This study was designed to test in vitro efficacy of 2 improved hydrogen peroxide (HP) products against 3 standard HP products and 1 quaternary ammonium compound. Improved HP is significantly superior to standard HP at the same concentration and can be used for disinfection of environmental surfaces or noncritical patient care items

Gergen, Maria

Rutala, William

Weber, David

Infection Control and Hospital Epidemiology

English

This study was designed to test in vitro efficacy of 2 improved hydrogen peroxide (HP) products against 3 standard HP products and 1 quaternary ammonium compound. Improved HP is significantly superior to standard HP at the same concentration and can be used for disinfection of environmental surfaces or noncritical patient care items.</jats:p

William A. Rutala

Maria F. Gergen

David J. Weber

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Efficacy of Improved Hydrogen Peroxide against Important Healthcare-Associated Pathogens

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infection control and hospital epidemiology november 2012, vol. 33, no. 11c o n c i s e c o m m u n i c a t i o nEfficacy of Improved HydrogenPeroxide against Important Healthcare-Associated PathogensWilliam A. Rutala, PhD, MPH;1,2Maria F. Gergen, MT (ASCP);1David J. Weber, MD, MPH1,2This study was designed to test in vitro efficacy of 2 improvedhydrogen peroxide (HP) products against 3 standard HP productsand 1 quaternary ammonium compound. Improved HP is signifi-cantly superior to standard HP at the same concentration and canbe used for disinfection of environmental surfaces or noncriticalpatient care items.Infect Control Hosp Epidemiol 2012;33(11):1159-1161An improved hydrogen peroxide–based technology has beenintroduced into health care for disinfection of noncriticalenvironmental surfaces and patient equipment1 and high-level disinfection of semicritical equipment such as endo-scopes.2-4 Improved hydrogen peroxide (HP) contains verylow levels of anionic and/or nonionic surfactants in an acidicproduct, which act with HP to produce microbicidal activity.This combination of ingredients speeds the antimicrobial ac-tivity of hydrogen peroxide and cleaning efficiency.3,4 Im-proved HP is considered safe for humans and equipment andbenign for the environment. In fact, improved HP has thelowest Environmental Protection Agency (EPA) toxicity cat-egory (ie, category IV) based on its oral, inhalation, anddermal toxicity, which means it is practically nontoxic andnot an irritant.1,3,5 It is prepared and marketed by severalcompanies in various concentrations (eg, 0.5%–7%) and dif-ferent products may use different terminology for these prod-ucts such as “accelerated” or “activated.” Lower concentra-tions (ie, 0.5%, 1.4%) are designed for the low-leveldisinfection of noncritical environmental surfaces and patientcare objects while the higher concentrations (ie, 12%) canbe used as high-level disinfectants for semicritical medicaldevices (eg, endoscopes).The purpose of the study was to evaluate the antimicrobialactivity of new HP formulations designed for disinfection onnoncritical environmental surfaces and noncritical patientcare equipment with older standard HP formulations and aquaternary ammonium compound (QUAT).methodsDisinfectants TestedWe tested the following disinfectants: A456-II a QUAT (Eco-lab) at 1 : 256; Clorox Healthcare Hydrogen Peroxide CleanerDisinfectant (Clorox), undiluted; hydrogen peroxide (Owensand Minor) at undiluted (3.0%), 1.4%, and 0.5%; and OxivirTB (Johnson Diversey), undiluted.Test OrganismsWe tested 3 epidemiologically important pathogens: a com-munity-acquired methicillin-resistant Staphylococcus aureusstrain (MRSA; USA300), vancomycin-resistant Enterococcus(VRE; ATCC 51299), and multidrug-resistant (MDR) Aci-netobacter baumannii (clinical strain).Our test organism suspensions were prepared fresh dailyby plating each organism to sheep blood agar (SBA; Remel)and incubating it at 37C for approximately 18 hours beforeeach run. Immediately before each run, 0.5 McFarland stan-dard suspensions were prepared from these plates separatelyfor each organism in trypticase soy broth (TSB; Remel). Tosimulate loading with organic material, fetal calf serum (Re-mel) at a final concentration of 5% was added to the TSB.Disinfectant TestingThe second tier of a quantitative carrier test, a standard ofASTM International, was used to determine the bactericidalactivity of the formulations.6 In this test, stainless steel disks(1-cm diameter # 0.7 mm thick; Muzeen and Blythe) werecontaminated with 10 mL of test suspension (103–106 colony-forming units [CFUs] of the test organism). To detect low-level antimicrobial activity (ie, !3-log10 reduction), a lowerinoculum (103 CFUs per carrier) was used when the disin-fectant showed no bactericidal activity at the higher microbialload. One disk each was placed, with contaminated side up,at the bottom of a sterile 20-mL glass vial, covered with 50mL of the test disinfectant and held for the desired contacttime (eg, 30 seconds, 1 minute) at room temperature (202C). We did not test times greater than 1 minute, whichmay have been part of the label claim (eg, 10 minutes) becausethese longer times are difficult to achieve in practice. At theend of the contact time, the action of the disinfectant wasstopped by the addition of 9.95 mL neutralizer (0.85% NaCl 0.1% Tween 80%  3% glycine [except for quaternaryammonium compound used 1% sodium thiosulfate] atpHp7.2–7.4). The contents of the vial were vortexed on highfor 1 minute to elute the inoculum from the surface of thedisks. The eluates and 3 washes of the vials with sterile salinewere passed through a membrane filter (Savur analytical fun-nel containing a 0.22-mL filter; GE Water and Process Tech-nologies). After the vial had been adequately rinsed, the sidesof the analytical funnel were rinsed with 40 mL of sterilesaline. Each filter was aseptically placed on the surface of SBAand incubated at 37C for 48 hours. After 48 hours, the CFUswere counted and the log10 reductions were calculated.1160 infection control and hospital epidemiology november 2012, vol. 33, no. 11table 1. Bactericidal Activity of Disinfectants (log10 Reduction) with a Contact Time of 30 Seconds or 1 Minute at 20C with and withoutFetal Calf Serum (FCS)OrganismOxivir TB(0.5% H2O2) 0.5% H2O2CHHPCD(1.4% H2O2) 1.4% H2O2 3.0% H2O2A456-II(QUAT)∼106 inoculum, contact time p 1 minute,no 5% FCSMRSA 16.62 ≤4.04 16.54 ≤4.04 ≤4.04 5.55VRE 16.34 ≤3.61 16.13 ≤3.61 ≤3.61 4.58MDR A. baumannii 16.76 ≤4.28 16.76 ≤4.28 ≤4.28 16.76∼106 inoculum, contact time p 30 seconds,no 5% FCSMRSA 16.64 NT 16.64 NT ≤4.16 ≤4.16VRE 16.28 NT 16.28 NT ≤3.80 ≤3.80MDR A. baumannii 16.76 NT 16.76 NT ≤4.28 6.11∼103 inoculum, contact time p 1 minute,no 5% FCSMRSA 13.71 ≤1.23 13.71 ≤1.23 ≤1.23 13.71VRE 13.26 1.45 13.26 NT 1.40 13.26MDR A. baumannii 13.53 ≤1.05 13.53 1.75 13.53 13.53∼106 inoculum, contact time p 1 minute,5% FCS presentMRSA 16.72 NT 16.72 NT ≤4.24 ≤4.24VRE 16.26 NT 16.26 NT ≤3.78 ≤3.78MDR A. baumannii 16.56 NT 16.56 NT ≤4.08 16.56note. Individual mean values may have the same result because the same inoculums on the same day may have been run against multipledisinfectants. If complete killing occurred, the minimum inactivation would equal the initial inoculum. Some results reported as “greaterthan X” because complete killing of the inoculums occurred. A. baumannii, Acinetobacter baumannii; CHHPCD, Clorox Healthcare HydrogenPeroxide Cleaner Disinfectant; MDR, multidrug-resistant; MRSA, methicillin-resistant Staphylococcus aureus; NT, not tested; VRE, vanco-mycin-resistant Enterococcus.resultsThe bactericidal activities of the disinfectants tested are dis-played in Table 1, and the statistical analysis is summarizedin Table 2. The 2 improved HP products had similar effec-tiveness (eg, 16-log10 reduction within 30 seconds) againstthe test organisms and were significantly superior to all 3concentrations of HP. The improved HP products were su-perior or similar to the QUAT tested. The standard HP prod-ucts (ie, 3.0%, 1.4%, 0.5%) generally had similar bactericidalactivity. Finally, the QUAT was significantly superior or sim-ilar to the standard HP products. These relationships heldtrue regardless of the presence or absence of fetal calf serumand contact time.discussionThere is excellent evidence in the scientific literature thatenvironmental contamination plays an important role in thetransmission of MRSA, VRE, Clostridium difficile, and Aci-netobacter.7,8 These pathogens have been demonstrated to per-sist in the environment for days (and in some cases, months)to frequently contaminate the environmental surfaces inrooms of colonized or infected patients, to transiently col-onize the hands of healthcare personnel, to be transmittedby healthcare personnel, and to cause outbreaks in whichenvironmental transmission was deemed to play a role. Fur-thermore, admission to a room in which the previous patienthad been colonized or infected with MRSA, VRE, C. difficile,or Acinetobacter has been shown to be a risk factor for thenewly admitted patient to develop colonization or infection.7,8Although environmental contamination has been demon-strated as an important component of patient-to-patienttransmission of these pathogens, the effectiveness of disin-fectants to clean contaminated surfaces has not been com-pletely assessed.It has long been recommended in the United States thatenvironmental surfaces in patient rooms be cleaned and dis-infected on a regular basis (eg, daily, 3 times per week), whensurfaces are visibly soiled, and after patient discharge.9 Disin-fection is generally performed using a 1-step process with anEPA-registered hospital disinfectant such as a QUAT. We com-pared the bactericidal activity of a QUAT to 2 new, improvedHP products. The improved HP appeared to be superior orsimilar to the QUAT tested. When the 2 improved HP productswere compared to 0.5%, 1.4%, and 3% HP formulations, theimproved HP-based environmental surface disinfectantsproved to be more effective (16-log10 reduction) and fast-acting(30–60 seconds) microbicides in the presence of a soil load (tosimulate the presence of body fluids) than commercially avail-able HP. Only 30–60-second contact time was studied becauseimproved hydrogen peroxide 1161table 2. Comparative Efficacy of Improved Hydrogen Peroxide (HP), Standard HP, and a Quaternary Ammonium CompoundOxivir TB 0.5% HP CHHPCD 1.4% HP 3.0% HP A456-IIOxivir TB ... Oxivir TB 10.5% HPOxivir TB pCHHPCDOxivir TB 11.4% HPOxivir TB 13.0% HPaOxivir TB 1 orp A456-II0.5% HP Oxivir TB 10.5% HP... CHHPCD 10.5% HP1.4% HP 1 orp 0.5% HP3.0% HP 1 orp 0.5% HPA456-II 1 orp 0.5% HPCHHPCD Oxivir TB pCHHPCDCHHPCD 10.5% HP... CHHPCD 11.4% HPCHHPCD 13.0% HPaCHHPCD 1 orp A456-II1.4% HP Oxivir TB 11.4% HP1.4% HP 1 orp 0.5% HPCHHPCD 11.4% HP... 3.0% HP 1 orp 1.4% HPA456-II 1 orp 1.4% HP3.0% HP Oxivir TB 13.0% HPa3.0% HP 1 orp 0.5% HPCHHPCD 13.0% HPa3.0% HP 1 orp 1.4% HP... A456-II 1 orp 3.0% HPA456-II Oxivir TB 1 orp A456-IIA456-II 1 orp 0.5% HPCHHPCD 1 orp A456-IIA456-II 1 orp 1.4% HPA456-II 1 orp 3.0% HP...note. Mean log10 reductions, standard deviations, and 95% confidence intervals (CI) were calculated using replicate mea-surements (2–4) for interproduct comparisons. CHHPCD, Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant; “1,”nonoverlapping 95% CI (ie, means were statistically significant at P ! .05); “p,” overlapping 95% CI (ie, means P 1 .05).Environmental Protection Agency (EPA) registration claim for A456-II is 10 minutes, CHHPCD is 30 seconds to 1 minute(bactericidal), Oxivir TB is 1 minute (bactericidal), and standard HP had no EPA registration.a Except against MDR-Acinetobacter baumannii (103 colony-forming units, contact 1 minute, no fetal calf serum).longer contact times (eg, 10 minutes) are not achievable inclinical practice. It appears, therefore, that the surfactants wereable to significantly increase the bactericidal activity of HP.Additionally, the improved HP products have an EPA-regis-tered contact time that is substantially less than most EPA-registered low-level disinfectants.Standard HP is among the oldest microbicides; however,it is relatively unstable, somewhat slow acting, and has limitedantimicrobial activity. The stabilizers, surfactants, and otherexcipients added to the improved HP formulations have ad-dressed these weaknesses.1 Improved HP was also more ef-fective than the tested quaternary ammonium compound andstandard HP. Thus, improved HP offers an option for non-critical environmental surfaces and patient equipment, andit addresses some concerns associated with some low-leveldisinfectants (eg, toxicity, a contact time of 30–60 seconds).acknowledgmentsWe acknowledge Dr. Emily Sickbert-Bennett for the statistical analysis.Potential conflicts of interest. W.A.R. and D.J.W. report that they have beenconsultants to Clorox and Advanced Sterilization Products within the past 3years. M.F.G. reports no conflicts of interest relevant to this article. All authorssubmitted the ICMJE Form for Disclosure of Potential Conflicts of Interest,and the conflicts that the editors consider relevant to this article are disclosedhere.Affiliations: 1. Hospital Epidemiology, University of North Carolina HealthCare, Chapel Hill, North Carolina; 2. Division of Infectious Diseases, Universityof North Carolina School of Medicine, Chapel Hill, North Carolina.Address correspondence to William Rutala, PhD, MPH, 130 Mason FarmRoad, Bioinformatics, Chapel Hill, NC 27599 (brutala@unch.unc.edu).Received January 25, 2012; accepted May 4, 2012; electronically publishedSeptember 21, 2012. 2012 by The Society for Healthcare Epidemiology of America. All rightsreserved. 0899-823X/2012/3311-0016$15.00. DOI: 10.1086/668014references1. Omidbakhsh N, Sattar SA. Broad-spectrum microbicidal activity,toxicologic assessment, and materials compatibility of a new gen-eration of accelerated hydrogen peroxide-based environmentalsurface disinfectant. Am J Infect Control 2006;34:251–257.2. Sattar SA, Adegbunrin O, Ramirez J. Combined application ofsimulated reuse and quantitative carrier test to assess high-leveldisinfection: experiments with an accelerated hydrogen peroxide-based formulation. Am J Infect Control 2002;30:449–457.3. Omidbakhsh N. A new peroxide-based flexible endoscope-com-patible high-level disinfectant. Am J Infect Control 2006;34:571–577.4. Omidbakhsh N, Kenny N. An accelerated hydrogen peroxide(AHP)-based fast-acting and reusable microbicide for manualdisinfection of heat-sensitive semi-critical medical devices. CanJ Infect Control 2008;Spring:81–88.5. Rochon M, Sullivan N. Products based on accelerated and sta-bilized hydrogen peroxide: evidence for cleaning and sanitizingefficiency, environmental and human safety and non-corrosive-ness. Can J Infect Control 1999;Summer:51–55.6. Springthorpe SV, Sattar SA. Quantitative carrier tests (QCT) toassess the germicidal activities of chemicals: rationales and proce-dures. Ottawa: Centre for Research on Environmental Microbi-ology, 2003.7. Otter JA, Yezli S, French GL. The role played by contaminatedsurfaces in the transmission of nosocomial pathogens. Infect Con-trol Hosp Epidemiol 2011;32:687–699.8. Weber DJ, Rutala WA, Miller MB, Huslage K, Sickbert-BennettE. Role of hospital surfaces in the transmission of emerging healthcare-associated pathogens: norovirus, Clostridium difficile, andAcinetobacter species. Am J Infect Control 2010;38:S25–S33.9. Rutala WA, Weber DJ, Healthcare Infection Control PracticesAdvisory Committee. Guideline for disinfection and sterilizationin healthcare facilities, 2008. www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf.

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Efficacy of Improved Hydrogen Peroxide against Important Healthcare-Associated Pathogens

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