DEKONTAMINASI &

PEMBERSIHAN, DISINFEKSI

MANUAL & MEKANIK

AMMAR WIDITAPUTRA
 Curriculum Vitae
Nama AMMAR WIDITAPUTRA, S.Farm., Apt.
TTL Malang, 4 Oktober 1987
Pendidikan Apoteker, Fakultas Farmasi Universitas Airlangga Surabaya
NIP 19871004 201101 1 011
Pangkat / Gol Penata / III-C
Jabatan Apoteker Muda
Pekerjaan Kepala Instalasi Sterilisasi dan Binatu RSUD Dr. Soetomo Surabaya
Anggota Komite PPI RSUD Dr. Soetomo Surabaya
Organisasi • Sekretaris Himpunan Sterilisasi Sentral Indonesia (HISSI)
• Anggota PERDALIN Jatim
Kontak 08123381269
ammar.widitaputra@gmail.com
Website widitaputra.wordpress.com
Pedoman WHO, 2016
Decontamination
Cycle
Decontamination removes pathogenic microorganisms from objects
so they are safe to handle, use, or discard.

Dekontaminasi, merupakan istilah umum untuk penghancuran atau

penghilangan kontaminasi mikroorganisme sehingga alat menjadi
aman untuk digunakan
Dekontaminasi meliputi pencucian, disinfeksi dan sterilisasi.
 Manajemen Instrumen/ Alkes
• Pembelian
Perencanaan • Peminjaman
& Jangka Pendek
Pengadaan • Peminjaman Pembersihan Disinfeksi
Jangka Panjang

Inspeksi dan
Penggunaan
Pengemasan

Transportasi Sterilisasi

Penyimpanan
dan • Penghancuran
Distribusi Pemusnahan • Pengembalian
Peralatan Kritis Resiko Tinggi Peralatan yang Surgical and Dental Pre-Cleaning
menembus sistem Instrument. Implant. Biopcy dan Sterilisasi
vaskuler atau mengenai forceps. Flexible endoscope
jaringan steril. accesories

Peralatan Semi Resiko Menengah Peralatan yang Peralatan respirasi, peralatan Pre-Cleaning
Kritis menyentuh membran anastesi, flexible scope, dan Disinfeksi
mukosa atau kulit laryngoscope, TEE, USG Tingkat Tinggi
terbuka. vaginal probe

Risk Assessment
Resiko Rendah
Peralatan Non
Kritis
Peralatan yang
menyentuh kulit utuh.
Patient Care Items: Bedpans,
Tourniquet, Kruk
Pembersihan
dan Disinfeksi
Penentuan tingkatan dekontaminasi, menggunakan Klasifikasi Rendah

Spaulding
Resiko Minimal Lingkungan pasien Bed rails, meja pasien, lantai, Pembersihan
komputer di ruang perawatan dan Disinfeksi
Rendah
Instrumen dan Peralatan Kompleks:
Resiko

8
The use of contaminated medical instruments can lead to
disabling or deadly patient infections or instrument
malfunctions.
• Outbreaks associated with the use of contaminated duodenoscopes—such
as those that caused headlines in recent years—illustrate the severity of
this issue. But duodenoscopes are not the only devices that warrant
attention.
• Complex, reusable instruments—such as endoscopes, cannulated drills,
and arthroscopic shavers—are of particular concern. They can be difficult
to clean and then disinfect or sterilize (i.e., reprocess) between uses, and
the presence of any lingering contamination on, or in, the instrument can
be difficult to detect.
• Often, we find that inattention to the cleaning steps within the
reprocessing protocol is a contributing factor. Healthcare facilities should
verify that comprehensive reprocessing instructions are available to staff
and that all steps are consistently followed, including precleaning of the
device at the point of use.
9
Temuan #1 dalam Laporan Outbreak

Petugas TIDAK
Mengikuti Instruksi Pabrikan
Instruction for Use (IFU)
 Skenario di Rumah Sakit
• Petugas tidak mengikuti kebijakan dan
prosedur

• Perawat dan Dokter meminta pengecualian

kebijakan dan prosedur

• Tidak adanya instruksi pabrikan

Alat Pelindung Diri
Pencucian Instrumen/ Alkes
Instrumen dimungkinkan tertutup darah dan cairan tubuh serta bahan kimia,
kotoran dan debu saat penggunaan, terutama instrumen berengsel dan berlumen.
Di Titik Pemakaian
• Pemrosesan di titik pemakaian untuk memastikan transportasi
yang aman dan mengurangi resiko pada petugas CSSD
• Pemrosesan akan menambah usia instrumen; darah dan saline
yang mengering akan merusak stainless steel dan instrumen juga
sulit dibersihkan.
• Tidak menggantikan proses pembersihan di CSSD

• Gunakan APD
• Pisahkan semua linen dan peralatan sekali pakai. Sampah tajam
dibuang di tempat yang semestinya
• Hilangkan kotoran padat dari instrumen menggunakan kain/ kasa
• Instrumen tetap lembab. Gunakan cairan pre-cleaning mencegah
instrumen menjadi kering atau tutup dengan handuk basah (air).
Hindari perendaman yang memanjang
Klorida berbahaya untuk instrumen!
Transportasi - APSIC Guideline
• Soiled equipment/devices shall be transported by
direct routes, that avoid high-traffic, clean/sterile
storage and client/patient/resident care areas, to
areas where cleaning will be done.
IGD

Inpatient CSSD OR

Outpatient
 Pembersihan

• Pembersihan adalah langkah pertama dalam pemrosesan instrumen

• Pembersihan yang kurang baik menyebabkan darah dan kotoran lainnya
tertinggal dan menggagalkan proses disinfeksi/ sterilisasi

• Cleaning is accomplished by manual cleaning with cleaning chemicals

(detergent) and water, brushing or flushing, or by using ultrasonic and or
washer disinfectors to remove foreign material
• Cleaning is the removal of visible soil (e.g., organic and inorganic material)
from objects and surfaces and normally is accomplished manually or
mechanically using water with detergents or enzymatic products.
Faktor Pembersihan

Gaya
Waktu
Mekanis

Bahan
Panas
Kimia
Pembersihan Manual (1)
• Rendam secara penuh selama proses • Indikasi pembersihan manual:
pembersihan untuk meminimalkan
terbentuknya aerosol. • Instrumen yang tidak bisa direndam
• Instrumen yang membutuhkan
pembersihan khusus
• Friksi, penggosokan menggunakan
peralatan sikat atau kain. • Langkah pembersihan awal sebelum
masuk pembersihan mekanis
• Gunakan sikat sesuai rekomendasi
pabrikan

• Fluidics, pembasahan menggunakan air

bertekanan pada rongga instrumen

• Validasi tidak bisa dilakukan, perlu SPO

yang tepat
Pembersihan Manual (2)
• Pembilasan manual untuk
menghilangkan kotoran dan sisa
deterjen. Sisa kotoran dan sisa
deterjen dapat bereaksi dengan
disinfektan/ proses sterilisasi
• Pengeringan menggunakan
udara atau kain bersih tanpa
serat (diutamakan sekali pakai).
Udara menggunakan udara yang
difilter HEPA atau medical grade
• Perawatan alat pencuci meliputi:
• Alat pencuci harus dibersihkan,
didisinfeksi, dan dikeringkan setiap
shift
• Periksa sikat dan alat pencuci
lainnya dari kerusakan, buang
apabila sudah rusak
• Alat pencuci sekali pakai
direkomendasikan
Pembersihan Mekanis

Ultrasonic Washer Washer Disinfector

Pembersihan Mekanis
Saat dimungkinkan selalu lakukan pembersihan mekanis:
• Gunakan pembersih mekanis sesuai dengan instruksi pabrikan
• Bersihkan instrumen yang sangat kotor secara manual sebelum pembersihan mekanis
• Pastikan instrumen yang akan dicuci sesuai dengan; tipe peralatan pembersih mekanis,
parameter siklus, dan bahan kimia yang digunakan

• Ultrasonik washer direkomendasikan untuk instrumen yang memiliki rongga, celah,

lumen dan area yang sulit untuk dibersihkan
• Washer disinfector direkomendasikan untuk semua instrumen yang tahan terhadap
pembersihan mekanis untuk mendapatkan paparan pembersihan yang baik dan
mengurangi resiko paparan pada petugas CSSD

Kecepatan, konsistensi, standar yang lebih tinggi, tervalidasi, perlindungan petugas

Ultrasonic Cleaner
• Penggantian air setiap hari atau setiap terlihat
kotor
• Degassing selama 5-10 menit setiap kali diisi
• Instrumen kondisi terbuka, seluruh bagian
terendam air
• Tutup mesin harus tertutup saat operasional
• Ikuti rekomendasi pabrik untuk penempatan
instrumen
• Mesin dibersihkan setiap hari

• Validasi:
• Inspeksi visual
• Alumunium foil test
• Uji komersial (minimal setahun sekali)
Washer Disinfector
• Impingement, tekanan air untuk
menghilangkan kotoran

• Rak tidak boleh berlebihan,

instrumen dalam kondisi terbuka
dan dalam rak
• Spray arm dalam kondisi baik
dan diperiksa setiap hari
• Tidak diperlukan pembersihan
awal untuk efisiensi waktu
Washer Disinfector
Thermal Disinfection
Deterjen
A detergent is a surfactant or a mixture of
surfactants with cleaning properties in dilute
solutions

Water Universal solvent

Bases, Acids, Enzymes Hydrolysis- in the presence of water

Surfactants Wet, emulsify, disperse & suspend solids

Chelants, Sequestering Agents Tie up hard water & metal ions

Builders Assist in detergency

Corrosion Inhibitors Protect surfaces against corrosion

Biocides Preservative, antimicrobial agents

Solvents Solubilise
Asam & Basa

• Traditionally based on sodium hydroxide (NaOH) or potassium hydroxide

(KOH) formulations with surfactants
• Very effective in breaking down fats, oils and protein in the presence of
water (hydrolysis)
Enzim
• Protease Darah
• Lipase Lemak
• Amilase Polisakarida

• Break down larger molecules into

smaller molecules (Hydrolysis)
Pengenceran
Air - H20
• Salah satu unsur terpenting
dalam kehidupan.
• Merupakan pelarut universal,
semua bahan dapat larut
dalam air

• Air Murni H20

32
Teknologi Penghilangan Kontaminan
WHO Water Quality
After Cleaning
Ringkasan Rekomendasi
• Barang sekali pakai dibuang di titik pemakaian menggunakan wadah yang sesuai sebelum
transportasi instrumen ke CSSD
• Instrumen kotor harus ditangani dengan baik untuk mengurangi resiko paparan dan
cedera pada petugas, pengunjung, pasien dan siswa, serta mencegah kontaminasi pada
lingkungan
• Instrumen kotor tidak dikirim melalui area bersih dan area padat pengunjung
• Instrumen kotor dan instrumen steril tidak boleh dikirim bersamaan
• Instrumen/ alkes pakai ulang harus dibersihkan sebelu disinfeksi atau sterilisasi
• Jika pembersihan tidak dapat dilakukan segera, lakukan pencegahan kotoran mengering
pada instrumen
• Proses pembersihan meliputi SPO tertulis untuk melepas, pemilahan, pembersihan awal,
pembersihan, pembilasan dan pengeringan
• Instrumen yang memiliki lumen kecil dan sulit dibersihkan direkomendasikan menjadi
instrumen sekali pakai
Do & Don’t
Do Don’t
• Pastikan deterjen disiapkan pada konsentrasi dan • Jangan gunakan sikat dari logam
suhu yang tepat dan digunakan pada waktu kontak
yang tepat • Jangan membersihkan instrumen di bawah air
mengalir
• Instrumen tetap lembab dan dibersihkan sesegera
mungkin • Jangan memasukkan instrumen terlalu banyak
pada washer disinfector
• Melepas instrumen sebelum pembersihan
• Jangan menghambat spray arm
• Instrumen dalam keadaan terbuka untuk
memastikan semua bagian terpapar pencucian • Jangan merendam instrumen dengan motor atau
instrumen elektronik
• Gunakan sikat yang sesuai untuk instrumen dengan
lumen • Jangan gunakan deterjen bukan untuk instrumen
• Gunakan sikat yang halus
• Bersihkan instrumen di bawah permukaan air
untuk mencegah aerosol
• Inspeksi instrumen setelah pembersihan
• Ikuti rekomendasi pabrikan
DISINFEKSI
Chemical Disinfection
• Disinfektan pada disinfeksi kimia membutuhkan waktu kontak
untuk membunuh mikroorganisme – selalu ikuti rekomendasi
pabrikan;
• konsentrasi, waktu kontak, suhu, pH, aturan keamanan, pembilasan.

• Pembersihan sangat penting, kotoran yang tertinggal dapat

melindungi mikroorganisme dari aksi disinfektan
Faktor yang Mempengaruhi Disinfektan
Quantity of the microorganisms.
• As the bioburden increases, the amount of time that a disinfectant needs
to act also increases.
• Therefore, it is essential to carry out a scrupulous cleaning of all the
surfaces of instruments. Instruments with multiple components should be
disassembled and cleaned and disinfected part by part.
Organic matter.
• The presence of biofilms and/or organic matter, such as serum, blood, pus,
faeces or other organic substances, has the ability not only to inactivate
the antimicrobial activity of disinfectants, but also to prevent contact with
the disinfectant and therefore compromise its effectiveness.
Faktor yang Mempengaruhi Disinfektan
Concentration of the agents.
• This refers to the concentration required of each disinfectant to
produce the expected antimicrobial action.
• Higher concentrations may have deleterious effect on the material,
e.g. corrosion.
Physical and chemical factors.
• Some disinfectants have optimal antimicrobial activity at a certain
temperature and/or pH.
Faktor yang Mempengaruhi Disinfektan
Duration of exposure.
• Each disinfection method and agent is associated with a specific
amount of time that is necessary to achieve the desired result.
Stability.
• Some disinfectants are unstable at use concentration, e.g. chlorine-
releasing agents, and should be discarded as recommended by the
disinfectant manufacturer/supplier.
Resistance of microorganisms to the chemical agent.
• This refers primarily to the spectrum of antimicrobial activities of the
various agents
 Glutaraldehyde

Ortho- Chlorine-based
phthaladehyde compounds

Peracetic acid Alcohol

Hydrogen
peroxide
Glutaraldehyde
• Senyawa aldehida dalam larutan • Acts on microorganisms by
alkali causing alkylation of cellular
components that alters the
protein synthesis of DNA and
• Konsentrasi 2% dalam pH alkali RNA.
• 10 menit bactericidal
• 20 menit tuberculocidal
• >3 jam, sporocidal
• Perlu aktivasi

• Shelf life 14-28 hari


Glutaraldehyde
+ 2% glutaraldehyde is widely used to
disinfect heat-sensitive items, such as
flexible endoscopes. Most preparations of
glutaraldehyde have the following
properties:
+ Non-corrosive to metalsand other
materials.
+ Inactivation in the presence of organic
matter is minimal.
+ Alkaline solutions have a wide range of
antimicrobial activity, including bacterial
spores.
- Irritancy and potential toxicity.
- Once activated, it tends to produce
vapour that may cause occupational
asthma and contact dermatitis. – Latex
gloves may be worn and discarded
after use if the duration of contact with
glutaraldehyde is brief, i.e. less than 5
minutes. For a longer duration, nitrile
gloves must be worn.
- Use in a well-ventilated area and
appropriate PPE (e.g. eye protection, a
plastic apron and gloves) must be worn
when glutaraldehyde liquid is made up,
disposed of, or when immersing
instruments.
- Concentrations of glutaraldehyde in the
environment should be monitored and
the occupational exposure standards
(threshold limit value/exposure value)
of glutaraldehyde should be 0.02 ppm
(parts per million) to 0.05 ppm in 8
work hours. – Respiratory protection
must be available in the event of a
spillage.
- Aldehyde-based disinfectants are
fixatives and items must be
scrupulously clean before immersion.
Test strips are available for some
products to check that the solution is
at an effective concentration.
Ortho-phthaladehyde
• Senyawa benzene -
carboxaldehyde
• Kills microorganisms by
• Konsentrasi 0,55% alkylation of cellular
• Amerika, 10-12 menit, 20oC components and acts
• Kanada, 10 menit directly on nucleic acids
• Eropa, 5 menit
• Tidak perlu aktivator

• Shelf life 14 hari setelah dibuka

Ortho-phthaladehyde
+ Excellent stability in a broad range of pH (3-9)
and as a result does not require activation.
+ Fast-acting with excellent material
compatibility and does not coagulate blood or
fix tissues to surfaces.
+ Barely perceptible odour
+ Not carcinogenic, but it is recommended that
it be used in ventilated areas (similar to all
chemicals) as the effects on health are not
fully understood
- More expensive than glutaraldehyde
and no claims for sporicidal activity are
made.
- A potential disadvantage is that it may
cause eye irritation and stains proteins
grey including unprotected skin,
mucous membranes, clothing and
environmental surfaces. Therefore
caution must be exercised when
handling the solution and PPE (e.g.
gloves, eye and mouth protection,
fluid-resistant gowns) is necessary
during it use.
- In addition, equipment must be
thoroughly rinsed to prevent
discolouration of a patient’s skin or
mucous membrane.
- Not recommended for use on
cystoscopes used on patients who are
post-surgery for bladder carcinoma due
to the risk of anaphylactic shock
associated with residue.
- Test strips are available for some
products to check that the solution is
at an effective concentration.
Peracetic Acid
• Peracetic acid is an oxidizing agent that acts similarly to hydrogen peroxide. Denatures the
proteins and alters the permeability of the cell wall

• It is used in concentrations of 0.1% to 0.2% with a contact time of 5 to 15 minutes.

• It is considered unstable, particularly when diluted. Once prepared, the current manufacturer’s
recommendation is that it should be used within 24 hours.

• Uses:Heat-sensitive equipment, e.g.flexible endoscopes.

• Properties
• Good bactericidal, virucidal, fungicidal and sporicidal activity.
• May be damaging to some materials.
• Some formulations are unstable.
• Irritant to the skin and mucous membranes.
• Some products are unstable once prepared for use.
Alcohol
• The bactericidal/ virucidal
mechanism of action is
dissolution (dissolving) of the
cell membrane
(phospholipidbilayer)

Alcohol
+ An important feature for their usability in
antisepsis is the miscibility of alcohols with water.
+ Only short-chained alcohols, such as methanol, ethanol
and the propanols, are completely miscible.
+ Of the large chemical group of alcohol substances,
three are mainly used in disinfection and antisepsis:
ethanol, iso-propanol (or 2-propanol) and n-propanol
(or 1-propanol).
+ Alcohol has a broad spectrum of activity, including
viruses and mycobacteria.
+ Alcohol evaporates so no rinsing to remove
residues is required.
- Alcohol does not penetrate well into
organic (especially protein-based)
matter, and should therefore be
used to disinfect only physically-
cleaned hard surfacesor equipment.
- Alcohol should be stored in a cool
place.
- Alcohol solutions are flammable, so
care should be taken when it is used
for skin preparation prior to the use
of diathermy.
- Do not leave uncapped bottles of
alcohol as it releases vapours and
irritates mucous membranes,
especially in an enclosed space.
- May cause eye and skin irritation if
used in a large quantity in an
enclosed space, therefore its use
should be avoided in a poorly
ventilated area.
- If inhaled in large quantities, it may
cause headache and drowsiness.
- Alcohol is not sporicidal and should
not be used for hand disinfection
when Clostridium difficile is known or
suspected.
Chlorine based Disifectant
• Bentuk cair, sodium hipoklorit,
bleach
• Bentuk padat, calcium hipoklorit
atau NaDCC
• Produces the inhibition of
enzymatic reactions,
denaturation of proteins
and inactivation of
nucleic acids.

• NaDCC tablets are stable and the

antimicrobial activity of a solution
prepared from NaDCC tablets may
be greater than that of sodium
hypochlorite solutions containing
the same total available chlorine
Chlorine based Disifectant
+ Fast acting.
+ Low cost.
+ Broad spectrum of antimicrobial activity
(including bacterial spores).
+ Does not leave toxic residues.
+ Unaffected by water hardness.
+ Very active against most viruses and the
disinfectant of choice for environmental
decontamination following infectious
cases and other items
- Corrosive to metal, damaged plastic,
rubber and similar components on
prolonged contact (> 30 minutes), or if
used at an incorrect concentration.
- Bleach fabrics, carpets or soft
furnishings
- Efficiency also diminishes with
decreased concentration, presence of
organic matter and an increase in pH.
- Hypochlorites can cause irritation to
the mucous membranes of the skin,
eyes and lungs, especially if used
frequently in a poorly ventilated area. –
Appropriate PPE must beworn when
hypochlorite is handled, whether in
liquid or powdered/granulated form.
- Sodium hypochlorite should not be
mixed with ammonia or acid or acidic
body fluids (e.g. urine) as it releases
toxic chlorine gas, especially in a
confined space.
- They should not be used in the
presence of formaldehyde as some of
the reaction products are carcinogenic.
Factors affect the stability of chlorine:
• Presence of heavy metal ions.
• Incompatible with cationic detergents.
• Decreased efficiency with an increase in pH of the solution.
• Temperature of the solution.
• Presence of biofilms.
• Presence of organic matter (particularly if used in low concentrations).
• Ultraviolet radiation.

• Decomposition and deterioration of hypochlorite is accelerated by light, heat and heavy metal. It
is also polymerized by sun rays and needs to be protected in opaque containers.
• Evaporation of hypochlorite causes the concentrations of available chlorine to decline
substantially. Hypochlorite solutions should not be stored in uncovered containers. It is important
that diluted hypochlorites solutions should be freshly prepared daily and kept in opaque
containers to prevent degradation.
Quaternary Ammonium Compounds (QAC/
QUATS)
• More active against Gram-positive than Gram-negative bacteria.
• No activity against bacterial spores.
• Variable mycobactericidal activity.
• Good fungicidal activity.
• Variable activity against viruses.
• Easily inactivated.
• Contamination and growth of Gram-negative bacilli in dilute solutions is possible.
• All have some detergent properties.
• Sterile QAC solutions with or without chlorhexidine may be used for cleaning dirty
wounds.
• Some used in catering areas.
• Newer formulations may be suitable for environmental disinfection within healthcare.
Phenol
• Uses:Environment.

• Wide range of bactericidal activity, including mycobacteria.

• No practical sporicidal activity.
• Good fungicidal activity; limited virucidal activity, usually poor against non-enveloped
viruses.
• Not readily inactivated by organic matter; absorbed by rubber and plastics.
• Contact with skin should be avoided.
• Taint food; do not use on food preparation surfaces or on equipment that may come into
contact with skin or mucous membranes, particularly of infants.
• Concentrates are stable but stability is reduced on dilution.
• Agents of choice for mycobacteria, including Mycobacterium tuberculosis, in the
environment and laboratories.
USE OF CHEMICAL
DISINFECTANTS – SAFETY
OF HEALTH-CARE WORKERS
Employer Duty
• The employer has a duty to inform, instruct and train employees and non-
employees on his premises in relevant safety matters; this includes the use of
chemical disinfectants.
• Concentrated disinfectants should always be stored and handled with care wearing
appropriate PPE, such as gloves, aprons, respiratory and eye protection
• Whenever possible, disinfectants should be stored in and dispensed from a closed container
to reduce the risk of vapour release
• Storage containers should never be left open to the atmosphere for longer than absolutely
necessary
• Work should be carried out in an area with easy access to running water, eye wash bottles
and adequate ventilation (e.g. an extractor fan or open window)
• It is essential that a risk assessment be carried out when disinfectants are selected in health-
care facilities
• Users must follow the manufacturer’s instructions and, where necessary, the exposure of
employees and others should be monitored according to recommended guidelines.
Summary Using Chemical Disinfectants
• The efficacy of chemical disinfection is often uncertain and difficult to
control/standardize, so wherever possible, disinfection by heat is preferable to
chemical methods
• All chemical disinfectants must be clearly labelled and used within the expiry date.
• They should be freshly prepared and used at the correct concentration and stored
in an appropriate container.
• Chemical disinfectant solutions must not be mixed or detergents added unless they are
compatible
• Disinfectant or detergent solutions must not be prepared and stored in multi-use
containers for occasional use. Solutions prepared and stored in this manner may
become easily contaminated with microorganisms and the use of such solutions will
readily contaminate a surface rather than clean it
• Disinfectants can be corrosive and may damage fabrics, metals and plastics.
Manufacturer’s instructions must be consulted on compatibility of materials with
the method of sterilization or disinfection
• Disinfectants must be disposed of in accordance with the manufacturers
recommendations and local guidance
TERIMA KASIH