Cheri Ackert-Burr, RN, MSN, CNOR, AGTS

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Biofilm and medical devices

• Cheri Ackert-Burr, RN, MSN, CNOR, AGTS
• Clinical Education Manager

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Disclosures

1. Successful completion Participants must complete
   the entire program and submit the required
   documentation
2. Conflict of interest Planners disclose no
   conflict the speaker discloses employment with
   Medivators, thereby declaring a conflict of
   interest.
3. Commercial company support Fees are underwritten
   by education funding provided by Medivators
4. Non-commercial company support None
5. Alternative Complementary therapy None

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Learner Objectives

• Upon completion of this presentation,
  participants will be able to
• Discuss the concept of biofilm communities in
  medical devices and in the human body
• Explain the relationship between biofilm and
  endoscope/instrument contamination
• Relate findings from studies and literature to
  clinical area practice
• Compare two detergent agents in their
  effectiveness against biofilm
• State three best practices of disinfection which
  are particularly important in biofilm elimination
  

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Glossary

• Exo-polysaccharide (EPS) polymers that are
  composed of sugar residues and are secreted by a
  micro-organism into the surrounding environment.
  Capsular exo-polysaccharides can protect
  pathogenic bacteria and contribute to their
  pathogenicity.
• Glycocalyx a general term referring to
  extra-cellular polymeric material produced by
  some bacteria composed of carbohydrates, lipids,
  and proteins. AKA - SLIME

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Glossary (contd)

• Planktonic passively floating, drifting, or
  somewhat motile organisms occurring in a body of
  water.
• Sessile fixed in one place immobile. Attached
  by a broad base. Being attached to the substrate
  or base not freely moving
• Vegetative Bacteria bacteria that are devoid of
  spores and usually can be readily inactivated by
  many types of germicides.

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What is Biofilm?

• Biofilm a collection of microorganisms
  surrounded by the slime they secrete, attached to
  either an inert or a living surface. Up to 99
  of all bacteria live in biofilm communities.
• Three basic elements to a Biofilm
• Microbes
• Glycocalyx/Exo-Polysaccharide (EPS)
• Surface (inert or living)

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Biofilm Lifecycle
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Biofilm

• Microbially derived sessile community
• Irreversible attachment
• Matrix embedded
• Altered phenotype

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Biofilm Formation

• First observations
• Communities vs. free-floating
• Formation in high-shear vs. low-sheer
  environments
• Polysaccharides adhere to the surface of medical
  device and allows other substances to adhere to
  the surface

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Where does biofilm live?

• In industrybiofilms are used to aid in
  decontaminating water
• Clogging filters
• Found in water systems
• Not just drains, but in the water supply as
  wellin fact, the higher the water pressure, the
  more tenaciously the biofilm attaches to the
  pipe!
• But where else do they live???

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River Rocks
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On teeth
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In the Body
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Colonization Environments

• Biofilm in the human body
• gt 80 of microbial infections are caused by
  biofilm NIH estimate

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Biofilm in Endoscopes

• New endoscopes and biofilm
• Use of endoscopes and biofilm creation
• Proper processing after each use

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Studies and Literature Findings

• Alfa and Howie (2010)
• Killing bioburden within young vs mature biofilm
• Glutaraldehyde vs Accelerated Hydrogen Peroxide
  (AHP) disinfection

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Studies and Literature Findings

• Pajkos (2004)
• Findings of scope contamination studies
• Evaluation of effectiveness of endoscope cleaning
  or reprocessing

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On Medical Devices and Endoscopes
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Photographic Documentation of Endoscopic Biofilm
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Scope Tip after Manual Cleaning

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Distal Tip after Cidex and Alcohol
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Distal Tip after Peracetic Acid
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Biofilm Debris in Channel
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Biofilms
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Biofilm
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What has been observed

• 99 of bacteria grow as aggregated, sessile
  communities (biofilm)
• Biofilm are highly protected and highly resistant
  to antibacterial treatments (antibiotics and
  disinfectants)
• Biofilm are genetically different than bacteria
  in the planktonic state
• Biofilm form preferentially in high shear
  environments
• Conditions suitable for biofilm development are
  practically limitless

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Why we should be afraid, very afraid!

• Structure and physiology of biofilm confer
  resistance to antibiotics, disinfectancts, and
  germicides
• Experiment biofilm can adhere to stainless
  steel, even highly polished SS, within 30 seconds
• NIH estimates more than 80 of microbial
  infections in humans caused by biofilm

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Biofilm in Endoscopes

• Shortly after its first use, endoscopes develop a
  conditioning film composed of bodily fluids,
  proteins, polysaccharides and other components.
  This alteration of the surface characteristics
  allows bacteria to commence growth and
  colonization.

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Reducing Biofilm Formation

• Precleaning
• Cleaning

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Cleaning Nomenclature

• Precleaning Done in the OR, during and
  immediately after use during a surgical
  procedure. Should occur at point of use. Can be
  a wipe down, cleaning spray, or foam to keep
  instruments moist and to begin the breakdown of
  bioburden.

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Manufacturers Cleaning Instructions for Use

• Utilities (eg, type of water, compressed air)
• Cleaning equipment
• Accessories (eg, adaptors) for creating a proper
  connection between the instruments and equipment,
  utilities, and cleaning equipment
• Accessories for cleaning lumens, ports, and
  internal parts
• Cleaning agents
• Lubricants
• Processing methods.

AORN RP 2014
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Cleaning Medical Instruments

• Manual cleaning
• Detergents - type
• Brushes
• Disassembly
• Sonic cleaning
• Detergent
• Time and temperature
• Repeat as instructed
• Washer decontaminator

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Eliminating Biofilm

• Destruction of biofilm cell formation
• Chemical/disinfection reaction with the
  polysaccharide network
• Protective shield inhibits cell destruction
• Hazards of incomplete biofilm removal

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What are Enzymatic Detergents?

• Enzymatic Detergents act by reducing the cohesive
  force within the soil itself
• Breaks up substances into fine particles which
  are rinsed away
• Enzymes act like a pair of scissorscutting off
  soils piece by piece

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Substrate Specific

• Different types of Enzymes react to different
  substances
• Proteins 1 concern in a reprocessing room
• High content of proteins in bodily fluids which
  need to be removed(blood, tissue, mucous, etc)
• Protease enzymes break down proteins into their
  components (amino acids) which are easily removed

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Substrate Specific

• Lipids (fats) difficult to penetrate and remove
• Ex Olestra is a very large and complex fat
  molecule
• Lipase enzymes help break down lipids
  (hydrolysis). Enzymatic reaction is slow
• Appropriate surfactants and detergents are
  generally a bigger player in the effectiveness at
  removing lipids

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Substrate Specific

• Carbohydrates (starches) very water soluble
• a-Amylase enzymes speed up the reaction which
  breaks starches down into sugars. The sugars
  are then quickly dissolved into the detergent
  water and removed

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Biofilm detaching detergent

• Biofilm treated with a
• bio-detaching detergent

• 6 day growth of a
• Ps Aeruginosa biofilm

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Remember the recipes

• Cleaning
• Concentration
• Temperature
• Time
• Packaging
• Handling
• Storage
• Each step has specific parameters that must be
  met

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Effective Disinfectant Agents

• Glutaraldehyde
• Saturated dialdehyde
• Acetic activated to alkaline to become sporicidal
• Used in manual or automated processing protocols
• Peracetic Acid (PAA)
• Oxidizing agent for disinfection of flexible
  endoscopes
• Highly biocidal in the presence of organic soil
• Improper processing results in regrowth of
  biofilm

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Ensuring Patient Safety

• Shared responsibility
• Medical instrument care and reprocessing
• Best practices of cleaning
• Policies and procedures
• Training, resources, quality improvement
• Infection control

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Orientation and Education Topics

• Standard Precautions
• Personal Protection Equipment (PPE)
• OSHA rules on occupational exposure
• Reprocessing procedures
• Mechanisms of disease transmission
• Maintenance of a safe work environment
• Safe handling of HLD and sterilants
• Procedures for waste management

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Administrative Responsibility

• Infection Control Guidelines
• Manufacturers Recommendations
• Identification of problems and lapses in
  technique
• Observation of scope storage areas
• Ensure that reprocessing procedures are followed.

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Time Out Test Your Knowledge

• What are three best practices of medical devices
  which are particularly important in biofilm
  elimination?
• Spray instruments at the point of use before
  transporting to SPD.
• Immediately flush the channel with water when
  contaminated with bioburden.
• Wipe the external surface of the medical device.

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When all else fails
SGNA
AORN
IFU
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Conclusions

• Every patient deserves a clean endoscope
• Patient safety is a team responsibility
• Biofilm elimination is critical

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Questions
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Thank You

• Thank you for your attention.
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