Effective infection control is fundamental in healthcare settings, where vulnerable individuals, including the elderly, patients with chronic diseases, and those with compromised immune systems, are at higher risk for healthcare-associated infections (HAIs). The rising global concern over these infections has spurred the exploration of novel disinfectants and cleaning agents, and one such agent gaining attention is chlorine dioxide (ClO₂). (ClO₂) is a small molecule with a molecular weight of 67.46 and exists as a stable radical. It acts as an oxidising agent and is reduced to the chlorite ion (ClO₂⁻) by gaining an electron (ClO₂ + e⁻ → ClO₂⁻). With a relatively high redox potential (Eº = 0.95 V), it does not negatively impact the human microbiome (Georgiou, 2021). This potent antimicrobial agent offers a broad spectrum of activity against bacteria, viruses, fungi, and bacterial spores, making it a valuable tool for cleaning and disinfection in healthcare environments. However, the use of chlorine dioxide in these settings requires careful evaluation of its effectiveness, safety, and practicality. This paper critically appraises the importance of using chlorine dioxide for cleaning in healthcare settings, focusing on its
antimicrobial efficacy, safety profile, and the challenges associated with its adoption.
Antimicrobial Efficacy of Chlorine Dioxide
One of the primary reasons for using chlorine dioxide in healthcare settings is its impressive antimicrobial efficacy. Chlorine dioxide is a highly effective disinfectant that is capable of eliminating a wide range of pathogens, including those that are difficult to eradicate using traditional cleaning agents. It acts as a powerful oxidising agent, breaking down cellular components such as proteins and lipids, ultimately leading to the destruction of the microorganisms (Georgiou, 2021). This mode of action allows chlorine dioxide to target a broad spectrum of pathogens, including bacteria, viruses, fungi, and spores, which are commonly present in healthcare environments (Jiang et al., 2024). Several studies have highlighted the effectiveness of chlorine dioxide in combating healthcare-associated pathogens. For instance, chlorine dioxide has been shown to be highly effective against Clostridium difficile (C. difficile) spores, a particularly troublesome pathogen in hospital environments. C. difficile is a major cause of healthcare-associated gastrointestinal infections, and its spores are notoriously resistant to most disinfectants (Hartman, 2015).
Research has demonstrated that chlorine dioxide is effective at reducing C. difficile spore contamination on surfaces. This effectiveness makes chlorine dioxide a valuable tool in preventing the spread of this pathogen (Zhang et al., 2020). Moreover, chlorine dioxide is also effective against other difficult-to-kill microorganisms, including multidrug-resistant organisms (MDROs) like methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) (Georgiou, 2021). The versatility of chlorine dioxide extends to its ability to function in a wide range of environmental conditions. Unlike other disinfectants, such as sodium hypochlorite (bleach), chlorine dioxide remains effective over a broader pH range, making it suitable for use in various cleaning applications (Rutala and Weber, 2019). This characteristic is particularly important in healthcare settings because the surfaces that need to be disinfected can vary widely in terms of material composition and environmental conditions.
Safety Profile of Chlorine Dioxide
While the antimicrobial efficacy of chlorine dioxide is well-established, its safety profile also plays a significant role in its suitability for use in healthcare settings. Traditional disinfectants, such as bleach, have been associated with various health risks, including skin irritation, respiratory problems, and the formation of harmful chlorinated by-products like trihalomethanes (THMs). These by-products can be
harmful to both healthcare workers and patients, particularly in poorly ventilated areas (Hassel et al., 2022; Fontana et al., 2025). In contrast, chlorine dioxide offers a safer alternative. It produces significantly fewer harmful by-products compared to bleach, making it a safer option for routine disinfection in healthcare environments. The primary by-products of chlorine dioxide are chlorite and chloride, both of which are less toxic than the by-products generated by chlorine bleach (Reed et al., 2016). This is particularly important in areas where vulnerable patients may be exposed to the disinfectant residues, such as patient rooms, operating theatres, and intensive care units.
Another key safety consideration is the potential toxicity of chlorine dioxide. While chlorine dioxide is effective at killing microorganisms, it is also a strong oxidising agent, and its improper handling or excessive concentrations can pose risks. Chlorine dioxide in high amounts can irritate the skin, eyes, and respiratory system (Rutala and Weber, 2019). Chlorine dioxide, on the other hand, has a low toxicity profile when used in the right amounts and under the right conditions. Studies have shown that when chlorine dioxide is diluted to appropriate concentrations, it is generally safe for use on surfaces and in the air in healthcare settings (Sabino et al., 2019). Importantly, the safety risks associated with chlorine dioxide can be mitigated through proper training and adherence to safety protocols.
Healthcare workers must be trained on the correct use of chlorine dioxide-based cleaning agents, including the importance of proper dilution, ventilation, and protective equipment to minimise exposure. When used correctly, chlorine dioxide poses minimal health risks to both staff and patients (Hassel et al., 2022).
Challenges in the Adoption of Chlorine Dioxide
Despite its significant benefits, there are challenges associated with the adoption of chlorine dioxide in healthcare settings. One of the primary obstacles is the cost of chlorine dioxide-based cleaning systems. Unlike conventional disinfectants, chlorine dioxide must often be generated onsite using specialised equipment. The process requires an initial investment in the equipment and ongoing maintenance expenses. For smaller healthcare facilities with limited budgets, these costs may present a barrier to widespread adoption (Sabino et al., 2019). Furthermore, the use of chlorine dioxide requires careful management to ensure its proper application. Chlorine dioxide is unstable in solution and must be fresh
generated before use. This situation can pose logistical challenges, particularly in large healthcare facilities where rapid turnaround times for cleaning are essential. To address this issue, some healthcare settings have opted for ready-to-use chlorine dioxide products, but these often come at a higher cost and may not be as effective as freshly generated solutions (Reed et al., 2016). As a result, healthcare facilities
need to weigh the costs and benefits of chlorine dioxide adoption, considering factors such as the size of the facility, the type of pathogens present, and the level of cleaning required.
Another challenge is the potential for resistance or non-compliance with cleaning protocols. Even the most effective disinfectants are only useful if they are applied consistently and correctly. In healthcare settings, where staff turnover and time constraints can be issues, there is a risk that cleaning protocols may not be followed rigorously. Ensuring compliance with chlorine dioxide-based cleaning protocols may require ongoing training and monitoring, which can be resource-intensive (NHS National Services Scotland, 2017).
Practical Applications of Chlorine Dioxide in Healthcare Settings
The practical application of chlorine dioxide in healthcare settings is diverse. It can be used to disinfect a wide range of surfaces, including high-touch surfaces such as doorknobs, bed rails, and countertops, which are common sites for pathogen transmission. Additionally, chlorine dioxide is effective for air disinfection, particularly in areas where airborne pathogens pose a significant risk, such as isolation rooms and operating theatres (Chen et al., 2020; Mohamed et al., 2022). Its ability to inactivate biofilms, which are clusters of bacteria that adhere to surfaces and are resistant to conventional disinfectants, further enhances its utility in environments where biofilm formation is a concern, such as in water systems and on medical devices (Zhang et al., 2020). In addition to surface and air disinfection, chlorine dioxide has been explored for use in the disinfection of healthcare waste, including contaminated textiles, and even in sterilising water used in medical procedures. This versatility makes chlorine dioxide an attractive option for integrated infection control strategies in healthcare settings.
Conclusion
Chlorine dioxide presents a promising solution for infection control in healthcare settings, offering significant antimicrobial efficacy, a favourable safety profile, and versatility in its applications. Its ability to combat a wide range of pathogens, including resistant organisms and spores, makes it an invaluable tool in reducing healthcare-associated infections. Furthermore, chlorine dioxide has lower toxicity and produces fewer harmful by-products Chlorine dioxide’s by-products make the environment safer for both patients and healthcare workers than traditional disinfectants. However, the adoption of chlorine dioxide is not without challenges. The cost of equipment, the need for on-site generation, and the logistical difficulties associated with its use may limit its widespread implementation. Additionally, ensuring proper training and adherence to cleaning protocols is crucial for maximising their effectiveness and minimising their safety risks. Nonetheless, with the right infrastructure and management, chlorine dioxide has the potential to significantly improve infection control practices in healthcare settings.
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