EGAWA Tomoko

NONAKA Manabu

SEO Yukako

YAMAMURA Yukie

Tokyo Women’s Medical University

Adenosine Triphosphate Bioluminescence Test ofthe Nasal Spray Nozzles Attached to anEar-nose-throat Treatment Unit著者名 YAMAMURA Yukie, EGAWA Tomoko, SEO Yukako,NONAKA Manabujournal orpublication titleTokyo Women's Medical University Journalvolume 2page range 1-5year 2018-12-25URL http://hdl.handle.net/10470/00032117doi: 10.24488/twmuj.2017002(https://doi.org/10.24488/twmuj.2017002)1―1―J.TWMU 2: 1-5, 2018OriginalAdenosine Triphosphate Bioluminescence Test of the Nasal Spray NozzlesAttached to an Ear-nose-throat Treatment UnitYukie YAMAMURA１, Tomoko EGAWA２, Yukako SEO１, and Manabu NONAKA１１Department of Otolaryngology, Tokyo Women’s Medical University, Tokyo, Japan２3rd Grade Medical Student, School of Medicine, Tokyo Women’s Medical University, Tokyo, Japan(Accepted October 31, 2017)(Advance Publication by J-STAGE January 20, 2018)To report a proper protocol for cleaning and disinfecting the nozzles attached to ear-nose-throat (ENT) treatment unit, con-tamination of nasal spray nozzle, nasal speculum, and suction tube before and after use was assessed by adenosine triphos-phate (ATP) bioluminescence test. The measured ATP was expressed as relative light units (RLU).There were no statistical differences in RLU scores among the nasal spray nozzles, nasal speculums, and suction tubes beforepatient use. Nozzle RLU scores increased after patient use. The RLU scores (mean± SD) of the nasal spray nozzles beforeuse was 12± 7.1, increasing to 30± 28.7 after patient use. The RLU scores of the nasal speculums increased to 9,722 ±12,398.9 after patient use. The RLU scores of the suction tubes increased to 88,366± 106,839.3 after patient use. IncreasedRLU scores of spray nozzles were statistically lower than those of nasal speculums and suction tubes.In conclusion, nasal spray nozzles should be wiped with a mid-level disinfectant after use. Alternatively, the nozzle tipsshould be changed between patients. These recommendations should be considered when developing protocols for cleaningand disinfection of nasal spray nozzles used in conjunction with ENT treatment units.Key Words: ENT treatment unit, spray nozzle, contamination, ATP bioluminescence testIntroductionNasal spray nozzles attached to ear-nose-throat (ENT)treatment units are not routinely changed between patientexaminations because the nozzles do not directly contactpatients’ skin or mucosa. However, there is a risk ofcross-contamination by accidental touching of the spraytip to the mucosa, or by contact with nasal discharge,droplets, or aerosolized material because the spray isused near the nostrils (Fig. 1). Past studies have reportedthe detection of coagulase-negative staphylococcus( CNS ) , methicillin-sensitive Staphylococcus aureus(MSSA), and sometimes methicillin-resistant S. aureus(MRSA) on the surface of nasal spray nozzles followingtheir use１）２）.Microbiological culturing is a traditional method forhygiene monitoring; however, these methods have somelimitations. They require several days to get results be-cause a colony growth incubation period is needed.Moreover, these methods cannot detect nonbacterial con-taminants such as blood and mucous.Recently, adenosine triphosphate (ATP)-based micro-Corresponding Author: Yukie Yamamura. Department of Otolaryngology, Tokyo Women’s Medical University, 8-1 Kawada-cho,Shinjuku-ku, Tokyo 162-8666, JapanE-mail: yamamura.yukie@twmu.ac.jpdoi: 10.24488/twmuj.2017002CopyrightⒸ 2018 Society of Tokyo Women’s Medical University2―2―Fig.　1　Using nasal spray near the nostrils of patientFig.　2　Nasal spray nozzles attached to ENT treatment unit (ar-rows: tip)biologic monitoring methods were developed for hygienemonitoring３）. These methods measure ATP, the principalcarrier of energy in all living organisms including micro-organisms. ATP testing can be completed within 10 sec-onds, and is considerably easier and produces more rapidresults compared to traditional swabbing culture meth-ods. We assess the presence of contaminants on the nasalspray nozzle surfaces attached to ENT treatment units viaATP test to report a proper protocol for cleaning and dis-infecting the nozzles.Materials and MethodsThe study was conducted in December 2016. We exam-ined six spray nozzles attached to three ENT treatmentunits located in the consultation room of an ENT prac-tice. Each unit was used to administer two sprays con-taining 2% lidocaine and 0.02% adrenaline (Fig. 2). Asper the clinic’s standard operating procedures, the spraynozzles were cleaned using hot (90°C) water once perweek prior to being reattached to the ENT treatmentunits.1. ATP bioluminescence testPrior to testing, the spray nozzles were wiped with cot-ton soaked in isopropanol. The 3 M™ Clean-Trace™Surface ATP test system was used, consisting of a testswab, cuvette, and 3M™ Clean-Trace™ NG Luminome-ter. The ATP testing protocol was performed accordingto the manufacturer’s instructions４）. The tips of the noz-zles were rubbed with a test swab. The swabs were theninserted into a cuvette containing a luciferin, luciferaseand Mg2+, causing the following enzymatic reaction:ATP + luciferin/luciferase→adenosine monophosphate(AMP) and phosphoric residues+ light (wave of 562 nm)The intensity of this light is proportional to the amountof ATP on the object surface, which corresponds to theamount of contamination by organic residues and micro-organisms. Measurement of light intensity requires a Lu-minometer. This device contains a measuring chamberisolated from external light sources, and a detector thatprocesses the optic signal to the electrical signal, which isexpressed in relative light units (RLU)4 ). Baseline RLUscores were recorded as “before use” scores.The spray nozzles were then used on three patients,and ATP testing was repeated, with the resultant RLUscores recorded as “after use” scores. This cycle of noz-zle cleaning, baseline ATP testing, nozzle use with threepatients, and repeat ATP testing was performed 4-6 timesper each spray nozzle, for a total of 28 times. For com-parison, we also obtained RLU scores from the outer sur-faces of nasal speculums, which were in direct contactwith the nasal cavity, and suction tubes, which were in-serted into the nasal cavity.All statistical analyses were performed using Graph-Pad Prism version 6.0 for Windows. Paired t-tests wereused to compare spray nozzle RLU scores obtained be-fore patient use (after cleaning) and after patient use. Aone way analysis of variance and Tukey-Kramer HSD3―3―Fig.　3　Comparison of RLU scores between nasal spray nozzles,nasal speculums and suction tubes before useThere were no statistical differences in RLU scores among the nasal spray nozzles, nasal speculums, and suction tubes before pa-tient use.Fig.　4　RLU scores of nasal spray nozzles before and after useNozzle RLU scores increased after patient use. The RLU scores(mean ± SD) of the nasal spray nozzles before use was 12 ± 7.1 (highest RLU = 25), increasing to 30 ± 28.7 (highest RLU = 164) after patient use.p<0.01Fig.　5　Comparison of logarithm of RLU scores between nasalspray nozzles, nasal speculums and suction tubes after useThe RLU scores (mean ± SD) after patient use is:nasal spray nozzles, 30 ± 28.7;nasal speculums, 9,722 ± 12,398.9;suction tubes, 88,366 ± 106,839.3.Increases in RLU scores of spray nozzles were statistically smallerthan the increases observed with the nasal speculums and suction tubes.612345** * p<0.01spraynozzlenasalspeculumsucƟŽŶtubeLogarithm of RLUtests were used to compare the logarithm of RLU scoresamong the spray nozzles, nasal speculums, and suctiontubes. Statistical significance was set at a p-value of＜0.05.2. Culturing methodsWe obtained 10 samples from the surfaces of nasalspray nozzles used with the three patients for culturingusing the TranswabTM ENT Amies charcoal MWE. Rou-tine laboratory procedures were used to identify bacterialspecies on the surface of the nozzles. All growths wereconsidered microbiologically positive, regardless of spe-cies or number of colonies forming the unit.Results1. ATP bioluminescence testThere were no statistical differences in RLU scoresamong the nasal spray nozzles, nasal speculums, and suc-tion tubes before patient use (Fig. 3). Nozzle RLU scoresincreased after patient use. The average RLU score(mean ± SD) of the nasal spray nozzles before use was12 ± 7.1, increasing to 30 ± 28.7 after patient use(Fig. 4). The average RLU score of the nasal speculumsincreased from 11 ± 2.8 to 9,722 ± 12,398.9 after pa-tient use. The average RLU score of the suction tubes in-creased from 13 ± 5.7 to 88,366 ± 106,839.3 after pa-tient use. Increases in RLU scores of spray nozzles werestatistically smaller than the increases observed with thenasal speculums and suction tubes (Fig. 5).4―4―2. Culturing methodsMicrobiological cultures of all 10 samples were nega-tive for bacterial growth.DiscussionAccording to Spaulding５）, medical devices are classifiedinto three categories based on the risk of infection associ-ated with use : critical, semi-critical, and noncritical.Critical devices contact sterile tissue or vasculature andshould therefore be sterilized. Semi-critical devices con-tact intact mucous membranes, but do not penetrate ster-ile tissue, and therefore should be cleaned with a high-level disinfectant or undergo hot water disinfection. Non-critical devices touch only intact skin or do not touch thepatient at all. These devices should be cleaned using alow-level disinfectant.Nasal spray nozzles are classified as noncritical de-vices because, in typical practice, they do not touch theskin or mucosa. However, our study demonstrated in-creased RLU scores following patient use, suggestingcontamination originating from the aerosol or accidentaltouching with patient’s mucus, or nasal discharge. RLUscores obtained from the spray nozzles were low com-pared with those obtained from the nasal speculums andsuction tubes, which directly contacted patient skin ormucosa.In the present study, all samples obtained from thespray nozzles were negative for conventional ( swab-based) tests of bacterial growth. However, previous stud-ies reported normal bacterial flora obtained from spraynozzle tips, including CNS, MSSA, and MRSA. Organ-isms that routinely cause respiratory tract infections suchas Haemophilus influenzae, Streptococcus pneumoniae,or Pseudomonas aeruginosa were not detected１）２）６）.Nasal spray nozzles should be wiped using a mid-leveldisinfectant such as ethanol or isopropanol following pa-tient use. Nasal sprays that use disposable tips are alsouseful.ATP tests for hygiene monitoring are well-establishedin food production facilities, with additional applicationsfor monitoring clinical devices and environments３）. Astudy assessing hospital kitchen surfaces showed a statis-tically significant relationship between ATP testing andtraditional cultures obtained via microbial swabbing７）.ATP testing can be completed easily and rapidly com-pared with traditional swabbing culture methods. How-ever, ATP tests are not a substitute for culturing methodsbecause the ATP test is unable to determine the identitiesof specific bacterial strains. Furthermore, ATP testingsensitivity varies among substrates. Turner et al.８） re-ported that pure bacteria are weakly detected with anlimit of detection of 104 for representative gram-negativeand 102 for representative gram-positive bacteria. ATPtesting is unable to detect the gram-negative bacteria be-cause of incomplete cell lysis.ATP tests can determine the general form of surfacecontamination, including cultivable and non-cultivablemicrobial and organic contamination. In the presentstudy, ATP testing detected mild contamination on thesurface of the nasal spray nozzles. These results wouldnot have been obtained using traditional swabbing cul-tural methods.ConclusionWe measured contamination of the surfaces of nasalspray nozzles using ATP bioluminescence testing. Afteruse with three patients, the nasal spray nozzles showedincreased RLU scores, indicative of contamination, al-though RLU scores obtained from nasal spray nozzleswere statistically lower than those obtained from nasalspecula and suction tubes, both of which directly contactthe nasal cavity or nasal discharge. Nasal spray nozzlesshould be wiped with a mid-level disinfectant after use.Alternatively, the nozzle tips should be changed betweenpatients. These recommendations should be consideredwhen developing protocols for cleaning and disinfectionof nasal spray nozzles used in conjunction with ENTtreatment units.AcknowledgementsThis study was performed as a part of Research Project for3rd grade (Segment 6) Medical Students at Tokyo Women’sMedical University. The authors would like to thank Prof.Hiroki Fujieda and the research project committee members.Conflicts of Interest: The authors have no conflicts of in-5―5―terest, and no financial disclosures to report.References1）Mori S: Quantitative evaluation of bacterial contamina-tion of the otorhinolaryngologic medical instrumentswithout thorough disinfection. J Jpn Soc Infect AerosolOtorhinolaryngol 4: 14―19, 2016 (in Japanese)2）Nakajima N, Abe M, Miwa M et al: Bacterial investiga-tion of nasal spray nozzles for ambulatory treatment. JpnJ Rhinol 49: 138―142, 2010 (in Japanese)3）Sygula-Cholewiska J, Lech T, Szostak-Kot J et al: ATPbioluminescence method in surface hygiene monitoring.https://www.researchgate.net/publication/270283798_ATP_BIOLUMINESCENCE_METHOD_IN_SURFACE_HYGIENE_MONITORING ( accessed on Nov 16,2017)4）3M Clean-Trace™ Product Instructions. 2013, http://multimedia.3m.com/mws/media/807474O/3m-clean-trace-surface-atp-uxl100-product-instruction.pdf ( accessed onNov 16, 2017)5）Spaulding EH, Cundy KR, Turner FJ: Part IV. Medicaland health-related applications 33 Chemical disinfectionof medical and surgical materials, infection. In Disin-fection, Sterilization and Preservation, 2nded. (Block SSed), pp654―684, Lea & Febiger, Philadelphia (1977)6）Ikeda K, Sakai Y, Misawa N et al: Bacterial contami-nation of multiple-use atomizers commonly used in Ja-pan. J Jpn Soc Infect Aerosol Otorhinolaryngol 26: 51―53, 2008 (in Japanese)7）Aycicek H, Oguz U, Karci K et al: Comparison of resultsof ATP bioluminescence and traditional hygiene swab-bing methods for the determination of surface cleanlinessat a hospital kitchen. Int J Hyg Environ Health 209: 203―206, 20068）Turner DE, Daugherity EK, Altier C et al: Efficacy andlimitations of an ATP-based monitoring system. J AmAssoc Lab Anim Sci 49: 190―195, 2010

Adenosine Triphosphate Bioluminescence Test of the Nasal Spray Nozzles Attached to an Ear-nose-throat Treatment Unit

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Adenosine Triphosphate Bioluminescence Test of the Nasal Spray Nozzles Attached to an Ear-nose-throat Treatment Unit

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