Disinfection: is it time to reconsider Spaulding?

The Spaulding classification, originally proposed in 1957, is a widely used system for matching the disinfection and sterilization of surfaces, particularly those of re-usable medical/surgical devices, with available processes. It presents a ranking, from simple disinfection through to sterilization, that should be considered in the reprocessing of devices, based on the risks associated with their use, ranging from 'critical' (presenting a high risk), through 'semi-critical' to 'non-critical' (presenting a low risk). The different levels of disinfection are based on demonstrating antimicrobial activity against established marker micro-organisms representing a range of pathogens. Although this classification system is probably as valid today as it was in 1957, the understanding of microbiology and micro-organisms has changed. This article discusses some examples of disinfection studies with viruses, bacteria, protozoa and prions that challenge the current definitions and expectations of high-, intermediate- and low-level disinfection. In many of these examples, the test micro-organisms demonstrate atypical tolerance or resistance profiles to disinfection processes. In addition to laboratory-based studies, there is now clinical evidence for at least some of these micro-organisms that biocide resistance can lead to infection outbreaks due to unexpected disinfection failure. These reports should encourage the reader to challenge current dogma, and reconsider the expectations of disinfection and sterilization practices.