cheri ackert-burr, rn, msn, cnor, agts clinical education manager biofilm and medical devices
TRANSCRIPT
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Cheri Ackert-Burr, RN, MSN, CNOR, AGTS
Clinical Education Manager
BIOFILM AND MEDICAL DEVICES
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Disclosures
1. Successful completion: Participants must complete the entire program and submit the required documentation
2. Conflict of interest: Planners disclose no conflict; the speaker discloses employment with Medivators, thereby declaring a conflict of interest.
3. Commercial company support: Fees are underwritten by education funding provided by Medivators
4. Non-commercial company support: None
5. Alternative Complementary therapy: None
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Learner ObjectivesUpon completion of this presentation,
participants will be able to:Discuss the concept of biofilm communities in
medical devices and in the human bodyExplain the relationship between biofilm and
endoscope/instrument contaminationRelate findings from studies and literature to
clinical area practiceCompare two detergent agents in their
effectiveness against biofilmState three best practices of disinfection
which are particularly important in biofilm elimination
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GlossaryExo-polysaccharide (EPS): polymers that
are composed of sugar residues and are secreted by a micro-organism into the surrounding environment. Capsular exo-polysaccharides can protect pathogenic bacteria and contribute to their pathogenicity.
Glycocalyx: a general term referring to extra-cellular polymeric material produced by some bacteria composed of carbohydrates, lipids, and proteins. AKA - SLIME
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Glossary (cont’d)Planktonic: passively floating, drifting, or
somewhat motile organisms occurring in a body of water.
Sessile: fixed in one place; immobile. Attached by a broad base. Being attached to the substrate or base; not freely moving
Vegetative Bacteria: bacteria that are devoid of spores and usually can be readily inactivated by many types of germicides.
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What is Biofilm?Biofilm: a collection of microorganisms
surrounded by the slime they secrete, attached to either an inert or a living surface. Up to 99% of all bacteria live in biofilm communities.
Three basic elements to a Biofilm:MicrobesGlycocalyx/Exo-Polysaccharide (EPS)Surface (inert or living)
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Biofilm Lifecycle
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Biofilm
Microbially derived sessile communityIrreversible attachmentMatrix embeddedAltered phenotype
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Biofilm Formation
First observations Communities vs. free-floatingFormation in high-shear vs. low-sheer
environmentsPolysaccharides adhere to the surface of
medical device and allows other substances to adhere to the surface
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Where does biofilm live?In industry—biofilms are used to aid in
decontaminating waterClogging filtersFound in water systems
Not just drains, but in the water supply as well—in fact, the higher the water pressure, the more tenaciously the biofilm attaches to the pipe!
But where else do they live???
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River Rocks
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On teeth
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In the Body
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Colonization Environments
Biofilm in the human body> 80% of microbial infections are
caused by biofilm – NIH estimate
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Biofilm in Endoscopes
New endoscopes and biofilmUse of endoscopes and biofilm creationProper processing after each use
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Studies and Literature Findings
Alfa and Howie (2010)Killing bioburden within young vs mature
biofilmGlutaraldehyde vs Accelerated Hydrogen
Peroxide (AHP) disinfection
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Studies and Literature Findings
Pajkos (2004)Findings of scope contamination studiesEvaluation of effectiveness of endoscope
cleaning or reprocessing
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On Medical Devices and Endoscopes
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Photographic Documentation of Endoscopic Biofilm
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Scope Tip after Manual Cleaning
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Distal Tip after Cidex and Alcohol
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Distal Tip after Peracetic Acid
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Biofilm Debris in Channel
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Biofilms
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Biofilm
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What has been observed:99% of bacteria grow as aggregated, sessile
communities (biofilm)Biofilm are highly protected and highly
resistant to antibacterial treatments (antibiotics and disinfectants)
Biofilm are genetically different than bacteria in the planktonic state
Biofilm form preferentially in high shear environments
Conditions suitable for biofilm development are practically limitless
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Why we should be afraid, very afraid!Structure and physiology of biofilm confer
resistance to antibiotics, disinfectancts, and germicides
Experiment: biofilm can adhere to stainless steel, even highly polished SS, within 30 seconds
NIH estimates more than 80% of microbial infections in humans caused by biofilm
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Biofilm in Endoscopes
Shortly after its first use, endoscopes develop a conditioning film composed of bodily fluids, proteins, polysaccharides and other components. This alteration of the surface characteristics allows bacteria to commence growth and colonization.
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Reducing Biofilm FormationPrecleaningCleaning
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Cleaning NomenclaturePrecleaning: Done in the OR, during and
immediately after use during a surgical procedure. Should occur at point of use. Can be a wipe down, cleaning spray, or foam to keep instruments moist and to begin the breakdown of bioburden.
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Manufacturer’s Cleaning Instructions for Use
Utilities (eg, type of water, compressed air);Cleaning equipment;Accessories (eg, adaptors) for creating a
proper connection between the instruments and equipment, utilities, and cleaning equipment;
Accessories for cleaning lumens, ports, and internal parts;
Cleaning agents;Lubricants;Processing methods.
AORN RP 2014
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Cleaning Medical InstrumentsManual cleaning
Detergents - typeBrushesDisassembly
Sonic cleaningDetergentTime and temperatureRepeat as instructed
Washer decontaminator
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Eliminating Biofilm
Destruction of biofilm cell formationChemical/disinfection reaction with the
polysaccharide networkProtective shield inhibits cell destructionHazards of incomplete biofilm removal
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What are Enzymatic Detergents?Enzymatic Detergents act by reducing
the cohesive force within the soil itselfBreaks up substances into fine particles
which are rinsed awayEnzymes act like a pair of scissors
“cutting off” soils piece by piece
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Substrate Specific
Different types of Enzymes react to different substances
Proteins: #1 concern in a reprocessing roomHigh content of proteins in bodily fluids which
need to be removed(blood, tissue, mucous, etc)
Protease enzymes break down proteins into their components (amino acids) which are easily removed
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Substrate SpecificLipids (fats): difficult to penetrate and
removeEx: Olestra is a very large and complex fat
moleculeLipase enzymes help break down lipids
(hydrolysis). Enzymatic reaction is slowAppropriate surfactants and detergents are
generally a bigger player in the effectiveness at removing lipids
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Substrate Specific
• Carbohydrates (starches): very water soluble– a-Amylase enzymes speed up the
reaction which breaks starches down into sugars. The sugars are then quickly dissolved into the detergent water and removed
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Biofilm detaching detergent
6 day growth of aPs Aeruginosa biofilm
Biofilm treated with a bio-detaching detergent
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Remember the recipesCleaningConcentrationTemperatureTimePackagingHandlingStorageEach step has specific parameters that
must be met
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Effective Disinfectant AgentsGlutaraldehyde
Saturated dialdehydeAcetic activated to alkaline to become
sporicidalUsed in manual or automated processing
protocolsPeracetic Acid (PAA)
Oxidizing agent for disinfection of flexible endoscopes
Highly biocidal in the presence of organic soil
Improper processing results in regrowth of biofilm
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Ensuring Patient Safety
Shared responsibilityMedical instrument care and reprocessingBest practices of cleaningPolicies and proceduresTraining, resources, quality improvementInfection control
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Orientation and Education TopicsStandard PrecautionsPersonal Protection Equipment (PPE)OSHA rules on occupational exposureReprocessing proceduresMechanisms of disease transmissionMaintenance of a safe work environmentSafe handling of HLD and sterilantsProcedures for waste management
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Administrative Responsibility
Infection Control GuidelinesManufacturer’s RecommendationsIdentification of problems and lapses in
techniqueObservation of scope storage areasEnsure that reprocessing procedures are
followed.
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Time Out: Test Your Knowledge
What are three best practices of medical devices which are particularly important in biofilm elimination?Spray instruments at the point of use
before transporting to SPD. Immediately flush the channel with
water when contaminated with bioburden.
Wipe the external surface of the medical device.
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When all else fails
SGNA
AORN
IFU
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Conclusions
Every patient deserves a clean endoscope Patient safety is a team responsibility Biofilm elimination is critical
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Questions
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Thank You
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