Chlorine-releasing Agents Research Articles

Assessing the stability and sporicidal efficacy of oxidizing disinfectants

The role of the healthcare environment in the transmission of clinical pathogens is well established. EN 17126:2018 was developed to address the need for regulated sporicidal product testing and includes a realistic medical soil to enable validation of products that claim combined cleaning and disinfection efficacy. To investigate the chemical stability and sporicidal efficacy of oxidizing disinfectant products in the presence of simulated clean and medical dirty conditions. Disinfectant stability and sporicidal efficacy were evaluated in like-for-like ratios of soil:product. Disinfectants were exposed to simulated test soils and free chlorine, chlorine dioxide or peracetic acid concentrations were measured using standard colorimetric methods. Efficacy of disinfectants against C. difficile R027 endospores was assessed as per EN 17126:2018. Comparisons of performance between clean and medical dirty conditions were performed using one-way analysis of variance. Correlation analysis was performed using Pearson product-moment correlation. Performance of chlorine-releasing agents (sodium dichloroisocyanurate, chlorine dioxide and hypochlorous acid) was concentration dependent, with 1000 ppm chlorine showing reduced stability and efficacy in dirty conditions. By contrast, peracetic acid product demonstrated stability and consistently achieved efficacy in dirty conditions. These results have implications for clinical practice, as ineffective environmental decontamination may increase the risk of transmission of pathogens that can cause healthcare-associated infections.

Virucidal efficacy of hypochlorous acid water for aqueous phase and atomization against SARS-CoV-2.

Coronavirus disease 2019 (COVID-19) is an infectious viral disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that emerged at the end of 2019. SARS-CoV-2 can be transmitted through droplets, aerosols, and fomites. Disinfectants such as alcohol, quaternary ammonium salts, and chlorine-releasing agents, including hypochlorous acid, are used to prevent the spread of SARS-CoV-2 infection. In the present study, we investigated the efficacy of ionless hypochlorous acid water (HOCl) in suspension and by spraying to inactivate SARS-CoV-2. The virucidal efficacy of HOCl solution in tests against SARS-CoV-2 was evaluated as 50% tissue culture infectious dose. Although the presence of organic compounds influenced the virucidal efficacy, HOCl treatment for 20 s was significantly effective to inactivate Wuhan and Delta strains in the suspension test. HOCl atomization for several hours significantly reduced the SARS-CoV-2 attached to plastic plates. These results indicate that HOCl solution with elimination containing NaCl and other ions may have high virucidal efficacy against SARS-CoV-2. This study provides important information about the virucidal efficacy and use of HOCl solution.

Clostridioides difficile spores tolerate disinfection with sodium hypochlorite disinfectant and remain viable within surgical scrubs and gown fabrics.

Clostridioides difficile is the most common cause of antibiotic-associated diarrhoea globally. Its spores have been implicated in the prevalence of C. difficile infection due to their resistance and transmission ability between surfaces. Currently, disinfectants such as chlorine-releasing agents (CRAs) and hydrogen peroxide are used to decontaminate and reduce the incidence of infections in clinical environments. Our previous research demonstrated the ability of C. difficile spores to survive exposure to recommended concentrations of sodium dichloroisocyanurate in liquid form and within personal protective fabrics such as surgical gowns; however, the present study examined the spore response to clinical in-use concentrations of sodium hypochlorite. Spores were exposed to a 10 min contact time of 1000, 5000 and 10 000 p.p.m. sodium hypochlorite, and spore recovery was determined. To understand whether biocide-exposed spores transmitted across clinical surfaces in vitro, biocide-exposed spores were spiked onto surgical scrubs and patient gowns and recovery was determined by a plate transfer assay. Scanning electron microscopy was used to establish if there were any morphological changes to the outer spore coat. The results revealed that viable biocide-exposed C. difficile spores can be recovered from surgical scrubs and patient gowns, with no observable changes to spore morphology, highlighting the potential of these fabrics as vectors of spore transmission. This study demonstrates that alternative strategies should be urgently sought to disinfect C. difficile spores to break the chain of transmission in clinical environments.

Comparative assessment of commercially available wound gels in ex vivo human skin reveals major differences in immune response-modulatory effects

Wound healing is a crucial process for maintaining the function of human skin as a protective barrier to pathogens and other external stress factors. Hydrogels—in combination with antimicrobials—are often used, as moist wound care has been widely accepted as standard therapy. Recently, we reported about immune response-modulatory effects of an octenidine-based hydrogel, however little is known about the mechanism of action of other hydrogels including antiseptic molecules or chlorine-based and chlorine-releasing agents, respectively. The aim of this study was the comparative assessment of commercially available wound gels (octenilin®, Prontosan®, Lavanid®, Betadona®, ActiMaris®, Microdacyn60®, VeriforteTMmed) with regard to their effects on the secretion of distinct cytokines (IL-6, IL-8, IL-10), matrix-metalloproteinases as well as their potential to cause alterations in skin structure and apoptosis. Hence, tape-stripped human ex vivo skin biopsies were treated topically with wound gels and cultured for 48 h. Enzyme-linked immunosorbent assays and an enzyme activity assay of culture supernatants revealed that octenilin® demonstrates significantly broader anti-inflammatory and protease-inhibitory capacities than other wound gels. Further, haematoxylin & eosin as well as caspase-3 staining of treated biopsies showed that octenilin® does not alter skin morphology and shows the least interfering effect on human epidermal cells compared to untreated controls. Overall, this study clearly demonstrates totally different effects for several commercially available hydrogels in our wound model, which gives also new insight into their tissue compatibility and mode of action.

Cleaning agent occupational asthma in the West Midlands, UK: 2000–16

Cleaning agents are now a common cause of occupational asthma (OA) worldwide. Irritant airway and sensitization mechanisms are implicated for a variety of old and new agents. To describe the exposures responsible for cleaning agent OA diagnosed within a UK specialist occupational lung disease service between 2000 and 2016. The Birmingham NHS Occupational Lung Disease Service clinical database was searched for cases of OA caused by cleaning agents, and data were gathered on age, gender, atopic status, smoking history, symptom onset, diagnostic investigations (including Occupational Asthma SYStem analysis of workplace serial peak expiratory flow measurements and specific inhalational challenge), proposed mechanism, industry, occupation and causative agent. Eighty patients with cleaning agent OA (77% female, 76% arising de novo) were identified. The median annual number of cases was 4 (interquartile range = 2-7). The commonest cleaning agents causing OA were chloramines (31%), glutaraldehyde (26%) and quaternary ammonium compounds (11%) and frequently implicated industries were healthcare (55%), education (18%) and leisure (8%). Certain cleaning agents in common usage, such as chlorine-releasing agents, quaternary ammonium compounds and aldehydes, are associated with sensitization and asthma. Their use alters over time, and this is particularly evident in UK healthcare where cleaning and decontamination practice and policy have changed. Vigilance for OA in workplaces such as hospitals, nursing homes, leisure centres and swimming pools, where these cleaning agents are regularly used, is therefore essential.

What causes occupational asthma in cleaners?

Epidemiological studies have consistently found cleaners to be at increased risk of new-onset asthma,1 ,2 the risk seems to be particularly high in domestic cleaners using spray bleaches.2 Due to...

In vitro microbicidal, anti-biofilm and cytotoxic effects of different commercial antiseptics.

Topical antiseptics are widely used for wound treatment, with the goal of disrupting biofilm capacity. We analysed the effectiveness of a variety of antiseptics to inhibit various stages of biofilm formation and to remove biofilms in vitro as well as the agents' cytotoxic effects on fibroblasts. We found that the chlorine-releasing agents exhibited immediate anti-biofilm effects in the short term, with lesser cytotoxicity than agents prepared from more stable compounds, such as biguanide or modified diallyl disulfide-oxide, which, conversely, have better long-term effectiveness. Among the examined organisms, Gram-positive bacteria and Candida albicans were the most sensitive to the antiseptics, whereas Pseudomonas aeruginosa and Acinetobacter baumannii were relatively resistant to them. Formulations whose mechanisms of action involve the release of chemically active chlorine were more effective when administered in solution than the gel form, likely because of the stability of the active ingredients during or after preparation of the formula. Interestingly, hypochlorous acid and some superoxidation solutions were effective in preventing biofilm formation within a short time period and showed virtually no toxicity. Our study indicates that most antiseptics remain effective long enough to prevent biofilm formation; thus, even brief application of an antiseptic agent during initial wound treatment can lead to better wound management outcomes.

S134 Comparison of Specific Inhalation Challenge (SIC) with Oasys Analysis of Serial PEF Analysis in the Diagnosis of Occupational Asthma: Abstract S134 Table 1

Aims to compare Specific inhalation challeng (SIC) with serial measurements of PEF in the diagnosis of occupational asthma Methods; All workers having SIC with occupational agents over a 3 year period were included. Their serial PEF records made during exposure to the suspected agents where analysed using Oasys software. Positive records were those with any of the following; Oasys score >2.5; ABC score ≥15litres/min/hr or timepoint ≥1 non-waking reading Results; 211 challenges were done in 51 workers. 45/51 kept serial PEF records suitable for Oasys analysis. SIC and Oasys analysis were concordant in 17/45 (38%), particularly those exposed to isocyanates or metal-working fluids. SIC was positive in 5 workers with equivocal Oasys analysis in line with its known sensitivity of c70–80%. 12 workers had negative or non-asthmatic SIC responses with positive Oasys analysis. Further investigation showed that occupational asthma was the most likely diagnosis. Negative SIC responses were due failure to identify the correct causative agent or problems with reproducing the work exposures. This was a particular problem with cleaning agents where a protein source may be needed to convert chlorine-releasing agents to chloramines (as shown in swimming pool asthma). Nine workers had equivocal challenges and clearly positive Oasys analysis, helping to clarify the diagnosis in this group, again non-standard agents were common in this group. Conclusion SIC and serial PEF analysis are complementary methods for validating a diagnosis of occupational asthma. SIC has particular problems when methods of exposure for newer agents have not been fully developed, Oasys analysis lacks sensitivity when current specificity is fixed at >90%.

Hypervirulent Clostridium difficile PCR-ribotypes exhibit resistance to widely used disinfectants.

The increased prevalence of Clostridium difficile infection (CDI) has coincided with enhanced transmissibility and severity of disease, which is often linked to two distinct clonal lineages designated PCR-ribotype 027 and 017 responsible for CDI outbreaks in the USA, Europe and Asia. We assessed sporulation and susceptibility of three PCR-ribotypes; 012, 017 and 027 to four classes of disinfectants; chlorine releasing agents (CRAs), peroxygens, quaternary ammonium compounds (QAC) and biguanides. The 017 PCR-ribotype, showed the highest sporulation frequency under these test conditions. The oxidizing biocides and CRAs were the most efficacious in decontamination of C. difficile vegetative cells and spores, the efficacy of the CRAs were concentration dependent irrespective of PCR-ribotype. However, there were differences observed in the susceptibility of the PCR-ribotypes, independent of the concentrations tested for Virkon®, Newgenn®, Proceine 40® and Hibiscrub®. Whereas, for Steri7® and Biocleanse® the difference observed between the disinfectants were dependent on both PCR-ribotype and concentration. The oxidizing agent Perasafe® was consistently efficacious across all three PCR ribotypes at varying concentrations; with a consistent five Log10 reduction in spore titre. The PCR-ribotype and concentration dependent differences in the efficacy of the disinfectants in this study indicate that disinfectant choice is a factor for llimiting the survival and transmission of C. difficile spores in healthcare settings.

Minimal inhibitory concentration (MIC) determination of disinfectant and/or sterilizing agents

Due to the growing number of outbreaks of infection in hospital and nurseries, it becomes essential to set up a sanitation program that indicates that the appropriate chemical agent was chosen for application in the most effective way. Validating the effectiveness of decontamination and disinfection is an important and often challenging task. In order to study and compare the behavior of selected microorganisms, they were submitted to minimal inhibitory concentration (MIC). The MIC intervals, which reduced bacteria populations over 6 log10, were: 59 to 156 mg/L of quaternary ammonium compounds (QACs); 63 to 10000 mg/L of chlorhexidine; 1375 to 3250 mg/L of glutaraldehyde; 39 to 246 mg/L of formaldehyde; 43750 to 87500 mg/L of ethanol; 1250 to 6250 mg/L of iodine in polyvinyl-pyrolidone complexes, 150 to 4491 mg/L of chlorine-releasing-agents (CRAs) and 469 to 2500 mg/L of hydrogen peroxide. Chlorhexidine showed non inhibitory activity over germinating spores. A. calcoaceticus showed resistance to the majority of the agents tested, followed by E. cloacae and S. marcescens.

Determination of the Antibacterial Efficacy of Common Chemical Agents in Cleaning and Disinfection in Hospitals of North Jordan

Problem statement: Hospital cleanleness and hygene are consederd among the most important aspects of clinical success and in preventing nosocomial infections. In this study we will address the problem of effectiveness of commonly used chemical agents in cleaning and disinfection in hospitals of north Jordan. For evaluating the effectiveness of chemical agents. Approach: The minimum inhibitory concentration (MIC) was determined by the method of serial broth dilutions. The bacteria used were Acinetobactev calcoaceticus, Enterobacter cloacae and Serratia marcescens were isolated from material collected from Princess Badea and Princess Rahma hospitals in north Jordan, Bacillus subtilis ATCC 9372, Bacillus stearothermophilus ATCC 7953, Escherichia coli ATCC 25922 and Staphylococcus aureus ATCC 25923,were used as controls. Results: Chlorhexidine showed no inhibitory activity for Bacillus subtilis and Bacillus stearothermophilus. A. calcoaceticus, showed resistance to the majority of the agents tested, followed by E. cloacae and S. marcescens. The MIC intervals, which reduced bacteria populations over 08 log10, were: 65-11000 mg L −1 of chlorhexidine digluconate, 200-4500 mg L −1 of chlorine-releasing-agents (CRAs), 4100-82000 mg L −1 of isopropanol or ethanol, 1350-3500 mg L −1 of glutaraldehyde, 50-250 mg L −1 of formaldehyde, 1200-6000 mg L −1 of iodine in polyvinyl-pyrolidone complexes, 450-2400 mg L −1 of hydrogen peroxide and 60-160 mg L −1 of quaternarium ammonium compounds (QACs). Conclusion: Ethanol, Ethanol plus glycerin and Ethanol iodine were found to be the most effective agents against microorganims tested p<0.05.

Sporicidal activity of two disinfectants against Clostridium difficile spores

The sporicidal activity of an odour-free peracetic acid-based disinfectant (Wofasteril) and a widely-used dichloroisocyanurate preparation (Chlor-clean) was assessed against spores of the hyper-virulent strain of Clostridium difficile (ribotype 027), in the presence and absence of organic matter. In environmentally clean conditions, dichloroisocyanurate achieved a >3 log10 reduction in 3 minutes, but a minimum contact time of 9 minutes was required to reduce the viable spore load to below detection levels. Peracetic acid achieved a >3 log10 reduction in 30 minutes and was overall significantly less effective (P<0.05). However, in the presence of organic matter - which reflects the true clinical environment - there was no significant difference between the sporicidal activity of dichloroisocyanurate and peracetic acid over a 60-minute period (P=0.188). Given the greater occupational health hazards generally associated with chlorine-releasing agents, odour-free peracetic acid-based disinfectants may offer a suitable alternative for environmental disinfection.

Hospital disinfection: efficacy and safety issues

To review recent publications relevant to hospital disinfection (and cleaning) including the reprocessing of medical instruments. The key question as to whether the use of disinfectants on environmental surfaces rather than cleaning with detergents only reduces nosocomial infection rates still awaits conclusive studies. New disinfectants, mainly peroxygen compounds, show good sporicidal properties and will probably replace more problematical substances such as chlorine-releasing agents. The safe reprocessing of medical devices requires a well-coordinated approach, starting with proper cleaning. New methods and substances show promising activity for preventing the transmission of prions. Different aspects of virus inactivation have been studied, and the transmissibility, e.g. of norovirus, shows the need for sound data on how different disinfectant classes perform. Biofilms or other forms of surface-adherent organisms pose an extraordinary challenge to decontamination. Although resistance to biocides is generally not judged to be as critical as antibiotic resistance, scientific data support the need for proper use, i.e. the avoidance of widespread application, especially in low concentrations and in consumer products. Chemical disinfection of heat-sensitive instruments and targeted disinfection of environmental surfaces are established components of hospital infection control. To avoid danger to staff, patients and the environment, prudent use as well as established safety precautions are required. New technologies and products should be evaluated with sound methods. As emerging resistant pathogens will challenge healthcare facilities in the future even more than at present, there is a need for well-designed studies addressing the role of disinfection in hospital infection control.

Introduction of biocides into clinical practice and the impact on antibiotic-resistant bacteria

Biocides and other antimicrobial agents have been employed for centuries. Much later, iodine found use as a wound disinfectant, chlorine water in obstetrics, alcohol as a hand disinfectant and phenol as a wound dressing and in antiseptic surgery. In the early part of the twentieth century, other chlorine-releasing agents (CRAs), and acridine and other dyes were introduced, as were some quaternary ammonium compounds (QACs, although these were only used as biocides from the 1930s). Later still, various phenolics and alcohols, formaldehyde and hydrogen peroxide were introduced and subsequently (although some had actually been produced at an earlier date) biguanides, iodophors, bisphenols, aldehydes, diamidines, isocyanurates, isothiazolones and peracetic acid. Antibiotics were introduced clinically in the 1940s, although sulphonamides had been synthesized and used previously. After penicillin came streptomycin and other aminoglycosides-aminocyclitols, tetracyclines, chloramphenicol, macrolides, semi-synthetic beta-lactams, glycopeptides, lincosamides, 4-quinolones and diaminopyrimidines. Bacterial resistance to antibiotics is causing great concern. Mechanisms of such resistance include cell impermeability, target site mutation, drug inactivation and drug efflux. Bacterial resistance to biocides was described in the 1950s and 1960s and is also apparently increasing. Of the biocides listed above, cationic agents (QACs, chlorhexidine, diamidines, acridines) and triclosan have been implicated as possible causes for the selection and persistence of bacterial strains with low-level antibiotic resistance. It has been claimed that the chronological emergence of qacA and qacB determinants in clinical isolates of Staphylococcus aureus mirrors the introduction and usage of cationic biocides.

Bacterial target sites for biocide action

Although biocides have been used for a century, the number of products containing biocides has recently increased dramatically with public awareness of hygiene issues. The antimicrobial efficacy of biocides is now well documented; however, there is still a lack of understanding of their antimicrobial mechanisms of action. There is a wide range of biocides showing different levels of antimicrobial activity. It is generally accepted that, in contrast to chemotherapeutic agents, biocides have multiple target sites within the microbial cell and the overall damage to these target sites results in the bactericidal effect. Information about the antimicrobial efficacy of a biocide (i.e. the eta-value) might give some useful indications about the overall mode of action of a biocide. Bacteriostatic effects, usually achieved by a lower concentration of a biocide, might correspond to a reversible activity on the cytoplasmic membrane and/or the impairment of enzymatic activity. The bacteriostatic mechanism(s) of action of a biocide is less documented and a primary (unique?) target site within the cell might be involved. Understanding the mechanism(s) of action of a biocide has become an important issue with the emergence of bacterial resistance to biocides and the suggestion that biocide and antibiotic resistance in bacteria might be linked. There is still a lack of understanding of the mode of action of biocides, especially when used at low concentrations (i.e. minimal inhibitory concentration (MIC) or sublethal). Although this information might not be required for highly reactive biocides (e.g. alkylating and oxidizing agents) and biocides used at high concentrations, the use of biocides as preservatives or in products at sublethal concentrations, in which a bacteriostatic rather than a bactericidal activity is achieved, is driving the need to better understand microbial target sites. Understanding the mechanisms of action of biocides serves several purposes: (i) it will help to design antimicrobial formulations with an improved antimicrobial efficacy and (ii) it will ensure the prevention of the emergence of microbial resistance.

Bacterial spores and sporocidal agents

Bacterial spores are highly resistant to a wide array of chemical and physical agents, due to their specialised chemical and physical structure. Clostridium difficile spores are of considerable importance from an infection control perspective, since this organism is the most common cause of nosocomial diarrhoea. Few chemical biocides are actively sporocidal, and many of the disinfectants in use in hospitals are capable only of sporostasis. Examples include phenols, cresols, chlorhexidine, quaternary ammonium compounds and sub-lethal concentrations of chlorine-releasing agents and gluteraldehyde. Sporocidal agents include gluteraldehyde, sodium hypochlorite, iodine/iodophors, hydrogen peroxide and peracetic acid. Assessment or comparison of sporocidal agents should incorporate procedures for the recovery and revival of injured spores, to prevent overestimation of efficacy.

Interaction of Bacillus subtilis spores with sodium hypochlorite, sodium dichloroisocyanurate and chloramine-T.

Solutions of chlorine-releasing agents (CRAs) show varying activity against Bacillus subtilis spores; sodium hypochlorite (NaOCl) shows higher activity than sodium dichloroisocyanurate (NaDCC) which is more active than chloramine-T. Investigations with coat- and cortex-extracted spores indicate that resistance to CRAs depends not only on the spore coat but also the cortex. Whereas extraction of alkali-soluble coat protein increased sensitivity to NaOCl and NaDCC, degradation of coat and cortex material was required to achieve significant activity with chloramine-T. NaOCl (in the presence and absence of NaOH) and NaDCC (in the presence of NaOH only) produced degradation of spore coat and cortex material which may be related to their rapid sporicidal action at low concentrations under these conditions. By contrast, chloramine-T produced no degradation of cortex peptidoglycan and was only effective against normal and alkali-treated spores at high concentrations, requiring extraction of peptidoglycan with urea/dithiothreitol/sodium lauryl sulphate (UDS) or UDS/lysozyme to achieve significant activity at low concentrations. Results suggest that the sporicidal action of CRAs is associated with spore coat and cortex degradation causing rehydration of the protoplast allowing diffusion to the site of action on the underlying protoplast.

Assay of antiseptic agents in cell culture: conditions affecting cytotoxicity

In-vivo studies suggest that chlorine-releasing antiseptic agents inhibit wound healing. Studies which have used cell culture systems to evaluate cytotoxicity have generated conflicting results for the toxicity of free-chlorine agents relative to other antiseptics. Here we examine the following three factors which may influence the toxicity of individual agents within a cell culture assay: (1) cell number; (2) duration of exposure; and (3) the nature of the antiseptic diluent. Three agents (sodium hypochlorite, chlorhexidine and hydrogen peroxide) were tested on transformed human keratinocytes (SVK 14 cells). It was found that increasing cell number, and using serum or medium as a diluent, reduced the toxicity of all agents but had the greatest effect on sodium hypochlorite. In contrast, increasing the duration of exposure increased the toxicity of all agents but had the greatest effect on hydrogen peroxide. These observations may explain the high toxicity of hydrogen peroxide and relatively low toxicity of sodium hypochlorite which have been observed in vitro and are the reverse of in-vivo findings. Culture systems in which high cell numbers are coupled with an agent diluted in serum or medium, and a long exposure time, seem likely to decrease the toxicity of chlorine-releasing agents relative to hydrogen peroxide.

Effect of chlorine-releasing agents on Bacillus subtilis vegetative cells and spores

Buffered solutions of chlorine-releasing agents, sodium hypochlorite (NaOCl), sodium dichloroisocyanurate (NaDCC), and chloramine-T, showed similar activity against vegetative cells of Bacillus subtilis but there was considerable variation in activity against spores, NaOCl showing higher activity than NaDCC, which in turn was more active than chloramine-T. The effect of coat and cortex extraction on sporicidal activity was determined. It was concluded that although spore coats play a role, they do not totally account for chlorine resistance and that the cortex is also involved, probably through its function in maintaining a low water level in the enclosed core. Observed differences in the sporicidal action of NaOCl, NaDCC, and chloramine-T may be related to their differing ability to produce core and cortex degradation.