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1
Biofilms Hazards They Present
in ASC Settings
Wava Truscott PhD
Director Scientific Affairs and Clinical Education
Kimberly-Clark Health Care
2
Biofilms
Hazards They Present in ASC Settings
Objectives
Describe the unique characteristics of microbial biofilms
List patient consequences associated with biofilms
Discuss strategies to reduce biofilm-associated patient risks
3
History
Bacteria here a lot longer than we have been
bull Bacteria 3600000000 years ago (36 billion yrs)
bull Man 100000 years ago
van Leeuvenhoek (1670s) discovered first bacteria
Koch (1884) specific bacteria cause specific diseases
Costerton (1978) biofilms first described
Estimated biofilms responsible for gt60 human infections
Costerton JW Bacterial biofilms a common cause of persistent infections Science 19992841318-1322
Publications on Biofilms In the year 2002 2000 By January 2012 2400000
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What the Heck is a Biofilm
Survival mechanism for bacteria
A collection of bacteria
bull attach to surfaces and to each other forming communities
bull within a slimy-sticky protective coating
4
1
2
3
5
Perspective Please
Harnessing Biofilms
Water treatment ndash tremendous benefit
(biological pre-treatment)
Decay of dead plants and animals enabling reuse
of their elements
Clean up oil amp gasoline spills (bioremediation)
Soil or aquifer clean up of contaminates
Bio-leaching 10 ndash 20 of copper mined in US
extracted from low grade ore with biofilm help
Microbial fuel cells to generate electricity from
complex organic waste and renewable biomass
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7
About 90 deep sea creatures possess own light
Born with
bull chemical light production capability or
bull organsindentations for luminescent bacterial biofilms
Mixture of different functions
bull blinddistract predators
bull attract mates
bull provide camouflage
bull lure prey
Light in The Deep Dark Sea
Intestinal Provide amp Protect
Good
Intestinal biofilms commensalistic bacteria
bull digest part of our food passing nutrition to us
bull produce essential vitamins K and B12
bull prevent pathogens from attaching to intestine
bull produce rueterin that inhibits pathogens
bull modulate cytokines to restrain inflammation
Bad
Antibiotics can wipe out resident biofilm bacteria
Bacteria like Clostridium difficile 027 can ldquohatchrdquo
from their spores deposited into small intestine
Can produce pseudomembranous colitis and
toxins delivered to unprotected large intestine
Success with human probiotic infusion (feces)
Toxic Megacolon from C diff
Intestinal Crypts resident biofilm
9
Clostridium difficile 027
Pseudomembraneous colitis
Healthy Colon
Colitis
Howeverhellip Biofilms of C difficile strain 027 produce strong toxins
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10
Undesirable Biofilms
Swamp Coolers
Water pipes Legionella
Cooled air filtration
Poor manufacturing maintenance
Poor housekeeping
Biofilms CDC gt 70 Human Infections
But How Do Biofilms Form
What are Their Characteristics
12
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13
Progression Stages to a Mature
Biofilm
14
Stage 1
Bacteria Attach to a Surface
Bacteria land on a surface
If surface not favorable will let go
Surface favorable if proteins mucus blood dead cell debris
Send out signals attracting other bacteria to site
15
Stage 2
Irreversible Adhesion
Favorable conditions trigger hyper-drive increase of
bull sticky strong adhesins to strengthen attachment
bull pumping out polysaccharides ldquogooey matrixrdquo
bull exponential cell division = rapid population growth
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Stage 3
Aggregationorganization
Mixed-species community forms within the gooey matrix
Function responsibility influenced by location in biofilm
bull periphery = defensive
bull upper levels = harvest food
bull lower levels = get rid of waste
bull bottom level = adherence to surface
Bacteria pump out more goo attachment amp elastic
stretch so strong survives outside of jet in flight
17
Stage 4
Maturation Complex Community
Bacteria communicate changes in environment from
their post and alter behavior if needed
A
B
C
18
Importance of Bacterial
Communication Within Biofilms
Pseudomonas biofilm on
1 standard untreated polyurethane
2 usnic acid treated polyurethane ndash disrupts
communication and ability to organize community
(1) (2)
Montana State University Bozeman MT
Three Dimensional
Classic Biofilm Shape
One Dimensional
Flat Weak Biofilm
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19
Stage 5
Dispersal
Creation and release of free-floating
single-celled ldquochildrenrdquo called planktonic bacteria to start
bull new colonies
bull local infections
bull remote infections
bull systemic infections
bull embolic complications
Planktonic bacteria are the most vulnerable to biocides
Recurrent symptoms (eg sinus implant biofilm infections)
7 days 2 days 6 hours
Legionella
20
Biofilms Excel in
The Resistance Movement
Difficult for antibiotics and disinfectants too
bull hard to diffuse through matrix more diluted further goes
bull molecules in matrix degrade antimicrobial agents
bull when reaches pathogens is diluted encourages resistance
bull resistance factors passed to neighbors amp next generation
bull 10 to 2400X more antibiotic resistant than free pathogens
Bacteria pass resistance to others by DNA code transfer
Dye diffusion
through matrix gel
DNA Transfer
VRE Staph aureus
21
Biofilms Excel in
The Resistance Movement
Additional Resistance Mechanisms
Fortress protection amp ldquogriprdquo resists physical disruption
Incapacitates White Cells that might penetrate matrix
Poor phagocytic (capture) capability
Poor killing capability
WBC (Macrophages here) trying to attack biofilm bacteria
Bacteria in biofilm (stained pink here)
WBC (Neutrophil large red balls) gets in through water
channels but cannot kill much hellip small red bacteria are
dead
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22
Patient Associated Consequences
23
Typical Biofilm-Related Infections
(live biofilms)
Chronic wounds
Cystic fibrosis
Dental plaquecalculus
Dental cavities
GingivitisPeriodontitis
Endocarditis
Osteomyelitis
Otitis media
Tonsillitis
Device implant
24
Wound Infections
Biofilm along fascia
Biofilm throughout the mesh
Biofilm in chronic wound
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25
Dental Disease
Biofilm on the teeth is called dental plaque
48 hrs after tooth brushing biofilm matures
72 hrs after tooth brushing calcium-
phosphate (Tartar calculus) protective
structure
bull only removed by hygienistrsquos pick
1mm3 mature dental plaque contains gt 108 bacteria
100000000 bacteria per cubic millimeter
26
More Biofilms
Sinusitis
Tonsillitis
Necrotizing fasciitis
27
Pneumonia Biofilm in Alveoli
Alveoli nice moist dark area to build biofilm
Easier if immune compromised of lungs
functioning poorly
bull COPD
bull cystic fibrosis
bull on Ventilator
bull old age
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28
Catheters amp
Tubes
Central venous catheters
Hemodialysis catheters
Pulmonary artery catheters
Arterial catheters
Urinary catheters
Peritoneal catheters
Umbilical catheters
Enteral feeding tubes
Gastrostomy tubes
Nasogastric tubes
Endotracheal tubes
Tracheostomy tubes
Peritoneal dialysis
Drainage tubes
Endotracheal tube for patients on ventilation
29
Vascular Catheters
5-6 million central lines placed annually
gt 5 infections
gt250000 central line-associated infections (CLABSI)
Approximately 20 attributable death rate
Cirioni O J Infect Dis 2006193180-186 CDC MMRW 2002101-28
30
Bloodstream Infections Reduced 5 Fold
After blood draw retained blood provides
breeding ground for biofilm formation
Opaque valves do not show residual blood
Switching to clear housing
10mL flush did not clear blood 20 mL did
5 fold reduction in Blood stream infections
Poster Royer T VHA MRSA Prevention Forum Orlando FL Nov 5-6 2007
Biofilm forms in
blood left coating
the inner surface of
the plastic housing
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31
Biofilms In Surgery
32
Surgical Drain Tubes
Favorite Biofilm Hangouts
Biofilm Inside Tube (A)
bull Biofilm inside catheter dispersed biofilm towers
Close up of the mature biofilm community (B)
bull Golden spheres Staphylococcus aureus
bull Green matrix substance
bull Orange smooth surface catheter cross section
Thurlow LR J Immunol 20111866585-96
Downloaded from wwwjimmunolorg on January 10 2012
33
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Wound Drains
Primed for Biofilms
Biofilm on drainage tube surface
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34
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
35
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
36
Implants
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37
Expanding Realm of Implantables
Market for implants over $23 billion per year in USA
Expected to grow 10 annually with increased demand and technologies available
Most frequently implanted devices
bull cardioverter defibrillators
bull cardiac resynchronization therapy devices
bull cosmetic implants
bull dental implants
bull hip replacements
bull pacemakers
bull phakic intraocular lenses
bull spinal implants
bull tissue implants (eg bone)
38
Why Are Biofilms On Implants
So Successful
Tissue surrounding implants have reduced blood vessels so
bull fewer bacteria-killer white blood cells delivered
bull less antibiotics and other drugs delivered
White blood cells that do make it there have
bull reduced ability to capture bacteria
bull reduced ability to kill bacteria
39
Pins Wires Plates Cushions
Great surfaces for biofilm formation and protection
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Biofilms
On Medical Devices
Infections usually follow alternating up and down pattern
Antibiotic initially effective
bull relapses frequent
bull pathogens grow more tolerant develop antibiotic resistance
Usually requires removal of implant to eliminate infection
(even tiny biofilm fragments will multiply again)
Fatality 5 to 60
Prevent biofilmsinfections in the first place
Hendricks S J Biomed Materials Research 200050160-70 Seare W J Endourology 2000149-17
41
Restoring Function ndash Relieving Pain
42
Biofilm Formed On Implants Both Hands
Implants in both hands acquired biofilm infection
Implants had to be removed all bacteria killed before new implants
Culprit Remote infection
Prevent this cause of implant
biofilm by ensuring all remote
infections treated and resolved
before surgery
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43
Keeping Things Straight
Pins screws wires
44
So Vulnerable
Stringent adherence to antiseptic regimens
45
Vertebral Implant or Pain Relief
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46
Rotator Cuff Surgeries
With anchor screws and tough braided sutures
Increasing number performed due to success of
the procedures due to
Aging ldquoBaby Boomersrdquo
47
Necessity Mother of Invention
Sutures are great structures on which biofilms can form
Braided sutures ndash more biofilms
bull greater surface area than monofilament
bull protected crevices
bull higher infection rates
A) Standard braided suture
bull green spots are live bacteria or micro-colonies of bacterial biofilms
B) CHG treated braided suture
bull red spots are dead bacteria or micro-colonies A
B
48
Neurosurgical stimulators
Pulse generators
Intraspinal pumps
Cerebral Spinal Fluid (CSF) shunts
General pain pumps
Neurological
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49
Cerebral Spinal Shunts
Hydrocephalus caused by accumulation of cerebral
spinal fluid (CSF) in cerebral ventricles 140000yr
122000 ventriculostomy (VA) shuntsyear
bull Average 10 infection
18000 ventriculoperitoneal (VP) shuntsyear
bull 25 must undergo revision due to biofilm growth
50
Cerebral Spinal Shunts
Antimicrobial shunts effective in some studies
Prevent contamination by pathogens and particulates
51
Poorly Reprocessed Electrodes
Electroencephalogram electrodes not properly cleaned
Residual dried on biofilm provided
bull protection of entrapped virus
bull prevented adequate sterilization
Several patients acquired hepatitis B (HBV)
$275 million legal settlement against neurologist amp hospital
Mackay B CMAJ 2002 166(7)943
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52
Circulatory amp Coronary Implants
Cardiac valves
Mechanical heart valves
Implanted defibrillators
Pacemakers
Vascular grafts
Stents
53
Cardiac amp
Vascular
Biofilms
54
Prosthetic Heart Valves
3 ndash 57 form biofilm leading to overt
infection (endocarditis)
Vinh DC J Long Term Effects Medical Implants 200515467-488
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55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
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58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
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61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
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64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
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67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
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70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
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73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
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76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
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Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
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82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
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85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
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88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
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91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
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94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
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But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
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100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
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103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
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Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
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109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
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Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
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115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
2
What the Heck is a Biofilm
Survival mechanism for bacteria
A collection of bacteria
bull attach to surfaces and to each other forming communities
bull within a slimy-sticky protective coating
4
1
2
3
5
Perspective Please
Harnessing Biofilms
Water treatment ndash tremendous benefit
(biological pre-treatment)
Decay of dead plants and animals enabling reuse
of their elements
Clean up oil amp gasoline spills (bioremediation)
Soil or aquifer clean up of contaminates
Bio-leaching 10 ndash 20 of copper mined in US
extracted from low grade ore with biofilm help
Microbial fuel cells to generate electricity from
complex organic waste and renewable biomass
952012
3
7
About 90 deep sea creatures possess own light
Born with
bull chemical light production capability or
bull organsindentations for luminescent bacterial biofilms
Mixture of different functions
bull blinddistract predators
bull attract mates
bull provide camouflage
bull lure prey
Light in The Deep Dark Sea
Intestinal Provide amp Protect
Good
Intestinal biofilms commensalistic bacteria
bull digest part of our food passing nutrition to us
bull produce essential vitamins K and B12
bull prevent pathogens from attaching to intestine
bull produce rueterin that inhibits pathogens
bull modulate cytokines to restrain inflammation
Bad
Antibiotics can wipe out resident biofilm bacteria
Bacteria like Clostridium difficile 027 can ldquohatchrdquo
from their spores deposited into small intestine
Can produce pseudomembranous colitis and
toxins delivered to unprotected large intestine
Success with human probiotic infusion (feces)
Toxic Megacolon from C diff
Intestinal Crypts resident biofilm
9
Clostridium difficile 027
Pseudomembraneous colitis
Healthy Colon
Colitis
Howeverhellip Biofilms of C difficile strain 027 produce strong toxins
952012
4
10
Undesirable Biofilms
Swamp Coolers
Water pipes Legionella
Cooled air filtration
Poor manufacturing maintenance
Poor housekeeping
Biofilms CDC gt 70 Human Infections
But How Do Biofilms Form
What are Their Characteristics
12
952012
5
13
Progression Stages to a Mature
Biofilm
14
Stage 1
Bacteria Attach to a Surface
Bacteria land on a surface
If surface not favorable will let go
Surface favorable if proteins mucus blood dead cell debris
Send out signals attracting other bacteria to site
15
Stage 2
Irreversible Adhesion
Favorable conditions trigger hyper-drive increase of
bull sticky strong adhesins to strengthen attachment
bull pumping out polysaccharides ldquogooey matrixrdquo
bull exponential cell division = rapid population growth
952012
6
16
Stage 3
Aggregationorganization
Mixed-species community forms within the gooey matrix
Function responsibility influenced by location in biofilm
bull periphery = defensive
bull upper levels = harvest food
bull lower levels = get rid of waste
bull bottom level = adherence to surface
Bacteria pump out more goo attachment amp elastic
stretch so strong survives outside of jet in flight
17
Stage 4
Maturation Complex Community
Bacteria communicate changes in environment from
their post and alter behavior if needed
A
B
C
18
Importance of Bacterial
Communication Within Biofilms
Pseudomonas biofilm on
1 standard untreated polyurethane
2 usnic acid treated polyurethane ndash disrupts
communication and ability to organize community
(1) (2)
Montana State University Bozeman MT
Three Dimensional
Classic Biofilm Shape
One Dimensional
Flat Weak Biofilm
952012
7
19
Stage 5
Dispersal
Creation and release of free-floating
single-celled ldquochildrenrdquo called planktonic bacteria to start
bull new colonies
bull local infections
bull remote infections
bull systemic infections
bull embolic complications
Planktonic bacteria are the most vulnerable to biocides
Recurrent symptoms (eg sinus implant biofilm infections)
7 days 2 days 6 hours
Legionella
20
Biofilms Excel in
The Resistance Movement
Difficult for antibiotics and disinfectants too
bull hard to diffuse through matrix more diluted further goes
bull molecules in matrix degrade antimicrobial agents
bull when reaches pathogens is diluted encourages resistance
bull resistance factors passed to neighbors amp next generation
bull 10 to 2400X more antibiotic resistant than free pathogens
Bacteria pass resistance to others by DNA code transfer
Dye diffusion
through matrix gel
DNA Transfer
VRE Staph aureus
21
Biofilms Excel in
The Resistance Movement
Additional Resistance Mechanisms
Fortress protection amp ldquogriprdquo resists physical disruption
Incapacitates White Cells that might penetrate matrix
Poor phagocytic (capture) capability
Poor killing capability
WBC (Macrophages here) trying to attack biofilm bacteria
Bacteria in biofilm (stained pink here)
WBC (Neutrophil large red balls) gets in through water
channels but cannot kill much hellip small red bacteria are
dead
952012
8
22
Patient Associated Consequences
23
Typical Biofilm-Related Infections
(live biofilms)
Chronic wounds
Cystic fibrosis
Dental plaquecalculus
Dental cavities
GingivitisPeriodontitis
Endocarditis
Osteomyelitis
Otitis media
Tonsillitis
Device implant
24
Wound Infections
Biofilm along fascia
Biofilm throughout the mesh
Biofilm in chronic wound
952012
9
25
Dental Disease
Biofilm on the teeth is called dental plaque
48 hrs after tooth brushing biofilm matures
72 hrs after tooth brushing calcium-
phosphate (Tartar calculus) protective
structure
bull only removed by hygienistrsquos pick
1mm3 mature dental plaque contains gt 108 bacteria
100000000 bacteria per cubic millimeter
26
More Biofilms
Sinusitis
Tonsillitis
Necrotizing fasciitis
27
Pneumonia Biofilm in Alveoli
Alveoli nice moist dark area to build biofilm
Easier if immune compromised of lungs
functioning poorly
bull COPD
bull cystic fibrosis
bull on Ventilator
bull old age
952012
10
28
Catheters amp
Tubes
Central venous catheters
Hemodialysis catheters
Pulmonary artery catheters
Arterial catheters
Urinary catheters
Peritoneal catheters
Umbilical catheters
Enteral feeding tubes
Gastrostomy tubes
Nasogastric tubes
Endotracheal tubes
Tracheostomy tubes
Peritoneal dialysis
Drainage tubes
Endotracheal tube for patients on ventilation
29
Vascular Catheters
5-6 million central lines placed annually
gt 5 infections
gt250000 central line-associated infections (CLABSI)
Approximately 20 attributable death rate
Cirioni O J Infect Dis 2006193180-186 CDC MMRW 2002101-28
30
Bloodstream Infections Reduced 5 Fold
After blood draw retained blood provides
breeding ground for biofilm formation
Opaque valves do not show residual blood
Switching to clear housing
10mL flush did not clear blood 20 mL did
5 fold reduction in Blood stream infections
Poster Royer T VHA MRSA Prevention Forum Orlando FL Nov 5-6 2007
Biofilm forms in
blood left coating
the inner surface of
the plastic housing
952012
11
31
Biofilms In Surgery
32
Surgical Drain Tubes
Favorite Biofilm Hangouts
Biofilm Inside Tube (A)
bull Biofilm inside catheter dispersed biofilm towers
Close up of the mature biofilm community (B)
bull Golden spheres Staphylococcus aureus
bull Green matrix substance
bull Orange smooth surface catheter cross section
Thurlow LR J Immunol 20111866585-96
Downloaded from wwwjimmunolorg on January 10 2012
33
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Wound Drains
Primed for Biofilms
Biofilm on drainage tube surface
952012
12
34
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
35
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
36
Implants
952012
13
37
Expanding Realm of Implantables
Market for implants over $23 billion per year in USA
Expected to grow 10 annually with increased demand and technologies available
Most frequently implanted devices
bull cardioverter defibrillators
bull cardiac resynchronization therapy devices
bull cosmetic implants
bull dental implants
bull hip replacements
bull pacemakers
bull phakic intraocular lenses
bull spinal implants
bull tissue implants (eg bone)
38
Why Are Biofilms On Implants
So Successful
Tissue surrounding implants have reduced blood vessels so
bull fewer bacteria-killer white blood cells delivered
bull less antibiotics and other drugs delivered
White blood cells that do make it there have
bull reduced ability to capture bacteria
bull reduced ability to kill bacteria
39
Pins Wires Plates Cushions
Great surfaces for biofilm formation and protection
952012
14
40
Biofilms
On Medical Devices
Infections usually follow alternating up and down pattern
Antibiotic initially effective
bull relapses frequent
bull pathogens grow more tolerant develop antibiotic resistance
Usually requires removal of implant to eliminate infection
(even tiny biofilm fragments will multiply again)
Fatality 5 to 60
Prevent biofilmsinfections in the first place
Hendricks S J Biomed Materials Research 200050160-70 Seare W J Endourology 2000149-17
41
Restoring Function ndash Relieving Pain
42
Biofilm Formed On Implants Both Hands
Implants in both hands acquired biofilm infection
Implants had to be removed all bacteria killed before new implants
Culprit Remote infection
Prevent this cause of implant
biofilm by ensuring all remote
infections treated and resolved
before surgery
952012
15
43
Keeping Things Straight
Pins screws wires
44
So Vulnerable
Stringent adherence to antiseptic regimens
45
Vertebral Implant or Pain Relief
952012
16
46
Rotator Cuff Surgeries
With anchor screws and tough braided sutures
Increasing number performed due to success of
the procedures due to
Aging ldquoBaby Boomersrdquo
47
Necessity Mother of Invention
Sutures are great structures on which biofilms can form
Braided sutures ndash more biofilms
bull greater surface area than monofilament
bull protected crevices
bull higher infection rates
A) Standard braided suture
bull green spots are live bacteria or micro-colonies of bacterial biofilms
B) CHG treated braided suture
bull red spots are dead bacteria or micro-colonies A
B
48
Neurosurgical stimulators
Pulse generators
Intraspinal pumps
Cerebral Spinal Fluid (CSF) shunts
General pain pumps
Neurological
952012
17
49
Cerebral Spinal Shunts
Hydrocephalus caused by accumulation of cerebral
spinal fluid (CSF) in cerebral ventricles 140000yr
122000 ventriculostomy (VA) shuntsyear
bull Average 10 infection
18000 ventriculoperitoneal (VP) shuntsyear
bull 25 must undergo revision due to biofilm growth
50
Cerebral Spinal Shunts
Antimicrobial shunts effective in some studies
Prevent contamination by pathogens and particulates
51
Poorly Reprocessed Electrodes
Electroencephalogram electrodes not properly cleaned
Residual dried on biofilm provided
bull protection of entrapped virus
bull prevented adequate sterilization
Several patients acquired hepatitis B (HBV)
$275 million legal settlement against neurologist amp hospital
Mackay B CMAJ 2002 166(7)943
952012
18
52
Circulatory amp Coronary Implants
Cardiac valves
Mechanical heart valves
Implanted defibrillators
Pacemakers
Vascular grafts
Stents
53
Cardiac amp
Vascular
Biofilms
54
Prosthetic Heart Valves
3 ndash 57 form biofilm leading to overt
infection (endocarditis)
Vinh DC J Long Term Effects Medical Implants 200515467-488
952012
19
55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
3
7
About 90 deep sea creatures possess own light
Born with
bull chemical light production capability or
bull organsindentations for luminescent bacterial biofilms
Mixture of different functions
bull blinddistract predators
bull attract mates
bull provide camouflage
bull lure prey
Light in The Deep Dark Sea
Intestinal Provide amp Protect
Good
Intestinal biofilms commensalistic bacteria
bull digest part of our food passing nutrition to us
bull produce essential vitamins K and B12
bull prevent pathogens from attaching to intestine
bull produce rueterin that inhibits pathogens
bull modulate cytokines to restrain inflammation
Bad
Antibiotics can wipe out resident biofilm bacteria
Bacteria like Clostridium difficile 027 can ldquohatchrdquo
from their spores deposited into small intestine
Can produce pseudomembranous colitis and
toxins delivered to unprotected large intestine
Success with human probiotic infusion (feces)
Toxic Megacolon from C diff
Intestinal Crypts resident biofilm
9
Clostridium difficile 027
Pseudomembraneous colitis
Healthy Colon
Colitis
Howeverhellip Biofilms of C difficile strain 027 produce strong toxins
952012
4
10
Undesirable Biofilms
Swamp Coolers
Water pipes Legionella
Cooled air filtration
Poor manufacturing maintenance
Poor housekeeping
Biofilms CDC gt 70 Human Infections
But How Do Biofilms Form
What are Their Characteristics
12
952012
5
13
Progression Stages to a Mature
Biofilm
14
Stage 1
Bacteria Attach to a Surface
Bacteria land on a surface
If surface not favorable will let go
Surface favorable if proteins mucus blood dead cell debris
Send out signals attracting other bacteria to site
15
Stage 2
Irreversible Adhesion
Favorable conditions trigger hyper-drive increase of
bull sticky strong adhesins to strengthen attachment
bull pumping out polysaccharides ldquogooey matrixrdquo
bull exponential cell division = rapid population growth
952012
6
16
Stage 3
Aggregationorganization
Mixed-species community forms within the gooey matrix
Function responsibility influenced by location in biofilm
bull periphery = defensive
bull upper levels = harvest food
bull lower levels = get rid of waste
bull bottom level = adherence to surface
Bacteria pump out more goo attachment amp elastic
stretch so strong survives outside of jet in flight
17
Stage 4
Maturation Complex Community
Bacteria communicate changes in environment from
their post and alter behavior if needed
A
B
C
18
Importance of Bacterial
Communication Within Biofilms
Pseudomonas biofilm on
1 standard untreated polyurethane
2 usnic acid treated polyurethane ndash disrupts
communication and ability to organize community
(1) (2)
Montana State University Bozeman MT
Three Dimensional
Classic Biofilm Shape
One Dimensional
Flat Weak Biofilm
952012
7
19
Stage 5
Dispersal
Creation and release of free-floating
single-celled ldquochildrenrdquo called planktonic bacteria to start
bull new colonies
bull local infections
bull remote infections
bull systemic infections
bull embolic complications
Planktonic bacteria are the most vulnerable to biocides
Recurrent symptoms (eg sinus implant biofilm infections)
7 days 2 days 6 hours
Legionella
20
Biofilms Excel in
The Resistance Movement
Difficult for antibiotics and disinfectants too
bull hard to diffuse through matrix more diluted further goes
bull molecules in matrix degrade antimicrobial agents
bull when reaches pathogens is diluted encourages resistance
bull resistance factors passed to neighbors amp next generation
bull 10 to 2400X more antibiotic resistant than free pathogens
Bacteria pass resistance to others by DNA code transfer
Dye diffusion
through matrix gel
DNA Transfer
VRE Staph aureus
21
Biofilms Excel in
The Resistance Movement
Additional Resistance Mechanisms
Fortress protection amp ldquogriprdquo resists physical disruption
Incapacitates White Cells that might penetrate matrix
Poor phagocytic (capture) capability
Poor killing capability
WBC (Macrophages here) trying to attack biofilm bacteria
Bacteria in biofilm (stained pink here)
WBC (Neutrophil large red balls) gets in through water
channels but cannot kill much hellip small red bacteria are
dead
952012
8
22
Patient Associated Consequences
23
Typical Biofilm-Related Infections
(live biofilms)
Chronic wounds
Cystic fibrosis
Dental plaquecalculus
Dental cavities
GingivitisPeriodontitis
Endocarditis
Osteomyelitis
Otitis media
Tonsillitis
Device implant
24
Wound Infections
Biofilm along fascia
Biofilm throughout the mesh
Biofilm in chronic wound
952012
9
25
Dental Disease
Biofilm on the teeth is called dental plaque
48 hrs after tooth brushing biofilm matures
72 hrs after tooth brushing calcium-
phosphate (Tartar calculus) protective
structure
bull only removed by hygienistrsquos pick
1mm3 mature dental plaque contains gt 108 bacteria
100000000 bacteria per cubic millimeter
26
More Biofilms
Sinusitis
Tonsillitis
Necrotizing fasciitis
27
Pneumonia Biofilm in Alveoli
Alveoli nice moist dark area to build biofilm
Easier if immune compromised of lungs
functioning poorly
bull COPD
bull cystic fibrosis
bull on Ventilator
bull old age
952012
10
28
Catheters amp
Tubes
Central venous catheters
Hemodialysis catheters
Pulmonary artery catheters
Arterial catheters
Urinary catheters
Peritoneal catheters
Umbilical catheters
Enteral feeding tubes
Gastrostomy tubes
Nasogastric tubes
Endotracheal tubes
Tracheostomy tubes
Peritoneal dialysis
Drainage tubes
Endotracheal tube for patients on ventilation
29
Vascular Catheters
5-6 million central lines placed annually
gt 5 infections
gt250000 central line-associated infections (CLABSI)
Approximately 20 attributable death rate
Cirioni O J Infect Dis 2006193180-186 CDC MMRW 2002101-28
30
Bloodstream Infections Reduced 5 Fold
After blood draw retained blood provides
breeding ground for biofilm formation
Opaque valves do not show residual blood
Switching to clear housing
10mL flush did not clear blood 20 mL did
5 fold reduction in Blood stream infections
Poster Royer T VHA MRSA Prevention Forum Orlando FL Nov 5-6 2007
Biofilm forms in
blood left coating
the inner surface of
the plastic housing
952012
11
31
Biofilms In Surgery
32
Surgical Drain Tubes
Favorite Biofilm Hangouts
Biofilm Inside Tube (A)
bull Biofilm inside catheter dispersed biofilm towers
Close up of the mature biofilm community (B)
bull Golden spheres Staphylococcus aureus
bull Green matrix substance
bull Orange smooth surface catheter cross section
Thurlow LR J Immunol 20111866585-96
Downloaded from wwwjimmunolorg on January 10 2012
33
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Wound Drains
Primed for Biofilms
Biofilm on drainage tube surface
952012
12
34
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
35
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
36
Implants
952012
13
37
Expanding Realm of Implantables
Market for implants over $23 billion per year in USA
Expected to grow 10 annually with increased demand and technologies available
Most frequently implanted devices
bull cardioverter defibrillators
bull cardiac resynchronization therapy devices
bull cosmetic implants
bull dental implants
bull hip replacements
bull pacemakers
bull phakic intraocular lenses
bull spinal implants
bull tissue implants (eg bone)
38
Why Are Biofilms On Implants
So Successful
Tissue surrounding implants have reduced blood vessels so
bull fewer bacteria-killer white blood cells delivered
bull less antibiotics and other drugs delivered
White blood cells that do make it there have
bull reduced ability to capture bacteria
bull reduced ability to kill bacteria
39
Pins Wires Plates Cushions
Great surfaces for biofilm formation and protection
952012
14
40
Biofilms
On Medical Devices
Infections usually follow alternating up and down pattern
Antibiotic initially effective
bull relapses frequent
bull pathogens grow more tolerant develop antibiotic resistance
Usually requires removal of implant to eliminate infection
(even tiny biofilm fragments will multiply again)
Fatality 5 to 60
Prevent biofilmsinfections in the first place
Hendricks S J Biomed Materials Research 200050160-70 Seare W J Endourology 2000149-17
41
Restoring Function ndash Relieving Pain
42
Biofilm Formed On Implants Both Hands
Implants in both hands acquired biofilm infection
Implants had to be removed all bacteria killed before new implants
Culprit Remote infection
Prevent this cause of implant
biofilm by ensuring all remote
infections treated and resolved
before surgery
952012
15
43
Keeping Things Straight
Pins screws wires
44
So Vulnerable
Stringent adherence to antiseptic regimens
45
Vertebral Implant or Pain Relief
952012
16
46
Rotator Cuff Surgeries
With anchor screws and tough braided sutures
Increasing number performed due to success of
the procedures due to
Aging ldquoBaby Boomersrdquo
47
Necessity Mother of Invention
Sutures are great structures on which biofilms can form
Braided sutures ndash more biofilms
bull greater surface area than monofilament
bull protected crevices
bull higher infection rates
A) Standard braided suture
bull green spots are live bacteria or micro-colonies of bacterial biofilms
B) CHG treated braided suture
bull red spots are dead bacteria or micro-colonies A
B
48
Neurosurgical stimulators
Pulse generators
Intraspinal pumps
Cerebral Spinal Fluid (CSF) shunts
General pain pumps
Neurological
952012
17
49
Cerebral Spinal Shunts
Hydrocephalus caused by accumulation of cerebral
spinal fluid (CSF) in cerebral ventricles 140000yr
122000 ventriculostomy (VA) shuntsyear
bull Average 10 infection
18000 ventriculoperitoneal (VP) shuntsyear
bull 25 must undergo revision due to biofilm growth
50
Cerebral Spinal Shunts
Antimicrobial shunts effective in some studies
Prevent contamination by pathogens and particulates
51
Poorly Reprocessed Electrodes
Electroencephalogram electrodes not properly cleaned
Residual dried on biofilm provided
bull protection of entrapped virus
bull prevented adequate sterilization
Several patients acquired hepatitis B (HBV)
$275 million legal settlement against neurologist amp hospital
Mackay B CMAJ 2002 166(7)943
952012
18
52
Circulatory amp Coronary Implants
Cardiac valves
Mechanical heart valves
Implanted defibrillators
Pacemakers
Vascular grafts
Stents
53
Cardiac amp
Vascular
Biofilms
54
Prosthetic Heart Valves
3 ndash 57 form biofilm leading to overt
infection (endocarditis)
Vinh DC J Long Term Effects Medical Implants 200515467-488
952012
19
55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
4
10
Undesirable Biofilms
Swamp Coolers
Water pipes Legionella
Cooled air filtration
Poor manufacturing maintenance
Poor housekeeping
Biofilms CDC gt 70 Human Infections
But How Do Biofilms Form
What are Their Characteristics
12
952012
5
13
Progression Stages to a Mature
Biofilm
14
Stage 1
Bacteria Attach to a Surface
Bacteria land on a surface
If surface not favorable will let go
Surface favorable if proteins mucus blood dead cell debris
Send out signals attracting other bacteria to site
15
Stage 2
Irreversible Adhesion
Favorable conditions trigger hyper-drive increase of
bull sticky strong adhesins to strengthen attachment
bull pumping out polysaccharides ldquogooey matrixrdquo
bull exponential cell division = rapid population growth
952012
6
16
Stage 3
Aggregationorganization
Mixed-species community forms within the gooey matrix
Function responsibility influenced by location in biofilm
bull periphery = defensive
bull upper levels = harvest food
bull lower levels = get rid of waste
bull bottom level = adherence to surface
Bacteria pump out more goo attachment amp elastic
stretch so strong survives outside of jet in flight
17
Stage 4
Maturation Complex Community
Bacteria communicate changes in environment from
their post and alter behavior if needed
A
B
C
18
Importance of Bacterial
Communication Within Biofilms
Pseudomonas biofilm on
1 standard untreated polyurethane
2 usnic acid treated polyurethane ndash disrupts
communication and ability to organize community
(1) (2)
Montana State University Bozeman MT
Three Dimensional
Classic Biofilm Shape
One Dimensional
Flat Weak Biofilm
952012
7
19
Stage 5
Dispersal
Creation and release of free-floating
single-celled ldquochildrenrdquo called planktonic bacteria to start
bull new colonies
bull local infections
bull remote infections
bull systemic infections
bull embolic complications
Planktonic bacteria are the most vulnerable to biocides
Recurrent symptoms (eg sinus implant biofilm infections)
7 days 2 days 6 hours
Legionella
20
Biofilms Excel in
The Resistance Movement
Difficult for antibiotics and disinfectants too
bull hard to diffuse through matrix more diluted further goes
bull molecules in matrix degrade antimicrobial agents
bull when reaches pathogens is diluted encourages resistance
bull resistance factors passed to neighbors amp next generation
bull 10 to 2400X more antibiotic resistant than free pathogens
Bacteria pass resistance to others by DNA code transfer
Dye diffusion
through matrix gel
DNA Transfer
VRE Staph aureus
21
Biofilms Excel in
The Resistance Movement
Additional Resistance Mechanisms
Fortress protection amp ldquogriprdquo resists physical disruption
Incapacitates White Cells that might penetrate matrix
Poor phagocytic (capture) capability
Poor killing capability
WBC (Macrophages here) trying to attack biofilm bacteria
Bacteria in biofilm (stained pink here)
WBC (Neutrophil large red balls) gets in through water
channels but cannot kill much hellip small red bacteria are
dead
952012
8
22
Patient Associated Consequences
23
Typical Biofilm-Related Infections
(live biofilms)
Chronic wounds
Cystic fibrosis
Dental plaquecalculus
Dental cavities
GingivitisPeriodontitis
Endocarditis
Osteomyelitis
Otitis media
Tonsillitis
Device implant
24
Wound Infections
Biofilm along fascia
Biofilm throughout the mesh
Biofilm in chronic wound
952012
9
25
Dental Disease
Biofilm on the teeth is called dental plaque
48 hrs after tooth brushing biofilm matures
72 hrs after tooth brushing calcium-
phosphate (Tartar calculus) protective
structure
bull only removed by hygienistrsquos pick
1mm3 mature dental plaque contains gt 108 bacteria
100000000 bacteria per cubic millimeter
26
More Biofilms
Sinusitis
Tonsillitis
Necrotizing fasciitis
27
Pneumonia Biofilm in Alveoli
Alveoli nice moist dark area to build biofilm
Easier if immune compromised of lungs
functioning poorly
bull COPD
bull cystic fibrosis
bull on Ventilator
bull old age
952012
10
28
Catheters amp
Tubes
Central venous catheters
Hemodialysis catheters
Pulmonary artery catheters
Arterial catheters
Urinary catheters
Peritoneal catheters
Umbilical catheters
Enteral feeding tubes
Gastrostomy tubes
Nasogastric tubes
Endotracheal tubes
Tracheostomy tubes
Peritoneal dialysis
Drainage tubes
Endotracheal tube for patients on ventilation
29
Vascular Catheters
5-6 million central lines placed annually
gt 5 infections
gt250000 central line-associated infections (CLABSI)
Approximately 20 attributable death rate
Cirioni O J Infect Dis 2006193180-186 CDC MMRW 2002101-28
30
Bloodstream Infections Reduced 5 Fold
After blood draw retained blood provides
breeding ground for biofilm formation
Opaque valves do not show residual blood
Switching to clear housing
10mL flush did not clear blood 20 mL did
5 fold reduction in Blood stream infections
Poster Royer T VHA MRSA Prevention Forum Orlando FL Nov 5-6 2007
Biofilm forms in
blood left coating
the inner surface of
the plastic housing
952012
11
31
Biofilms In Surgery
32
Surgical Drain Tubes
Favorite Biofilm Hangouts
Biofilm Inside Tube (A)
bull Biofilm inside catheter dispersed biofilm towers
Close up of the mature biofilm community (B)
bull Golden spheres Staphylococcus aureus
bull Green matrix substance
bull Orange smooth surface catheter cross section
Thurlow LR J Immunol 20111866585-96
Downloaded from wwwjimmunolorg on January 10 2012
33
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Wound Drains
Primed for Biofilms
Biofilm on drainage tube surface
952012
12
34
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
35
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
36
Implants
952012
13
37
Expanding Realm of Implantables
Market for implants over $23 billion per year in USA
Expected to grow 10 annually with increased demand and technologies available
Most frequently implanted devices
bull cardioverter defibrillators
bull cardiac resynchronization therapy devices
bull cosmetic implants
bull dental implants
bull hip replacements
bull pacemakers
bull phakic intraocular lenses
bull spinal implants
bull tissue implants (eg bone)
38
Why Are Biofilms On Implants
So Successful
Tissue surrounding implants have reduced blood vessels so
bull fewer bacteria-killer white blood cells delivered
bull less antibiotics and other drugs delivered
White blood cells that do make it there have
bull reduced ability to capture bacteria
bull reduced ability to kill bacteria
39
Pins Wires Plates Cushions
Great surfaces for biofilm formation and protection
952012
14
40
Biofilms
On Medical Devices
Infections usually follow alternating up and down pattern
Antibiotic initially effective
bull relapses frequent
bull pathogens grow more tolerant develop antibiotic resistance
Usually requires removal of implant to eliminate infection
(even tiny biofilm fragments will multiply again)
Fatality 5 to 60
Prevent biofilmsinfections in the first place
Hendricks S J Biomed Materials Research 200050160-70 Seare W J Endourology 2000149-17
41
Restoring Function ndash Relieving Pain
42
Biofilm Formed On Implants Both Hands
Implants in both hands acquired biofilm infection
Implants had to be removed all bacteria killed before new implants
Culprit Remote infection
Prevent this cause of implant
biofilm by ensuring all remote
infections treated and resolved
before surgery
952012
15
43
Keeping Things Straight
Pins screws wires
44
So Vulnerable
Stringent adherence to antiseptic regimens
45
Vertebral Implant or Pain Relief
952012
16
46
Rotator Cuff Surgeries
With anchor screws and tough braided sutures
Increasing number performed due to success of
the procedures due to
Aging ldquoBaby Boomersrdquo
47
Necessity Mother of Invention
Sutures are great structures on which biofilms can form
Braided sutures ndash more biofilms
bull greater surface area than monofilament
bull protected crevices
bull higher infection rates
A) Standard braided suture
bull green spots are live bacteria or micro-colonies of bacterial biofilms
B) CHG treated braided suture
bull red spots are dead bacteria or micro-colonies A
B
48
Neurosurgical stimulators
Pulse generators
Intraspinal pumps
Cerebral Spinal Fluid (CSF) shunts
General pain pumps
Neurological
952012
17
49
Cerebral Spinal Shunts
Hydrocephalus caused by accumulation of cerebral
spinal fluid (CSF) in cerebral ventricles 140000yr
122000 ventriculostomy (VA) shuntsyear
bull Average 10 infection
18000 ventriculoperitoneal (VP) shuntsyear
bull 25 must undergo revision due to biofilm growth
50
Cerebral Spinal Shunts
Antimicrobial shunts effective in some studies
Prevent contamination by pathogens and particulates
51
Poorly Reprocessed Electrodes
Electroencephalogram electrodes not properly cleaned
Residual dried on biofilm provided
bull protection of entrapped virus
bull prevented adequate sterilization
Several patients acquired hepatitis B (HBV)
$275 million legal settlement against neurologist amp hospital
Mackay B CMAJ 2002 166(7)943
952012
18
52
Circulatory amp Coronary Implants
Cardiac valves
Mechanical heart valves
Implanted defibrillators
Pacemakers
Vascular grafts
Stents
53
Cardiac amp
Vascular
Biofilms
54
Prosthetic Heart Valves
3 ndash 57 form biofilm leading to overt
infection (endocarditis)
Vinh DC J Long Term Effects Medical Implants 200515467-488
952012
19
55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
5
13
Progression Stages to a Mature
Biofilm
14
Stage 1
Bacteria Attach to a Surface
Bacteria land on a surface
If surface not favorable will let go
Surface favorable if proteins mucus blood dead cell debris
Send out signals attracting other bacteria to site
15
Stage 2
Irreversible Adhesion
Favorable conditions trigger hyper-drive increase of
bull sticky strong adhesins to strengthen attachment
bull pumping out polysaccharides ldquogooey matrixrdquo
bull exponential cell division = rapid population growth
952012
6
16
Stage 3
Aggregationorganization
Mixed-species community forms within the gooey matrix
Function responsibility influenced by location in biofilm
bull periphery = defensive
bull upper levels = harvest food
bull lower levels = get rid of waste
bull bottom level = adherence to surface
Bacteria pump out more goo attachment amp elastic
stretch so strong survives outside of jet in flight
17
Stage 4
Maturation Complex Community
Bacteria communicate changes in environment from
their post and alter behavior if needed
A
B
C
18
Importance of Bacterial
Communication Within Biofilms
Pseudomonas biofilm on
1 standard untreated polyurethane
2 usnic acid treated polyurethane ndash disrupts
communication and ability to organize community
(1) (2)
Montana State University Bozeman MT
Three Dimensional
Classic Biofilm Shape
One Dimensional
Flat Weak Biofilm
952012
7
19
Stage 5
Dispersal
Creation and release of free-floating
single-celled ldquochildrenrdquo called planktonic bacteria to start
bull new colonies
bull local infections
bull remote infections
bull systemic infections
bull embolic complications
Planktonic bacteria are the most vulnerable to biocides
Recurrent symptoms (eg sinus implant biofilm infections)
7 days 2 days 6 hours
Legionella
20
Biofilms Excel in
The Resistance Movement
Difficult for antibiotics and disinfectants too
bull hard to diffuse through matrix more diluted further goes
bull molecules in matrix degrade antimicrobial agents
bull when reaches pathogens is diluted encourages resistance
bull resistance factors passed to neighbors amp next generation
bull 10 to 2400X more antibiotic resistant than free pathogens
Bacteria pass resistance to others by DNA code transfer
Dye diffusion
through matrix gel
DNA Transfer
VRE Staph aureus
21
Biofilms Excel in
The Resistance Movement
Additional Resistance Mechanisms
Fortress protection amp ldquogriprdquo resists physical disruption
Incapacitates White Cells that might penetrate matrix
Poor phagocytic (capture) capability
Poor killing capability
WBC (Macrophages here) trying to attack biofilm bacteria
Bacteria in biofilm (stained pink here)
WBC (Neutrophil large red balls) gets in through water
channels but cannot kill much hellip small red bacteria are
dead
952012
8
22
Patient Associated Consequences
23
Typical Biofilm-Related Infections
(live biofilms)
Chronic wounds
Cystic fibrosis
Dental plaquecalculus
Dental cavities
GingivitisPeriodontitis
Endocarditis
Osteomyelitis
Otitis media
Tonsillitis
Device implant
24
Wound Infections
Biofilm along fascia
Biofilm throughout the mesh
Biofilm in chronic wound
952012
9
25
Dental Disease
Biofilm on the teeth is called dental plaque
48 hrs after tooth brushing biofilm matures
72 hrs after tooth brushing calcium-
phosphate (Tartar calculus) protective
structure
bull only removed by hygienistrsquos pick
1mm3 mature dental plaque contains gt 108 bacteria
100000000 bacteria per cubic millimeter
26
More Biofilms
Sinusitis
Tonsillitis
Necrotizing fasciitis
27
Pneumonia Biofilm in Alveoli
Alveoli nice moist dark area to build biofilm
Easier if immune compromised of lungs
functioning poorly
bull COPD
bull cystic fibrosis
bull on Ventilator
bull old age
952012
10
28
Catheters amp
Tubes
Central venous catheters
Hemodialysis catheters
Pulmonary artery catheters
Arterial catheters
Urinary catheters
Peritoneal catheters
Umbilical catheters
Enteral feeding tubes
Gastrostomy tubes
Nasogastric tubes
Endotracheal tubes
Tracheostomy tubes
Peritoneal dialysis
Drainage tubes
Endotracheal tube for patients on ventilation
29
Vascular Catheters
5-6 million central lines placed annually
gt 5 infections
gt250000 central line-associated infections (CLABSI)
Approximately 20 attributable death rate
Cirioni O J Infect Dis 2006193180-186 CDC MMRW 2002101-28
30
Bloodstream Infections Reduced 5 Fold
After blood draw retained blood provides
breeding ground for biofilm formation
Opaque valves do not show residual blood
Switching to clear housing
10mL flush did not clear blood 20 mL did
5 fold reduction in Blood stream infections
Poster Royer T VHA MRSA Prevention Forum Orlando FL Nov 5-6 2007
Biofilm forms in
blood left coating
the inner surface of
the plastic housing
952012
11
31
Biofilms In Surgery
32
Surgical Drain Tubes
Favorite Biofilm Hangouts
Biofilm Inside Tube (A)
bull Biofilm inside catheter dispersed biofilm towers
Close up of the mature biofilm community (B)
bull Golden spheres Staphylococcus aureus
bull Green matrix substance
bull Orange smooth surface catheter cross section
Thurlow LR J Immunol 20111866585-96
Downloaded from wwwjimmunolorg on January 10 2012
33
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Wound Drains
Primed for Biofilms
Biofilm on drainage tube surface
952012
12
34
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
35
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
36
Implants
952012
13
37
Expanding Realm of Implantables
Market for implants over $23 billion per year in USA
Expected to grow 10 annually with increased demand and technologies available
Most frequently implanted devices
bull cardioverter defibrillators
bull cardiac resynchronization therapy devices
bull cosmetic implants
bull dental implants
bull hip replacements
bull pacemakers
bull phakic intraocular lenses
bull spinal implants
bull tissue implants (eg bone)
38
Why Are Biofilms On Implants
So Successful
Tissue surrounding implants have reduced blood vessels so
bull fewer bacteria-killer white blood cells delivered
bull less antibiotics and other drugs delivered
White blood cells that do make it there have
bull reduced ability to capture bacteria
bull reduced ability to kill bacteria
39
Pins Wires Plates Cushions
Great surfaces for biofilm formation and protection
952012
14
40
Biofilms
On Medical Devices
Infections usually follow alternating up and down pattern
Antibiotic initially effective
bull relapses frequent
bull pathogens grow more tolerant develop antibiotic resistance
Usually requires removal of implant to eliminate infection
(even tiny biofilm fragments will multiply again)
Fatality 5 to 60
Prevent biofilmsinfections in the first place
Hendricks S J Biomed Materials Research 200050160-70 Seare W J Endourology 2000149-17
41
Restoring Function ndash Relieving Pain
42
Biofilm Formed On Implants Both Hands
Implants in both hands acquired biofilm infection
Implants had to be removed all bacteria killed before new implants
Culprit Remote infection
Prevent this cause of implant
biofilm by ensuring all remote
infections treated and resolved
before surgery
952012
15
43
Keeping Things Straight
Pins screws wires
44
So Vulnerable
Stringent adherence to antiseptic regimens
45
Vertebral Implant or Pain Relief
952012
16
46
Rotator Cuff Surgeries
With anchor screws and tough braided sutures
Increasing number performed due to success of
the procedures due to
Aging ldquoBaby Boomersrdquo
47
Necessity Mother of Invention
Sutures are great structures on which biofilms can form
Braided sutures ndash more biofilms
bull greater surface area than monofilament
bull protected crevices
bull higher infection rates
A) Standard braided suture
bull green spots are live bacteria or micro-colonies of bacterial biofilms
B) CHG treated braided suture
bull red spots are dead bacteria or micro-colonies A
B
48
Neurosurgical stimulators
Pulse generators
Intraspinal pumps
Cerebral Spinal Fluid (CSF) shunts
General pain pumps
Neurological
952012
17
49
Cerebral Spinal Shunts
Hydrocephalus caused by accumulation of cerebral
spinal fluid (CSF) in cerebral ventricles 140000yr
122000 ventriculostomy (VA) shuntsyear
bull Average 10 infection
18000 ventriculoperitoneal (VP) shuntsyear
bull 25 must undergo revision due to biofilm growth
50
Cerebral Spinal Shunts
Antimicrobial shunts effective in some studies
Prevent contamination by pathogens and particulates
51
Poorly Reprocessed Electrodes
Electroencephalogram electrodes not properly cleaned
Residual dried on biofilm provided
bull protection of entrapped virus
bull prevented adequate sterilization
Several patients acquired hepatitis B (HBV)
$275 million legal settlement against neurologist amp hospital
Mackay B CMAJ 2002 166(7)943
952012
18
52
Circulatory amp Coronary Implants
Cardiac valves
Mechanical heart valves
Implanted defibrillators
Pacemakers
Vascular grafts
Stents
53
Cardiac amp
Vascular
Biofilms
54
Prosthetic Heart Valves
3 ndash 57 form biofilm leading to overt
infection (endocarditis)
Vinh DC J Long Term Effects Medical Implants 200515467-488
952012
19
55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
6
16
Stage 3
Aggregationorganization
Mixed-species community forms within the gooey matrix
Function responsibility influenced by location in biofilm
bull periphery = defensive
bull upper levels = harvest food
bull lower levels = get rid of waste
bull bottom level = adherence to surface
Bacteria pump out more goo attachment amp elastic
stretch so strong survives outside of jet in flight
17
Stage 4
Maturation Complex Community
Bacteria communicate changes in environment from
their post and alter behavior if needed
A
B
C
18
Importance of Bacterial
Communication Within Biofilms
Pseudomonas biofilm on
1 standard untreated polyurethane
2 usnic acid treated polyurethane ndash disrupts
communication and ability to organize community
(1) (2)
Montana State University Bozeman MT
Three Dimensional
Classic Biofilm Shape
One Dimensional
Flat Weak Biofilm
952012
7
19
Stage 5
Dispersal
Creation and release of free-floating
single-celled ldquochildrenrdquo called planktonic bacteria to start
bull new colonies
bull local infections
bull remote infections
bull systemic infections
bull embolic complications
Planktonic bacteria are the most vulnerable to biocides
Recurrent symptoms (eg sinus implant biofilm infections)
7 days 2 days 6 hours
Legionella
20
Biofilms Excel in
The Resistance Movement
Difficult for antibiotics and disinfectants too
bull hard to diffuse through matrix more diluted further goes
bull molecules in matrix degrade antimicrobial agents
bull when reaches pathogens is diluted encourages resistance
bull resistance factors passed to neighbors amp next generation
bull 10 to 2400X more antibiotic resistant than free pathogens
Bacteria pass resistance to others by DNA code transfer
Dye diffusion
through matrix gel
DNA Transfer
VRE Staph aureus
21
Biofilms Excel in
The Resistance Movement
Additional Resistance Mechanisms
Fortress protection amp ldquogriprdquo resists physical disruption
Incapacitates White Cells that might penetrate matrix
Poor phagocytic (capture) capability
Poor killing capability
WBC (Macrophages here) trying to attack biofilm bacteria
Bacteria in biofilm (stained pink here)
WBC (Neutrophil large red balls) gets in through water
channels but cannot kill much hellip small red bacteria are
dead
952012
8
22
Patient Associated Consequences
23
Typical Biofilm-Related Infections
(live biofilms)
Chronic wounds
Cystic fibrosis
Dental plaquecalculus
Dental cavities
GingivitisPeriodontitis
Endocarditis
Osteomyelitis
Otitis media
Tonsillitis
Device implant
24
Wound Infections
Biofilm along fascia
Biofilm throughout the mesh
Biofilm in chronic wound
952012
9
25
Dental Disease
Biofilm on the teeth is called dental plaque
48 hrs after tooth brushing biofilm matures
72 hrs after tooth brushing calcium-
phosphate (Tartar calculus) protective
structure
bull only removed by hygienistrsquos pick
1mm3 mature dental plaque contains gt 108 bacteria
100000000 bacteria per cubic millimeter
26
More Biofilms
Sinusitis
Tonsillitis
Necrotizing fasciitis
27
Pneumonia Biofilm in Alveoli
Alveoli nice moist dark area to build biofilm
Easier if immune compromised of lungs
functioning poorly
bull COPD
bull cystic fibrosis
bull on Ventilator
bull old age
952012
10
28
Catheters amp
Tubes
Central venous catheters
Hemodialysis catheters
Pulmonary artery catheters
Arterial catheters
Urinary catheters
Peritoneal catheters
Umbilical catheters
Enteral feeding tubes
Gastrostomy tubes
Nasogastric tubes
Endotracheal tubes
Tracheostomy tubes
Peritoneal dialysis
Drainage tubes
Endotracheal tube for patients on ventilation
29
Vascular Catheters
5-6 million central lines placed annually
gt 5 infections
gt250000 central line-associated infections (CLABSI)
Approximately 20 attributable death rate
Cirioni O J Infect Dis 2006193180-186 CDC MMRW 2002101-28
30
Bloodstream Infections Reduced 5 Fold
After blood draw retained blood provides
breeding ground for biofilm formation
Opaque valves do not show residual blood
Switching to clear housing
10mL flush did not clear blood 20 mL did
5 fold reduction in Blood stream infections
Poster Royer T VHA MRSA Prevention Forum Orlando FL Nov 5-6 2007
Biofilm forms in
blood left coating
the inner surface of
the plastic housing
952012
11
31
Biofilms In Surgery
32
Surgical Drain Tubes
Favorite Biofilm Hangouts
Biofilm Inside Tube (A)
bull Biofilm inside catheter dispersed biofilm towers
Close up of the mature biofilm community (B)
bull Golden spheres Staphylococcus aureus
bull Green matrix substance
bull Orange smooth surface catheter cross section
Thurlow LR J Immunol 20111866585-96
Downloaded from wwwjimmunolorg on January 10 2012
33
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Wound Drains
Primed for Biofilms
Biofilm on drainage tube surface
952012
12
34
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
35
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
36
Implants
952012
13
37
Expanding Realm of Implantables
Market for implants over $23 billion per year in USA
Expected to grow 10 annually with increased demand and technologies available
Most frequently implanted devices
bull cardioverter defibrillators
bull cardiac resynchronization therapy devices
bull cosmetic implants
bull dental implants
bull hip replacements
bull pacemakers
bull phakic intraocular lenses
bull spinal implants
bull tissue implants (eg bone)
38
Why Are Biofilms On Implants
So Successful
Tissue surrounding implants have reduced blood vessels so
bull fewer bacteria-killer white blood cells delivered
bull less antibiotics and other drugs delivered
White blood cells that do make it there have
bull reduced ability to capture bacteria
bull reduced ability to kill bacteria
39
Pins Wires Plates Cushions
Great surfaces for biofilm formation and protection
952012
14
40
Biofilms
On Medical Devices
Infections usually follow alternating up and down pattern
Antibiotic initially effective
bull relapses frequent
bull pathogens grow more tolerant develop antibiotic resistance
Usually requires removal of implant to eliminate infection
(even tiny biofilm fragments will multiply again)
Fatality 5 to 60
Prevent biofilmsinfections in the first place
Hendricks S J Biomed Materials Research 200050160-70 Seare W J Endourology 2000149-17
41
Restoring Function ndash Relieving Pain
42
Biofilm Formed On Implants Both Hands
Implants in both hands acquired biofilm infection
Implants had to be removed all bacteria killed before new implants
Culprit Remote infection
Prevent this cause of implant
biofilm by ensuring all remote
infections treated and resolved
before surgery
952012
15
43
Keeping Things Straight
Pins screws wires
44
So Vulnerable
Stringent adherence to antiseptic regimens
45
Vertebral Implant or Pain Relief
952012
16
46
Rotator Cuff Surgeries
With anchor screws and tough braided sutures
Increasing number performed due to success of
the procedures due to
Aging ldquoBaby Boomersrdquo
47
Necessity Mother of Invention
Sutures are great structures on which biofilms can form
Braided sutures ndash more biofilms
bull greater surface area than monofilament
bull protected crevices
bull higher infection rates
A) Standard braided suture
bull green spots are live bacteria or micro-colonies of bacterial biofilms
B) CHG treated braided suture
bull red spots are dead bacteria or micro-colonies A
B
48
Neurosurgical stimulators
Pulse generators
Intraspinal pumps
Cerebral Spinal Fluid (CSF) shunts
General pain pumps
Neurological
952012
17
49
Cerebral Spinal Shunts
Hydrocephalus caused by accumulation of cerebral
spinal fluid (CSF) in cerebral ventricles 140000yr
122000 ventriculostomy (VA) shuntsyear
bull Average 10 infection
18000 ventriculoperitoneal (VP) shuntsyear
bull 25 must undergo revision due to biofilm growth
50
Cerebral Spinal Shunts
Antimicrobial shunts effective in some studies
Prevent contamination by pathogens and particulates
51
Poorly Reprocessed Electrodes
Electroencephalogram electrodes not properly cleaned
Residual dried on biofilm provided
bull protection of entrapped virus
bull prevented adequate sterilization
Several patients acquired hepatitis B (HBV)
$275 million legal settlement against neurologist amp hospital
Mackay B CMAJ 2002 166(7)943
952012
18
52
Circulatory amp Coronary Implants
Cardiac valves
Mechanical heart valves
Implanted defibrillators
Pacemakers
Vascular grafts
Stents
53
Cardiac amp
Vascular
Biofilms
54
Prosthetic Heart Valves
3 ndash 57 form biofilm leading to overt
infection (endocarditis)
Vinh DC J Long Term Effects Medical Implants 200515467-488
952012
19
55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
7
19
Stage 5
Dispersal
Creation and release of free-floating
single-celled ldquochildrenrdquo called planktonic bacteria to start
bull new colonies
bull local infections
bull remote infections
bull systemic infections
bull embolic complications
Planktonic bacteria are the most vulnerable to biocides
Recurrent symptoms (eg sinus implant biofilm infections)
7 days 2 days 6 hours
Legionella
20
Biofilms Excel in
The Resistance Movement
Difficult for antibiotics and disinfectants too
bull hard to diffuse through matrix more diluted further goes
bull molecules in matrix degrade antimicrobial agents
bull when reaches pathogens is diluted encourages resistance
bull resistance factors passed to neighbors amp next generation
bull 10 to 2400X more antibiotic resistant than free pathogens
Bacteria pass resistance to others by DNA code transfer
Dye diffusion
through matrix gel
DNA Transfer
VRE Staph aureus
21
Biofilms Excel in
The Resistance Movement
Additional Resistance Mechanisms
Fortress protection amp ldquogriprdquo resists physical disruption
Incapacitates White Cells that might penetrate matrix
Poor phagocytic (capture) capability
Poor killing capability
WBC (Macrophages here) trying to attack biofilm bacteria
Bacteria in biofilm (stained pink here)
WBC (Neutrophil large red balls) gets in through water
channels but cannot kill much hellip small red bacteria are
dead
952012
8
22
Patient Associated Consequences
23
Typical Biofilm-Related Infections
(live biofilms)
Chronic wounds
Cystic fibrosis
Dental plaquecalculus
Dental cavities
GingivitisPeriodontitis
Endocarditis
Osteomyelitis
Otitis media
Tonsillitis
Device implant
24
Wound Infections
Biofilm along fascia
Biofilm throughout the mesh
Biofilm in chronic wound
952012
9
25
Dental Disease
Biofilm on the teeth is called dental plaque
48 hrs after tooth brushing biofilm matures
72 hrs after tooth brushing calcium-
phosphate (Tartar calculus) protective
structure
bull only removed by hygienistrsquos pick
1mm3 mature dental plaque contains gt 108 bacteria
100000000 bacteria per cubic millimeter
26
More Biofilms
Sinusitis
Tonsillitis
Necrotizing fasciitis
27
Pneumonia Biofilm in Alveoli
Alveoli nice moist dark area to build biofilm
Easier if immune compromised of lungs
functioning poorly
bull COPD
bull cystic fibrosis
bull on Ventilator
bull old age
952012
10
28
Catheters amp
Tubes
Central venous catheters
Hemodialysis catheters
Pulmonary artery catheters
Arterial catheters
Urinary catheters
Peritoneal catheters
Umbilical catheters
Enteral feeding tubes
Gastrostomy tubes
Nasogastric tubes
Endotracheal tubes
Tracheostomy tubes
Peritoneal dialysis
Drainage tubes
Endotracheal tube for patients on ventilation
29
Vascular Catheters
5-6 million central lines placed annually
gt 5 infections
gt250000 central line-associated infections (CLABSI)
Approximately 20 attributable death rate
Cirioni O J Infect Dis 2006193180-186 CDC MMRW 2002101-28
30
Bloodstream Infections Reduced 5 Fold
After blood draw retained blood provides
breeding ground for biofilm formation
Opaque valves do not show residual blood
Switching to clear housing
10mL flush did not clear blood 20 mL did
5 fold reduction in Blood stream infections
Poster Royer T VHA MRSA Prevention Forum Orlando FL Nov 5-6 2007
Biofilm forms in
blood left coating
the inner surface of
the plastic housing
952012
11
31
Biofilms In Surgery
32
Surgical Drain Tubes
Favorite Biofilm Hangouts
Biofilm Inside Tube (A)
bull Biofilm inside catheter dispersed biofilm towers
Close up of the mature biofilm community (B)
bull Golden spheres Staphylococcus aureus
bull Green matrix substance
bull Orange smooth surface catheter cross section
Thurlow LR J Immunol 20111866585-96
Downloaded from wwwjimmunolorg on January 10 2012
33
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Wound Drains
Primed for Biofilms
Biofilm on drainage tube surface
952012
12
34
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
35
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
36
Implants
952012
13
37
Expanding Realm of Implantables
Market for implants over $23 billion per year in USA
Expected to grow 10 annually with increased demand and technologies available
Most frequently implanted devices
bull cardioverter defibrillators
bull cardiac resynchronization therapy devices
bull cosmetic implants
bull dental implants
bull hip replacements
bull pacemakers
bull phakic intraocular lenses
bull spinal implants
bull tissue implants (eg bone)
38
Why Are Biofilms On Implants
So Successful
Tissue surrounding implants have reduced blood vessels so
bull fewer bacteria-killer white blood cells delivered
bull less antibiotics and other drugs delivered
White blood cells that do make it there have
bull reduced ability to capture bacteria
bull reduced ability to kill bacteria
39
Pins Wires Plates Cushions
Great surfaces for biofilm formation and protection
952012
14
40
Biofilms
On Medical Devices
Infections usually follow alternating up and down pattern
Antibiotic initially effective
bull relapses frequent
bull pathogens grow more tolerant develop antibiotic resistance
Usually requires removal of implant to eliminate infection
(even tiny biofilm fragments will multiply again)
Fatality 5 to 60
Prevent biofilmsinfections in the first place
Hendricks S J Biomed Materials Research 200050160-70 Seare W J Endourology 2000149-17
41
Restoring Function ndash Relieving Pain
42
Biofilm Formed On Implants Both Hands
Implants in both hands acquired biofilm infection
Implants had to be removed all bacteria killed before new implants
Culprit Remote infection
Prevent this cause of implant
biofilm by ensuring all remote
infections treated and resolved
before surgery
952012
15
43
Keeping Things Straight
Pins screws wires
44
So Vulnerable
Stringent adherence to antiseptic regimens
45
Vertebral Implant or Pain Relief
952012
16
46
Rotator Cuff Surgeries
With anchor screws and tough braided sutures
Increasing number performed due to success of
the procedures due to
Aging ldquoBaby Boomersrdquo
47
Necessity Mother of Invention
Sutures are great structures on which biofilms can form
Braided sutures ndash more biofilms
bull greater surface area than monofilament
bull protected crevices
bull higher infection rates
A) Standard braided suture
bull green spots are live bacteria or micro-colonies of bacterial biofilms
B) CHG treated braided suture
bull red spots are dead bacteria or micro-colonies A
B
48
Neurosurgical stimulators
Pulse generators
Intraspinal pumps
Cerebral Spinal Fluid (CSF) shunts
General pain pumps
Neurological
952012
17
49
Cerebral Spinal Shunts
Hydrocephalus caused by accumulation of cerebral
spinal fluid (CSF) in cerebral ventricles 140000yr
122000 ventriculostomy (VA) shuntsyear
bull Average 10 infection
18000 ventriculoperitoneal (VP) shuntsyear
bull 25 must undergo revision due to biofilm growth
50
Cerebral Spinal Shunts
Antimicrobial shunts effective in some studies
Prevent contamination by pathogens and particulates
51
Poorly Reprocessed Electrodes
Electroencephalogram electrodes not properly cleaned
Residual dried on biofilm provided
bull protection of entrapped virus
bull prevented adequate sterilization
Several patients acquired hepatitis B (HBV)
$275 million legal settlement against neurologist amp hospital
Mackay B CMAJ 2002 166(7)943
952012
18
52
Circulatory amp Coronary Implants
Cardiac valves
Mechanical heart valves
Implanted defibrillators
Pacemakers
Vascular grafts
Stents
53
Cardiac amp
Vascular
Biofilms
54
Prosthetic Heart Valves
3 ndash 57 form biofilm leading to overt
infection (endocarditis)
Vinh DC J Long Term Effects Medical Implants 200515467-488
952012
19
55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
8
22
Patient Associated Consequences
23
Typical Biofilm-Related Infections
(live biofilms)
Chronic wounds
Cystic fibrosis
Dental plaquecalculus
Dental cavities
GingivitisPeriodontitis
Endocarditis
Osteomyelitis
Otitis media
Tonsillitis
Device implant
24
Wound Infections
Biofilm along fascia
Biofilm throughout the mesh
Biofilm in chronic wound
952012
9
25
Dental Disease
Biofilm on the teeth is called dental plaque
48 hrs after tooth brushing biofilm matures
72 hrs after tooth brushing calcium-
phosphate (Tartar calculus) protective
structure
bull only removed by hygienistrsquos pick
1mm3 mature dental plaque contains gt 108 bacteria
100000000 bacteria per cubic millimeter
26
More Biofilms
Sinusitis
Tonsillitis
Necrotizing fasciitis
27
Pneumonia Biofilm in Alveoli
Alveoli nice moist dark area to build biofilm
Easier if immune compromised of lungs
functioning poorly
bull COPD
bull cystic fibrosis
bull on Ventilator
bull old age
952012
10
28
Catheters amp
Tubes
Central venous catheters
Hemodialysis catheters
Pulmonary artery catheters
Arterial catheters
Urinary catheters
Peritoneal catheters
Umbilical catheters
Enteral feeding tubes
Gastrostomy tubes
Nasogastric tubes
Endotracheal tubes
Tracheostomy tubes
Peritoneal dialysis
Drainage tubes
Endotracheal tube for patients on ventilation
29
Vascular Catheters
5-6 million central lines placed annually
gt 5 infections
gt250000 central line-associated infections (CLABSI)
Approximately 20 attributable death rate
Cirioni O J Infect Dis 2006193180-186 CDC MMRW 2002101-28
30
Bloodstream Infections Reduced 5 Fold
After blood draw retained blood provides
breeding ground for biofilm formation
Opaque valves do not show residual blood
Switching to clear housing
10mL flush did not clear blood 20 mL did
5 fold reduction in Blood stream infections
Poster Royer T VHA MRSA Prevention Forum Orlando FL Nov 5-6 2007
Biofilm forms in
blood left coating
the inner surface of
the plastic housing
952012
11
31
Biofilms In Surgery
32
Surgical Drain Tubes
Favorite Biofilm Hangouts
Biofilm Inside Tube (A)
bull Biofilm inside catheter dispersed biofilm towers
Close up of the mature biofilm community (B)
bull Golden spheres Staphylococcus aureus
bull Green matrix substance
bull Orange smooth surface catheter cross section
Thurlow LR J Immunol 20111866585-96
Downloaded from wwwjimmunolorg on January 10 2012
33
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Wound Drains
Primed for Biofilms
Biofilm on drainage tube surface
952012
12
34
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
35
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
36
Implants
952012
13
37
Expanding Realm of Implantables
Market for implants over $23 billion per year in USA
Expected to grow 10 annually with increased demand and technologies available
Most frequently implanted devices
bull cardioverter defibrillators
bull cardiac resynchronization therapy devices
bull cosmetic implants
bull dental implants
bull hip replacements
bull pacemakers
bull phakic intraocular lenses
bull spinal implants
bull tissue implants (eg bone)
38
Why Are Biofilms On Implants
So Successful
Tissue surrounding implants have reduced blood vessels so
bull fewer bacteria-killer white blood cells delivered
bull less antibiotics and other drugs delivered
White blood cells that do make it there have
bull reduced ability to capture bacteria
bull reduced ability to kill bacteria
39
Pins Wires Plates Cushions
Great surfaces for biofilm formation and protection
952012
14
40
Biofilms
On Medical Devices
Infections usually follow alternating up and down pattern
Antibiotic initially effective
bull relapses frequent
bull pathogens grow more tolerant develop antibiotic resistance
Usually requires removal of implant to eliminate infection
(even tiny biofilm fragments will multiply again)
Fatality 5 to 60
Prevent biofilmsinfections in the first place
Hendricks S J Biomed Materials Research 200050160-70 Seare W J Endourology 2000149-17
41
Restoring Function ndash Relieving Pain
42
Biofilm Formed On Implants Both Hands
Implants in both hands acquired biofilm infection
Implants had to be removed all bacteria killed before new implants
Culprit Remote infection
Prevent this cause of implant
biofilm by ensuring all remote
infections treated and resolved
before surgery
952012
15
43
Keeping Things Straight
Pins screws wires
44
So Vulnerable
Stringent adherence to antiseptic regimens
45
Vertebral Implant or Pain Relief
952012
16
46
Rotator Cuff Surgeries
With anchor screws and tough braided sutures
Increasing number performed due to success of
the procedures due to
Aging ldquoBaby Boomersrdquo
47
Necessity Mother of Invention
Sutures are great structures on which biofilms can form
Braided sutures ndash more biofilms
bull greater surface area than monofilament
bull protected crevices
bull higher infection rates
A) Standard braided suture
bull green spots are live bacteria or micro-colonies of bacterial biofilms
B) CHG treated braided suture
bull red spots are dead bacteria or micro-colonies A
B
48
Neurosurgical stimulators
Pulse generators
Intraspinal pumps
Cerebral Spinal Fluid (CSF) shunts
General pain pumps
Neurological
952012
17
49
Cerebral Spinal Shunts
Hydrocephalus caused by accumulation of cerebral
spinal fluid (CSF) in cerebral ventricles 140000yr
122000 ventriculostomy (VA) shuntsyear
bull Average 10 infection
18000 ventriculoperitoneal (VP) shuntsyear
bull 25 must undergo revision due to biofilm growth
50
Cerebral Spinal Shunts
Antimicrobial shunts effective in some studies
Prevent contamination by pathogens and particulates
51
Poorly Reprocessed Electrodes
Electroencephalogram electrodes not properly cleaned
Residual dried on biofilm provided
bull protection of entrapped virus
bull prevented adequate sterilization
Several patients acquired hepatitis B (HBV)
$275 million legal settlement against neurologist amp hospital
Mackay B CMAJ 2002 166(7)943
952012
18
52
Circulatory amp Coronary Implants
Cardiac valves
Mechanical heart valves
Implanted defibrillators
Pacemakers
Vascular grafts
Stents
53
Cardiac amp
Vascular
Biofilms
54
Prosthetic Heart Valves
3 ndash 57 form biofilm leading to overt
infection (endocarditis)
Vinh DC J Long Term Effects Medical Implants 200515467-488
952012
19
55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
9
25
Dental Disease
Biofilm on the teeth is called dental plaque
48 hrs after tooth brushing biofilm matures
72 hrs after tooth brushing calcium-
phosphate (Tartar calculus) protective
structure
bull only removed by hygienistrsquos pick
1mm3 mature dental plaque contains gt 108 bacteria
100000000 bacteria per cubic millimeter
26
More Biofilms
Sinusitis
Tonsillitis
Necrotizing fasciitis
27
Pneumonia Biofilm in Alveoli
Alveoli nice moist dark area to build biofilm
Easier if immune compromised of lungs
functioning poorly
bull COPD
bull cystic fibrosis
bull on Ventilator
bull old age
952012
10
28
Catheters amp
Tubes
Central venous catheters
Hemodialysis catheters
Pulmonary artery catheters
Arterial catheters
Urinary catheters
Peritoneal catheters
Umbilical catheters
Enteral feeding tubes
Gastrostomy tubes
Nasogastric tubes
Endotracheal tubes
Tracheostomy tubes
Peritoneal dialysis
Drainage tubes
Endotracheal tube for patients on ventilation
29
Vascular Catheters
5-6 million central lines placed annually
gt 5 infections
gt250000 central line-associated infections (CLABSI)
Approximately 20 attributable death rate
Cirioni O J Infect Dis 2006193180-186 CDC MMRW 2002101-28
30
Bloodstream Infections Reduced 5 Fold
After blood draw retained blood provides
breeding ground for biofilm formation
Opaque valves do not show residual blood
Switching to clear housing
10mL flush did not clear blood 20 mL did
5 fold reduction in Blood stream infections
Poster Royer T VHA MRSA Prevention Forum Orlando FL Nov 5-6 2007
Biofilm forms in
blood left coating
the inner surface of
the plastic housing
952012
11
31
Biofilms In Surgery
32
Surgical Drain Tubes
Favorite Biofilm Hangouts
Biofilm Inside Tube (A)
bull Biofilm inside catheter dispersed biofilm towers
Close up of the mature biofilm community (B)
bull Golden spheres Staphylococcus aureus
bull Green matrix substance
bull Orange smooth surface catheter cross section
Thurlow LR J Immunol 20111866585-96
Downloaded from wwwjimmunolorg on January 10 2012
33
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Wound Drains
Primed for Biofilms
Biofilm on drainage tube surface
952012
12
34
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
35
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
36
Implants
952012
13
37
Expanding Realm of Implantables
Market for implants over $23 billion per year in USA
Expected to grow 10 annually with increased demand and technologies available
Most frequently implanted devices
bull cardioverter defibrillators
bull cardiac resynchronization therapy devices
bull cosmetic implants
bull dental implants
bull hip replacements
bull pacemakers
bull phakic intraocular lenses
bull spinal implants
bull tissue implants (eg bone)
38
Why Are Biofilms On Implants
So Successful
Tissue surrounding implants have reduced blood vessels so
bull fewer bacteria-killer white blood cells delivered
bull less antibiotics and other drugs delivered
White blood cells that do make it there have
bull reduced ability to capture bacteria
bull reduced ability to kill bacteria
39
Pins Wires Plates Cushions
Great surfaces for biofilm formation and protection
952012
14
40
Biofilms
On Medical Devices
Infections usually follow alternating up and down pattern
Antibiotic initially effective
bull relapses frequent
bull pathogens grow more tolerant develop antibiotic resistance
Usually requires removal of implant to eliminate infection
(even tiny biofilm fragments will multiply again)
Fatality 5 to 60
Prevent biofilmsinfections in the first place
Hendricks S J Biomed Materials Research 200050160-70 Seare W J Endourology 2000149-17
41
Restoring Function ndash Relieving Pain
42
Biofilm Formed On Implants Both Hands
Implants in both hands acquired biofilm infection
Implants had to be removed all bacteria killed before new implants
Culprit Remote infection
Prevent this cause of implant
biofilm by ensuring all remote
infections treated and resolved
before surgery
952012
15
43
Keeping Things Straight
Pins screws wires
44
So Vulnerable
Stringent adherence to antiseptic regimens
45
Vertebral Implant or Pain Relief
952012
16
46
Rotator Cuff Surgeries
With anchor screws and tough braided sutures
Increasing number performed due to success of
the procedures due to
Aging ldquoBaby Boomersrdquo
47
Necessity Mother of Invention
Sutures are great structures on which biofilms can form
Braided sutures ndash more biofilms
bull greater surface area than monofilament
bull protected crevices
bull higher infection rates
A) Standard braided suture
bull green spots are live bacteria or micro-colonies of bacterial biofilms
B) CHG treated braided suture
bull red spots are dead bacteria or micro-colonies A
B
48
Neurosurgical stimulators
Pulse generators
Intraspinal pumps
Cerebral Spinal Fluid (CSF) shunts
General pain pumps
Neurological
952012
17
49
Cerebral Spinal Shunts
Hydrocephalus caused by accumulation of cerebral
spinal fluid (CSF) in cerebral ventricles 140000yr
122000 ventriculostomy (VA) shuntsyear
bull Average 10 infection
18000 ventriculoperitoneal (VP) shuntsyear
bull 25 must undergo revision due to biofilm growth
50
Cerebral Spinal Shunts
Antimicrobial shunts effective in some studies
Prevent contamination by pathogens and particulates
51
Poorly Reprocessed Electrodes
Electroencephalogram electrodes not properly cleaned
Residual dried on biofilm provided
bull protection of entrapped virus
bull prevented adequate sterilization
Several patients acquired hepatitis B (HBV)
$275 million legal settlement against neurologist amp hospital
Mackay B CMAJ 2002 166(7)943
952012
18
52
Circulatory amp Coronary Implants
Cardiac valves
Mechanical heart valves
Implanted defibrillators
Pacemakers
Vascular grafts
Stents
53
Cardiac amp
Vascular
Biofilms
54
Prosthetic Heart Valves
3 ndash 57 form biofilm leading to overt
infection (endocarditis)
Vinh DC J Long Term Effects Medical Implants 200515467-488
952012
19
55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
10
28
Catheters amp
Tubes
Central venous catheters
Hemodialysis catheters
Pulmonary artery catheters
Arterial catheters
Urinary catheters
Peritoneal catheters
Umbilical catheters
Enteral feeding tubes
Gastrostomy tubes
Nasogastric tubes
Endotracheal tubes
Tracheostomy tubes
Peritoneal dialysis
Drainage tubes
Endotracheal tube for patients on ventilation
29
Vascular Catheters
5-6 million central lines placed annually
gt 5 infections
gt250000 central line-associated infections (CLABSI)
Approximately 20 attributable death rate
Cirioni O J Infect Dis 2006193180-186 CDC MMRW 2002101-28
30
Bloodstream Infections Reduced 5 Fold
After blood draw retained blood provides
breeding ground for biofilm formation
Opaque valves do not show residual blood
Switching to clear housing
10mL flush did not clear blood 20 mL did
5 fold reduction in Blood stream infections
Poster Royer T VHA MRSA Prevention Forum Orlando FL Nov 5-6 2007
Biofilm forms in
blood left coating
the inner surface of
the plastic housing
952012
11
31
Biofilms In Surgery
32
Surgical Drain Tubes
Favorite Biofilm Hangouts
Biofilm Inside Tube (A)
bull Biofilm inside catheter dispersed biofilm towers
Close up of the mature biofilm community (B)
bull Golden spheres Staphylococcus aureus
bull Green matrix substance
bull Orange smooth surface catheter cross section
Thurlow LR J Immunol 20111866585-96
Downloaded from wwwjimmunolorg on January 10 2012
33
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Wound Drains
Primed for Biofilms
Biofilm on drainage tube surface
952012
12
34
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
35
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
36
Implants
952012
13
37
Expanding Realm of Implantables
Market for implants over $23 billion per year in USA
Expected to grow 10 annually with increased demand and technologies available
Most frequently implanted devices
bull cardioverter defibrillators
bull cardiac resynchronization therapy devices
bull cosmetic implants
bull dental implants
bull hip replacements
bull pacemakers
bull phakic intraocular lenses
bull spinal implants
bull tissue implants (eg bone)
38
Why Are Biofilms On Implants
So Successful
Tissue surrounding implants have reduced blood vessels so
bull fewer bacteria-killer white blood cells delivered
bull less antibiotics and other drugs delivered
White blood cells that do make it there have
bull reduced ability to capture bacteria
bull reduced ability to kill bacteria
39
Pins Wires Plates Cushions
Great surfaces for biofilm formation and protection
952012
14
40
Biofilms
On Medical Devices
Infections usually follow alternating up and down pattern
Antibiotic initially effective
bull relapses frequent
bull pathogens grow more tolerant develop antibiotic resistance
Usually requires removal of implant to eliminate infection
(even tiny biofilm fragments will multiply again)
Fatality 5 to 60
Prevent biofilmsinfections in the first place
Hendricks S J Biomed Materials Research 200050160-70 Seare W J Endourology 2000149-17
41
Restoring Function ndash Relieving Pain
42
Biofilm Formed On Implants Both Hands
Implants in both hands acquired biofilm infection
Implants had to be removed all bacteria killed before new implants
Culprit Remote infection
Prevent this cause of implant
biofilm by ensuring all remote
infections treated and resolved
before surgery
952012
15
43
Keeping Things Straight
Pins screws wires
44
So Vulnerable
Stringent adherence to antiseptic regimens
45
Vertebral Implant or Pain Relief
952012
16
46
Rotator Cuff Surgeries
With anchor screws and tough braided sutures
Increasing number performed due to success of
the procedures due to
Aging ldquoBaby Boomersrdquo
47
Necessity Mother of Invention
Sutures are great structures on which biofilms can form
Braided sutures ndash more biofilms
bull greater surface area than monofilament
bull protected crevices
bull higher infection rates
A) Standard braided suture
bull green spots are live bacteria or micro-colonies of bacterial biofilms
B) CHG treated braided suture
bull red spots are dead bacteria or micro-colonies A
B
48
Neurosurgical stimulators
Pulse generators
Intraspinal pumps
Cerebral Spinal Fluid (CSF) shunts
General pain pumps
Neurological
952012
17
49
Cerebral Spinal Shunts
Hydrocephalus caused by accumulation of cerebral
spinal fluid (CSF) in cerebral ventricles 140000yr
122000 ventriculostomy (VA) shuntsyear
bull Average 10 infection
18000 ventriculoperitoneal (VP) shuntsyear
bull 25 must undergo revision due to biofilm growth
50
Cerebral Spinal Shunts
Antimicrobial shunts effective in some studies
Prevent contamination by pathogens and particulates
51
Poorly Reprocessed Electrodes
Electroencephalogram electrodes not properly cleaned
Residual dried on biofilm provided
bull protection of entrapped virus
bull prevented adequate sterilization
Several patients acquired hepatitis B (HBV)
$275 million legal settlement against neurologist amp hospital
Mackay B CMAJ 2002 166(7)943
952012
18
52
Circulatory amp Coronary Implants
Cardiac valves
Mechanical heart valves
Implanted defibrillators
Pacemakers
Vascular grafts
Stents
53
Cardiac amp
Vascular
Biofilms
54
Prosthetic Heart Valves
3 ndash 57 form biofilm leading to overt
infection (endocarditis)
Vinh DC J Long Term Effects Medical Implants 200515467-488
952012
19
55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
11
31
Biofilms In Surgery
32
Surgical Drain Tubes
Favorite Biofilm Hangouts
Biofilm Inside Tube (A)
bull Biofilm inside catheter dispersed biofilm towers
Close up of the mature biofilm community (B)
bull Golden spheres Staphylococcus aureus
bull Green matrix substance
bull Orange smooth surface catheter cross section
Thurlow LR J Immunol 20111866585-96
Downloaded from wwwjimmunolorg on January 10 2012
33
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Wound Drains
Primed for Biofilms
Biofilm on drainage tube surface
952012
12
34
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
35
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
36
Implants
952012
13
37
Expanding Realm of Implantables
Market for implants over $23 billion per year in USA
Expected to grow 10 annually with increased demand and technologies available
Most frequently implanted devices
bull cardioverter defibrillators
bull cardiac resynchronization therapy devices
bull cosmetic implants
bull dental implants
bull hip replacements
bull pacemakers
bull phakic intraocular lenses
bull spinal implants
bull tissue implants (eg bone)
38
Why Are Biofilms On Implants
So Successful
Tissue surrounding implants have reduced blood vessels so
bull fewer bacteria-killer white blood cells delivered
bull less antibiotics and other drugs delivered
White blood cells that do make it there have
bull reduced ability to capture bacteria
bull reduced ability to kill bacteria
39
Pins Wires Plates Cushions
Great surfaces for biofilm formation and protection
952012
14
40
Biofilms
On Medical Devices
Infections usually follow alternating up and down pattern
Antibiotic initially effective
bull relapses frequent
bull pathogens grow more tolerant develop antibiotic resistance
Usually requires removal of implant to eliminate infection
(even tiny biofilm fragments will multiply again)
Fatality 5 to 60
Prevent biofilmsinfections in the first place
Hendricks S J Biomed Materials Research 200050160-70 Seare W J Endourology 2000149-17
41
Restoring Function ndash Relieving Pain
42
Biofilm Formed On Implants Both Hands
Implants in both hands acquired biofilm infection
Implants had to be removed all bacteria killed before new implants
Culprit Remote infection
Prevent this cause of implant
biofilm by ensuring all remote
infections treated and resolved
before surgery
952012
15
43
Keeping Things Straight
Pins screws wires
44
So Vulnerable
Stringent adherence to antiseptic regimens
45
Vertebral Implant or Pain Relief
952012
16
46
Rotator Cuff Surgeries
With anchor screws and tough braided sutures
Increasing number performed due to success of
the procedures due to
Aging ldquoBaby Boomersrdquo
47
Necessity Mother of Invention
Sutures are great structures on which biofilms can form
Braided sutures ndash more biofilms
bull greater surface area than monofilament
bull protected crevices
bull higher infection rates
A) Standard braided suture
bull green spots are live bacteria or micro-colonies of bacterial biofilms
B) CHG treated braided suture
bull red spots are dead bacteria or micro-colonies A
B
48
Neurosurgical stimulators
Pulse generators
Intraspinal pumps
Cerebral Spinal Fluid (CSF) shunts
General pain pumps
Neurological
952012
17
49
Cerebral Spinal Shunts
Hydrocephalus caused by accumulation of cerebral
spinal fluid (CSF) in cerebral ventricles 140000yr
122000 ventriculostomy (VA) shuntsyear
bull Average 10 infection
18000 ventriculoperitoneal (VP) shuntsyear
bull 25 must undergo revision due to biofilm growth
50
Cerebral Spinal Shunts
Antimicrobial shunts effective in some studies
Prevent contamination by pathogens and particulates
51
Poorly Reprocessed Electrodes
Electroencephalogram electrodes not properly cleaned
Residual dried on biofilm provided
bull protection of entrapped virus
bull prevented adequate sterilization
Several patients acquired hepatitis B (HBV)
$275 million legal settlement against neurologist amp hospital
Mackay B CMAJ 2002 166(7)943
952012
18
52
Circulatory amp Coronary Implants
Cardiac valves
Mechanical heart valves
Implanted defibrillators
Pacemakers
Vascular grafts
Stents
53
Cardiac amp
Vascular
Biofilms
54
Prosthetic Heart Valves
3 ndash 57 form biofilm leading to overt
infection (endocarditis)
Vinh DC J Long Term Effects Medical Implants 200515467-488
952012
19
55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
12
34
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
35
Surface prepped favorably with wound debris
Nice flow of fluids and nutrients
Biofilm establishes rapidly and robustly
Open access to vulnerable post-surgical tissues
Infections may be local tunnel surgical site general
Prevention
bull do not allow gravity collection vessel above wound
bull closed system negative pressure huge improvement
bull remove as soon as possible
bull antimicrobial tubes
Wound Drains
Primed for Biofilms
36
Implants
952012
13
37
Expanding Realm of Implantables
Market for implants over $23 billion per year in USA
Expected to grow 10 annually with increased demand and technologies available
Most frequently implanted devices
bull cardioverter defibrillators
bull cardiac resynchronization therapy devices
bull cosmetic implants
bull dental implants
bull hip replacements
bull pacemakers
bull phakic intraocular lenses
bull spinal implants
bull tissue implants (eg bone)
38
Why Are Biofilms On Implants
So Successful
Tissue surrounding implants have reduced blood vessels so
bull fewer bacteria-killer white blood cells delivered
bull less antibiotics and other drugs delivered
White blood cells that do make it there have
bull reduced ability to capture bacteria
bull reduced ability to kill bacteria
39
Pins Wires Plates Cushions
Great surfaces for biofilm formation and protection
952012
14
40
Biofilms
On Medical Devices
Infections usually follow alternating up and down pattern
Antibiotic initially effective
bull relapses frequent
bull pathogens grow more tolerant develop antibiotic resistance
Usually requires removal of implant to eliminate infection
(even tiny biofilm fragments will multiply again)
Fatality 5 to 60
Prevent biofilmsinfections in the first place
Hendricks S J Biomed Materials Research 200050160-70 Seare W J Endourology 2000149-17
41
Restoring Function ndash Relieving Pain
42
Biofilm Formed On Implants Both Hands
Implants in both hands acquired biofilm infection
Implants had to be removed all bacteria killed before new implants
Culprit Remote infection
Prevent this cause of implant
biofilm by ensuring all remote
infections treated and resolved
before surgery
952012
15
43
Keeping Things Straight
Pins screws wires
44
So Vulnerable
Stringent adherence to antiseptic regimens
45
Vertebral Implant or Pain Relief
952012
16
46
Rotator Cuff Surgeries
With anchor screws and tough braided sutures
Increasing number performed due to success of
the procedures due to
Aging ldquoBaby Boomersrdquo
47
Necessity Mother of Invention
Sutures are great structures on which biofilms can form
Braided sutures ndash more biofilms
bull greater surface area than monofilament
bull protected crevices
bull higher infection rates
A) Standard braided suture
bull green spots are live bacteria or micro-colonies of bacterial biofilms
B) CHG treated braided suture
bull red spots are dead bacteria or micro-colonies A
B
48
Neurosurgical stimulators
Pulse generators
Intraspinal pumps
Cerebral Spinal Fluid (CSF) shunts
General pain pumps
Neurological
952012
17
49
Cerebral Spinal Shunts
Hydrocephalus caused by accumulation of cerebral
spinal fluid (CSF) in cerebral ventricles 140000yr
122000 ventriculostomy (VA) shuntsyear
bull Average 10 infection
18000 ventriculoperitoneal (VP) shuntsyear
bull 25 must undergo revision due to biofilm growth
50
Cerebral Spinal Shunts
Antimicrobial shunts effective in some studies
Prevent contamination by pathogens and particulates
51
Poorly Reprocessed Electrodes
Electroencephalogram electrodes not properly cleaned
Residual dried on biofilm provided
bull protection of entrapped virus
bull prevented adequate sterilization
Several patients acquired hepatitis B (HBV)
$275 million legal settlement against neurologist amp hospital
Mackay B CMAJ 2002 166(7)943
952012
18
52
Circulatory amp Coronary Implants
Cardiac valves
Mechanical heart valves
Implanted defibrillators
Pacemakers
Vascular grafts
Stents
53
Cardiac amp
Vascular
Biofilms
54
Prosthetic Heart Valves
3 ndash 57 form biofilm leading to overt
infection (endocarditis)
Vinh DC J Long Term Effects Medical Implants 200515467-488
952012
19
55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
13
37
Expanding Realm of Implantables
Market for implants over $23 billion per year in USA
Expected to grow 10 annually with increased demand and technologies available
Most frequently implanted devices
bull cardioverter defibrillators
bull cardiac resynchronization therapy devices
bull cosmetic implants
bull dental implants
bull hip replacements
bull pacemakers
bull phakic intraocular lenses
bull spinal implants
bull tissue implants (eg bone)
38
Why Are Biofilms On Implants
So Successful
Tissue surrounding implants have reduced blood vessels so
bull fewer bacteria-killer white blood cells delivered
bull less antibiotics and other drugs delivered
White blood cells that do make it there have
bull reduced ability to capture bacteria
bull reduced ability to kill bacteria
39
Pins Wires Plates Cushions
Great surfaces for biofilm formation and protection
952012
14
40
Biofilms
On Medical Devices
Infections usually follow alternating up and down pattern
Antibiotic initially effective
bull relapses frequent
bull pathogens grow more tolerant develop antibiotic resistance
Usually requires removal of implant to eliminate infection
(even tiny biofilm fragments will multiply again)
Fatality 5 to 60
Prevent biofilmsinfections in the first place
Hendricks S J Biomed Materials Research 200050160-70 Seare W J Endourology 2000149-17
41
Restoring Function ndash Relieving Pain
42
Biofilm Formed On Implants Both Hands
Implants in both hands acquired biofilm infection
Implants had to be removed all bacteria killed before new implants
Culprit Remote infection
Prevent this cause of implant
biofilm by ensuring all remote
infections treated and resolved
before surgery
952012
15
43
Keeping Things Straight
Pins screws wires
44
So Vulnerable
Stringent adherence to antiseptic regimens
45
Vertebral Implant or Pain Relief
952012
16
46
Rotator Cuff Surgeries
With anchor screws and tough braided sutures
Increasing number performed due to success of
the procedures due to
Aging ldquoBaby Boomersrdquo
47
Necessity Mother of Invention
Sutures are great structures on which biofilms can form
Braided sutures ndash more biofilms
bull greater surface area than monofilament
bull protected crevices
bull higher infection rates
A) Standard braided suture
bull green spots are live bacteria or micro-colonies of bacterial biofilms
B) CHG treated braided suture
bull red spots are dead bacteria or micro-colonies A
B
48
Neurosurgical stimulators
Pulse generators
Intraspinal pumps
Cerebral Spinal Fluid (CSF) shunts
General pain pumps
Neurological
952012
17
49
Cerebral Spinal Shunts
Hydrocephalus caused by accumulation of cerebral
spinal fluid (CSF) in cerebral ventricles 140000yr
122000 ventriculostomy (VA) shuntsyear
bull Average 10 infection
18000 ventriculoperitoneal (VP) shuntsyear
bull 25 must undergo revision due to biofilm growth
50
Cerebral Spinal Shunts
Antimicrobial shunts effective in some studies
Prevent contamination by pathogens and particulates
51
Poorly Reprocessed Electrodes
Electroencephalogram electrodes not properly cleaned
Residual dried on biofilm provided
bull protection of entrapped virus
bull prevented adequate sterilization
Several patients acquired hepatitis B (HBV)
$275 million legal settlement against neurologist amp hospital
Mackay B CMAJ 2002 166(7)943
952012
18
52
Circulatory amp Coronary Implants
Cardiac valves
Mechanical heart valves
Implanted defibrillators
Pacemakers
Vascular grafts
Stents
53
Cardiac amp
Vascular
Biofilms
54
Prosthetic Heart Valves
3 ndash 57 form biofilm leading to overt
infection (endocarditis)
Vinh DC J Long Term Effects Medical Implants 200515467-488
952012
19
55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
14
40
Biofilms
On Medical Devices
Infections usually follow alternating up and down pattern
Antibiotic initially effective
bull relapses frequent
bull pathogens grow more tolerant develop antibiotic resistance
Usually requires removal of implant to eliminate infection
(even tiny biofilm fragments will multiply again)
Fatality 5 to 60
Prevent biofilmsinfections in the first place
Hendricks S J Biomed Materials Research 200050160-70 Seare W J Endourology 2000149-17
41
Restoring Function ndash Relieving Pain
42
Biofilm Formed On Implants Both Hands
Implants in both hands acquired biofilm infection
Implants had to be removed all bacteria killed before new implants
Culprit Remote infection
Prevent this cause of implant
biofilm by ensuring all remote
infections treated and resolved
before surgery
952012
15
43
Keeping Things Straight
Pins screws wires
44
So Vulnerable
Stringent adherence to antiseptic regimens
45
Vertebral Implant or Pain Relief
952012
16
46
Rotator Cuff Surgeries
With anchor screws and tough braided sutures
Increasing number performed due to success of
the procedures due to
Aging ldquoBaby Boomersrdquo
47
Necessity Mother of Invention
Sutures are great structures on which biofilms can form
Braided sutures ndash more biofilms
bull greater surface area than monofilament
bull protected crevices
bull higher infection rates
A) Standard braided suture
bull green spots are live bacteria or micro-colonies of bacterial biofilms
B) CHG treated braided suture
bull red spots are dead bacteria or micro-colonies A
B
48
Neurosurgical stimulators
Pulse generators
Intraspinal pumps
Cerebral Spinal Fluid (CSF) shunts
General pain pumps
Neurological
952012
17
49
Cerebral Spinal Shunts
Hydrocephalus caused by accumulation of cerebral
spinal fluid (CSF) in cerebral ventricles 140000yr
122000 ventriculostomy (VA) shuntsyear
bull Average 10 infection
18000 ventriculoperitoneal (VP) shuntsyear
bull 25 must undergo revision due to biofilm growth
50
Cerebral Spinal Shunts
Antimicrobial shunts effective in some studies
Prevent contamination by pathogens and particulates
51
Poorly Reprocessed Electrodes
Electroencephalogram electrodes not properly cleaned
Residual dried on biofilm provided
bull protection of entrapped virus
bull prevented adequate sterilization
Several patients acquired hepatitis B (HBV)
$275 million legal settlement against neurologist amp hospital
Mackay B CMAJ 2002 166(7)943
952012
18
52
Circulatory amp Coronary Implants
Cardiac valves
Mechanical heart valves
Implanted defibrillators
Pacemakers
Vascular grafts
Stents
53
Cardiac amp
Vascular
Biofilms
54
Prosthetic Heart Valves
3 ndash 57 form biofilm leading to overt
infection (endocarditis)
Vinh DC J Long Term Effects Medical Implants 200515467-488
952012
19
55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
15
43
Keeping Things Straight
Pins screws wires
44
So Vulnerable
Stringent adherence to antiseptic regimens
45
Vertebral Implant or Pain Relief
952012
16
46
Rotator Cuff Surgeries
With anchor screws and tough braided sutures
Increasing number performed due to success of
the procedures due to
Aging ldquoBaby Boomersrdquo
47
Necessity Mother of Invention
Sutures are great structures on which biofilms can form
Braided sutures ndash more biofilms
bull greater surface area than monofilament
bull protected crevices
bull higher infection rates
A) Standard braided suture
bull green spots are live bacteria or micro-colonies of bacterial biofilms
B) CHG treated braided suture
bull red spots are dead bacteria or micro-colonies A
B
48
Neurosurgical stimulators
Pulse generators
Intraspinal pumps
Cerebral Spinal Fluid (CSF) shunts
General pain pumps
Neurological
952012
17
49
Cerebral Spinal Shunts
Hydrocephalus caused by accumulation of cerebral
spinal fluid (CSF) in cerebral ventricles 140000yr
122000 ventriculostomy (VA) shuntsyear
bull Average 10 infection
18000 ventriculoperitoneal (VP) shuntsyear
bull 25 must undergo revision due to biofilm growth
50
Cerebral Spinal Shunts
Antimicrobial shunts effective in some studies
Prevent contamination by pathogens and particulates
51
Poorly Reprocessed Electrodes
Electroencephalogram electrodes not properly cleaned
Residual dried on biofilm provided
bull protection of entrapped virus
bull prevented adequate sterilization
Several patients acquired hepatitis B (HBV)
$275 million legal settlement against neurologist amp hospital
Mackay B CMAJ 2002 166(7)943
952012
18
52
Circulatory amp Coronary Implants
Cardiac valves
Mechanical heart valves
Implanted defibrillators
Pacemakers
Vascular grafts
Stents
53
Cardiac amp
Vascular
Biofilms
54
Prosthetic Heart Valves
3 ndash 57 form biofilm leading to overt
infection (endocarditis)
Vinh DC J Long Term Effects Medical Implants 200515467-488
952012
19
55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
16
46
Rotator Cuff Surgeries
With anchor screws and tough braided sutures
Increasing number performed due to success of
the procedures due to
Aging ldquoBaby Boomersrdquo
47
Necessity Mother of Invention
Sutures are great structures on which biofilms can form
Braided sutures ndash more biofilms
bull greater surface area than monofilament
bull protected crevices
bull higher infection rates
A) Standard braided suture
bull green spots are live bacteria or micro-colonies of bacterial biofilms
B) CHG treated braided suture
bull red spots are dead bacteria or micro-colonies A
B
48
Neurosurgical stimulators
Pulse generators
Intraspinal pumps
Cerebral Spinal Fluid (CSF) shunts
General pain pumps
Neurological
952012
17
49
Cerebral Spinal Shunts
Hydrocephalus caused by accumulation of cerebral
spinal fluid (CSF) in cerebral ventricles 140000yr
122000 ventriculostomy (VA) shuntsyear
bull Average 10 infection
18000 ventriculoperitoneal (VP) shuntsyear
bull 25 must undergo revision due to biofilm growth
50
Cerebral Spinal Shunts
Antimicrobial shunts effective in some studies
Prevent contamination by pathogens and particulates
51
Poorly Reprocessed Electrodes
Electroencephalogram electrodes not properly cleaned
Residual dried on biofilm provided
bull protection of entrapped virus
bull prevented adequate sterilization
Several patients acquired hepatitis B (HBV)
$275 million legal settlement against neurologist amp hospital
Mackay B CMAJ 2002 166(7)943
952012
18
52
Circulatory amp Coronary Implants
Cardiac valves
Mechanical heart valves
Implanted defibrillators
Pacemakers
Vascular grafts
Stents
53
Cardiac amp
Vascular
Biofilms
54
Prosthetic Heart Valves
3 ndash 57 form biofilm leading to overt
infection (endocarditis)
Vinh DC J Long Term Effects Medical Implants 200515467-488
952012
19
55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
17
49
Cerebral Spinal Shunts
Hydrocephalus caused by accumulation of cerebral
spinal fluid (CSF) in cerebral ventricles 140000yr
122000 ventriculostomy (VA) shuntsyear
bull Average 10 infection
18000 ventriculoperitoneal (VP) shuntsyear
bull 25 must undergo revision due to biofilm growth
50
Cerebral Spinal Shunts
Antimicrobial shunts effective in some studies
Prevent contamination by pathogens and particulates
51
Poorly Reprocessed Electrodes
Electroencephalogram electrodes not properly cleaned
Residual dried on biofilm provided
bull protection of entrapped virus
bull prevented adequate sterilization
Several patients acquired hepatitis B (HBV)
$275 million legal settlement against neurologist amp hospital
Mackay B CMAJ 2002 166(7)943
952012
18
52
Circulatory amp Coronary Implants
Cardiac valves
Mechanical heart valves
Implanted defibrillators
Pacemakers
Vascular grafts
Stents
53
Cardiac amp
Vascular
Biofilms
54
Prosthetic Heart Valves
3 ndash 57 form biofilm leading to overt
infection (endocarditis)
Vinh DC J Long Term Effects Medical Implants 200515467-488
952012
19
55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
18
52
Circulatory amp Coronary Implants
Cardiac valves
Mechanical heart valves
Implanted defibrillators
Pacemakers
Vascular grafts
Stents
53
Cardiac amp
Vascular
Biofilms
54
Prosthetic Heart Valves
3 ndash 57 form biofilm leading to overt
infection (endocarditis)
Vinh DC J Long Term Effects Medical Implants 200515467-488
952012
19
55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
19
55
Dialysis Vascular Graft
Biofilm infection at dialysis access
Remove central line
Drain
Identify catheter biofilm and wound infection pathogens
Treat with antibiotics
Place CVC in different site
56
Stent Placement
Stenosis site identified
Stent placed
Stent initially effective
Stent biofilm infection
Inflamed blood vessel walls
Restenosis in the making
Planktonic bacteria initiate BSI
Stent removed
Antimicrobial stent - perhaps
57
Ophthalmics
Contact lens cases
Contact lenses
Intraocular lens
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
20
58
Eyes
Priceless Gifts
Captivating expressive
Windows of perception
Tools of learning
Often assisted protectedhellip
And sometimes treated
59
Contact Lenses
Biofilm on lens case then contaminated contacts
Example Tonometer - Outbreaks
Epidemic keratoconjunctivitis ndash Adenovirus bull Jernigan 126 patients (73amp) Koo 102 patients (167)
Microorganisms most targeted bull Adenovirus (non-enveloped)
bull Herpes simplex
bull Enteroviruses
bull Hepatitis B and C
bull Staphylococcus aureus (esp MRSA)
bull Pseudomonas
bull Acanthamoeba
Should immerse tips in one of the following bull 5-10 minutes
bull 5000ppm chlorine (110 bleach to water) ndashtono damage
bull 3 hydrogen peroxide - (tono damage Adeno kill)
bull 70 isopropyl or ethyl alcohol (Adeno kill)
bull Rinse with tap water (per CDC)
Note CDC Also states that there are indications that H2O2 and isopropanol are not sufficiently effective against adenovirus
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
21
61
Ophthalmics
Note particles left in
re-used tubing after
reprocessing
We cannot let this
happen
The Role of Lint and Particles
Particles left in body are miniature biofilm breeder-surfaces promote rapid biofilm formation
Miniature biofilm breeding surfaces
bull Lint
bull Dried tissues fragments
bull Detergent granules
bull Mineral deposits from hard water
bull Rust
bull Blood film
bull Dead biofilm debris
62
63
Debris and Eye Surgery
2000-03 LASIK surgery one clinic
gt100 cases diffuse lamellar keratitis
All required re-surgery irrigation and anti-inflammatory treatments
Cause bull Airborne debris attracted to electric field created by ocular machinery bull Lintparticle producing fabrics in the procedure area bull Incorrectly installed filter in ventilation system
The Search for the Cause of 100+ Cases of Diffuse Lamellar Keratitis Journal of Refractive Surgery 20028 551-4
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
22
64
Ophthalmic Surgery
From Eye
From immediate area
Lint attracted to
insertion sleeve
lens implant
instruments
retractors
Or fall from
microscope
equipment
drapes
gowns
65
ASCRSASORN Guidelines
ASCRSASORN Guidelines ldquoAll materials should be low lintingrdquo
Debris attracted to plastic sleeve deposited with intraocular lens on
insertion Powder lint phakic debris detergent residue etc
Fibers can enter the anterior chamber during or after surgery
Toxic Anterior Segment Syndrome (TASS) sterile ophthalmitis toxic lens
syndrome fibrosis
And provide a means of contamination protection for biofilm initiation and infection
Crimes of Distraction Promoting the
Biofilm Cause
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
23
67
Distraction
Crime Of Distraction
Things that strongly attract the attention of the immune system ndash
become the center of attention so microorganisms are ignored
and can multiply
germ
68
Bacteria (Pseudomonas)
Bacteria (Pseudomonas)
Particulates Or dead biofilm chunks
Macrophage Protecting Against Invasion
of Particles and Bacteria
69
Bacteria Multiply
Unchecked Biofilm Halo
Particulates
White Blood Cell Macrophage
Pseudomonas
Biofilm initiated and now surrounding particle
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
24
70
Altered Threshold for Infection
Jaffray
bull Wound no particles + 1000 Staph 110 infected
bull Wound 2mg sterile particles + 1000 Staph 910 infected
Staphylococcus aureus
Average pair powdered surgical gloves 200 mg +
Elek
bull Wound no particles = 10000000 to cause infection
bull Wound with sterile particles = 100 to cause infection
71
Breast Implants
Breast implant capsular contractures are hard scar tissues that
form around the implant
Now believe most result of tissue reaction to a subclinical
infection (eg staphylococcus) micro-biofilm on implant surface
Particles increased likelihood of the biofilm forming
Pajkos AB 2003 Netscher D 2004 Mladick RA 2005 Netscher DT 2005
72
Convinced particles + few bacteria responsible
Surgeon performed all breast implant surgeries
bull Lint-free
bull Powder-free
bull No implant placement on sterile drapes
bull No touch of patient skin (even though prepped for surgery)
Mladick RA Plast Reconstr Surg 2005 1426-27
Eight years without a single capsular contraction
Little things like lint powder other particles matter
Principle applies to all implants
Breast Implants
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
25
73
Plastic Surgery
Staphylococcus On Silicone
Silicone cartilage
Silicone plastic vinyl attract particles
Particles encourage biofilm formation
Particles reduce number of bacteria needed
to cause an infection -- dramatically
74
CDC Guideline for Prevention of
Surgical Site Infection 1999
ldquoAny foreign bodyhellipmay increase the probability of
Surgical Site Infection (SSI) after otherwise benign
levels of tissue contaminationrdquo
Mangum Pearson ML Infection Control and Hospital Epidemiology 1999 20 247-8
Along with biofilms causing infections
pieces break off causing
bull blood clotsemboli
bull granulomas
bull adhesions
bull inflammation
bull poor healing
75
Biofilm
Not Just ldquoAgents of Infectionrdquo
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
26
76
Lint Particulate Masses
Into Bloodstream
Drop biofilm chunk or lint into blood stream
Platelets are triggered
Fibrin deposited to wall off invading lint fibers
Complement cascade activated
hellipa blood clot forms and grows
77
Causes Foreign Body Reaction
White cells merge to wall off fibers
Then comes the fibrin
Then comes the collagen
hellipAnd we have a granuloma
Lint The Process
78
Adhesions
Fibrin deposited to wall off particulate mass
Fibrin anchors to anything near
If particles persists adhesions thicken
Granulomas often at center of adhesion
bull Lint powder and other particulates like biofilm
chunks at center of the granuloma
Adhesion contracts causing pain can strangle
organs or their blood supplies
L Holmdahl Eur J Surg 1997 Suppl 57756-62 Jeekel H Eur J of Surgery 1997 163 Supp 579 43-45 Chenoweth C 1981 Urology
1 month after kidney stone removed from ureter
Severe pain
Thick adhesions caused by particles from surgery
Adhesions strangled kidney blood supply
Lost kidney
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
27
Biofilm and Released Biofilm ldquoChunksrdquo
Cause Inflammation
79
80
Neutrophils (WBC) recognize
bacterial biofilm threat on
implant or other surface
Triggers neutrophils to become
activated Spitting out biocidal
oxygen radicals and enzymes
trying to kill biofilm bacteria
Frustrated White Cells Spit Destruction
81
White Blood Cells attack foreign debris as defense but end up injuring healthy tissues
Activated neutrophil
Frustrated White Cells Spit Destruction
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
28
82
Frustrated White Cells Spit Destruction
Neutrophil spitting injures
surrounding tissues that were
trying integrate the implant
Result amplified inflammation
delayed and poor quality
healing capsule formation poor
implant integration
83
Case Radical Mastectomy
pain drainage
wound edges erythematous
slow healing
patient never felt well
4 months later hard irregular scar excised
Janoff K Foreign body reactions secondary to cellulose lint fibers Amer Jr of Surgery
Consequence Re-surgery and 10 extra hospital days
Janoff K
Histopathology poor healing caused by reaction to particles with low level biofilm in the wound
84
Supplying The OR
With Particles
Powdered gloves
Gowns
Drapes
Table covers
Sterilization wrap
Instrument tray liners
Drying mats for drain and dry
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
29
85
Materials
Themselves
Guidewires dilators catheters set on and dragged across sterile drape
bull break off lint
bull attract lint to surface of guidewires and catheters by static cling
Lint then co-inserted with device into circulating blood or inside catheter
Linting amount varies cellulose highest linter (cellulose = paper cotton)
bull high full paper drapes or paper-synthetic combinations
bull high paper fenestration in any drape
bull high cotton materials
bull extremely low polypropylene
Cellulose fibers( paper or cotton)
bull high linting
bull very bioactive foreign bodies
Cellulose (paper) Cellulose (cotton)amp polyester Polypropylene
86
ldquoDo-It-Yourself rdquo Lint Tests
Rub fabric together a counted number of times
Place very clear packing tape on fabric
Smooth on
Peel off repeat at right angle with same tape
Observe place on clear plastic label and keep
andor
Ask maintenance for OR filters next time they
change them out and observe for tell-tell colors
andor
Collect in OR tweezers surface wipe air-sample
87
hellipMore Particles Headed For The OR
Absorbent towels
Tip cushions
Materials used to lock hemostats open
Lint-producing warming blankets
Instrument tray liners
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
30
88
Particle Sources
Dust dirt hair
Glove powder
Lint fibers
Particles from poorly cleaned re-useable
instruments
bull tissue fragments
bull dried blood
bull fat clumps
bull biofilm fragments
Inadequate Instrument Processing
90
Biofilm in Endoscopes Serious
Consequences Dead or Alive
Two different airwater channels
(A) Multilayered biofilm
(B) Low-power view showing a confluent
layer of soil and biofilm dried
bull protect from even high-level disinfectants
bull dead chunk-particulates
Pajkos K J Hosp Infec 200458224-9
B
A
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
31
91
Handling in SPD
How devices handled in CSD
bull tissues amp blood left to dry on device
bull scratched during processing
bull etched by harsh chemicals
bull poorly rinsed = detergents
bull minerals in water ndash hard water (rinse or steam)
92
Handling in SPD
How devices handled in CSD
bull reprocessing of single-use items
bull rough handling
bull oils not removed
bull poor assembly dead spaces
bull particles not removed
bull particles added lint hair
93
Inadequate Cleaning Can
Be Due To Poor
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
32
94
Improper Cleaning and
Disinfection
Pathogen transmission via endoscope associated with
Breaches in accepted cleaning amp disinfection guidelines
Use of inadequate or contaminated cleaning agents
Use of unacceptable liquid germicides
Improper drying
Defective equipment
Use of damaged endoscopes
Use of contaminated rinse water (biofilm)
Use of contaminated germicide
If liquid is contaminated pouring it out amp refilling container does NOT remove biofilm amp will contaminate refill fluid
95
Biofilm Cleaning Challenges
Each layer of added biofilm is more protected
harder to clean
Mature biofilms over 300 bacteria high
More time between procedure and processing
thicker and more entrenched the biofilm
Multi-Society guideline for reprocessing flexible gastrointestinal endoscopes 2003 Gastrointestinal Endoscopy 58(1) 1-8
ACS Poor Endoscope Cleaning
October 2011 Ottawa 6800 patients notified they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
August 2010 Vancouver 500 patients had to be notified they may have been exposed to
bull Hepatitis B bull Hepatitis C
2008 Las Vegas 50000 notified that they may have been exposed to
bull Hepatitis B bull Hepatitis C bull HIV
Viruses budding through cell
Human Cell
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
33
But viruses do not
construct grow or reproduce in biofilms
Confused
Correct Howeverhellip
Viruses are so small they can hide in the tiniest of scratches
Become engulfed during biofilms construction
Enmeshed in tissues feces dried mucus or blood not removed
These viruses can be in high numbers if patient has an active infection (they may not be aware yet)
Number of infectious viruses per one mL (cc) of blood
bull HBV (hepatitis B) 10000000 to 10000000000000 (107-1013)
bull HCV (hepatitis C) 1000000 (106)
bull HIV 10 to 10000 (101-104) viruses
98
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
Alvarado CJ AJIC Am J Infect Control 200028138-55
bull Blood feces gastric mucin seen in and on interior surface even
though instrument was flushed and brushed before disinfection
bull Contributes to disinfection failures by harboring microbes and
preventing germicide penetration
bull Some disinfectants inactivated by organic material
CDC Photos
99
Proper Device Preparation
Pre-clean per endoscope reprocessing guidelines
ldquoImmediately after removing the endoscope from the
patient wipe the insertion tube with the wet cloth or
sponge soaked in the freshly prepared enzymatic
detergent solutionrdquo
Bolander S 2005 SGNA Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
34
100
Emphasize Manufacturerrsquos Instructions
ldquoCleaning of endoscopes and accessories should be
performed with nonabrasive manufacturer-recommended
enzymatic detergents for medical instruments promptly after
use to prevent drying of secretions (this portion of
reprocessing takes place in the procedure room)rdquo
APIC Guideline for Infection Prevention
and Control in Flexible Endoscopy
101
Follow Directions for Use
Water quality
Temperature
Dilution ratio
Soak time
Rinsing
Drying
Insist on needed translations if not clear
Easy access to all instructions
102
Cleaning
Prevent caked-on blood amp tissues spraysoak
immediately after use
Biofilms form rapidly incorporating organics for nutrients
Enzyme-based cleaning specific to
bull proteins
bull fats
bull carbohydrates
bull starches
Instrument washer follow instructions
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
35
103
Water Quality
Poor water quality can
bull reduce the efficacy of cleaning solutions
bull leave mineral deposits (protected niches)
bull contaminate the cleaning process
bull deposit endotoxins
But still be fine to drink
AAMI TIR30
104
Temperature
Enzymes most effective at specific temperature
Cleaning solutions have optimal effective temperatures
bull too cold slows enzyme activity potentially stopping it
bull too hot breaks down enzymes
2004 AAMI TIR302003
105
Dilution Ratio amp pH
Dilute solution per manufacturerrsquos instructions
bull may differ for manual vs automated cleaning
Validate sink or container volume for solution used
Mark fill levels for mixing easier to be accurate
Assure sink or container deep enough to
completely cover devices
Make certain final pH required is achieved
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
36
Use the Right Tools
106
Right diameter
Right length
Right flexibilitystiffness
Right tip design
Right bristle type stiffness density
‒ disrupt biofilm dried tissue amp blood
‒ but not etch or scratch the surface
107
Rinsing
Adequate rinsing necessary to remove
bull traces of cleaning solutions
bull disrupted organic soil and biofilm
bull mineral waiting to be deposited
Rinse thoroughly ndash follow instructions for
bull device
bull cleaning solution used
bull volume
bull duration of rinse
Water must meet manufacturerrsquos instructions
bull filtered water (through a 02 micron filter)
bull tap or potable water
bull sterile water
Rinse Water Quality
Rinse water quality extremely important
Poor rinse water associated with
bull Damaged optics
bull Endotoxins to next patient
bull Infected next patient and full outbreaks of
‒Legionella
‒Pseudomonas
‒Mycobacterium
‒Acinetobacter
‒Burkholderia
108
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
37
109
Drying
Dry prior to disinfectionsterilization to prevent
bull Over-dilution of high level disinfectants
bull Cycle cancellation in some sterilizers
bull Colonization of waterborne pathogens
Dry and store safely
Moisture WILL encourage biofilm initiation
110
Other Contaminated Water Aerosolized Liquid Ice Surgical Infections
Waterice used to cool eye solutions
Contamination of epicardial pacemaker wires
Contaminated solutions used in processing endoscopes
Peritoneal dialysis fluids
Water used in rinsing dialysis equipment
Hospital tap water
Splashes of water after contacting contaminated drain
Stagnant lip of water in aeration faucet head
Mycobacterium Pseudomonas Legionella Acinetobacter
Prevent Environmental Biofilms
Drains
Suction canisters tubing
Wall vacuum systems
Water sources
Ice baths containers
Air conditioning systems
111
In the OR or Procedure Rooms
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
38
Wet-Vac
After detergent cleaning remember to
bull use the right type and level of disinfectant
bull keep surface wet for required contact time before vacuuming
Drain Wet-Vac cleandisinfect drain dry
112
113
Increased Virulence and
Antibiotic Resistance
Multi-Drug resistant organisms (MDRO)
Example Pseudomonas aeruginosa
Mariana Bridi finalist Brazilian stage of Miss World
pageant
Died 2009 after hands and feet removed in efforts
to save her life after MDRP infection
114
Enterococcus Resistant
amp Increased Virulence
Vancomycin Resistant Enterococcus (VRE)
Virulence via amplified toxins destroy tissues
And are resistant to Vancomycin one of the
most powerful antibiotics we have
Whole hospital units often closed when
VRE outbreaks occur
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
39
115
Staphylococcus aureus
Resistance + Virulence
US David Fitzgerald
Went in to have a benign growth removed
from head
Acquired MRSA from facility
Infection went systemicseptic
Septic shock = damaged all limbs
Gangrene ensued all limbs removed
$175 million by jury but state caps on pain
and suffering reduced to $75 million
ldquoIn effect an end to modern medicine as we know it Things
as common as strep throat or a childs scratched knee could
once again kill Patients infected with some drug-resistant
pathogens mortality has been shown to increase by around
50 per centrdquo
ldquohellip we are potentially headed for a post-antibiotic world in
which we will have few or no clinical interventions for some
infectionsrdquo
116
Dr Thomas Frieden
CDC Director
httpwwwcdcgovwashingtontestimony2010t20100428htm Accessed 92810
CDC in US Congressional Testimony 2010
Dr Margaret Chan
WHO Director General
Antibiotic Resistance Threat to Public Health
World Health Organization (WHO) 2012
117
AntibioticDrug Resistant
Pathogens ndash Partial List
Acinetobacter baumannii
Aspergillus
Candida albicans
Clostridium difficile
Diphtheroids
Enterococcus
Escherichia coli
Klebsiella pneumoniae
Morganella
By Don Smith
Mycobacterium tuberculosis
Proteus
Providencia
Pseudomonas aeruginosa
Salmonella
Staphylococcus aureus
Stenotrophomonas maltophilia
Streptococcus pneumoniae
Streptococcus pyogenes
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
40
118
We must prevent nosocomial Infections (HAIs)
We must prevent the formation of biofilms
119
Summary Biofilms organized microbial communities responsible gt 60 of infections
Biofilm bacteria are more resistant to antimicrobials than individual bacteria
Almost always necessary to remove implant to enable effective treatment
Lint debris dead biofilm chunks etc increase risk of biofilm formation make
certain drapes gowns sterilization wrap low-linting and gloves powder-free
Delayed cleaning residual organics incorrect disinfectant concentration pH
water quality temperature rinsing and drying all increase biofilm threat
Increase of antibiotic resistant pathogens heightens attention on HAI amp biofilms
The most effective way to reduce biofilm impact is to prevent contamination
and thus biofilm formation in the first place
120
Patients Entrust Their Quality Of Life And Life Itself Into Our Care
We Cannot Be Pressured To Put Them At Risk
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom
952012
41
121
Described unique biofilm characteristics
Listed patient consequences
Discussed strategies for risk reduction
Biofilms Hazards They Present
in ASC Settings
Thank You
122
ANY QUESTIONS
WavaTruscottkcccom