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 Table of Contents  
BRIEF COMMUNICATION
Year : 2022  |  Volume : 24  |  Issue : 1  |  Page : 35-37

Is adenosine triphosphate test really required in hospital sterile supply quality monitoring purposes: An observation done in an oncology centre in Eastern India


Department of Central Sterile Supply, Tata Medical Center, Kolkata, West Bengal, India

Date of Submission17-Dec-2021
Date of Acceptance01-Feb-2022
Date of Web Publication11-Jul-2022

Correspondence Address:
Debabrata Basu
Department of Central Sterile Supply, Tata Medical Center, New Town, Kolkata - 700 156, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacm.jacm_69_21

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  Abstract 


Assessment of cleaning is an important part for ensuring health and hygiene, especially before disinfection and sterilisation procedure. Cleaning assessment can be done by different techniques. Although there is no standard to define when a device is 'Clean', from various study, it is observed that proper cleaning can reduce more than 90% bio-burden on any object. The cleaning and disinfection monitoring in Central Sterile Supply Department are to ensure that subsequent cleaning and disinfection process is successful. To verify cleaning monitoring of surgical instruments, the ATP testing method is fast, technically effective and easiest way among all other cleaning assessment techniques.

Keywords: Adenosine triphosphate test requirement, Central Sterile Supply Department requirement, chemical reaction, cleaning monitoring limitation, different cleaning assessment


How to cite this article:
Basu D, Dutta SK, Bag SC, Das A, Rozario JD. Is adenosine triphosphate test really required in hospital sterile supply quality monitoring purposes: An observation done in an oncology centre in Eastern India. J Acad Clin Microbiol 2022;24:35-7

How to cite this URL:
Basu D, Dutta SK, Bag SC, Das A, Rozario JD. Is adenosine triphosphate test really required in hospital sterile supply quality monitoring purposes: An observation done in an oncology centre in Eastern India. J Acad Clin Microbiol [serial online] 2022 [cited 2022 Aug 11];24:35-7. Available from: https://www.jacmjournal.org/text.asp?2022/24/1/35/350320



Assessment of cleaning is an important part for ensuring health and hygiene, especially before disinfection and sterilisation procedure. Cleaning assessment may be done by different methods such as:

  1. Visual inspection
  2. Ultra violet (UV) light
  3. Surface microbiology
  4. Microscopic examination
  5. User feedback
  6. SOIL test
  7. Adenosine triphosphate (ATP) bioluminescent test.


Among these various methods, visual inspection and user feedback are most commonly used because they are easy, cheap and quick and can be readily done in most situations without need of expensive technology. Microbiological assessment of cleanliness is time-consuming, resource intensive and technologically demanding. Moreover, microbiological assessment cannot determine that the inanimate material of organic debris is present or not. Viable but not cultivable microorganism cannot also be detected by culture-based method. Microscopic-based methods are used mostly for research and industrial applications and cannot be routinely used in other situations. UV light along with fluorescent dye or gel has limited application in the assessment of cleanliness.[1] The Central Sterile Supply Department (CSSD) specialised test such as 'SOIL' test is generally used only for quality control of automated washing. To monitor 'SOIL' test 'Wash-Check' indicator is used comprising sheep blood with protamine Sulphate, nigrosine with flour and egg, potato starch, semolina pudding, bovine albumin and wallpaper paste and ink. The soil is generally smeared on the instruments which are subjected to standard methods of cleaning and visually inspect after the cleaning process is over.[2]

ATP is the source of energy for use and storage at the cellular level. The structure of ATP is a nucleoside triphosphate, consisting of a nitrogenous base, a ribose sugar and three serially bonded phosphate groups. It provides readily releasable energy in the bond between the second and third phosphate groups. In addition to providing energy, the breakdown of ATP through hydrolysis serves a broad range of cell functions, including DNA/RNA synthesis. The cells within the human body depend on the hydrolysis of more than 100–150 moles of ATP per day to ensure proper functioning. In ATP-based test, the generation of ATP by microbial metabolism is detected. The limitation of this test includes the fact that if the microbes do not generate ATP in sufficient amount, it may not be detected by the system. The quality of swabbing may also determine the sensitivity of the test.[3]

It is therefore clear from the above description that no method for assessment of cleanliness is ideal in terms of accuracy, cost, convenience and applicability. In reality, a combination of methods is used to certify something clean. The specific method or methods used will depend on the premise, device and context in which it is being used. For sterile procedures, a highly sensitive and specific method is essential, whereas for a clean procedure, visual inspection may be justified. For example, the standard of cleaning for a toilet or an operation theatre is not same. Similarly, cleaning standard of surgical instruments used for sterile procedure and cleaning standard for stethoscope are different. Hence, depending on the situation and the requirement of cleaning assessment techniques have to be used.[4]

The objective of cleaning and disinfection procedure in CSSD is to eliminate remaining blood and tissues from the surgical instruments and ensures that subsequent cleaning and disinfection process is successful. Cleaning is the first step, where blood and small tissues are visibly removed from the instruments by manual and automated method. The cleaning is required before disinfection or sterilisation because organic and inorganic materials that remain on the surfaces of instruments interfere with the effectiveness of these processes.[5] Although there is no standard to define when a device is 'Clean', from various study, it is observed that proper cleaning method can reduce more than 90% bio-burden on any object. Therefore, any compromise in cleaning process can give adverse results because microorganisms may pile up on instruments surfaces and transmit to other patients and causes infection.

The ATP bioluminescence method can detect different types of organic material, including bacteria, blood, human secretions and food. To verify cleaning monitoring of surgical instruments, the self-contained ATP testing is fast, effective and easiest way in CSSD procedure among all other cleaning assessment techniques. The ATP monitoring process is activated to allow the enzyme luciferase mix with ATP (ATP collect by swab sampling) and produce luciferyl adenylate. When luciferyl adenylate is again reacted with oxygen, they generate a light signal (oxyluciferin + adenosine monophosphate + light). The quantity of the emitted light is measured by a luminometer and translated into a numerical value and expressed as relative light unit (RLU), which can be converted into RLU/mole of ATP. Adenosine triphosphate (ATP) bioluminescence was used to determine whether there was a linear relationship between cultured cell number and measured luminescence using the luciferin-luciferase reaction. The results are available within few seconds providing a 'Real-Time Test' that indicates the how clean the instruments are. As per manufacture's specification (3M), results of RLU up to 150 are in 'Pass' category, whereas more than 150 are in 'Fail' category.[6] The shelf life of the product is 10–12 months as per manufacture to save enzyme from denaturisation.

In our oncology centre, it is observed that materials which are cleaned through automated washer do not required ATP testing on a regular basis (RLU always below 30) because of periodic fresh water supply which is chemically and microbiologically tested. On the contrary, the instruments which are heat sensitive, electromedical or fragile and cleaned manually often required ATP testing (RLU always above 80 or even fail) due to the lack of automated washing and multiple technical errors. The test is performed in daily basis (minimum 2–3 times) or even surprisingly where ATP detection above 150 RLU is reprocessed again and tested until it is 'Pass' [Table 1].[7]
Table 1: Central Sterile Supply Department water quality monitoring systems at Tata Medical Centre, Kolkata, India

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Finally, the country such as India the hospitals are almost over crowded all the day. Hence, the huge numbers of instruments are used where proper turnaround time is poorly maintained. Hence, to maintain time, safe practice and proper documentation purposes, ATP monitoring test is ideal, especially when the instruments are sterilised without automated cleaning cum disinfection processes.[8]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Surface Sampling and the Detection of Contamination. Available from: https://doi.org/10.1016/B978-0-08-100155-4.00044-3. [Last accessed on 2021 Aug 23].  Back to cited text no. 1
    
2.
Gke Clean-Record® Cleaning Process Monitoring Indicators with Hollow Flow-PCD and Holder. Available from: https://babichsteriliser.com.au/gke-clean-record- cleaning-process-monitoring-indicators-with-hollow -flow-pcd-and-holder/. [Last accessed on 2021 Aug 20].  Back to cited text no. 2
    
3.
Dunn J, Grider MH. Physiology, adenosine triphosphate. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553175/. [Last updated on 2021 Feb 27].  Back to cited text no. 3
    
4.
Using the Spaulding Classification Scheme for Sterile Processing Facilities. Available from: https://www.hfmmagazine.com/articles/3621-using-the -spaulding-classification -scheme-for-sterile -processing-facilities. [Last accessed on 2021 Aug 15].  Back to cited text no. 4
    
5.
Basu D. The importance of chemical solutions used for cleaning stainless steel surgical instruments in the central sterile supply department. Infect Control Hosp Epidemiol 2015;36:868-9.  Back to cited text no. 5
    
6.
Setting Pass/Fail Limits for the 3M™ Clean-Trace™ Hygiene Monitoring and Management System. Available from: https://multimedia. 3m.com/mws/media/1763752O/clean-trace-setting-pass-fail-limits-pdf-lm1-implementation.pdf. [Last accessed on 2021 Aug 21].  Back to cited text no. 6
    
7.
Routine Control of Washer-Disinfectors. Available from: https://www.gke.eu/en/publications.html?file=files/gke_2013/content/en/downloads/Publications/Others/Routine%20Control%20of%20Washer-disinfectors.pdf. [Last accessed on 2021 Aug 23].  Back to cited text no. 7
    
8.
Hygiene Management Guide for Surgical Instruments. Available from: https://multimedia. 3m.com/mws/media/1482775O/hygiene-management-guide-for-surgical-instruments.pdf. [Last accessed on 2021 Aug 24].  Back to cited text no. 8
    



 
 
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