Dental Health-Care Settings—2003, with the recommendation: “Use only FDA-cleared medical devices for sterilization and follow the manufacturer’s instructions for correct use.” Neither household ovens nor smaller toaster ovens meet the stringent criteria required in testing and evaluation as heat sterilizers.