P2B209: Activated 2% Hydrogen Peroxide Chemical High-level Disinfection Guidelines for Continuous Positive Airway Pressure Tubing in Resource-limited Settings

Background: Infection is a leading cause of neonatal mortality, particularly in resource-limited settings (RLS). One cause is ineffective disinfection (reprocessing) of medical equipment. In response, the nongovernmental global organization PATH developed guidelines for high-level disinfection (HLD) of neonatal resuscitation equipment. However, questions about the feasibility of these recommendations in RLS remain. Another common cause of newborn death is birth asphyxia, the lack of blood and oxygen flow to the brain. Continuous positive airway pressure (CPAP) delivery is one effective respiratory therapy method for infants in respiratory distress. We investigate the efficacy and feasibility of a novel HLD protocol for reusable CPAP tubing using activated 2% hydrogen peroxide (H2O2), a widely available and commonly used chemical disinfectant in RLS.

Methods: To determine bacterial burden from a surface it is assessed at 3 time points: “before use” (BU), “after use/” (AU), and “after reprocessing” (AR). Contamination, simulating clinical use, is performed by depositing artificial mucus inoculated with Escherichia coli and Staphylococcus aureus at four sites (A, B, C, D) of the CPAP tubing. See Figure for site identification. Positive controls with inoculated artificial mucus and negative controls with non-contaminated artificial mucus are also performed. Two reprocessing methods are tested. Our H2O2 HLD procedure is performed by scrubbing the tubing with warm soapy water, rinsing in warm water, and air drying, followed by submersion in 2 liters of H2O2 for 20 minutes then rinsing 3x in warm water. Autoclave sterilization is performed by scrubbing with warm soapy water, rinsing in warm water, air drying, and autoclaving at 121ºC for 5 minutes. Test samples undergo serial dilutions and plating on 5% sheep blood agar in triplicate, followed by incubation for 24 hours. Colony forming units per centimeter squared (CFU/cm^2) are calculated using plates with colony counts between 30-300.

Results: The majority of “before contamination” samples demonstrated no growth. Sufficient bacteria grew “after contamination” with E. coli and S. aureus, demonstrating effective contamination of CPAP tubing. Following autoclave sterilization, the bacterial burden was reduced below confidence limits. Bacterial burden was also reduced below confidence limits following our H2O2 HLD procedure. See Table.

Conclusion: Sterilization remains the gold-standard for reprocessing and was shown effective in reducing bacterial burden in our work. However, our H2O2 HLD procedure demonstrated equivalent bacterial reduction. This could be a viable reprocessing option in settings that do not have the ability to perform autoclave sterilization or the protocols published in PATH. Investigation of additional HLD methods could increase the number of reprocessing options available in RLS with the potential to reduce global neonatal morbidity and mortality due to infection.