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Myth Or Reality? Efficacy of Different Disinfection Regimens on Tonometer Tips

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Myth Or Reality? Efficacy of Different Disinfection Regimens on Tonometer Tips Eye (2007) 21, 541–546 & 2007 Nature Publishing Group All rights reserved 0950-222X/07 $30.00 www.nature.com/eye 1 1 2 Tonometers and S Cillino , A Casuccio , GM Giammanco , LABORATORY STUDY C Mammina2, D Morreale1, F Di Pace1 infectious risk: myth and G Lodato1 or reality? Efficacy of different disinfection regimens on tonometer tips Abstract that disposable prism tonometry provides a safe alternative to Goldmann tonometry. Purpose To evaluate the adequacy of Eye (2007) 21, 541–546. doi:10.1038/sj.eye.6702269; common disinfection regimens for disposable published online 3 February 2006 tonometer tips and assess if disinfection of reusable prisms or the use of disposable tips is Keywords: disposable tonometer prisms; preferable. ophthalmic device disinfection; cross-infection 1 Methods We used disposable tonometer tips, Dipartimento di ophthalmic transmission Neurologia, Oftalmologia, using the same material and tip diameter of Otorinolaringoiatria e standard Goldmann tonometer prism. Strains Introduction Psichiatria, Sezione di of Pseudomonas aeruginosa, Staphylococcus Oftalmologia, Universita` aureus, Bacillus subtilis and Candida albicans The ophthalmologist’s office is an environment degli Studi di Palermo, were tested according to the European with significant potential for the transmission of Palermo, Italy standard guidelines for disinfectants test. infections. Pathogens are regularly introduced 2Dipartimento di Igiene e Antimicrobial effectiveness of the following into the office by patients with systemic or Microbiologia, Universita` disinfection practices has been assessed: ocular infections and the eye is particularly degli Studi di Palermo, dry wipe, Minuten wipes (Alpros), soaking susceptible to infection with Gram-negative Palermo, Italy in 3% hydrogen peroxide, 0.5% benzalkonium bacilli, adenoviruses, Herpes simplex and fungi, chloride, and 0.5% Pantasepts for 1, 5, and transferred by contaminated ophthalmic Correspondence: S Cillino, 15 min. All tests have been performed instruments.1 Dipartimento di Neurologia, Oftalmologia, three times and all conditions tested in Moreover, the acquired immunodeficiency Otorinolaringoiatria e duplicate. syndrome (AIDS) epidemic and the isolation of Psichiatria, Results Dry wiping and 1 min soak in 3% human immunodeficiency virus (HIV) from Sezione di Oftalmologia – hydrogen peroxide were ineffective on all human tears,2 corneas3 and contact lenses4 have Universita` degli Studi di microrganisms. Minuten wipes, 1 min soak in focused attention on the infected patient as a Palermo, Via Liborio Giuffre` , no. 13, 0.5% benzalkonium chloride or 3% hydrogen source of transmission of disease. 90127 Palermo, Italy peroxide were ineffective on B. subtilis. 0.5% The most frequently reported infections Tel: þ 39 91 655 3904; Pantasepts soak was effective in 1 min for all transmitted by contaminated ophthalmic Fax: þ 39 91 626 1438. microrganisms tested, whereas 3% hydrogen equipment have been those with adeno- E-mail: [email protected]; peroxide and 0.5% benzalkonium chloride viruses5–7 but in theory, a number of diseases [email protected] soaks were effective when performed for at could be spread in the same manner. Whereas Received: 29 April 2005 least 5 min. B. subtilis was the most resistant some ocular infections, such as adenoviral Accepted in revised form: organism to disinfectant regimes at 1 min time. conjunctivitis, are self-limiting and their long- 16 December 2005 Conclusions Results of our study term sequelae are very infrequent, some agents Published online: 3 February demonstrate a relative disinfection efficacy for are responsible for sight threatening courses. 2006 the different evaluated regimens, provided Among these, bacteria and Acanthamoeba have Competing Interest: The that correct exposure times are adopted for the become much more prevalent since the advent authors have no financial chosen disinfectants, a condition difficult to of widespread soft contact lens wear and can be interest in any of the ensure in a busy clinic setting. We conclude responsible for infection cases enough severe to products mentioned Tonometers disinfection and infectious risk S Cillino et al 542 require penetrating keratoplasty or even enucleation as The Centers for Disease Control and Prevention (CDC) treatment.8,9 and the American Academy of Ophthalmology (AAO) Hepatitis B (HBV) and C (HCV) viruses are far more have established guidelines for office disinfection of trial prevalent in the population than HIV10,11 and can cause contact lenses and tonometers.33 chronic hepatitis. It has been demonstrated that hepatitis The aim of this study was to evaluate the adequacy of B infection can be transmitted after infectious exposure of some cleansing and disinfection regimens recommended the ocular surface alone.12 by tonometer manufacturers and by the guidelines of the The isolation of hepatitis C virus from tear fluid and CDC and the AAO, using sterile disposable tonometer aqueous humour13–16 raises the possibility of transfer of tips contaminated on their contact surfaces with different hepatitis C virus during the course of an ophthalmologic microrganisms belonging to the most frequent species examination, that is, Goldmann tonometry and trial responsible for corneal infections. This will enable us to contact lens fitting.17 assess risk for horizontal transmission by contact Possible risk of horizontal transmission of vCJD via tonometry and to address the question whether a contact tonometry has given further cause for concern.18–21 stringent decontamination of reusable prisms or use of Tonometer heads used for measuring intraocular sterile disposable tips or shields should be preferred. pressure come into direct contact with the cornea and so pose a high risk of cross-infection.1 Materials and methods Tonometer tips have been frequently identified as major vehicles of infection.22,23 Prevention of all Disposable sterile tonometer tips (TONOJET L900, infections is desirable, but it is especially critical in the Luneau, France) made from clear acrylic plastic but with case of HIV and hepatitis C virus because it is currently the same tip diameter as the standard Goldmann not possible to immunize against these viruses. tonometer prism were used. Good hygienic practice, including hand washing, is the Four different strains were used for the test: P. logical first step in reducing the spread of infections and aeruginosa ATCC 15 442, S. aureus ATCC 6538, Bacillus is good medical practice to disinfect any office subtilis ATCC 6633 and Candida albicans ATCC 10231. The equipment that comes in direct contact with patients. strains were grown on Mueller–Hinton and Sabouraud Failure to efficiently disinfect Goldmann tonometer agar plates, respectively, at 351C for 48 h. Isolated tips could represent a possible mode of infection colonies were suspended in sterile phosphate-buffered transmission.17 saline (PBS) to an optical density corresponding to 108 A review of the literature reveals that many colony forming units per ml for each organism to be disinfection methods are suggested for tonometric tested according to the European Committee for prisms, even if it is not always clear which organisms are Standardization (ECS)34 for disinfectants testing on eliminated and which may be left behind with every surfaces. Serial dilutions of the inoculum were made in single regimen.24 0.85% saline and plated in duplicate onto Mueller– Hinton and Sabouraud agar to check for inoculum size Chemical disinfectants have variable ability to and purity of suspensions. eradicate pathogenic bacteria such as Pseudomonas Antibacterial and antifungal effectiveness of the aeruginosa, Serratia marcescens, and Staphylococcus following disinfection practices was evaluated: aureus.25–28 HIV has been proved to be susceptible (a) wiping by towels moistened with o1% tert. to most chemical cleaning regimens while these alkylamines and quat. alkyl-ammoniumpropionate in agents are differently effective in their ability to kill 55% ethanol, nÀ/isopropanol mixture (Minuten wipes, fungal spores, prions and Acanthamoeba. Actually, Alpros), according to the instructions for use provided data from literature report some problems con- by the manufacturer; (b) soaking in 3% hydrogen cerning disinfectant efficacy (appropriate concen- peroxide for 1, 5, and 15 min; (c) soaking in 0.5% tration and exposure times, in vitro and in vivo benzalkonium chloride for 1, 5, and 15 min; (d) soaking different interactions between tested strains and in 0.5% glutaraldheyde (Pantasepts, Haag-Streit germicides) even considering the consequent ton- International) for 1, 5, and 15 min. No treatment and dry ometer prism damages and iatrogenic corneal wiping (simple cleaning) were used as growth control deepithelialization and stromal opacification procedures. caused by incomplete removal of disinfectant from The tests were performed by the following procedure: tonometer tip.7,29–32 Consequently, it is very diffi- (i) the tonometer tip was soaked for 10 s, corresponding cult to find an ideal chemical disinfecting system to the average tonometry time, into the suspension of the for tonometer prism easily and safely applicable in organism under study; (ii) the entire tonometer was the ophthalmologist’s office. soaked into the disinfectant solution under test for 1, 5, Eye Tonometers disinfection and infectious risk S Cillino et al 543 and 15 min or, alternatively, the tonometer tip was wiped tonometry. Goldmann applanation tonometry is for 10 s with dry or Minuten wipes (according
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