STERILIZATION & DISINFECTION.pptx

 INTRODUCTION
 HISTORY
 CROSS- INFECTION
 BACTERIAL AND VIRAL THREAT
 STERLIZATION AND DISINFECTION
definition, principles, methods
 INFECTION CONTROL
 OPERATING ROOM PROCEDURE
 WASTE DISPOSAL
 NEWER ADVANCEMENTS
 CONCLUSION

“were we but able to explain;
the fiefdom of the microbes,
why one man is his serf,
another is his lord,
when all are his domain”
Anonymous

 BIBLE, RIG VEDA, QURAAN
 2700 BC- Chinese medicine; infection control
 800 BC- 400 AD : Sushrutha and charka
Samhitha
 MID 19TH CENTURY- an era of advancement
 1832- WILLIAM HENRY ;heat sterilization
by boiling water
 1839- DAVIES; iodine for wound dressing
 1843- LE FERNE; introduced chlorine water
for disinfection

 1847- IGNATZ SEMMELWESS
 Introduced routine hand wash
 Began using chlorinated lime
 Pioneer of modern disinfection

 1867- JOSEPH LISTER
 Introduced British surgery to hand
washing
 Introduced phenol as anti microbial agent
for wound dressing
 1883- American Surgical Associates
approved Listerian technique
 Beginning of a new era of infection control

 Organisms capable of causing cross
infection may take a route-
› Patient to patient
› Patient to doctor
› Doctor to patient
 Principles of cross infection
a) source
b) mode
c) route

 People with overt infection
 People in prodromal stage
 People who are healthy
› Convalescent carriers
› Asymptomatic carriers
 Key point - Convalescent carriers can be
identified by past history but asymptomatic
carriers cant.

 Direct contact
 Inhalation
 Injection/ inoculation
 Ingestion
 transplacental

 Direct contact of tissue with various
secretions of body, blood may act as
direct mode of transmission
 Rare – least common mode of transmission
 May occur due to improper practice by the
doctor

 Droplet infectionair-borne infection
 Infective organisms –infectious aerosols
 Size of aerosols dose matter
 Droplets > 100um – SPATTER
 Droplets < 100um – DROPLET NUCLEI
 Droplet nuclei consist of dried salivary or
serum secretions and organisms
 VIRUS : Cytomegalo, influenza, rhino,adeno
 BACTERIA: streptococcus pyogens

 Major route of cross infection in oral
surgery
 Accidental penetration in skin or mucosa
due to any sharp object or needles
 Evidences depict that it is major cause of
HIV and HBV transmission from patient to
dentist and vice versa

 Ingestion (diarrhoeal diseases)
 Trasplacental
>T O R C H
>Congenital syphilis
>HIV acquired diseases

BACTERIA ROUTE INCUBATION
PERIOD
M. tuberculosis Saliva; sputum 6 months
S. aureus Saliva; exudate;
skin
4-10 days
S. pyogens Open wound;
blood
1 -7 days
T. pallidum Direct contact 1-10 weeks

VIRUS ROUTE INCUBATION
PERIOD
Hepatitis A& E FECO- ORAL 2-6 WEEKS
Hepatitis B,C&D BLOOD,SALIVA
SEMEN
6 WEEKS -6 MONTHS
HIV/ ARC BLOOD,SEMEN,BOD
Y SECRETIONS,
TRANSPLACENTAL
10 YEAR or MORE
Herpes simplex 1& 2 SALIVA,BODY
SECRETIONS
2 WEEKS

STERILIZATION : - Process by which an
article, surface or medium is freed of all
micro-organisms either in vegetative or
spore state.
DISINFECTION : - Destruction of all
pathogenic organisms, or organisms
capable of giving rise to infection.

STERILITY : -An absolute state which
depicts freedom from viable forms of
micro-organisms.
ANTISEPSIS :- Used to indicate the
prevention of infection, usually by
inhibition of growth of bacteria.
ANTISEPTICS : - Chemical disinfectants
which can be safely applied to skin or
mucous membrane surfaces & are used to
prevent infection by inhibition of growth
of bacteria

BACTERIOSTATIC : - Agents which only
prevent multiplication of bacteria, which
may however remain alive.
BACTERICIDAL : - Agents which are able to
kill the bacteria completely.
FUNGICIDAL : - Agents which are able to
kill the fungi completely
VIRECIDAL : - Agents which are able to kill
the virus completely

 All used instruments to be thoroughly
cleaned.
 Essential for sterilizing agent to be in
contact with every surface of each item.
 All sterilized instruments must be
regularly serviced and maintained.
 Appropriate test must be done to check
temp., humidity, pressure.
 Manufacturers instructions to be followed
strictly.

 LAWRENCE & BLOCK - 1968
 Separation of contaminated
instruments and equipments from
treatment area
 Instruments should be cleaned
scrupulously
 Heavy duty utility gloves, eye glasses and face masks
must be worn before cleaning manually i.e scrubbing
 If immediate cleaning not feasible then instruments
should be kept in disinfectant until cleaned
 Critical , semi-critical ,non-critical

 ↑ cleaning efficiency
 ↓ danger of aerosol
infection
 ↓ incidence of sharp
injury
 ↓ manual labour s
 Uses soaps &
detergents

 An open tray system sealed with see
through sterilization bag .
 Perforated trays with fitted corners
wrapped with sterilization paper
 Individual packaging in commercially
available sterilization bags
 Disposable items should be stored in
covered plastics or containers

 Physical methods
 Chemical methods
 Gaseous methods

 Sunlight
 Drying
 Dry heat (flaming, hot air, incineration)
 Moist heat
> below 100˚C
> at 100˚C
> more than 100˚C
 Filtration
 Radiation
 Sonic and ultra sonic

 Organic disinfectants :- alcohols, aldehydes
 Inorganic disinfectants:- halogens, heavy
metal salts
 Coal Tar derivatives:- phenols, CHX
 Dyes :- aniline or acridine
 Surface acting agents

 Ethylene oxide
 Formaldehyde
 β- propiolactone

 Appreciable bactericidal and germicidal.
 Spontaneous sterilization due to combined
effect of UV rays & heat
 SEMPLE & GRIEG :- Killing of typhoid
bacilli exposed to sun.
 Bacteria suspended in water readily killed
when exposed to sunlight.
 Efficient method of purifying water in
river and sea.

 4/5th of weight of bacterial cell consists
of water.
 Moisture is essential for their growth.
 Drying has deleterious effects on
bacteria.
 Unreliable method
 Spores are unaffected by drying.

 Factors influencing heat sterilization :-
a) Nature of heat
b) Temperature & time
c) No. of micro-organisms present
d) Characteristics of organism
e) Material from which organism have to be
eradicated.

FLAMING :-
i)Articles held in a BUNSEN FLAME
till they become red hot:-
( Inoculating loop of
wires,points
of forceps, searing spatulas )
ii)Articles passed for few seconds without
letting them get red hot:-
( scalpels, needles ,mouth of culture tubes,
glass slides, cover slips )

 Excellent method for destroying used
materials and disposal of waste.
 Contaminated material is sterilized and
burned in bulk at temp of 870-980˚c
 Articles sterilized:-
i) all surgical dressings
i i) used disposable syringes
iii) contaminated lab materials
iv) animal carcass
v) beddings and pathological materials

 Luise Pasteur – 1876
 Contains compartments which distributes
heat uniformly
 Usually heated by electricity with heating
elements in wall of the chamber
 Fitted with fan for even distribution of
air
 Load should be arranged in a manner to
allow free circulation of air in between
instruments
 Proper operation of HAO to be done

 RAPID HEAT HOT AIR OVEN
>rapid heat transfer device
>short sterilization cycle
> 190˚c for 12 min – packaged inst.
6 min – unwrapped inst.

 Glass ware
 Test tubes & flasks
 Extraction Forceps
 Scissors
 Scalpels
 Glass syringes
 Swabs
 Pharmaceutical products( parraffin,
sulphonamides, dusting powder)
 Only silicone rubber

Holding period
Sterilization cycle
Time
Temperature

TEMPERATURE HOLDING TIME
121˚ C ( 250˚ F) 6-12 Hrs
140˚ C (285˚ F) 3Hrs
150˚ C (300˚ F) 2 ½ Hrs
160˚ C (320˚ F) 2 Hrs
170˚ C (340˚ F) 1Hr
180˚ C (375˚ F) 30 mins

 PROS
>no rusting and dulling of sharp inst.
>large capacity and low cost
 CONS
>low penetration
>long sterilization cycle
>damages plastics and rubber
>combustion of paper at temp>175˚ C
>charring of cotton wool at temp 180˚C
>cycle interruption possible if no TIME LOCK

 BIOLOGICAL
>spores of non-toxicogenic strains of
CLOSTRIDIUM TETANI &BACILLUS
SUBTILIS
>incubated for sterility test
 CHEMICAL
>BROWN’S TUBE
>GREEN SPOT TEST
>red colour changes to green
 PHYSICAL
>thermocouple
>centigrade thermometer

 Heat transfer device
 Media used are glass bead,salt,metal
 Temp. achieved is 220˚ C for 10 sec
 Small inst. as endodontic files,burs

 TEMPERATURE < 100˚ C
 TEMPERATURE AT 100˚ C
 TEMPERATURE > 100˚ C

 PASTEURISATION
>Holding method ( 63˚c for 30 min )
>Flash method ( 72˚ c for 15-20 sec )
>Ultra high temp. (130˚ c for 2 sec )
 VACCINES OF NON-SPORING CTERIA
>Heat inactivated ( 60˚ c for 1 hour )
 SERUM & BODY FLUIDS
>Water bath ( 56˚ c for 1 hour for several days )
 CULTURE MEDIA
>Heat inactivated(80-85˚ c for 30 min)
>for 3 successive days in inspissator
 SOME INSTRUMENTS
>Cytoscope, specula( 75˚ c for 10 min )
>clothings,bed linen,eating utensils
( water bath at 70-80˚c for few min )

 BOILING
>hard water should not be used
> 2% sodium bicarbonate enhances sterilization
>lid of sterilizer should be closed during period
> 90˚ c -100˚ c for 10 min( only vegetative bacteria)
 STEAM AT 100˚C
>KOCH & ARNOLD steamer
>single exposure sterilizer
> at 100˚ c for 90 min
>for media containing gelatin
(100˚c for 20min on 3 successive days)
TYNDALLISATION ( John Tyndall )
FRACTIONAL/ INTERMITTENT
STERILIZATION

 AUTOCLAVE
> CHAMBERLAND 1880
>( auto = self ) ( clave = lock )
>Works on principle of steam condensation to water at
pressure of 15 lbs at 121˚c/ 30 lbs 134˚c
>So all air must be removed as will affect DALTON’S
LAW
>Liberates 518 calories of heat
>A glorified domestic pressure cooker
>Most accepted instrument for sterilization by both
BRITISH & EUROPEAN PHARMACOPOEIA

 Surgical instruments
 Surgical dressings
 Liquids bearing high temp.
 Culture media(except those with gelatin)
 Rubber articles ( tubing , washer ,caps)
 Discarded media with growth
 Metallic syringes
 Waste disposal

 PROS
>most efficient and reliable
>simple to operate
>most dental inst. can be sterilized
>flexibility of packaging & loading
>inexpensive
 CONS
>non-stainless metals may get rusted
>Insufficient method of discharge of air
>load that retains moisture increases sterilization cycle
>non-provision for drying of load inside the autoclave

 PRE-VACCUME AUTOCLAVES
> known as porous autoclaves
> air evacuated from chamber by vacuum
suction
>available as small bench top units
>most demanded for daily use

TEMPERATURE HOLDING TIME
116˚C ( 240˚F ) 60 MIN
118˚ C ( 245˚ F ) 36 MIN
121˚C ( 250˚F ) 24 MIN
125˚C ( 257˚F ) 15 MIN
132˚C ( 270˚F ) 4 MIN
138˚C ( 280˚F ) 2 MIN

 BIOLOGICAL
 > Spores of non- toxicogenic
 BACILLUS STEAROTHERMOPHILUS
 PHYSICAL ( Bowie’s Dick test )
 CHEMICAL
 >autoclave tapes
 >chemical soln

 LTSF CHEMICLAVE
 Dry saturated steam+formaldehyde
 Dual action-HEAT+ALKYLATION
 127-132˚C at 20-30 psi for 30 min
 Lack of corrosion
 Short duration

 Method for heat – labile liquids
 Useful for antibiotic solutions, culture
sensitive media, sera & carbohydrates
used in culture media( sugar & gelatin)
 Useful to separate organisms & study
them
 Bacteria free filtrates and
bacteriophages can be obtained
 Filter disc containg organisms can again be
cultured
 Serratia marcenses for sterilization check

 CANDLE FILTERS
>Have different grades of porosity to
purify water
1.)UNGLAZED CERAMIC FILTER
(cleaned by Na hypochlorite after use)
eg: Chamberland, Doulton
2.)DIAMATECEOUS EARTH FILTER
(cleaned by Na hypochlorite after use)
eg: Berkfeld ,Mandler

 Made of porous cellulose esters
 Wide range of porous diameter
 0.22μm most widely used

 Heat-fusing finely powdered glass
 Low absorptive property
 Cleaned easily
 Brittle & expensive

 NON-IONISING
1.)UV-RADATION
( low penetrating )used for sterilization of
OT,BIOLOGICAL SAFETY CABINETS,PLASTIC
SYRINGES
>Damage eye & skin
2.)INFRARED RADIATION
>electromagnetic rays
>180˚c for 7 min
>rapid mass sterilization of syringes,
metallic & glassware instruments
 IONISING ( COLD- STERILIZATION )
>Highly penetrative
( cosmic,x-rays,γ-rays)
>plastics,syringes,swabs,catheters

 Must have wide spectrum of activity
 Be active in presence of organic matter
 Be active in both acid & alkaline medium
 Speedy and high penetrating power
 Be stable and compatible with other
chemicals
 Should not corrode metals
 Should not be toxic, irritaing,sensitizing
 Be safe and easy to use
 Be cheap and easily available

 Protein coagulation
 Disruption of cell membrane
 Removal of free sulfhydryl group
 Substrate competition
 Fixation of cell membrane
 Oxydation

 Concentration of substance
 Time of action
 pH of medium
 Temperature
 Nature of organism
 Presence of extraneous material

 SPAULDING 1939- (60-70%) for 10 min
 Bactericidal and fungicidal
 Ethyl alcohol ( volatile & inflammable)
 Isopropyl alcohol is preferred
(clinical thermometer & other inst.)
 Methyl alcohol( cabinets,incubators)
 Corrosive to carbon steel,reacts with
rubber,hardens and swells plastic
 Dissolves cement holding inst.

 FORMALDEHYDE ( HCHO )
>Batericidal,fungicidal,sporicidal
>active against amino group of protien
USED TO STERILIZE
1. 10-40% to Preserve anatomic specimens
2. 3 % to Destroy spores of ANTHRAX in hair & wool
3. 10 % to Sterilize metallic inst. &heat sensitive
catheters,books,clothes,furnitures
DISADVANTAGES
1. Contact of 18-30 hours is necessary
2. Toxic up to an extent
3. Irritant to eyes and tooth

 Batericidal,fungicidal,sporicidal
 MOA-alkylation on 10 hour contact
 Activated by Na bicarbonate but only for 14 days
 Sterilizes
>lenses of cytoscope,brochoscope
>corrugated rubber anesthetic tubes
>plastic endotracheal tubes
>polythene tubings
>metallic instruments
>face masks
 Gluteraldehyde 2% alkaline( CIDEX,PROCIDE,OMNICIDE)
 Gluteraldehyde 2%+phenol( SPORICIDIN )
 Gluteraldehyde 2% neutral ( GLUTAREX )
 Gluteraldehyde 2% acidic+alcohol (BANICIDE,WARICIDE)
 Irritant to eyes so must be washed before use

 HALOGENS
A. IODINE :-
>(aqueous &alcoholic solutions)
>bactericidal,vericidal,sporicidal
>POVIDONE-IODINE (most common skin
disinfectant)
>Strong iodine 19% wt/vol of iodine
>weak iodine 2% wt/vol of iodine
>medium 12% wt/vol of iodine (BETADINE )
>Hand wash,skin prepration,sterilization of surgical
inst.
>IODOFORM(non-ionic,surface active)
>more active than iodine
>white-head warnish in DRY SOCKET,BONY DEFECTS

 CHLORINE - Le Ferne in 1843
>Bactericidal ,Vericidal
>Commonly used as HYPOCHLORITES
> Ca& Na hypochlorite
>CHLOROS & DOMESTOS
> Release nascent Oxygen
>Used for : -
a) disinfection of swimming pool
b) disinfection of food and dairy
c)antiseptics for wound dressing
DAKIN’S SOLUTION

 Salts of silver, copper, mercury
 Protein coagulant& sulfhydryl inhibittor
 Mercuric chloride is strong fungicide
 1% silver nitrate-DRY SOCKET
( reduces pain & induces granulation)

 PHENOL
>( LISTER-1865-carbolic acid )
>Cell membrane damage,bactericidal
>lysol &cresol more active at 3-10%
>not inactivated by organic matter
>chlorophenol&chloroxylophenol less toxic
>hexachlorophene potent but toxic
>Dettol( CHOLOROXYLENOL ) is potent & 100%
disinfectants
 CHLORHEXIDINE( bisguanide)
>against gm +ve and gm _ve,but not spore&fungi
>0.5% CHX+ 70% ALCOHOL( hibitane Skin disinfectant)
>CHX+ CETRIMIDE( cetavalon , savlon)
>4% CHX +DETERGENT(hibiscrub)
>0.2% SOLN or 1% GEL ( mouthwash)

 Potent skin and wound disinfectants bactericidal
 Impair DNA and destroy reproductive capacity
 Bacteriostatic & low bactericidal action
 ANILINE DYES
>brilliant green,malachite green,crystal violet
>more active for gm +ve than gm_ve
>selective agent in lowenstein jensen media no activity
agaist M.tuberculae
>inhibited by organic matter like pus
 ACRIDINE DYES
>Mainly against gm +ve
>slow release when impregnated in gauze
>proflavine,acryflavin,euflavin,aminacrine

 Alter energy relationship at interface and
reduce surface tension,damage cell
membrane.
 Wetting agents,detergents,emulsifiers
 Cationic(cetavelon,benzalkonium Cl )
 Anionic ( soaps )
saturated fatty acid-gm_ve
unsaturated fatty acid- gm+ve
 Amphoteric( TEGO )
both gm+ve and gm_ve

 ETHYLENE OXIDE
>colourless,highly
penetrative,inflammable,explosive
>sweet etherel smell &boiling point 10.7˚c
>alkylation of protein & affects DNA,RNA
>Unsuitable for fumigation as explosive
>irritant gas
>mixed with CO2 & N to reduce conc. Upto
10% so that less explosive

 USES TO STERILIZE
>Heart – lung machines
>respirators
>sutures
>dental equipments
>disposable syringes
>books & clothings

 FORMALDEHYDE GAS
>used for FUMIGATION of wards,OT
>40%HCHO+potassium permanganate
>instrument used is STERI TRAX for 30
min
>irritant and toxic effects nullified with
ammonia
>parameters for fumigation:
RELATIVE
HUMIDITY
OVER 70%
TEMPERATURE 30-40˚C
FORMALDEHYDE
LEVEL
5 ppm OR MORE

 HIV and hepatitis patients cannot be refused dental
or OMFS treatment.
 Universal barrier techniques are mandatory.
 Instruments must be both cleaned and sterilized
between patients.
 Environmental disinfection must be performed
 Infectious waste disposal must follow specific
guidelines.
 Training records in infection control must be kept
for each employee.

 Strictly followed code of hygiene will
greatly reduce cross infection
 Keep hands away from eyes, nose, mouth
and hair and avoid touching sores and
abrasions.
 Cover cuts and bruises on fingers with
dressings because they serve as easy
portals for pathogen.
 Personal hygiene of all the members
directly or indirectly in contact with
patient should be scrupulous.

 Thoroughly scrub hands to remove superficial
contaminants,loose epithelium & to reduce bacterial count
 Resident flora Vs transient flora
 No touch technique to be followed
 DOBSON &SHULLS – rule of 3
 Scrub all 4 surfaces of fingers,knuckels,back of
palm.Wash hands and forearms upto 2 inches above elbow.
 Varioius antimicrobIial agents used :-
>HIBISCRUB & PHISOMED(4% chx)
>HIBISOL(2.5% chx+70% alcohol)
>BETADINE(7.5% povidone iodine)
>TRICLOSAN&CHLOROXYLENOL

 Freshly laundried uniform to be worn daily
to protect from body fluids and aerosols
 High neck,long sleeved,knee length
overgarments to be worn
 Grossly contaminated dressing should be
dealt separately
 Clinic clothing should be worn in clinic
premises only
 Waterproof vinyl apron should be worn
when working in instrument cleaning area.

 To be compulsorily worn to protect from
aerosols and debris.
 Not to be touched with gloves once worn
 Preferably wear eye shield with side
protection.
 Filtration capacity of aerosols depends on
material used for face masks.
 Mask should have 95% filtration efficiency
for particles 3-5 μm in diameter
 Glass fibre and polypropylene masks are
superior to paper masks.
 Life span of mask is 30-60 mins.

 Check for perforations and visible defects.
 Never wash and reuse.
 Change gloves atleast hourly during long procedures
on same patient.
 If latex allergy, then skin creams and cotton glove
liner may help.
 TYPES:
> Protective latex gloves(high quality,examination)
> Sterile gloves(for surgical/blood letting procedures)
> Heavy duty utility gloves(for cleaning instruments)
> Polyethylene gloves(multiple use, over gloving)
> Vinyl or latex gloves(single use,examination)

 Depends on type of surgery & anesthesia
 Purpose is to isolate surgical area from
other part of body & from non-sterile
operating room
 Pts head covered with double layer
drapes,enabels easy tiling of head
 Additional drapes are used to complete
isolation and secured with towel clips

 To reduce pts own flora as well as
resistant bacteria acquired from hospital
 Extra-oral procedure is accompanied by
pre-surgical scrub,shaving of area
 Cirum-oral preparation precedes intraoral
preparation
 Iodophor ,cetrimide,betadine(extra-oral)
 Iodine,2% CHX ( intra-oral )
 Scrub begins at centre then to periphery
moving concentrically

 Water supply from municipal corp.
 Bacteria tend to form BIOFILM
 Water entering DUWL has 0-100 CFU/ml
but till it exits from instrument 10,000
CFU/ml
 All DUWL to be flushed for 2 min before
treatment and 20-30 sec in b/w each pt
 Should never be used as irrigant in procedure
involving mucosal breach and bone exposure
 Use filters,biocides,chemicals ( CI,Clo2 )

 Its merely a clean area,NOT STERILE
 Clear demarcation b/w contaminated and clear
zone
 Ceiling,floors,wall regularly disinfected
 No eating or smoking permitted
 Carpets not used to minimize dust
 Flooring to be disinfectant resistant vinyl
 Centrally controlled ventilation
 Special venting to scavenge noxious vapour
 Remove street clothes and acquire barrier
technique

“ Let the wastes
of the SICK
Not contaminate the…
Lives of the HEALTHY “

CATEGORY WASTE
MATERIAL
INFECTIOUS Lab cultures, instruments in
contact with blood, serum
PATHOLOGICAL Human body parts,fluids
SHARPS Needles ,blade ,scalpel
GENOTOXIC Cyto-toxic drugs, vomits
CHEMICAL Solvents & disinfectants

COLOUR WASTE DISPOSAL
YELLOW Anatomical waste,animal
waste,blood &body fluids
Incineration/burial
Inertization.
RED Microbiological
waste,blood,catheters, IV
sets
Autoclaving
,microwaving, chemical
treatment
BLUE Sharps,catheters,IV sets Autoclaving
,microwaving, chemical
treatment
BLACK Cyto-toxic
drugs,chemicals &
diinfectants
Burial in secured
land,incineration

 EXTRACTED TOOTH
1. If to be used for research (0.005% thymol)
2. If patient wants the teeth (5000-6000ppm
bleach )
3. If to be stored ( 10% formalin for 2 weeks)
4. If to be disposed ( NaOcl+water ) 1:10
 BIOSY SPECIMENS
1. Immediately placed in 10% formalin
2. Packed in leak proof container
3. Biological hazard labeling done
4. Specify name & conc. Of chemical used

 CLIMO – STERIC FUMIGATOR
 Offers unique dry fogging technique
 Uses micro diffusion process
 Spreads ultra fine fog
 Produces disinfection droplets
 Size 5-10 μm
 Droplets are bio-flavanoid solution
 Kills all organisms in area of 50 m3
in 30 mins

 Micro-processor controlled electronics
 Patented steam generation system
 Fractionated vacuum system
 ROBOT controlled locking system for safety
 Wide range of sterilization programs

 Ananthnarayan & panicker
 Laxman samaranayake
 Nisengard &Newman
 Bailey & scott
 Peterson
 Archer
 Medical Micro-PLAYFAIR
 Medical Micro-PRESSCOTT
 Tortora & Shimeld
 Sherries microbiology
 Melnick & Jawetz
 Donald & connie

STERILIZATION & DISINFECTION.pptx

STERILIZATION & DISINFECTION.pptx

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STERILIZATION & DISINFECTION.pptx