biofilms: the hidden menace - central plains...
TRANSCRIPT
3M Sterile U Webinar 04.19.12 April 19, 2012
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Biofilms: The Hidden Menace
© 3M 2012. All Rights Reserved. 2
Introducing the 3M Learning Connection:
New Name, Same Great Courses
•It’s an educational resource bringing you
3M™ Sterile U and other Infection
Prevention courses. You’ll soon see
some exciting new benefits as our
program evolves!
•Improved features:
• “Add to my Calendar” feature
added this month!
•Other 3M courses will be more
accessible as we expand our
offerings.
•What do you need to do?
•Nothing. Your current registrations
remain and our Sterile U offerings
have not changed.
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Welcome!
Topic: Biofilms: The Hidden Menace
Speaker: Steven Kubler, CSPDT
3M Infection Prevention Technical Service
For more information: www.3M.com/3MSterileU
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Learning Objectives
• List the various types of biofilms and describe how they are
formed.
• Discuss how biofilm formation increases the risk of disease
transmission.
• Identify those instruments and devices that are most prone
to biofilm formation.
• Explain why biofilm is so difficult to remove from surfaces.
• Compare the different methods for the control and removal
of biofilm formation on surgical instruments and medical
devices.
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Biofilms in our daily life
What do these photos have in common?
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Biofilm in nature
Yellowstone Nat’l Park
Cleaning a ship hull
Wastewater treatment
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Biofilm can be difficult to see!
Photos: Center for Biofilm Engineering, Univ. of Montana
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What is a biofilm?
• A collection of microbes
• Encased in slime
• Attached to a surface
• A survival mechanism
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How do biofilms form? A recipe
• Almost any surface will do
• Presence of water (even
intermittent presence)
• Hot, cold, acid, clean, dirty,
low oxygen, no light, high
pressure, disinfectants
• Microbes
• All types of microbes can
be found in biofilms
• Yeast, molds, bacteria,
viruses, protozoa, algae
• Biofilms can be
polymicrobic (more than
one kind of microbe)
Undersea volcano
Heart valve
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How Biofilms form: A closer look
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Biofilm Formation: Attachment
• Microbes can exist in two
states:
• Free floating (planktonic) or
Attached (sessile)
• Free floating bacteria
encounter a surface and attach
• Can take only minutes
• Microbes attach to a surface by
means of a molecular “glue”.
• Extra cellular polymeric
substance (EPS)
• After a certain amount of time,
attachment is permanent and
irreversible
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Biofilm Formation: Growth
• Growth can be slow or fast
depending on environment • A full community can form within
hours.
• Cells are held together by EPS
to form complex 3D structures
• Can be several cells thick to
many inches thick
• Very resistant to
• Antibiotic treatment
• Killing by disinfectants
• Physical removal
E. coli biofilm
Pseudomonas Biofilm
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Biofilm Formation: Detachment
• Large or small clumps of
the biofilm detach
• The microbes in these
detached clumps “travel”
downstream
• Find a new surface to
attach and grow
• Mechanism for disease
transmission
Photo: Annu. Rev. Microbiol. 2002. 56:187–209
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Interesting…but why should we care?
“Microbial biofilms, which often are formed by antimicrobial-
resistant organisms, are responsible for 65% of infections
treated in the developed world”
Ryder, Marcia. 2005. Catheter-Related Infections: It’s all About Biofilm. Topics in Advanced
Practice Nursing eJournal. 2005;5(3)
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Some trends
• Rates of postoperative sepsis, or bloodstream infections, increased by 8%
• Postoperative catheter-associated urinary tract infections increased by 3.6%
• Rates of selected infections due to medical care increased by 1.6%
• There was no change in the number of bloodstream infections associated with central venous catheter placements, which are tubes placed in a large vein in the patient's neck, chest, or groin to give medication or fluids or to collect blood samples.
• Rates of postoperative pneumonia improved by 12%
HHS – Agency for Healthcare Research and Quality press release 4/13/2010
http://www.ahrq.gov/news/press/pr2010/qrdr09pr.htm
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Biofilm-related diseases
• Otitis media (ear infection)
• Bacterial endocarditis (infection of heart)
• Cystic fibrosis (lung)
• Legionnaires Disease
• Periodontitis (gums)
• Sinusitis (sinuses)
• Osteomyelitis
• Surgical Site Infections
• Blood-stream Infections
• Urinary Tract Infections © 3M 2012. All Rights Reserved.
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Sources of Biofilm
• Implants
• Stents/Shunts
• Orthopedic Prostheses
• Catheters
• Wound Dressings
• Surgical Instruments
• Medical Devices
• Lint
• Environmental Surfaces
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Figure 2 Examples of crystalline biofilms on blocked catheters taken from
patients
Stickler DJ (2008) Bacterial biofilms in patients with indwelling urinary catheters Nat Clin Pract Urol doi:10.1038/ncpuro1231
Permission to reproduce Figure B obtained from Elsevier Ltd © Stickler DJ (1999)
Eur Urol Update Series 5: 1–8
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CSSD Perspective: What are the issues?
• Remember – biofilms form anytime there is water, a
surface and bacteria
• Biofilms can be microscopic therefore you can’t see them
most of the time
• Surgical instruments and medical devices are prone to
biofilm formation
• Biofilms are very resistant to disinfectants
• Fast turnaround times needed during reprocessing promote
biofilm formation
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Surfaces: Surgical Instruments
What affects biofilm formation?
Instrument Complexity
• Crevices
• Pores
• Edges
• Serrations
• Shape
• Lumens
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Biofilm Formation on Surgical Instruments
Water Quality Is Important!!!
• Presence of minerals (hard water)
• Water quality affects your detergents and disinfectants
• Contaminated water
• Does rinse water contain bacteria, organic material?
• Rinsing
• Volume
• Type of water
• Duration
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Biofilm Formation on Surgical Instruments
Reprocessing
Handling
• Scratches, lubricant not removed, poor assembly
• Presence of particles (lint, hair, fibers, glove powder)
• Etching – use of harsh chemicals
Practices
• Time – too much time between use and reprocessing
• Multiple reprocessing of single-use items
• Loaner instruments
• Poor rinse techniques
• Leave behind particles, soil, detergents Partially adapted from :Wava Truscott, Ph.D, IAHCSMM 2011,
Biofilms in Medicine and What it means to Central Services © 3M 2012. All Rights Reserved. 24
What can you do to prevent biofilm formation?
CLEANING……
• Cleaning is the primary mechanism for preventing biofilm
formation
• Factors for success
• Proper training
• Effective Policies and Procedures
• Supportive monitoring to make sure process is in control
• Time to do the job correctly
• Up to date IFUs
• Proper tools
• Chemicals
• Brushes (size, diameter, length, design)
• PPE
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Cleaning (Manual and Automated)
Points to Consider…..
• the quality of the water
• the quality, concentration, and type of detergent or
enzymatic cleaner
• an acceptable washing method, Manufacturer Instructions!!
• proper rinsing and drying
• correct preparation of the items to be processed by
cleaning equipment
• time temperature parameters for equipment
• load capacity of the equipment
• operator performance © 3M 2012. All Rights Reserved.
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Biofilm Removal
Enzymatics + Mechanical Action
• Instruments should not be allowed to dry out before
reprocessing
• Enzymatics – “chews up” the molecular glue that holds the
biofilm to the surface.
• Most enzymatics do not have biofilm removal claims (EPA)
• Enzymatics can be contaminated with bacteria
• Contact time
• Elbow grease!
+
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Biofilm Resistance to Detergents and
Disinfectants
• Back to the slime layer and 3D structure….
• Protects microbes from action of detergents, enzymes,
disinfectants as well as antibiotics
• Biofilms have been shown to be up to 1000 times more resistant
to environmental and antimicrobial stress than their planktonic
counterparts
• Proper use of detergents:
• temperature, dilution, pH
• EPA claim for biofilm removal?
Photo: Center for Biofilm Engineering,
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Make sure the instruments are dry!!
• No water = No biofilm
• Instruments should be dry before they are sterilized or
disinfected
• Store instruments so they stay dry
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Biofilm Formation: Flexible Endoscopes
• Flexible endoscopes are reportedly associated with more
documented cases of healthcare-acquired infections than
any other type of reusable medical device .
• Of these scopes, bronchoscopes and duodenoscopes
account for the highest number of transmitted infections. Muscarella, L., "Investigation and prevention of infectious outbreaks during endoscopic retrograde
cholangiopancreatography," Endoscopy, 2010; 42: 957-959
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“The biggest problem is that we can’t
see inside these scopes. To put it
bluntly, we’re just taking a shot in the
dark with reprocessing.”
Nancy Chobin, RN, St. Barnabas Health Care System. Livingston, New Jersey
“Probing the Challenges of Endoscopes”
Biomedical Instrumentation & Technology May/June 2011
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“Flexible endoscope reprocessing has been shown
to have a narrow margin of safety. Any slight
deviation from the recommended reprocessing
protocol can lead to the survival of microorganisms
and an increased risk of infection.”
Alfa, M.J., et al. (2006). American Journal of Infection Control, 34(9), 561-570. © 3M 2012. All Rights Reserved.
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In other words….
“Failure to adhere to established
reprocessing guidelines accounts for most, if
not all, of the reported cases of bacterial and
viral transmissions.”
American Society for Gastrointestinal Endoscopy (ASGE). (2001). Transmission of
infection by gastrointestinal endoscopy. Gastrointestinal Endoscopy, 54(6), 824-
828.
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Why are flexible endoscopes difficult to
reprocess?
• Complex design
• Multiple, long, narrow,
channels that are difficult to
clean
• Lack of consistent effective
training
• Lack of time and resources for
adequate reprocessing
• Visual inspection not adequate
to monitor efficacy of
reprocessing.
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Basic steps for Reprocessing Flexible
Endoscopes
• Pre-cleaning – Bedside
• Transport to Reprocessing - <1 hour
• Manual Cleaning
• Rinsing
• High-level disinfection – Manual, Automated (AER)
• Drying (Alcohol flush, Air flush)
• Storage
Everyone of these steps has implications for biofilm
formation
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Manual Cleaning – a little more detail Multi-Society Guideline on Reprocessing Flexible Gastrointestinal Endoscopes
2011 Infection Control & Hospital Epidemiology 32(6) pp.527-537
Meticulously clean the entire endoscope
Clean all valves, channels, connectors, all detachable parts
Flush/brush all accessible channels to remove all organic
and other residues
Clean external surfaces
Rinse
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Manual Cleaning is not an option!
Manual cleaning of endoscopes is necessary immediately after removing
the endoscope from the patient and prior to automated or manual
disinfection. This is the first and most important step in removing the
microbial burden from an endoscope. Retained debris may inactivate or
interfere with the capability of the active ingredient of the chemical solution
to effectively kill and/or inactivate microorganisms.
Standards of Infection Control in Reprocessing of Flexible Gastrointestinal
Endoscopes. 2009
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How do we know a scope is clean?
Visual Inspection is the current method for
monitoring effectiveness of manual cleaning.
*SGNA says: “Continue brushing until there is no
debris visible on the brush.”
*Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes. 2009
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Just because it looks clean….
does not mean it is clean.
You can’t see biofilm or microbes
You can’t see biological residues
You can’t see inside the lumens
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How do you monitor cleaning efficacy?
• A hot topic!
• 3M Sterile U offers a webinar focused on this topic.
• Here is how to access the archived webinar.
• http://solutions.3m.com/wps/portal/3M/en_US/sterilization/3
MSterileU/Home/Webinars/
• Click “Webinars”
• Click “Previously Recorded Session”
• Click “February 16‚ 2012: "You Can't See Clean: Clean
Monitoring in the CSSD"
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Biofilm Formation: Flexible Endoscopes
Water, microbes, suitable surface…..
How does a clean scope acquire biofilm?
• Surface:
• As a scope is used the surface is “coated” or “conditioned” with
body fluids that contain proteins, polysacharides
• Changes the surface to allow attachment of microbes
• Water
• Residual moisture left after reprocessing
• Microbes
• Microbes present in contaminated water
• Incomplete removal of microbes from endoscope
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Removing Biofilm from an Endoscope
• Goal? Don’t let biofilms establish a “ foot hold”
• Using proper procedures, the initial biofilm can be removed
• Manual pre-cleaning – bed side flush!
• Critical to removing bioburden
• Prevents biofilm formation
• Brushing accessible channels
• Use proper tools that fit the channel size
• High level disinfection
• Thorough drying
• Proper storage (always vertical!)
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Biofilm formation may cause failure of disinfection
procedures
• Biofilms form a protective barrier around infectious
microbes; allows infectious microbes to survive the
disinfection process.
• Young biofilm may be more susceptible to disinfection
when compared to “old” biofilm.
• Most biocides are not tested against biofilms
• Free (planktonic bacteria) are used to test biocides
• More susceptible
• Biofilms (not generally used to test biocides)
• More resistant
• Oxidizing agents and some enzymatics are effective
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Drying – A Critical Step in Reprocessing
• The drying step
• Between cases
• At the end of the day
• Hang vertically
• Drying agents
• Air
• Alcohol
• How to tell if a scope is not dry?
• Look for fluid underneath scopes that are vertically stored
• Smell – any odors?
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Conclusions
• Biofilms will form anywhere there is water, a surface and microbes
• Biofilms are almost impossible to remove once they have been
established.
• Failure to completely clean and dry instruments and endoscopes
using the current guidelines may lead to biofilm formation
• Biofilm must be completely removed or
• Risk continued growth
• Risk disease transmission
• Ensure that reprocessing personnel:
• Are properly trained
• Have access to current IFU’s and proper tools
• Have time to perform their job
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Certificate of Attendance
for attending the seminar:
BioFilms: The Hidden Menace 3M Health Care
Provider Approved by the Certification Board for Sterile Processing and Distribution (CBSPD) for 1.0 Contact Hour
Approval Code 22795WCOR11
IAHCSMM has awarded 1.0 Contact Hour
Approval Code 00041113
Mary Kundus, RN, BSN, MPH, CIC
Date
(print name)
CS cert. © 3M 2012. All Rights Reserved.
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Thank you!
Questions?