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Disinfection with sodium hypochlorite in hospital environmental surfaces in the reduction of contamination and infection prevention: a systematic review* * Extracted from the Scientific Initiation Project PIBIC "Desinfecção de superfícies ambientais hospitalares com hipoclorito de sódio e redução de infecção ou contaminação: uma revisão sistemática", Escola de Enfermagem, Universidade de São Paulo, 2014.

Desinfección con hipoclorito de sodio en superficies ambientales hospitalarias en la reducción de contaminación y prevención de infección: revisión sistemática

Abstracts

OBJECTIVE

To search for evidence of the efficiency of sodium hypochlorite on environmental surfaces in reducing contamination and prevention of healthcare-associated infection HAIs.

METHOD

Systematic review in accordance with the Cochrane Collaboration.

RESULTS

We analyzed 14 studies, all controlled trials, published between 1989-2013. Most studies resulted in inhibition of microorganism growth. Some decreased infection, microorganism resistance and colonization, loss of efficiency in the presence of dirty and surface-dried viruses.

CONCLUSION

The hypochlorite is an effective disinfectant, however, the issue of the direct relation with the reduction of HAIs remains. The absence of control for confounding variables in the analyzed studies made the meta-analysis performance inadequate. The evaluation of internal validity using CONSORT and TREND was not possible because its contents were not appropriate to laboratory and microbiological studies. As a result, there is an urgent need for developing specific protocol for evaluating such studies.

Disinfection; Sodium Hypochlorite; Health Facilities; Cross Infection; Review


OBJETIVO

Buscar evidencias acerca de la eficiencia del hipoclorito de sodio en superficies ambientales en la reducción de contaminación y prevención de infección asociada con la asistencia a la salud-IRAS.

MÉTODO

Revisión sistemática en conformidad con la Colaboración Cochrane. Resultados: Se analizaron 14 estudios, todos experimentales controlados, publicados entre 1989-2013. La mayoría resultó en inhibición de crecimiento microbiano. Algunos presentaron reducción de infección, de la resistencia microbiana y la colonización, pérdida de eficiencia en la presencia de suciedad y virus secos rehidratados.

CONCLUSIÓN

El hipoclorito constituye desinfectante efectivo. Sin embargo, persiste el tema de la relación directa con la reducción de IRAS. La ausencia de control de variables de confusión en los estudios analizados imposibilitó el metanálisis. No fue posible la evaluación de validez interna por los CONSORT y TREND, pues sus contenidos no se mostraron apropiados para las investigaciones llevadas a cabo, tanto de laboratorio como microbiológicas. En virtud de eso, urge la necesidad de desarrollo de protocolo específico a fin de evaluar los estudios de esa naturaleza.

Desinfección; Hipoclorito de Sodio; Instituciones de Salud; Infección Hospitalaria; Revisión


OBJETIVO

Buscar evidências sobre a eficiência do hipoclorito de sódio em superfícies ambientais na redução de contaminação e prevenção de infecção associada à assistência à saúde-IRAS.

MÉTODO

Revisão sistemática em conformidade com a Colaboração Cochrane.

RESULTADOS

Foram analisados 14 estudos, todos experimentais controlados, publicados entre 1989-2013. A maioria resultou em inibição de crescimento microbiano. Alguns apresentaram redução de infecção, da resistência microbiana e da colonização, perda de eficiência na presença de sujidade e vírus secos reidratados.

CONCLUSÃO

O hipoclorito constitui desinfetante efetivo, todavia persiste a questão da relação direta com a redução de IRAS. A ausência de controle de variáveis de confusão nos estudos analisados impossibilitou a metanálise. Não foi possível avaliação de validade interna pelos CONSORT e TREND, pois seus conteúdos não se mostraram apropriados às investigações realizadas, laboratorial e microbiológica. Em razão disso, urge a necessidade de desenvolvimento de protocolo específico para avaliação de estudos dessa natureza.

Desinfecção; Hipoclorito de Sódio; Instituições de Saúde; Infecção Hospitalar; Revisão


Introduction

Over 30 years ago, Spaulding established an approach to the treatment of hospital equipment, classifying them according to their potential risk of contamination and transmission of infection in: critical, semi-critical and non-critical items(1Spaulding EH. Chemical disinfection of medical and surgical materials. In: Lawrence C, Block SS, editors. Disinfection, sterilization, and preservation. Philadelphia: Lea & Febiger; 1968. p. 517-31.). This classification also founded several guidelines recommendations for aseptic procedures(2Garner JS, Favero MS. CDC guidelines for the prevention and control of nosocomial infections. Guideline for handwashing and hospital environmental control, 1985. Supersedes guideline for hospital environmental control published in 1981. Am J Infect Control. 1986;14(3):110-29.

Centers for Disease Control (CDC). Guidelines for prevention of transmission of human immunodeficiency virus and hepatitis B virus to health-care and public-safety workers. MMWR Morb Mortal Wkly Rep. 1989;38 Suppl 6:1-37.

Sehulster L, Chinn RY; Centers for Disease Control, Healthcare Infection Control Practices Advisory Committee. Guidelines for environmental infection control in health-care facilities. MMWR Recomm Rep. 2003;52(RR-10):1-42.
-5Rutala WA, Weber DJ; Centers for Disease Control, Healthcare Infection Control Practices Advisory Committee. CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Atlanta: CDC; 2008.).

According to this classification, the critical items are those which come into direct contact with sterile tissues or vascular system as well as other items that are connected to them. They, therefore, need sterilization. The semi-critical items come into contact with mucous membranes or non-intact skin. In these cases, high-level disinfection is recommended. And non-critical items come in contact with intact skin, but not mucous membranes, so the only recommendation is cleaning(1Spaulding EH. Chemical disinfection of medical and surgical materials. In: Lawrence C, Block SS, editors. Disinfection, sterilization, and preservation. Philadelphia: Lea & Febiger; 1968. p. 517-31.).

In 1991, the Centers for Disease Control and Prevention (CDC) proposed an additional category to the original Spaulding classification for non-critical items called environmental surfaces which, in turn, can be divided into equipment surfaces (X-ray apparatus, hemodialysis machine etc.) and housekeeping surfaces (furniture, floor, wall, table top etc.)(6Favero MS, Bond WW. Chemical disinfection of medical and surgical materials. In:, Block SS editor. Disinfection, sterilization, and preservation. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 881-917.).

There are still doubts about the treatment to be given to environmental surfaces. Theoretically, if included as non-critical items in the original Spaulding classification, they only need cleaning(1Spaulding EH. Chemical disinfection of medical and surgical materials. In: Lawrence C, Block SS, editors. Disinfection, sterilization, and preservation. Philadelphia: Lea & Febiger; 1968. p. 517-31.). But the Disinfection and Sterilization in Healthcare Facilities guidelines proposed by CDC considers that environmental surfaces are frequently touched by hands and may potentially contribute to secondary transmission by contaminated hands of health professionals or by contact of medical equipment, which are subsequently used in patients(4Sehulster L, Chinn RY; Centers for Disease Control, Healthcare Infection Control Practices Advisory Committee. Guidelines for environmental infection control in health-care facilities. MMWR Recomm Rep. 2003;52(RR-10):1-42.). It is also known that certain microorganisms that cause healthcare-associated infections (HAIs) are resistant to common cleaning processes, survive for long periods on surfaces under dry conditions and can be transferred not only through hands, but also by air movement in the environment(7Weber DJ,. Rutala WA Environmental issues and nosocomial infections. In: Wenzel RP, editor. Prevention and control of nosocomial infections. Baltimore: Williams & Wilkins; 1997. p. 491-514.). Such considerations have been referred to defend the disinfection and not just cleaning environmental surfaces.

Virtually, the risk of transmission of infection by non-critical items has not been documented(7Weber DJ,. Rutala WA Environmental issues and nosocomial infections. In: Wenzel RP, editor. Prevention and control of nosocomial infections. Baltimore: Williams & Wilkins; 1997. p. 491-514.). However, a systematic review has shown that available studies do not yet allow a conclusion and, given the complex and multifactorial nature of HAIs, well-designed studies that systematically investigate the role of disinfecting surfaces in the transmission of infection are still needed(8Dettenkofer M, Wenzler S, Amthor S, Antes G, Motschall E, Daschner FD. Does disinfection of environmental surfaces influence nosocomial infection rates? A systematic review. Am J Infect Cotrol. 2004;32(2):84-89. ). In turn, the National Evidence-Based Guide Related to Infection Prevention in Health Care (epic3), instead of generalizing the treatment of any item recommend levels of cleaning or disinfection procedures, according to circumstances of use, contamination and occurrences of cases of colonization or infection(9Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Bak A, et al. epic 3: national evidence-based guideline for preventing healthcare-associated infections in NHS Hospitals in England. J Hosp Infect. 2014;86 Suppl 1: S1-70.).

Despite the new products and new technologies for disinfection procedures, sodium hypochlorite is still one of the most widely used and accessible products in terms of cost and benefit. This study intends to seek evidence on their efficiency on environmental surfaces in reducing contamination and prevention of healthcare-associated infections - HAIs.

Method

A systematic review in accordance with the recommendations of the Cochrane Collaboration was conducted. The searches were performed from December 2013 to February 2014 in the databases COCHRANE, LILACS, PubMed/MEDLINE, SciELO, CINAHL, in addition to references cited in the studies found. We used the PICO strategy: Participants = tests in situ or in vitro with microorganisms commonly isolates from environmental surfaces and medical equipment; Intervention = sodium hypochlorite application; Comparison = other products or different concentrations of hypochlorite; Outcome = degree of colonization reduction, contamination or microorganism resistance, or prevention of HAIs.

The inclusion criteria were: primary studies without language restriction and publication period, obtained in full. Exclusion criteria were: multimodal interventions, the lack of use of sodium hypochlorite and the non-use of the product on laboratory surfaces.

For the selection of the descriptors, we used the tools provided by CINAHL (Cumulative Index to Nursing and Allied Health Literature), MeSH (Medical Subject Headings Section) of the PubMed/MEDLINE and DeCS (Health Sciences Descriptors) and Synonyms combinations of terms obtained by means of prior readings, resulting in combinations: "sodium hypochlorite/pharmacology" AND "disinfection/methods" AND hospitals AND surfac* / "infections control/methods" AND "environmental microbiology" AND hospitals AND surfac* /"cross infection" AND "sodium hypochlorite" / "sodium hypochlorite/pharmacology" AND hospitals. The search strategy used was the same for each database, the screening was performed for more than two reviewers.

The data analysis criteria followed the steps: 1) screening of studies; 2) study characteristics (methodological design, scope, setting, tested microorganism, sodium hypochlorite concentration, outcome, conclusion); 3) analysis of evidence provided by TREND protocol version 1.0 (designed for non-randomized studies)(1010 Jarlais DCD, Lyles C, Crepaz N. Improving the reporting quality of non-randomized evaluations of behavioral and public health interventions: the TREND statement. Am J Public Health. 2004;94(3):361-6.) and CONSORT (designed for randomized trials)(1111 Schulz KF, Altman DG, Moher D. Consort 2010 Statement: updated guidelines for reporting parallel [Internet]. [cited 2014 May 15]. Available from: http://www.equator-network.org/reporting-guidelines/consort/
http://www.equator-network.org/reporting...
), if their applications were possible.

Results

Figure 1 shows the result of the flow chart diagram. There was a predominance of studies from PubMed/Medline (99), followed by CINAHL (66), LILACS (7), SciELO (3) and COCHRANE (1). Most studies were excluded because they were duplicates, not primary study, did not meet the question asked, or was not possible to obtain the full-text to apply the inclusion or exclusion criteria. Of the 26 remaining studies after reading in full, the other 12 studies were excluded since they are simultaneous multi-interventions, they did not test the sodium hypochlorite or have it tested in non-environmental surface or tested along with other products, preventing recognition of their isolates effect. Thus, 14 studies were included.

Figure 1
Selection process of studies in the databases - Sao Paulo, SP, Brazil, 2014

A total of five full-text studies not found were excluded: 1) Hoefel HHK, Porto BS, Petrillo VF. Soluções germicidas e detergentes para uso no Hospital de Clinicas de Porto Alegre/Desinfetantes e sabonetes. Rev. HCPA Fac. Med. Univ. Fed. Rio Gd. Sul 1988;8(3):208-11; 2) Coates D. Disinfectants and spills of body fluids. Nurs RSA. 1992 Jun;7(6):25-7; 3) Kaboth U, Junge U. Prophylaxis of viral hepatitis. Clin Gastroenterol. 1974 May;3(2):453-70; 4) Carswell JW. Precautions against HIV transmission in hospitals.Trop Doct. 1989 Jul;19(3):131-2; 5) Lehman HH. Flame-resistant fabrics. Hospitals. 1973 Oct 16;47(20):98-106.

Of the included studies, 12 were published in the twenty-first century, four studies in the last decade (2010-2013). Only two were published in the previous century (1989-1999). The publications were mainly on internationally recognized and specialized journals on the topic of HAIs: Infection Control and Hospital Epidemiology (5); Journal of Hospital Infection (5); American Journal of Infection Control (2). Two were published in Brazil, one of them also in a specialized journal on the topic of HAIs (Brazilian Journal of Microbiology) and another in a general nursing journal (Ciência, Cuidado e Saúde).

Chart 1 presents a summary of the included studies, containing scope, types of study, testing and outcome, investigated microorganisms, hypochlorite concentrations applied and conclusion.

Chart 1
Synthesis and evaluation of the studies included in the systematic review - Sao Paulo, SP, Brazil, 2014.

All studies used interventions and tested the action of sodium hypochlorite. Regarding the type of intervention, they are divided between those which conducted tests only in laboratory (in vitro)(1212 Campos GB, Souza SG, Lob OTN, Silva DC, Sousa DS, Oliveira PS, et al. Isolation, molecular characteristics and disinfection of methicillin-resistant Staphylococcus aureus from ICU units in Brazil. New Microbiol. 2012;35(2):183-90.

13 Fawley WN, Underwood S, Freeman J, Baines SD, Saxton K, Stephenson K, et al. Efficacy of hospital cleaning agents and germicides against epidemic Clostridium difficile strains. Infect Control Hosp Epidemiol. 2007;28(8):920-5.

14 Bloomfield SF, Miller EA. A comparison of hypochlorite and phenolic disinfectants for disinfection of clean and soiled surfaces and blood spillages. J Hosp Infect. 1989;13(3):231-9.

15 Svidzinski AE, Posseto I, Pádua RAF, Tavares TR, Svidzinski TIE. Eficiência do ácido peracético no controle de staphylococcus aureus meticilina resistente. Ciênc Cuidado Saúde. 2007;6(3):312-8.

16 Perez J, Springthorpe VS, Sattar SA. Activity of selected oxidizing microbicides against the spores of Clostridium difficile: relevance to environmental. Am J Infect Control. 2005;33(6):320-5.

17 Silverman J, Vazquez JA, Sobel JD, Zervos MJ. Comparative in vitro activity of antiseptics and disinfectants versus clinical isolates of candida species. Infect Control Hosp Epidemiol. 1999;20(10):676-84.

18 Ekizoglu MT, Özalp M, Sultan N, Gür D. An investigation of the bactericidal effect of certain antiseptics and disinfectants on some hospital isolates of gram‐negative bacteria. Infect Control Hosp Epidemiol. 2003;24(3):225-7.
-1919 Guimarães MA, Tibana A, Nunes MP, Santos KRN. Disinfectant and antibiotic activities: a comparative analysis in Brazilian hospital bacterial isolates. Braz J Microbiol. 2000;31(3):193-9.) and those which tested samples directly (in situ) in various environmental surfaces: floors, walls, equipment etc.(2020 Orenstein R, Aronhalt KC, McManus JE Jr, Fedraw LA. A targeted strategy to wipe out Clostridium difficile. Infect Control Hosp Epidemiol. 2011;32(11):1137-9.

21 Barbut F, Menuet D, Verachten M, Girou E. Comparison of the efficacy of a hydrogen peroxide dry-mist disinfection system and sodium hypochlorite solution for eradication of Clostridium difficile spores. Infect Control Hosp Epidemiol. 2009;30(6):507-14.

22 Hacek DM, Ogle AM, Fisher A, Robicsek A, Peterson LR. Significant impact ofterminal room cleaning with bleach on reducing nosocomial Clostridium difficile. Am J Infect Control. 2010;38(5):350-3.

23 McMullen KM, Zack J, Coopersmith CM, Kollef M, Dubberke E, Warren DK. Use of hypochlorite solution to decrease rates of Clostridium difficile-associated diarrhea. Infect Control Hosp Epidemiol. 2007;28(2):205-7.
-2424 Wilcox MH, Fawley WN, Wigglesworth N, Parnell P, Verity P,. Freeman J Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile infection. J Hosp Infect. 2003;54(2):109-14.). Thus, all induced microbiological tests. Among the tested microorganisms, most strains represented clinical isolates from patients or surfaces and equipment, being resistant to several antibiotics. The most tested microorganism was C.difficile(1313 Fawley WN, Underwood S, Freeman J, Baines SD, Saxton K, Stephenson K, et al. Efficacy of hospital cleaning agents and germicides against epidemic Clostridium difficile strains. Infect Control Hosp Epidemiol. 2007;28(8):920-5.,1616 Perez J, Springthorpe VS, Sattar SA. Activity of selected oxidizing microbicides against the spores of Clostridium difficile: relevance to environmental. Am J Infect Control. 2005;33(6):320-5.,2020 Orenstein R, Aronhalt KC, McManus JE Jr, Fedraw LA. A targeted strategy to wipe out Clostridium difficile. Infect Control Hosp Epidemiol. 2011;32(11):1137-9.

21 Barbut F, Menuet D, Verachten M, Girou E. Comparison of the efficacy of a hydrogen peroxide dry-mist disinfection system and sodium hypochlorite solution for eradication of Clostridium difficile spores. Infect Control Hosp Epidemiol. 2009;30(6):507-14.

22 Hacek DM, Ogle AM, Fisher A, Robicsek A, Peterson LR. Significant impact ofterminal room cleaning with bleach on reducing nosocomial Clostridium difficile. Am J Infect Control. 2010;38(5):350-3.

23 McMullen KM, Zack J, Coopersmith CM, Kollef M, Dubberke E, Warren DK. Use of hypochlorite solution to decrease rates of Clostridium difficile-associated diarrhea. Infect Control Hosp Epidemiol. 2007;28(2):205-7.
-2424 Wilcox MH, Fawley WN, Wigglesworth N, Parnell P, Verity P,. Freeman J Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile infection. J Hosp Infect. 2003;54(2):109-14.), followed by S. aureus, MRSA or not(1212 Campos GB, Souza SG, Lob OTN, Silva DC, Sousa DS, Oliveira PS, et al. Isolation, molecular characteristics and disinfection of methicillin-resistant Staphylococcus aureus from ICU units in Brazil. New Microbiol. 2012;35(2):183-90.,1414 Bloomfield SF, Miller EA. A comparison of hypochlorite and phenolic disinfectants for disinfection of clean and soiled surfaces and blood spillages. J Hosp Infect. 1989;13(3):231-9.-1515 Svidzinski AE, Posseto I, Pádua RAF, Tavares TR, Svidzinski TIE. Eficiência do ácido peracético no controle de staphylococcus aureus meticilina resistente. Ciênc Cuidado Saúde. 2007;6(3):312-8.,1919 Guimarães MA, Tibana A, Nunes MP, Santos KRN. Disinfectant and antibiotic activities: a comparative analysis in Brazilian hospital bacterial isolates. Braz J Microbiol. 2000;31(3):193-9.), various species of Candida(1717 Silverman J, Vazquez JA, Sobel JD, Zervos MJ. Comparative in vitro activity of antiseptics and disinfectants versus clinical isolates of candida species. Infect Control Hosp Epidemiol. 1999;20(10):676-84.)and lipophilic viruses(2525 Terpstra FG, van den Blink AE, Bos LM, Boots AG, Brinkhuis FH, Gijsen E, et al. Resistance of surface-dried virus to common disinfection procedures. J Hosp Infect. 2007;66(4):332-8.), various Gram(1818 Ekizoglu MT, Özalp M, Sultan N, Gür D. An investigation of the bactericidal effect of certain antiseptics and disinfectants on some hospital isolates of gram‐negative bacteria. Infect Control Hosp Epidemiol. 2003;24(3):225-7.), E. coli(14) and others(1919 Guimarães MA, Tibana A, Nunes MP, Santos KRN. Disinfectant and antibiotic activities: a comparative analysis in Brazilian hospital bacterial isolates. Braz J Microbiol. 2000;31(3):193-9.).

Only four studies sought, as an outcome, a direct correlation between microbicidal action of disinfectant and infection rates(2020 Orenstein R, Aronhalt KC, McManus JE Jr, Fedraw LA. A targeted strategy to wipe out Clostridium difficile. Infect Control Hosp Epidemiol. 2011;32(11):1137-9.,2222 Hacek DM, Ogle AM, Fisher A, Robicsek A, Peterson LR. Significant impact ofterminal room cleaning with bleach on reducing nosocomial Clostridium difficile. Am J Infect Control. 2010;38(5):350-3.

23 McMullen KM, Zack J, Coopersmith CM, Kollef M, Dubberke E, Warren DK. Use of hypochlorite solution to decrease rates of Clostridium difficile-associated diarrhea. Infect Control Hosp Epidemiol. 2007;28(2):205-7.
-2424 Wilcox MH, Fawley WN, Wigglesworth N, Parnell P, Verity P,. Freeman J Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile infection. J Hosp Infect. 2003;54(2):109-14.). Most of them were correlated to inactivation rates, reduction or inhibition of microbial growth(1313 Fawley WN, Underwood S, Freeman J, Baines SD, Saxton K, Stephenson K, et al. Efficacy of hospital cleaning agents and germicides against epidemic Clostridium difficile strains. Infect Control Hosp Epidemiol. 2007;28(8):920-5.,1515 Svidzinski AE, Posseto I, Pádua RAF, Tavares TR, Svidzinski TIE. Eficiência do ácido peracético no controle de staphylococcus aureus meticilina resistente. Ciênc Cuidado Saúde. 2007;6(3):312-8.

16 Perez J, Springthorpe VS, Sattar SA. Activity of selected oxidizing microbicides against the spores of Clostridium difficile: relevance to environmental. Am J Infect Control. 2005;33(6):320-5.

17 Silverman J, Vazquez JA, Sobel JD, Zervos MJ. Comparative in vitro activity of antiseptics and disinfectants versus clinical isolates of candida species. Infect Control Hosp Epidemiol. 1999;20(10):676-84.

18 Ekizoglu MT, Özalp M, Sultan N, Gür D. An investigation of the bactericidal effect of certain antiseptics and disinfectants on some hospital isolates of gram‐negative bacteria. Infect Control Hosp Epidemiol. 2003;24(3):225-7.
-1919 Guimarães MA, Tibana A, Nunes MP, Santos KRN. Disinfectant and antibiotic activities: a comparative analysis in Brazilian hospital bacterial isolates. Braz J Microbiol. 2000;31(3):193-9.,2121 Barbut F, Menuet D, Verachten M, Girou E. Comparison of the efficacy of a hydrogen peroxide dry-mist disinfection system and sodium hypochlorite solution for eradication of Clostridium difficile spores. Infect Control Hosp Epidemiol. 2009;30(6):507-14.,2525 Terpstra FG, van den Blink AE, Bos LM, Boots AG, Brinkhuis FH, Gijsen E, et al. Resistance of surface-dried virus to common disinfection procedures. J Hosp Infect. 2007;66(4):332-8.). Furthermore, a study tested the outcome microbial resistance(1212 Campos GB, Souza SG, Lob OTN, Silva DC, Sousa DS, Oliveira PS, et al. Isolation, molecular characteristics and disinfection of methicillin-resistant Staphylococcus aureus from ICU units in Brazil. New Microbiol. 2012;35(2):183-90.). With two exceptions(1414 Bloomfield SF, Miller EA. A comparison of hypochlorite and phenolic disinfectants for disinfection of clean and soiled surfaces and blood spillages. J Hosp Infect. 1989;13(3):231-9.,2525 Terpstra FG, van den Blink AE, Bos LM, Boots AG, Brinkhuis FH, Gijsen E, et al. Resistance of surface-dried virus to common disinfection procedures. J Hosp Infect. 2007;66(4):332-8.), the other studies presented results favorable to the action of sodium hypochlorite to the proposed outcomes, either for inactivation or inhibition of microbial growth(1313 Fawley WN, Underwood S, Freeman J, Baines SD, Saxton K, Stephenson K, et al. Efficacy of hospital cleaning agents and germicides against epidemic Clostridium difficile strains. Infect Control Hosp Epidemiol. 2007;28(8):920-5.,1515 Svidzinski AE, Posseto I, Pádua RAF, Tavares TR, Svidzinski TIE. Eficiência do ácido peracético no controle de staphylococcus aureus meticilina resistente. Ciênc Cuidado Saúde. 2007;6(3):312-8.

16 Perez J, Springthorpe VS, Sattar SA. Activity of selected oxidizing microbicides against the spores of Clostridium difficile: relevance to environmental. Am J Infect Control. 2005;33(6):320-5.

17 Silverman J, Vazquez JA, Sobel JD, Zervos MJ. Comparative in vitro activity of antiseptics and disinfectants versus clinical isolates of candida species. Infect Control Hosp Epidemiol. 1999;20(10):676-84.

18 Ekizoglu MT, Özalp M, Sultan N, Gür D. An investigation of the bactericidal effect of certain antiseptics and disinfectants on some hospital isolates of gram‐negative bacteria. Infect Control Hosp Epidemiol. 2003;24(3):225-7.
-1919 Guimarães MA, Tibana A, Nunes MP, Santos KRN. Disinfectant and antibiotic activities: a comparative analysis in Brazilian hospital bacterial isolates. Braz J Microbiol. 2000;31(3):193-9.,2121 Barbut F, Menuet D, Verachten M, Girou E. Comparison of the efficacy of a hydrogen peroxide dry-mist disinfection system and sodium hypochlorite solution for eradication of Clostridium difficile spores. Infect Control Hosp Epidemiol. 2009;30(6):507-14.), reduction of infection(2020 Orenstein R, Aronhalt KC, McManus JE Jr, Fedraw LA. A targeted strategy to wipe out Clostridium difficile. Infect Control Hosp Epidemiol. 2011;32(11):1137-9.,2222 Hacek DM, Ogle AM, Fisher A, Robicsek A, Peterson LR. Significant impact ofterminal room cleaning with bleach on reducing nosocomial Clostridium difficile. Am J Infect Control. 2010;38(5):350-3.

23 McMullen KM, Zack J, Coopersmith CM, Kollef M, Dubberke E, Warren DK. Use of hypochlorite solution to decrease rates of Clostridium difficile-associated diarrhea. Infect Control Hosp Epidemiol. 2007;28(2):205-7.
-2424 Wilcox MH, Fawley WN, Wigglesworth N, Parnell P, Verity P,. Freeman J Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile infection. J Hosp Infect. 2003;54(2):109-14.), microbial resistance(1212 Campos GB, Souza SG, Lob OTN, Silva DC, Sousa DS, Oliveira PS, et al. Isolation, molecular characteristics and disinfection of methicillin-resistant Staphylococcus aureus from ICU units in Brazil. New Microbiol. 2012;35(2):183-90.). Among the exceptions, one of them showed loss of efficiency in a situation of heavy dirtying with organic matter(1414 Bloomfield SF, Miller EA. A comparison of hypochlorite and phenolic disinfectants for disinfection of clean and soiled surfaces and blood spillages. J Hosp Infect. 1989;13(3):231-9.). The other was effective for dry viruses, but not in the presence of rehydrated virus(2525 Terpstra FG, van den Blink AE, Bos LM, Boots AG, Brinkhuis FH, Gijsen E, et al. Resistance of surface-dried virus to common disinfection procedures. J Hosp Infect. 2007;66(4):332-8.).

Although in most studies the results have been favorable to the action of hypochlorite, efficiency varied according to time of exposure and concentration. The concentrations ranged from 0.01% to 5.25%. Similarly, the concentrations of the products used for comparison.

The hypochlorite was superior to quaternary ammonium(1313 Fawley WN, Underwood S, Freeman J, Baines SD, Saxton K, Stephenson K, et al. Efficacy of hospital cleaning agents and germicides against epidemic Clostridium difficile strains. Infect Control Hosp Epidemiol. 2007;28(8):920-5.,1919 Guimarães MA, Tibana A, Nunes MP, Santos KRN. Disinfectant and antibiotic activities: a comparative analysis in Brazilian hospital bacterial isolates. Braz J Microbiol. 2000;31(3):193-9.,2222 Hacek DM, Ogle AM, Fisher A, Robicsek A, Peterson LR. Significant impact ofterminal room cleaning with bleach on reducing nosocomial Clostridium difficile. Am J Infect Control. 2010;38(5):350-3.,2525 Terpstra FG, van den Blink AE, Bos LM, Boots AG, Brinkhuis FH, Gijsen E, et al. Resistance of surface-dried virus to common disinfection procedures. J Hosp Infect. 2007;66(4):332-8.), composed by quaternary ammonium(1717 Silverman J, Vazquez JA, Sobel JD, Zervos MJ. Comparative in vitro activity of antiseptics and disinfectants versus clinical isolates of candida species. Infect Control Hosp Epidemiol. 1999;20(10):676-84.), detergent(1313 Fawley WN, Underwood S, Freeman J, Baines SD, Saxton K, Stephenson K, et al. Efficacy of hospital cleaning agents and germicides against epidemic Clostridium difficile strains. Infect Control Hosp Epidemiol. 2007;28(8):920-5.,2424 Wilcox MH, Fawley WN, Wigglesworth N, Parnell P, Verity P,. Freeman J Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile infection. J Hosp Infect. 2003;54(2):109-14.), hydrogen peroxide(1313 Fawley WN, Underwood S, Freeman J, Baines SD, Saxton K, Stephenson K, et al. Efficacy of hospital cleaning agents and germicides against epidemic Clostridium difficile strains. Infect Control Hosp Epidemiol. 2007;28(8):920-5.), povidone iodine(1717 Silverman J, Vazquez JA, Sobel JD, Zervos MJ. Comparative in vitro activity of antiseptics and disinfectants versus clinical isolates of candida species. Infect Control Hosp Epidemiol. 1999;20(10):676-84.), 4% chlorhexidine(1717 Silverman J, Vazquez JA, Sobel JD, Zervos MJ. Comparative in vitro activity of antiseptics and disinfectants versus clinical isolates of candida species. Infect Control Hosp Epidemiol. 1999;20(10):676-84.), phenolic(1919 Guimarães MA, Tibana A, Nunes MP, Santos KRN. Disinfectant and antibiotic activities: a comparative analysis in Brazilian hospital bacterial isolates. Braz J Microbiol. 2000;31(3):193-9.). It was equivalent to 2% quaternary ammonium(1212 Campos GB, Souza SG, Lob OTN, Silva DC, Sousa DS, Oliveira PS, et al. Isolation, molecular characteristics and disinfection of methicillin-resistant Staphylococcus aureus from ICU units in Brazil. New Microbiol. 2012;35(2):183-90.) chlorhexidine(1212 Campos GB, Souza SG, Lob OTN, Silva DC, Sousa DS, Oliveira PS, et al. Isolation, molecular characteristics and disinfection of methicillin-resistant Staphylococcus aureus from ICU units in Brazil. New Microbiol. 2012;35(2):183-90.), formaldehyde(1212 Campos GB, Souza SG, Lob OTN, Silva DC, Sousa DS, Oliveira PS, et al. Isolation, molecular characteristics and disinfection of methicillin-resistant Staphylococcus aureus from ICU units in Brazil. New Microbiol. 2012;35(2):183-90.), ethanol(2525 Terpstra FG, van den Blink AE, Bos LM, Boots AG, Brinkhuis FH, Gijsen E, et al. Resistance of surface-dried virus to common disinfection procedures. J Hosp Infect. 2007;66(4):332-8.), NaOH(2525 Terpstra FG, van den Blink AE, Bos LM, Boots AG, Brinkhuis FH, Gijsen E, et al. Resistance of surface-dried virus to common disinfection procedures. J Hosp Infect. 2007;66(4):332-8.), peracetic acid(1515 Svidzinski AE, Posseto I, Pádua RAF, Tavares TR, Svidzinski TIE. Eficiência do ácido peracético no controle de staphylococcus aureus meticilina resistente. Ciênc Cuidado Saúde. 2007;6(3):312-8.), hydrogen peroxide(1616 Perez J, Springthorpe VS, Sattar SA. Activity of selected oxidizing microbicides against the spores of Clostridium difficile: relevance to environmental. Am J Infect Control. 2005;33(6):320-5.), aldehydes(1919 Guimarães MA, Tibana A, Nunes MP, Santos KRN. Disinfectant and antibiotic activities: a comparative analysis in Brazilian hospital bacterial isolates. Braz J Microbiol. 2000;31(3):193-9.), and phenol in the presence of large amounts of organic matter(1414 Bloomfield SF, Miller EA. A comparison of hypochlorite and phenolic disinfectants for disinfection of clean and soiled surfaces and blood spillages. J Hosp Infect. 1989;13(3):231-9.). And it was less than the hydrogen peroxide under dry steam(2121 Barbut F, Menuet D, Verachten M, Girou E. Comparison of the efficacy of a hydrogen peroxide dry-mist disinfection system and sodium hypochlorite solution for eradication of Clostridium difficile spores. Infect Control Hosp Epidemiol. 2009;30(6):507-14.) hydrogen peroxide(1616 Perez J, Springthorpe VS, Sattar SA. Activity of selected oxidizing microbicides against the spores of Clostridium difficile: relevance to environmental. Am J Infect Control. 2005;33(6):320-5.), chlorhexidine(1818 Ekizoglu MT, Özalp M, Sultan N, Gür D. An investigation of the bactericidal effect of certain antiseptics and disinfectants on some hospital isolates of gram‐negative bacteria. Infect Control Hosp Epidemiol. 2003;24(3):225-7.), and chlorhexidine with cetrimide(1818 Ekizoglu MT, Özalp M, Sultan N, Gür D. An investigation of the bactericidal effect of certain antiseptics and disinfectants on some hospital isolates of gram‐negative bacteria. Infect Control Hosp Epidemiol. 2003;24(3):225-7.).

All studies are controlled trials, thus, all of them performed interventions that included product testing and established comparisons. Only three assessed their interventions, two considering before and after with randomization(2020 Orenstein R, Aronhalt KC, McManus JE Jr, Fedraw LA. A targeted strategy to wipe out Clostridium difficile. Infect Control Hosp Epidemiol. 2011;32(11):1137-9.-2121 Barbut F, Menuet D, Verachten M, Girou E. Comparison of the efficacy of a hydrogen peroxide dry-mist disinfection system and sodium hypochlorite solution for eradication of Clostridium difficile spores. Infect Control Hosp Epidemiol. 2009;30(6):507-14.), and a cross-over without mentioning randomization(2424 Wilcox MH, Fawley WN, Wigglesworth N, Parnell P, Verity P,. Freeman J Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile infection. J Hosp Infect. 2003;54(2):109-14.). The randomization has been done to the surfaces for comparison of applying different products. However, authors who reported randomization in the methodology, recognized in the conclusion that this was not a randomized controlled trial, but only before-and-after randomization(2020 Orenstein R, Aronhalt KC, McManus JE Jr, Fedraw LA. A targeted strategy to wipe out Clostridium difficile. Infect Control Hosp Epidemiol. 2011;32(11):1137-9.).

While all studies have used a single type of investigation (controlled trial), meta-analysis was not adequate due to the variety of resources used in conducting the interventions, regarding the source, types of microorganisms, collecting materials, means of microbial culture, surfaces, products, concentrations and outcomes. It can be considered that each study used a singular intervention strategy. None of them were similar to each other. Similarly, in the internal validity analysis, the protocols available - CONSORT and TREND were not possible to apply. The content of the checklists were not adequate to the nature of the studies whose subjects were surfaces and microorganisms.

Discussion

It is known that healthcare-associated infections (HAIs) represent a substantial risk to patient safety and several transmitter pathogens of these infections are on surfaces and equipment more often handled by professionals and patients. Although the direct relationship of the presence of pathogens in these surfaces with the transmission of HAIs is not yet sufficiently clarified, at least in specific locations and situations disinfection actions are recommended, not just cleaning(9Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Bak A, et al. epic 3: national evidence-based guideline for preventing healthcare-associated infections in NHS Hospitals in England. J Hosp Infect. 2014;86 Suppl 1: S1-70.).

It is observed that despite being one of the most traditional disinfectants, hypochlorite remains studied and compared with other technologies and products.

It was presented that hypochlorite showed superior action or equivalence to most other products with broad microbicidal action, including spores, and progressive action as longer exposure time and concentration, especially those related to HAIs transmission.

When compared to other products, hypochlorite was equal or more effective in the majority of studies, however, it was inferior in concentration of 0.5% to the dry steam system of hydrogen peroxide(2121 Barbut F, Menuet D, Verachten M, Girou E. Comparison of the efficacy of a hydrogen peroxide dry-mist disinfection system and sodium hypochlorite solution for eradication of Clostridium difficile spores. Infect Control Hosp Epidemiol. 2009;30(6):507-14.).

There were also contradictory results compared to chlorhexidine(1717 Silverman J, Vazquez JA, Sobel JD, Zervos MJ. Comparative in vitro activity of antiseptics and disinfectants versus clinical isolates of candida species. Infect Control Hosp Epidemiol. 1999;20(10):676-84.-1818 Ekizoglu MT, Özalp M, Sultan N, Gür D. An investigation of the bactericidal effect of certain antiseptics and disinfectants on some hospital isolates of gram‐negative bacteria. Infect Control Hosp Epidemiol. 2003;24(3):225-7.) and hydrogen peroxide(1616 Perez J, Springthorpe VS, Sattar SA. Activity of selected oxidizing microbicides against the spores of Clostridium difficile: relevance to environmental. Am J Infect Control. 2005;33(6):320-5.). The breadth and efficiency of their action were directly related to the concentration and the time employed, with variation between studies, as well as the types of microorganisms. Such situations led to varying degrees of inactivation or inhibition of microorganism growth.

Nearly all microorganisms tested corresponded to those most often responsible for occurrences of HAIs. C. difficile is the most tested(1313 Fawley WN, Underwood S, Freeman J, Baines SD, Saxton K, Stephenson K, et al. Efficacy of hospital cleaning agents and germicides against epidemic Clostridium difficile strains. Infect Control Hosp Epidemiol. 2007;28(8):920-5.,1616 Perez J, Springthorpe VS, Sattar SA. Activity of selected oxidizing microbicides against the spores of Clostridium difficile: relevance to environmental. Am J Infect Control. 2005;33(6):320-5.,2020 Orenstein R, Aronhalt KC, McManus JE Jr, Fedraw LA. A targeted strategy to wipe out Clostridium difficile. Infect Control Hosp Epidemiol. 2011;32(11):1137-9.

21 Barbut F, Menuet D, Verachten M, Girou E. Comparison of the efficacy of a hydrogen peroxide dry-mist disinfection system and sodium hypochlorite solution for eradication of Clostridium difficile spores. Infect Control Hosp Epidemiol. 2009;30(6):507-14.

22 Hacek DM, Ogle AM, Fisher A, Robicsek A, Peterson LR. Significant impact ofterminal room cleaning with bleach on reducing nosocomial Clostridium difficile. Am J Infect Control. 2010;38(5):350-3.

23 McMullen KM, Zack J, Coopersmith CM, Kollef M, Dubberke E, Warren DK. Use of hypochlorite solution to decrease rates of Clostridium difficile-associated diarrhea. Infect Control Hosp Epidemiol. 2007;28(2):205-7.
-2424 Wilcox MH, Fawley WN, Wigglesworth N, Parnell P, Verity P,. Freeman J Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile infection. J Hosp Infect. 2003;54(2):109-14.), probably for its great ability to survive in the environment. This result favors the recognition of hypochlorite action on hospital microorganisms.

The results of the direct relationship of hypochlorite action with the transmission of HAIs are questionable, because, although four studies have sought this relationship with an outcome that showed favorable results, these studies have problematic aspects in their research designs(2020 Orenstein R, Aronhalt KC, McManus JE Jr, Fedraw LA. A targeted strategy to wipe out Clostridium difficile. Infect Control Hosp Epidemiol. 2011;32(11):1137-9.,2222 Hacek DM, Ogle AM, Fisher A, Robicsek A, Peterson LR. Significant impact ofterminal room cleaning with bleach on reducing nosocomial Clostridium difficile. Am J Infect Control. 2010;38(5):350-3.

23 McMullen KM, Zack J, Coopersmith CM, Kollef M, Dubberke E, Warren DK. Use of hypochlorite solution to decrease rates of Clostridium difficile-associated diarrhea. Infect Control Hosp Epidemiol. 2007;28(2):205-7.
-2424 Wilcox MH, Fawley WN, Wigglesworth N, Parnell P, Verity P,. Freeman J Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile infection. J Hosp Infect. 2003;54(2):109-14.). For example, all compared the infection rates before and after the intervention, they did not control for confounding variables, mainly related to intrinsic and extrinsic risk factors. Two of them recognize this limitation(2020 Orenstein R, Aronhalt KC, McManus JE Jr, Fedraw LA. A targeted strategy to wipe out Clostridium difficile. Infect Control Hosp Epidemiol. 2011;32(11):1137-9.,2323 McMullen KM, Zack J, Coopersmith CM, Kollef M, Dubberke E, Warren DK. Use of hypochlorite solution to decrease rates of Clostridium difficile-associated diarrhea. Infect Control Hosp Epidemiol. 2007;28(2):205-7.).

Even so, despite obtaining significant reductions of environmental contamination (66.5%) and new colonization (24.8%). The others did not help determine if intervention occurred only with the use of hypochlorite or if there were also changes in techniques and cleaning frequency(1313 Fawley WN, Underwood S, Freeman J, Baines SD, Saxton K, Stephenson K, et al. Efficacy of hospital cleaning agents and germicides against epidemic Clostridium difficile strains. Infect Control Hosp Epidemiol. 2007;28(8):920-5.,2222 Hacek DM, Ogle AM, Fisher A, Robicsek A, Peterson LR. Significant impact ofterminal room cleaning with bleach on reducing nosocomial Clostridium difficile. Am J Infect Control. 2010;38(5):350-3.).

Thus, the 14 included studies responded favorably to the question of this systematic review, in relation to the antimicrobial action of hypochlorite, but not in reducing the occurrence of HAIs, so there is no way to conclude by evidence, either through meta-analysis, or by internal validity analysis.

Most studies of this review sought to detail the stages of the investigation; however, none of them presented references or standards for previously validated experimental procedures, determining extremely variable strategies. Moreover, although they constitute comparative studies, none of them had strict care control for confounding variables(2626 Larson E, Cortazal M. Publication guidelines need widespread adaption. J Clin Epidemiol. 2012;65(3):239-46.).

Even if the use of sodium hypochlorite present efficiency in its action against microorganisms associated with HAIs transmission, several issues still hinder the development of a protocol for safe use, including, especially, a relationship between concentration, action time, type and resistance of the microorganism, type and concentration of dirty.

Conclusion

Sodium hypochlorite presents undeniable microbicidal action on causative agents of HAIs. It was not possible to complete their direct participation in reducing colonization and/or transmission of HAIs, due to methodological problems of the analyzed studies, mainly related to the control of confounding variables. Overall, the studies in this review have extreme methodological variations, which was not sufficient to conclude that evidence to be prepared a hypochlorite application protocol that includes specific conditions of time of action, concentration and type of microorganism. At the same time, it urges the development of protocols to analyze the internal validity of microbiological experimental studies that precisely allow the evidence sought in this review.

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    Campos GB, Souza SG, Lob OTN, Silva DC, Sousa DS, Oliveira PS, et al. Isolation, molecular characteristics and disinfection of methicillin-resistant Staphylococcus aureus from ICU units in Brazil. New Microbiol. 2012;35(2):183-90.
  • 13
    Fawley WN, Underwood S, Freeman J, Baines SD, Saxton K, Stephenson K, et al. Efficacy of hospital cleaning agents and germicides against epidemic Clostridium difficile strains. Infect Control Hosp Epidemiol. 2007;28(8):920-5.
  • 14
    Bloomfield SF, Miller EA. A comparison of hypochlorite and phenolic disinfectants for disinfection of clean and soiled surfaces and blood spillages. J Hosp Infect. 1989;13(3):231-9.
  • 15
    Svidzinski AE, Posseto I, Pádua RAF, Tavares TR, Svidzinski TIE. Eficiência do ácido peracético no controle de staphylococcus aureus meticilina resistente. Ciênc Cuidado Saúde. 2007;6(3):312-8.
  • 16
    Perez J, Springthorpe VS, Sattar SA. Activity of selected oxidizing microbicides against the spores of Clostridium difficile: relevance to environmental. Am J Infect Control. 2005;33(6):320-5.
  • 17
    Silverman J, Vazquez JA, Sobel JD, Zervos MJ. Comparative in vitro activity of antiseptics and disinfectants versus clinical isolates of candida species. Infect Control Hosp Epidemiol. 1999;20(10):676-84.
  • 18
    Ekizoglu MT, Özalp M, Sultan N, Gür D. An investigation of the bactericidal effect of certain antiseptics and disinfectants on some hospital isolates of gram‐negative bacteria. Infect Control Hosp Epidemiol. 2003;24(3):225-7.
  • 19
    Guimarães MA, Tibana A, Nunes MP, Santos KRN. Disinfectant and antibiotic activities: a comparative analysis in Brazilian hospital bacterial isolates. Braz J Microbiol. 2000;31(3):193-9.
  • 20
    Orenstein R, Aronhalt KC, McManus JE Jr, Fedraw LA. A targeted strategy to wipe out Clostridium difficile. Infect Control Hosp Epidemiol. 2011;32(11):1137-9.
  • 21
    Barbut F, Menuet D, Verachten M, Girou E. Comparison of the efficacy of a hydrogen peroxide dry-mist disinfection system and sodium hypochlorite solution for eradication of Clostridium difficile spores. Infect Control Hosp Epidemiol. 2009;30(6):507-14.
  • 22
    Hacek DM, Ogle AM, Fisher A, Robicsek A, Peterson LR. Significant impact ofterminal room cleaning with bleach on reducing nosocomial Clostridium difficile. Am J Infect Control. 2010;38(5):350-3.
  • 23
    McMullen KM, Zack J, Coopersmith CM, Kollef M, Dubberke E, Warren DK. Use of hypochlorite solution to decrease rates of Clostridium difficile-associated diarrhea. Infect Control Hosp Epidemiol. 2007;28(2):205-7.
  • 24
    Wilcox MH, Fawley WN, Wigglesworth N, Parnell P, Verity P,. Freeman J Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile infection. J Hosp Infect. 2003;54(2):109-14.
  • 25
    Terpstra FG, van den Blink AE, Bos LM, Boots AG, Brinkhuis FH, Gijsen E, et al. Resistance of surface-dried virus to common disinfection procedures. J Hosp Infect. 2007;66(4):332-8.
  • 26
    Larson E, Cortazal M. Publication guidelines need widespread adaption. J Clin Epidemiol. 2012;65(3):239-46.
  • *
    Extracted from the Scientific Initiation Project PIBIC "Desinfecção de superfícies ambientais hospitalares com hipoclorito de sódio e redução de infecção ou contaminação: uma revisão sistemática", Escola de Enfermagem, Universidade de São Paulo, 2014.

Publication Dates

  • Publication in this collection
    Jul-Aug 2015

History

  • Received
    12 Nov 2014
  • Accepted
    19 May 2015
Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br