952012

1

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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