or low risk items are those that contact normal intact
skin or the environment and do not touch the patient.
This category includes bedpans, crutches, blood pressure
cuffs, bed rails, walls, floors, some patient furniture,
sinks and drains. These items are expected to be clean,
but can be contaminated with some microorganisms.
For equipment in this category, low-level disinfection
can be achieved with a variety of agents, including
chlorine at 100ppm (500 parts dilution).
or high risk items include healthcare equipment that
enters sterile tissue or the vascular system. Intravenous
and urinary catheters, surgical instruments, implants
and other invasive devices are in this category. High
risk equipment requires sterilization by either chemical
or thermal means, such as steam, ethylene oxide, hydrogen
peroxide plasma and ozone. Chlorine products are not
recommended for sterilization.
third category, semi-critical or intermediate
risk, includes those items that do not penetrate the
skin or enter sterile body areas, but are in contact
with mucous membranes or non-intact skin or other
surfaces contaminated with potentially virulent and
transmissible organisms. The objective of high-level
disinfection is to render the objects free from vegetative
organisms with the exception of bacterial spores.
Items in this category are respiratory therapy and
anesthesia equipment, endoscopes, tonometers and endocavity
probes. Semi-critical items present the greatest infection
challenges in healthcare organizations. Fortunately,
chlorine products have been quite useful in reducing
risk with these items. The U.S. Food and Drug Administration
(FDA) has approved chlorine for high level disinfection
at 650-675 ppm for 10 minutes.8
for Emerging Pathogens
potential for emerging pathogens to cause HAIs and
the ability of available disinfectants to destroy
these organisms remains an ongoing concern.9
According to the World Health Organization (WHO) emerging
pathogens are those that are making their appearance
in a human population for the first time or have occurred
previously but are increasing in incidence or expanding
into areas where they have not previously been reported,
usually over the last 20 years. Emerging organisms
of concern include cryptosporidium parvum and
Enterobacter coli 0157:H7 that are transmitted by
contaminated food, water, the environment and from
one person to another. Helicobacter pylorus
has been transmitted from inadequately disinfected
endoscopes and hepatitis C from percutaneous or mucous
membrane exposure to blood via sharps injuries or
from contaminated blood products. The SARS coronavirus,
newer more resistant strains of Clostridium difficile,
multi-drug resistant M. tuberculosis and non tuberculous
mycobacteria (Mycobacterium chleonae), human
papilloma virus, prions, norovirus and rotavirus have
all caused HAIs. Additionally, the agents of plague,
small pox and the hemorrhagic fevers are worrisome
because of their easy transmissibility and high level
of morbidity among persons should they enter the community
or healthcare setting.
It is important to note that, for the most part, standard
disinfection and sterilization procedures in HCOs
are adequate to disinfect or sterilize instruments
or devices contaminated with blood and other body
fluids from persons infected with emerging pathogens
and bloodborne pathogens.10. Exceptions include the
human papilloma virus and prions (Creutzfeld-Jakob
following three emerging pathogens are worthy of mention
because of their ability to 1) cause severe healthcare
associated gastroenteritis, 2) their relative resistance
to chemical disinfection, and 3) the recommended use
of hypochlorite-based products during outbreaks or
high levels of contamination.
Clostridium difficile, an anaerobic, spore-forming
bacterium, has been around for a long time. However,
a new strain has emerged recently that appears to
be more virulent, more resistant to antimicrobial
agents, more difficult to treat and is associated
with increased morbidity and mortality.13.14,15,
16 This strain has caused large outbreaks in
Canada, the U.S and other countries. It is responsible
for about 15-25 percent of all C. difficile
associated diarrhea [CDAD] in the U.S. and nearly
all pseudomembraneous colitis. These infections have
a 10-15 percent mortality rate and add over a billion
dollars per year to health system costs.17
The vegetative form of C. difficile can live
24 hours and spores can remain viable up to 5 months
on surfaces. The patient environment may be highly
contaminated depending on whether the patient is incontinent
or has CDAD. Significantly, major contamination has
been found even when patients are asymptomatic.18,19,20
Investigators have established correlations between
high levels of environmental contamination and the
presence of C difficile on the hands of healthcare
staff or disease in patients.21,22 It is
generally acknowledged that the potential for transmission
from environment-to-patient can occur from shared
instruments, environmental surfaces, the hands of
hospital personnel and infected roommates.
surface disinfection is very effective against C.
difficile. In one study, the use of chlorine at
500-1600 ppm decreased the surface contamination and
ended an outbreak.18 In another study,
the incidence of CDAD in bone marrow transplant patients
decreased from 8.6 to 3.3 per 1000 patient days when
the disinfecting agent for the environment was changed
from a quaternary ammonium compound to a 1:10 dilution
of hypochlorite solution.23 Hypochlorite
at 1,000 ppm was effective in decontaminating the
environment of one ward where over one-third of cultures
were positive for C. difficile.24 And acidified
bleach at 5,000 ppm inactivated all spores in less
than 10 minutes in another study 25.
the healthcare setting, good hand-washing with soap
and water (alcohol-based hand rubs are not recommended
with spore-forming organisms), contact precautions
(gown and gloves) for those caring for patients with
C. difficile and thorough and persistent environmental
cleaning with an EPA registered disinfectant have
been effective in preventing the spread of the organism.26
During an outbreak or in units with high endemic rates
of C. difficile, the CDC recommends dilute
solutions of sodium hypochlorite (1:10 dilution of
bleach) for cleaning the environment.27
Norovirus and rotavirus have emerged as healthcare
infection pathogens and have been increasingly implicated
in outbreaks in hospitals and rehabilitation centers.
These viruses can be transmitted through the fecal-oral
route, contaminated food or water and droplets from
vomiting. They appear to survive well in the environment
and transmission in the hospital can occur through
direct contact with contaminated items in patient
areas. In a study of norovirus, cultures were positive
from commodes, curtains and lockers in the immediate
patient care environment.28 In a pediatric setting,
rotavirus was most prevalent on the surfaces in direct
contact with children such as play mats and thermometers.29
One researcher found that a detergent-based cleaning
product failed to eliminate norovirus contamination
whereas hypochlorite with detergent at 5000 ppm chlorine
was effective.30 For rotavirus, dilutions of either
2000 ppm or 6000 ppm chlorine resulted in significant
reductions on environmental surfaces.31
of these viruses in healthcare organizations can be
interrupted or minimized in several ways, including
when contact precautions are strictly observed; when
there is rigorous environmental cleaning; and when
an agent such as a hypochlorite is used to disinfect
Healthcare Setting Water Quality and Water Systems
the health care associated transmission of pathogens
from water is relatively low. However, HAI outbreaks
have been reported in association with water sources;
some with very serious consequences.3,4
It is important for health care organizations to maintain
a high level of suspicion for all water sources and
reservoirs used for patient care because of the potential
for direct or indirect transmission of nosocomial
pathogens. Healthcare organizations typically have
multiple water reservoirs including:
from rinsing equipment and patients with potable water
have led to infections such as Mycobacterium chelonae
from otolgic equipment32, Pseudomonas
paucimobillis from tracheal suction tubing 33
, Pseudomonas aeruginosa from endoscopy 34
and rinsing burn patients.35 Additionally,
fungi and mold can result from flood and water leakage
in hospitals. When this occurs, it is important to
remove the moisture source and clean and dry the area
promptly. Diluted bleach solutions can be used for
disruption in an organization can also result in standing
or stagnant water. When water is still, the water
treatment designed to minimize microbial growth can
be compromised. Scale and sediment can develop in
pipes as well as biofilm, which supports microbial
growth. When a system is restarted and water is recirculated,
it is important to assure that the pipes are disinfected
and the water is safe to drink or use for patient
In one study, 19 cases of nosocomial pulmonary disease
occurred from hot water generators and water taps
in hospitals.36 Other environmental water
sources in healthcare organizations that have been
linked to outbreaks include faucet aerators and showers.
There is potential for direct or indirect transmission
of organisms from faucets and sinks. One outbreak
with hand held showerheads involved group A streptococcus
and Legionella.37 Other infections have
resulted from bath water contamination which has led
to endocarditis, bacteremia and peritonitis with organisms
such as Pseudomonas and Acinteobacter.4
products have proven effective for the disinfection
of many of these reservoirs or equipment. For example,
the water in pools and large water tanks in hospitals
and rehabilitation centers are routinely chlorinated
to achieve a free chlorine residual of 0.5 mg/L and
a pH of 7.2-7.6 to minimize risk of the multiplication
of organisms.4 Smaller water tanks used
in physical therapy departments are drained after
each use, disinfected and a chlorine solution of 200-300
mg/L is circulated through the agitator tank where
most organisms reside. Ice, ice machines and cold
water tanks have been linked with nosocomial epidemics
or pseudoepidemincs with organisms such as Enterobacter,
Pseudomonas, Flavobacterium, Mycobacterium,
and Legionella pneumophila.4, 38-41 The CDC
has published recommendations for cleaning and disinfecting
One of the most challenging organisms related to water
and environmental contamination is Legionella.
Legionella is a bacterium that grows and multiplies
in water systems including the cooling towers associated
with health care structures. Outbreaks of Legionella
healthcare-associated infections have been largely
related to poor water maintenance, contaminated potable
water, ice machines, aspiration of feeding tubes and
the poor design and planning of hospital systems.
One study found that Legionella could be isolated
from more than 50% of potable water supplies and more
than 10% of distilled water supplies in hospitals.3,4,43-45
Symptoms of Legionella infection range from
mild flu-like infection to severe pneumonia, called
Legionnaire's disease. Outbreaks have been reported
in acute and long term care throughout the world.
Some outbreaks have been so mild as to be unrecognized
for years. 46,47
is transmitted via aerosolization, not from person
to person. Once the organism enters the potable water
system of an organization, it can multiply, spread
through the water distribution system and contaminate
the output areas such as faucets and shower heads.3,4
A wide variety of environmental treatment options
have been recommended and tested to eliminate or contain
Legionella, including ozone, ultraviolet light,
copper/silver ionization, thermal methods (e.g., superheating)
and hyperchlorination. The fact is no single method
has demonstrated the ability to consistently and permanently
eradicate Legionella from water systems. The
CDC currently recommends diagnostic testing and culturing
of water distribution systems and superheating or
hyperchlorination.27 Mono-chloramines have proven
encouraging for adequate disinfection48 and chlorine
dioxide is highly useful for reducing biofilm.49,
Disinfection in Health Care Settings
The issue of surface disinfection in healthcare is
currently under debate. The question is the balance
between the advantages of disinfectants in preventing
infection and the associated risks to health care
workers and others from the use of these products,
e.g. incorrect dilution with resultant toxic effects,
contact dermatitis. Given the environment as one variable
of a complex process for disease transmission, most
experts believe that surfaces in patient care areas
should be disinfected on a routine basis and particularly
when there is visible soil or when spills occur. 51,
general surface disinfection, the CDC specifies concentrations
of chlorine bleach required to disinfect countertops,
floors, tonometer heads, needles, syringes, dental
appliances, hydrotherapy tanks, water distribution
systems and other equipment.53 Many organisms can
survive on patient surfaces. Therefore it is imperative
in potentially highly contaminated patient care environments
that persons responsible for cleaning procedures in
any healthcare setting be familiar with these recommendations
and the broad disinfection capabilities of chlorine
and other cleaning and disinfecting products.
in Non-Hospital Healthcare Settings
healthcare shifts from acute care to long term care,
ambulatory clinics, outpatient settings, homes and
hospice care providers must deal with communicable
diseases, invasive devices and contaminated environments
that were formerly largely confined to hospitals.
In these settings, it is important to follow the Spaulding
scheme for disinfection and sterilization. Although
cross infection and epidemics are less prevalent or
even rare in these settings, patient care equipment
requires constant vigilance to prevent contamination
and disease transmission.
great deal of healthcare is now provided in homes.
In home settings, chlorine products are available,
inexpensive, easy to use and often recommended for
disinfection. For example, tracheostomy tubes can
be immersed in a 1:2 dilution of household bleach
(6.00% - 6.15% sodium hypochlorite) for adequate disinfection.
The patient's immediate care environment can be cleaned
with a bleach solution or wiped with bleach impregnated
In outpatient settings, such as an ophthalmology office
or clinic, tonometers used to measure eye pressure
can potentially transmit herpes simplex virus and
adenovirus. Tonometers swabbed with 70% alcohol may
not be effectively decontaminated. The CDC recommends
disinfecting applanation tonometers with a chlorine
solution of 5000 ppm for 5-10 minutes.27 During outbreaks,
daycare centers may consider chlorine products for
surface decontamination. Dental offices, emergency
departments and clinics may also find towels impregnated
with a chlorine ingredient helpful.
procedures are performed in both acute care and ambulatory
care settings. Effective cleaning and high level disinfection
of endoscopes poses significant challenges for health
care providers and many outbreaks have been reported.54
For example, bronschoscopes have been implicated in
multiple outbreaks and pseudo-outbreaks with pseudomonas
species and other organisms.55-59 The complex design
of endoscopes, with narrow channels and many small
parts, requires that their cleaning, disinfection,
drying and storage processes are followed strictly
according to the manufacturer's recommendations and
evidence-based policy. While the most commonly used
agent for disinfecting endoscopes is 2% glutaraldehyde,
recent studies have explored the use of chlorine dioxide.60-63
Generation Disinfection Targets: New Healthcare Equipment
constantly changes the tools for providing patient
care. In recent years, computers and mobile phones
have been used extensively to enhance access to staff,
quick retrieval of complex and changing information,
and increased productivity. These items can be heavily
colonized by organisms and serve as a reservoir for
the transmission of pathogens via the hands of healthcare
personnel.64-66 Chlorine can be used as a disinfecting
agent. One recent study recommends a daily 5 seconds
disinfection regime for healthcare facility computer
keyboards when visibly soiled.65-66
In summary, the risk of healthcare-associated infections
continues to generate world-wide concern. Health professional,
researchers, and industry constantly seek better ways
to prevent these infections. Chlorine products have
proven effective for cleaning and disinfection and
have contributed to reduced risk for infections and
outbreaks in health care settings.
of the content of this paper comes from the ongoing
research of William Rutala, PhD, University of North
Carolina. The author thanks him for his continued
leadership in the field of disinfection and sterilization
related to healthcare-associated infections.
Block, S. S. 1991. Historical review, p. 3-17. In
S. S. Block (ed.), Disinfection, sterilization, and
preservation, 4th ed. Lea & Febiger, Philadelphia,
Biography of Ignaz Philipp Semmelweis. http://www.mindfully.org/Health/Ignaz-Philipp-Semmelweis5mar1865.htm-
Accessed Aug, 2006
Bartley J. Water issues. In Carrico R (ed): APIC
Text of Infection Control and Epidemiology. Second
Edition. Washington, DC: Association for Professionals
in Infection Control & Epidemiology, Inc., 2005:107-1-16
Rutala WA, Weber DJ. Water as a reservoir of nosocomial
pathogens. Infect Control Hosp Epidemiol. 1997;18;9:609-16.
Rutala WA, Weber DJ. Cleaning, disinfection, and sterilization
in healthcare facilities. In Carrico R (ed): APIC
Text of Infection Control and Epidemiology. Second
Edition. Washington, DC: Association for Professionals
in Infection Control & Epidemiology, Inc., 2005:21-1
Rutala WA, Weber DJ. Uses of inorganic hypochlorite
(bleach) in health-care facilities. Clin Microbiol
Spaulding EH. Chemical disinfection of medical and
surgical materials. In: Lawrence. C, Block SS, editors.
Disinfection, sterilization and preservation. Philadelphia
1968. Lea & Febiger.
Food and Drug Administration: FDA-cleared sterilants
and high level disinfectants with general claims for
processing reusable medical and dental devices. May,
Accessed July 2006
Weber DJ, Rutala WA. The emerging nosocomial pathogens
Cryptosporidium, Escherichia coli O157:H7,
Helicobacter pylori, and hepatitis C: epidemiology,
environmental survival, efficacy of disinfection,
and control measures. Infect Control Hosp Epidemiol.
Rutala WA, Weber JD, Infection control: the role of
disinfection and sterilization. J Hosp Infect 1999;43:545-55.
Weber DJ. Rutala WA. Managing the risk of nosocomial
transmission of prion diseases. Curr Opin Infect Dis.
Centers for Disease Control (CDC). Questions and Answers:
Creutzfeldt-Jakob Disease Infection-Control Practices.
Accessed July 2006
Oldfield EC 3rd. Clostridium difficile-associated
diarrhea: resurgence with a vengeance. Rev Gastroenterol
Sunenshine RH, McDonald LC. Clostridium difficile-associated
disease: new challenges from an established pathogen
Cleve Clin J Med. 2006 2006 ;73;2:187-97.
McDonald LC, Killgore GE, Thompson A, Owens RC Jr.,
Kazakova SV, Sambol SP, Johnson S, Gerding DN. An
epidemic, toxin gene-variant strain of Clostridium
difficile. N Engl J Med. 2005 Dec 8;353(23):2433-41.
A simple guide to Clostridium difficile. http://www.dh.gov.uk
Ref Number 5264. Accessed July 2006.
Rutala WA, Gergen MF, Weber DJ. Inactivation of Clostridium
difficile spores by disinfectants. Infect Control
Hosp Epidemiol. 1993;14;1:36-39
Kaatz GW, Gitlin SD, Schaberg vDR, et al. Acquisition
of Clostridium difficile from the hospital
environment. Am J Epidemiol 1988;127;6:1289-94.
Kim KH, Fekety R, Batts DH, Brown D, Cudmore M, Silva
J Jr, et al. Isolation of Clostridium difficile
from the environment and contacts of patients with
antibiotic-associated colitis. J Infect Dis. 1981;1;143;1:42-50.
Fekety R, Kim K, Brown D, Batts DH, Cudmore M. Silva
J. Epidemiology of antibiotic-associated colitis:
Isolation of Clostridium difficile from the
hospital environment. Am J Med 1981;70:907.
Samore MH, Venkataraman L, DeGirolami PC, Arbeit RD,
Karchmer AW. Clinical and molecular epidemiology of
sporadic and clustered cases of nosocomial Clostridium
difficile diarrhea. Am J Med. 1996 Jan;100(1):32-40.
Fawley WN, Wilcox MH. Molecular epidemiology of endemic
Clostridium difficile infection. Epidemiol
Mayfield JL, Leet T, Miller J, Mundy LM. Environmental
control to reduce transmission of Clostridium difficile.
Clin Infect Dis 2000;31;4:995-1000.
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 Jun;54(2):109-14.
25. Perez J, Springthorpe VS, Sattar SA. Activity
of selected oxidizing microbicides against the spores
of Clostridium difficile: Relevance to environmental
control. Am J Infect Control 2005;33;6:320-5.
McFarland LV, Mulligan ME, Kwok RY, Stamm WE. Nosocomial
acquisition of Clostridium difficile infection.
N Engl J Med. 1989 Jan 26;320(4):204-10
Sehulster LM, Chinn RYW, Arduino MJ, Carpenter J,
Donlan R, Ashford D, Besser R, Fields B, McNeil MM,
Whitney C, Wong S, Juranek D, Cleveland J. Guidelines
for environmental infection control in health-care
facilities. Recommendations from CDC and the Healthcare
Infection Control Practices Advisory Committee (HICPAC).
Chicago IL; American Society for Healthcare Engineering/American
Hospital Association; 2004
Green J, Wright PA, Gallimore CI, Mitchell O, Morgan-Capner
P, Brown DW. The role of environmental contamination
with small round structured viruses in a hospital
outbreak investigated by reverse-transcriptase polymerase
chain reaction assay. J Hosp Infect. 1998 May;39;1:39-45.
Barker J, Vipond IB, Bloomfield SF. Effects of cleaning
and disinfection in reducing the spread of Norovirus
contamination via environmental surfaces. J Hosp Infect.
Sattar SA, Springthorpe VS, Adegbunrin O, Zafer AA,
Busa M. A disc-based quantitative carrier test method
to assess the virucidal activity of chemical germicides.
J Virol Methods. 2003 Sep;11(1-2):3-12.
Lowry PW, Jarvis WR, Oberle AD, Bland LA, Silberman
R, Bocchini JA Jr, Dean HD, Swenson JM, Wallace RJ
Jr. Mycobacterium chelonae causing otitis media
in an ear-nose-and-throat practice. N Engl J Med.
Crane LR. Tagle, LC, Palutke WA. Outbreak of Pseudomonas
paucimililis in an intensive care facility. JAMA
Doherty DE, Falko JM, Lefkovitz N. Rogers J, Fromkes
J. Pseudomona aeruginosa sepsis following retrograde
cholangiopancreatography (ECRP). Dig Dis Sci 1982;27:169-70.
Kolmos HJ, Thuesen B, Nielsen sV, Lohmann M, Kristoffersen
K, Rosdahl VT. Outbreak of infection in a burns unit
due to Pseudomonas aeruginosa originating from
contaminated tubing used for irrigation of patients.
J Hosp Infect 1993;24:1-21.
Costrini AM, Mahler DA, Gross WM, Hawkins JE, Yesner
R, D'Esopo ND. Clinical and roentgenographic features
of nosocomial pulmonary disease due to Mycobacterium
xenopi. Am Rev Respir Dis 1981;123:104-9.
Oren I, Zuckerman T, Avivi I, Finkelstein R, Yigia
M, Rowe JM. Nosocomial outbreak of Legionella pneumophila
serogroup pneumonia in a new bone marrow transplant
unit: evaluation, treatment and control. Bone Marrow
Newson SWB. Hospital infection from contaminated ice.
Panwalker AP, Fuhse E. Nosocomial Mycobacterium
gordonae pseudoinfection from contaminated ice
machines. Infect Control 1986; Feb 7;2:67-70.
Stout JE, Yu VL, Muraca P. Isolation of Legionella
pneumophila from the cold water of hospital ice machines
: implications for origin and transmission of the
organism. Infect Control 1985;6:4:141-6.
41. Stamn WE, Colella JJ, Anderson RL, Dixon RE. Indwelling
arterial catheters as a source of nosocomial bacteremia:
an outbreak caused by Flavobacterium species. N Engl
J Med 1975;292:1099-1102.
Manangan LP, Anderson RL, Arduino MJ, Bond WW. Sanitary
care and maintenance of ice-storage chests and ice-making
machines in health care facilities. Am J Infect Control
Mermel LA, Josephson SL. Giorgio CH, et. al. Association
of Legionnaires disease with construction: contamination
of potable water? Infect Control Hosp Epidemiol 1995;16;2:
44. Yu VL, Liu Z, Stout JE. Goetz A. Legionella
disinfection of water distribution systems: Principles,
Problems and Practice
Goetz, A. Legionella pneumophila. In Carrico
R (ed): APIC Text of Infection Control and Epidemiology.
Second Edition. Washington, DC: Association for Professionals
in Infection Control & Epidemiology, Inc., 2005 76-1-8.
Kool JL. Fiore AE, Kioski CM. et al. More than 10
years of unrecognized nosocomial transmission of Legionnaires'
disease among transplant patients. In Infect Control
Lepine MD, Jernigan DB, Pruckler M. et al. A recurrent
outbreak of nosocomial Legionnaire's disease detected
by urinary antigen testing: evidence for long term
colonization of a hospital plumbing system. ICHE 19;12;
Heffelginger JD, Kool MD, Fridkin S, Fraser VJ, Hageman
MHS, Carpenter J, et al. Risk of hospital-acquired
Legionnaires' disease in cities using monochloramine
versus other water disinfectants. Infect Control Hosp
Epidemiol 2003 24;8:569-74.
Srinivasan A. Bova g, Ross T, Mackie K, Paquette N,
Merz W, et a. A 17 month evaluation of a chlorine
dioxice water treatment system to control Legionella
species in a hospital water supply. Infect Control
Hosp Epidemiol. 2003;24;8:575-79.
Dettenkofer 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 Control 2004;32;2:8409.
Loret JF, Robert S, Thomas V, Cooper AJ, McCoy WF,
Levi Y. Comparison of disinfectants for biofilm, protozoa
and Legionella control. J Water Health, 2005;3;4:423-33.
Rutala WA, Weber DJ. Surface disinfection: should
we do it? J Hosp Infect. 2001;48 Suppl A:S64-8. 42,
Rutala WA, Weber DJ, and the healthcare Infection
Control Practices Advisory Committee Guideline for
Disinfeciton and Sterilization in Healthcare Facilities.
Rutala WA, Weber DJ. Reprocessing endoscopes: United
Sates perspective. J Hosp Infect 2004;56;S2:S27-39.
Silva CV, Magalhaes VD, Pereira CR, Kawagoe JY, Ikura
C, Ganc AJ. Pseudo-outbreak of Pseudomonas aeruginosa
and Serratia marcescens related to bronchoscopes.
Infect Control Hosp Epidemiol 2003;24:195-7.
Kirschke DL, Jones TF. Craig AS, Chu PS, Mayrnick
GG, Patel JA, Schaffner W. Pseudomonas aeruginosa
and Serratia marcescens contamination associated
with a manufacturing defect in bronchoscopes. N Engl
J Med 2003 16;3:214-20.
Corne P, Godreuil S, Jean-Pierre H, Jonquet O, Campos
J, Jumas-Bilak E, et. al. Unusual implication of biopsy
forceps in outbreaks of Pseudomonas aeruginosa
infections and pseudo-infections related to bronchoscopy.
J Hosp Infect 2005;61;1:20-6.
Schelenz S, French G. An outbreak of multidrug-resistant
Pseudomonas aeruginosa infection associated with contamination
of bronchoscopes and an endoscope washer-disinfector.
J Hosp Infect 2000;46;1:23-30.
Srinivasan A, Wolfenden LL, Song X, Mackie K, Hartsell
TL, Jones HD, et al. An outbreak of Pseudomonas
aeruginosa infections associated with flexible
bronchoscopes. N Engl J Med 2003;348;3:191-2.
60. Isomoto H, Urata M, Kawazoe K, Matsuda J, Nishi
Y, Wasa A, et. Al. Endoscope disinfection using chlorine
dioxide in an automated washer-disinfector. J Hosp
Srinivasan A, Bova G, Ross T, Mackie K, Paquette N,
Merz W, Perl TM A 17-month evaluation of a chlorine
dioxide water treatment system to control Legionella
species in a hospital water supply. Infect Control
Hosp Epidemiol. 2003 Aug;24(8):575-9.
Ayliffe G; Minimal Access Therapy Decontamination
Working Group. Decontamination of minimally invasive
surgical endoscopes and accessories. J Hosp Infect.
Cleaning and disinfection of equipment for gastrointestinal
endoscopy. Report of a Working Party of the British
Society of Gastroenterology Endoscopy Committee. Gut.
Schultz M, Gill J, Zubairi S, Huber R, Gordin F :
Bacterial contamination of computer keyboards in a
teaching hospital. Infect Control Hosp Epidemiol.
Rutala WA, White MS, Gergen MF, Weber DJ. Bacterial
contamination of keyboards: efficacy and functional
impact of disinfectants. Infect Control Hosp Epidemiol.
2006 Apr;27(4):372-7. .
Brady RR, Wasson A, Stirling I, McAllister C, Damani
NN. Is your phone bugged? The incidence of bacteria
known to cause nosocomial infection on healthcare
workers' mobile phones. J Hosp Infect. 2006 Jan;62(1):123-5.