Using an efficient biofilm detaching agent: an essential step for the improvement of endoscope reprocessing protocols

Multisociety guidance for sterilization and high-level disinfection

SHEA, in partnership with ASGE, APIC, AAMI, AORN, HSPA, IDSA, SGNA, and The Joint Commission, developed this multisociety infection prevention guidance document for individuals and organizations that engage in sterilization or high-level disinfection (HLD). This document follows the CDC Guideline for Disinfection and Sterilization in Healthcare Facilities. This guidance is based on a synthesis of published scientific evidence, theoretical rationale, current practices, practical considerations, writing group consensus, and consideration of potential harm when applicable. The supplementary material includes a summary of recommendations. The guidance provides an overview of the Spaulding Classification and considerations around manufacturers' instructions for use (MIFUs). Its recommendations address: point-of-use treatment prior to sterilization or HLD, preparation of reusable medical devices at the location of processing, sterilization, and immediate use steam sterilization (IUSS), HLD of lumened and non-lumened devices, processing of reusable medical devices used with lubricating or defoaming agents, monitoring for effectiveness of processing, handling of devices after HLD, augments and alternatives to HLD, processing of investigational devices, tracking of reusable medical devices, and approaches to implementation.

Evaluation of plasma activated liquids for the elimination of mixed species biofilms within endoscopic working channels

The use of reusable flexible endoscopes has increased dramatically over the past decade, however despite improvements in endoscope reprocessing, the continued emergence of endoscopy-associated outbreaks as a result of multi-drug resistant bacteria has highlighted the need for a new approach to disinfection. Here, the use of plasma activated liquids (PALs) for the elimination of mixed species biofilm contamination within the working channels of endoscopes was evaluated. Cold atmospheric pressure plasma was used to chemically activate water and a commercially available pH buffered peracetic acid to create PALs. Polytetrafluoroethylene endoscope surrogate test pieces were contaminated with clinically relevant mixed species biofilms. The efficacy of PALs for the decontamination of narrow lumens was compared against the commercial disinfectant. Plasma activation was found to increase the antibiofilm capabilities of pH buffered peracetic acid by introducing reactive chemical species into the solution. Disinfection of endoscopic test pieces with plasma activated disinfectant (PAD) resulted in a 7.30 log10 reduction of biofilm contamination in 5 min, surpassing the 4.39 log10 reduction observed with the currently used endoscope disinfection method. PAD also resulted in reduced regrowth and recolonization of the surface of the endoscopic test pieces. Minimal changes to the surface morphology and composition were observed following exposure to PAD in comparison to the commercial disinfectant, suggesting the developed approach is no more aggressive than current disinfection approaches.

Microbiological surveillance result of endoscopes after INTERCEPT Foam Spray: a quasi-experimental pilot study in Singapore

BACKGROUND/AIMS

This study aimed to assess the impact of INTERCEPT Foam Spray (IFS) application on delayed endoscope reprocessing through microbiological surveillance culture (MSC).

METHODS

A quasi-experimental, matched-comparison pilot study was conducted using gastrointestinal endoscopy. IFS was applied to the endoscopes after precleaning and before reprocessing the next day. An equal number of endoscopes, matched by endoscope type, were subjected to routine reprocessing. The MSC were subjected to high-level disinfection to detect any contamination. Data were analyzed using the chi-square test or Fisher exact test (categorical data) and Student t-test (continuous data).

RESULTS

In total, 150 MSCs were collected from 42 endoscopes. Positive MSCs were observed in 4.0% (4/75) of the sprayed group and 1.3% (1/75) of the control group (95% confidence interval, 30.34-0.31; p>0.05), all of which were contributed by colonoscopes. Colonoscope were more prone to positive MSC (mean difference in percentage, p<0.05). Mean spraying hours were not associated with detected growth (11.7% vs. 13.6%; 95% confidence interval, 1.43 to -5.27; p>0.05), with environmental and skin flora being the primary contaminants.

CONCLUSIONS

IFS may be applied when delayed endoscope processing is necessary, but with caution when applied to colonoscopes. However, further research is warranted to verify the result.

Reprocessing semicritical items: An overview and an update on the shift from HLD to sterilization for endoscopes

BACKGROUND

Semicritical medical devices are defined as items that come into contact with mucous membranes or nonintact skin (e.g., gastrointestinal endoscopes, endocavitary probes). Such medical devices require minimally high-level disinfection.

METHODS

Analyze the methods used to reprocess semicritical medical devices and identify methods and new technologies to reduce the risk of infection.

RESULTS

The reprocessing methods for semicritical medical devices is described as well as a shift from high-level disinfection to sterilization for lumened endoscopes.

CONCLUSIONS

Strict adherence to current guidelines and transition to sterilization for endoscopes is required as more outbreaks have been linked to inadequately disinfected endoscopes and other semicritical items than any other reusable medical devices.

Evaluation of two detergent-disinfectants and a detergent on a Klebsiella pneumoniae biofilm formed within Tygon tubes

BACKGROUND

Transmission of infections via contaminated endoscopes is a common problem. Manual cleaning, using at least a detergent, is an important step in endoscope processing and should be performed as soon as possible to avoid drying of organic residues that might interfere with high-level disinfection and promote biofilm formation.

AIM

To assess the efficacy of two detergent-disinfectants, enzymatic and non-enzymatic, and of an enzymatic detergent used during the manual cleaning against a Klebsiella pneumoniae biofilm.

METHODS

A 24 h biofilm statically formed in a Tygon tube was exposed to detergent-disinfectants at 20 °C and 35 °C for 10 mn, and to enzymatic detergent at 45 °C for 60 mn. The logarithmic reduction in bacteria in the Tygon tube and the number of bacteria in the product supernatant were calculated.

FINDINGS

Biofilm formation was reproducible between assays. After exposure to detergent-disinfectants, the logarithmic reduction was between 6.32 and 6.71 log10 cfu/cm2 in the Tygon tubes. No bacteria were found in their supernatants. Results in the detergent-disinfectant group were not affected by the exposure temperature or the addition of enzymes. No decrease in the bacterial load was observed in the Tygon tubes after exposure to the enzymatic detergent. Bacteria were found in its supernatant.

CONCLUSION

These results show the importance of the choice of products used during the manual cleaning phase. They also show the potential benefit of combining detergent and disinfectant activity to decrease the bacterial load during the manual cleaning step of endoscope processing.

A nationwide survey on the effectiveness of training on endoscope reprocessing within the national cancer screening program in Korea

BACKGROUND

The National Cancer Center has provided nationwide endoscope reprocessing training to hospitals annually performing national gastric and colorectal cancer screening in Korea since 2012. This study aimed to evaluate the adherence of past participants of endoscope reprocessing training to the reprocessing guidelines and their satisfaction with the current training.

METHODS

Training on endoscope reprocessing was implemented 18 times across the country, from June 2019 to November 2019. Immediately after the training, participants filled a paper questionnaire related to reprocessing practices and satisfaction with the current training anonymously.

RESULTS

A total of 1,132 participants trained responded to the survey (response rate, 95.4%). Of the study participants, 45.7% participated in the past endoscope reprocessing training, and 94.6% of them answered that they have adhered to the endoscope reprocessing guidelines. Experience of participation in endoscope reprocessing training was significantly associated with practical adherence to endoscope reprocessing guidelines (aOR, 6.55; 95% CI, 3.93 to 10.91). And, 91% of study participants were satisfied with the current endoscope reprocessing training.

CONCLUSIONS

The current training on endoscope reprocessing provided at the national level could help ensure adherence to reprocessing guidelines, resulting in obtaining quality control for endoscopy. However, about half of practitioners currently working in endoscopy units had not received sufficient reprocessing training, and thus more training is needed for them.

The establishment of the CBE launched biofilms as a field of specialized research

The Center for Biofilm Engineering was the first center of excellence focused on biofilms and was originally funded through the Engineering Research Center Program from the U.S. National Science Foundation. After almost 30 years, biofilm continues to be a stand-alone scientific topic of inquiry that has broad implications for fundamental and applied science and engineering of bio-systems. However, much remains to be done, not only for research discovery but also education and outreach, to increase and grow the biofilm paradigm as well as our understanding of the microbial world.

Medical instrument reprocessing: current issues with cleaning and cleaning monitoring

The complexity of medical devices has increased over the past 10 years, and outbreaks of infections due to contaminated devices have focused attention on the need to adequately clean medical devices in order to ensure the adequacy of disinfection and sterilization. There has been a paradigm shift in reprocessing of medical devices, with increased emphasis on a quality management systems approach that requires validated cleaning instructions from manufacturers and ongoing monitoring by reprocessing personnel to ensure adequacy of cleaning. This article reviews the current issues related to medical device reprocessing and summarizes the approaches used for monitoring cleaning efficacy for surgical instruments and flexible endoscopes.

Biofilms on instruments and environmental surfaces: Do they interfere with instrument reprocessing and surface disinfection? Review of the literature

There is a growing appreciation for the role of biofilm-embedded microbes in many different aspects of infection transmission. The format of biofilm includes traditional hydrated biofilm, build-up biofilm, and dry surface biofilm. The objectives of this article are to discuss how traditional biofilm differs from build-up biofilm and dry surface biofilm, and to review the evidence supporting infection transmission from biofilm that accumulates in reprocessed instruments and from dry biofilm that forms environmental reservoirs.

Quantifying the combined effects of pronase and benzalkonium chloride in removing late-stage Listeria monocytogenes-Escherichia coli dual-species biofilms

This work presents the assessment of the effectivity of a pronase (PRN)-benzalkonium chloride (BAC) sequential treatment in removing Listeria monocytogenes-Escherichia coli dual-species biofilms grown on stainless steel (SS) using fluorescence microscopy and plate count assays. The effects of PRN-BAC on the occupied area (OA) by undamaged cells in 168 h dual-species samples were determined using a first-order factorial design. Empirical equations significantly (r² = 0.927) described a negative individual effect of BAC and a negative interactive effect of PRN-BAC achieving OA reductions up to 46%. After treatment, high numbers of remaining attached and released viable and cultivable E. coli cells were detected in PRN-BAC combinations when low BAC concentrations were used. Therefore, at appropriate BAC doses, in addition to biofilm removal, sequential application of PRN and BAC represents an appealing strategy for pathogen control on SS surfaces while hindering the dispersion of live cells into the environment.

A novel polytetrafluoroethylene-channel model, which simulates low levels of culturable bacteria in buildup biofilm after repeated endoscope reprocessing

BACKGROUND AND AIMS

Clinical studies have shown variable culture results from flexible endoscope channels possibly because of low levels of bacteria that are difficult to extract. The aim of this study was to develop a simulated-use buildup biofilm (BBF) model that mimics low levels of viable bacteria after repeated rounds of aldehyde fixation and accumulation.

METHODS

New endoscope channels were exposed to 8 days of repeated rounds of biofilm formation using ATS2015 containing Enterococcus faecalis and Pseudomonas aeruginosa, rinsing, fixation with glutaraldehyde, and rinsing. Viable count and scanning electron microscopy and borescope examination were used to compare the impact of dry storage over 26 weeks on the level of culturable bacteria and to compare the Centers for Disease Control and Prevention flush method of channel harvesting with a flush-brush-flush method.

RESULTS

E faecalis (log₁₀ 6.6) and P aeruginosa (log₁₀ 8.6) accumulated over 8 days of cyclic biofilm formation and partial glutaraldehyde fixation, but after a final exposure to 2.6% glutaraldehyde the level of culturable bacteria was less than 2 log₁₀. The Centers for Disease Control and Prevention channel harvesting method appeared by borescope to be inferior to a flush-brush-flush sample collection method for detection of viable bacteria. P aeruginosa increased up to 7 log₁₀ after 26 weeks of dry storage, indicating there were viable but nonculturable bacteria present initially that recovered during storage.

CONCLUSIONS

Viable but nonculturable P aeruginosa within the BBF model are able to recover, and this phenomenon may explain the variability of culture in patient-used endoscopes. Our data also indicated that friction may be a critical part of sample collection from endoscope channels.

Bacterial Biofilms in Jones Tubes

PURPOSE

To investigate the presence and microbiology of bacterial biofilms on Jones tubes (JTs) by direct visualization with scanning electron microscopy and polymerase chain reaction (PCR) of representative JTs, and to correlate these findings with inflammation and/or infection related to the JT.

METHODS

In this study, prospective case series were performed. JTs were recovered from consecutive patients presenting to clinic for routine cleaning or recurrent irritation/infection. Four tubes were processed for scanning electron microscopy alone to visualize evidence of biofilms. Two tubes underwent PCR alone for bacterial quantification. One tube was divided in half and sent for scanning electron microscopy and PCR. Symptoms related to the JTs were recorded at the time of recovery.

RESULTS

Seven tubes were obtained. Five underwent SEM, and 3 out of 5 showed evidence of biofilms (60%). Two of the 3 biofilms demonstrated cocci and the third revealed rods. Three tubes underwent PCR. The predominant bacteria identified were Pseudomonadales (39%), Pseudomonas (16%), and Staphylococcus (14%). Three of the 7 patients (43%) reported irritation and discharge at presentation. Two symptomatic patients, whose tubes were imaged only, revealed biofilms. The third symptomatic patient's tube underwent PCR only, showing predominantly Staphylococcus (56%) and Haemophilus (36%) species. Two of the 4 asymptomatic patients also showed biofilms. All symptomatic patients improved rapidly after tube exchange and steroid antibiotic drops.

CONCLUSIONS

Bacterial biofilms were variably present on JTs, and did not always correlate with patients' symptoms. Nevertheless, routine JT cleaning is recommended to treat and possibly prevent inflammation caused by biofilms.

Protein diffusion characteristics in the hydrogels of poly(ethylene glycol) and zwitterionic poly(sulfobetaine methacrylate) (pSBMA)

Nonfouling materials such as neutral poly(ethylene glycol) (PEG) and zwitterionic poly(sulfobetaine methacrylate) (pSBMA) are ideal biocompatible materials for drug, especially protein drug delivery. The interaction behavior of protein between the nonfouling materials could cause great impact on their future applications, such as controlled release drug delivery systems. In this work, we investigated the diffusion behavior of the fluorescence-labeled model proteins (bovine serum albumin (BSA) and lysozyme (LYZ)) in nonfouling PEG, pSBMA and mixed PEG-SBMA hydrogels (SBMA:PEG 4:1, SBMA:PEG 1:4). It was observed that these four hydrogels showed varied diffusion behavior for either negatively charged BSA or positively charged LYZ due to protein-polymer interaction and the free water content in hydrogel matrix. The relatively stronger interaction between protein-PEG than protein-pSBMA could increase protein loading efficiency and control release rate by changing ratio of PEG to SBMA in the hybrid hydrogel. Moreover, it is further demonstrated the free water (freezable water) content in low cross-linked hydrogel, not the equilibrium water content (EWC), is a more accurate parameter to reflect the diffusion behavior of protein molecules. Thus, these results together provide new insights of the interactions between protein molecules and nonfouling polymers as well as the bio applications of the nonfouling polymeric hydrogels.

STATEMENT OF SIGNIFICANCE

This work shows that the relative stronger interaction between protein-PEG than protein-pSBMA could increase protein loading efficiency and control release rate by the change ratio of PEG to SBMA in the hydrogel, while the free water (freezable water) content in low cross-linked hydrogel, not the equilibrium water content (EWC), is a more accurate parameter to reflect the diffusion behavior of protein molecules. The impact of this work (i) gains some new insights of the interactions between protein molecules and nonfouling polymer matrixes for protein drug delivery; (ii) prompts to apply the weak PEG-protein interactions to protein drug loading and release; (iii) provides a new fundamental understanding of free water in hydrogel for protein diffusion.

Escaping the biofilm in more than one way: desorption, detachment or dispersion

Biofilm bacteria have developed escape strategies to avoid stresses associated with biofilm growth, respond to changing environmental conditions, and disseminate to new locations. An ever-expanding body of research suggests that cellular release from biofilms is distinct from a simple reversal of attachment and reversion to a planktonic mode of growth, with biofilm dispersion involving sensing of specific cues, regulatory signal transduction, and consequent physiological alterations. However, dispersion is only one of many ways to escape the biofilm mode of growth. The present review is aimed at distinguishing this active and regulated process of dispersion from the passive processes of desorption and detachment by highlighting the regulatory processes and distinct phenotypes specific to dispersed cells.

Is peracetic acid suitable for the cleaning step of reprocessing flexible endoscopes?

The bioburden (blood, protein, pathogens and biofilm) on flexible endoscopes after use is often high and its removal is essential to allow effective disinfection, especially in the case of peracetic acid-based disinfectants, which are easily inactivated by organic material. Cleaning processes using conventional cleaners remove a variable but often sufficient amount of the bioburden. Some formulations based on peracetic acid are recommended by manufacturers for the cleaning step. We performed a systematic literature search and reviewed the available evidence to clarify the suitability of peracetic acid-based formulations for cleaning flexible endoscopes. A total of 243 studies were evaluated. No studies have yet demonstrated that peracetic acid-based cleaners are as effective as conventional cleaners. Some peracetic acid-based formulations have demonstrated some biofilm-cleaning effects and no biofilm-fixation potential, while others have a limited cleaning effect and a clear biofilm-fixation potential. All published data demonstrated a limited blood cleaning effect and a substantial blood and nerve tissue fixation potential of peracetic acid. No evidence-based guidelines on reprocessing flexible endoscopes currently recommend using cleaners containing peracetic acid, but some guidelines clearly recommend not using them because of their fixation potential. Evidence from some outbreaks, especially those involving highly multidrug-resistant gram-negative pathogens, indicated that disinfection using peracetic acid may be insufficient if the preceding cleaning step is not performed adequately. Based on this review we conclude that peracetic acid-based formulations should not be used for cleaning flexible endoscopes.

Evaluation of detergents and contact time on biofilm removal from flexible endoscopes

BACKGROUND

The formation of endoscopic biofilm reduces the results of cleaning and disinfection and may increase nosocomial infection. This study aims to evaluate the effects of various detergents and different contact time on the removal of biofilm on flexible endoscopes based on an artificial biofilm model.

METHOD

Endoscopic biofilm model was established and treated with various detergents (detergent 1, Rapid Multi-Enzyme; detergent 2, Scopezime; and detergent 3, Intercept) for 3, 5, and 7 minutes. Escherichia coli viable counts and biofilm changes were measured by colony counting and electron microscopy scanning, respectively.

RESULTS

Statistical differences were observed between various detergents and the control group (P < .001) but not among the different contact time groups (3, 5, and 7 minutes, P > .05). Multiple comparisons showed that statistical differences in residual biofilm bacteria were observed between the detergents and the control (P < .001). Significant differences (P < .001) in residual biofilm bacteria existed between the 2 enzymatic detergents and the nonenzymatic detergent group, whereas no significant difference was observed between the 2 enzymatic detergents (P > .05). No crossover effect was observed between various detergent groups, contact time, and the control group (P > .05). Electron microscopy scanning revealed that, after various detergents and contact time of 3, 5, and 7 minutes, the residual biofilm in the enzymatic detergent group was significantly more than that of the nonenzymatic detergent group. No significant difference was observed among the groups with the same detergent and different contact time.

CONCLUSION

Significantly more biofilm bacteria and biofilms were found in the enzymatic detergent groups compared with the nonenzymatic detergent group, whereas no significant difference was observed among 3, 5, and 7 minutes groups.

Double network hydrogels from polyzwitterions: high mechanical strength and excellent anti-biofouling properties

Polyzwitterionic materials, which have both cationic and anionic groups in the polymeric repeat unit, show excellent anti-biofouling properties and are drawing more attention in the biomedical field. In this study, we have successfully synthesized novel single network hydrogels and double network (DN) hydrogels from the zwitterionic monomer, N-(carboxymethyl)-N,N-dimethyl-2-(methacryloyloxy) ethanaminium, inner salt (CDME). The polyCDME (PCDME) single network hydrogel behaves like a hydrophilic neutral hydrogel and its properties are not sensitive to temperature, pH, or ionic strength over a wide range. DN hydrogels using the poly(2-acrylamido-2-methylpropanesulfonic) (PAMPS) as the first network and PCDME as the second network, having a Young's modulus of 0.2-0.9 MPa, possess excellent mechanical strength (fracture stress: 1.2-1.4 MPa, fracture strain: 2.2-6.0 mm/mm) and toughness (work of extension at fracture: 0.9-2.4 MJ m^-3) depending on the composition ratio of PCDME to PAMPS. The strength and toughness of the optimized PAMPS/PCDME DN is comparable to the normal PAMPS/PAAm DN hydrogels that use poly(acrylamide) (PAAm) as the second network. By macrophage adhesion test, both the PCDME hydrogels and the PAMPS/PCDME DN hydrogels have shown excellent anti-biofouling properties. These results demonstrate that the PCDME-based DN hydrogels have high potential as a novel soft and wet biomaterial.

Steps of reprocessing and equipments

With the increasing interest in endoscopy and the rising number of endoscopic examinations in hospitals, the importance of endoscopic reprocessing is also increasing. Cure facilities that are understaffed and ill-equipped are trying to cope with the problems of insufficient cleaning and high infection risks. To prevent endoscopy-associated infection, the endoscope cleaning, and disinfection guidelines prepared by the Korean Society of Gastrointestinal Endoscopy must be followed. In this review, the steps of endoscopic reprocessing and the equipments required in each step are discussed.

[Removing biofilm from a endoscopic: evaluation of disinfection methods currently used]

Laboratory experimental study that compared the effectiveness of five methods of disinfection for the removal of biofilm in gastrointestinal endoscopes. New transparent tubes of polytetrafluoroethylene (Teflon®) were used as specimens to simulate the channels of flexible endoscopes. After pre-cleaning the tubes were intentionally contaminated with Pseudomonas aeruginosa and subjected to disinfection methods. As a result, none removed 100% of these biofilms. What else physically removed biofilm was 2% glutaraldehyde in an automatic processor, probably justified by the double clean, since the equipment has this phase at the beginning of your cycle. The method less effective for removing plaque and other debris was the acidic electrolytic water. These results suggest that the cleaning is most striking in the removal of biofilms that disinfection of consecutive since glutaraldehyde disinfectant by machine is more efficient, it is a fastener organic waste.

Antimicrobial Pressure of Ciprofloxacin and Gentamicin on Biofilm Development by an Endoscope-Isolated Pseudomonas aeruginosa

This work aims at characterizing endoscope biofilm-isolated (PAI) and reference strain P. aeruginosa (PA) adhesion, biofilm formation and sensitivity to antibiotics. The recovery ability of the biofilm-growing bacteria subjected to intermittent antibiotic pressure (ciprofloxacin (CIP) and gentamicin (GM)), as well as the development of resistance towards antibiotics and benzalkonium chloride (BC), were also determined. The capacity of both strains to develop biofilms was greatly impaired in the presence of CIP and GM. Sanitization was not complete allowing biofilm recovery after the intermittent cycles of antibiotic pressure. The environmental pressure exerted by CIP and GM did not develop P. aeruginosa resistance to antibiotics nor cross-resistance towards BC. However, data highlighted that none of the antimicrobials led to complete biofilm eradication, allowing the recovery of the remaining adhered population possibly due to the selection of persister cells. This feature may lead to biofilm recalcitrance, reinforcement of bacterial attachment, and recolonization of other sites.

EVOTECH endoscope cleaner and reprocessor (ECR) simulated-use and clinical-use evaluation of cleaning efficacy

BACKGROUND

The objective of this study was to perform simulated-use testing as well as a clinical study to assess the efficacy of the EVOTECH Endoscope Cleaner and Reprocessor (ECR) cleaning for flexible colonoscopes, duodenoscopes, gastroscopes and bronchoscopes. The main aim was to determine if the cleaning achieved using the ECR was at least equivalent to that achieved using optimal manual cleaning.

METHODS

Simulated-use testing consisted of inoculating all scope channels and two surface sites with Artificial Test Soil (ATS) containing 108 cfu/mL of Enterococcus faecalis, Pseudomonas aeruginosa and Candida albicans. Duodenoscopes, colonoscopes, and bronchoscopes (all Olympus endoscopes) were included in the simulated use testing. Each endoscope type was tested in triplicate and all channels and two surface sites were sampled for each scope. The clinical study evaluated patient-used duodenoscopes, bronchoscopes, colonoscopes, and gastroscopes (scopes used for emergency procedures were excluded) that had only a bedside flush prior to being processed in the ECR (i.e. no manual cleaning). There were 10 to 15 endoscopes evaluated post-cleaning and to ensure the entire ECR cycle was effective, 5 endoscopes were evaluated post-cleaning and post-high level disinfection. All channels and two external surface locations were sampled to evaluate the residual organic and microbial load. Effective cleaning of endoscope surfaces and channels was deemed to have been achieved if there was < 6.4 microg/cm2 of residual protein, < 1.8 microg/cm2 of residual hemoglobin and < 4 Log10 viable bacteria/cm2. Published data indicate that routine manual cleaning can achieve these endpoints so the ECR cleaning efficacy must meet or exceed these to establish that the ECR cleaning cycle could replace manual cleaning

RESULTS

In the clinical study 75 patient-used scopes were evaluated post cleaning and 98.8% of surfaces and 99.7% of lumens met or surpassed the cleaning endpoints set for protein, hemoglobin and bioburden residuals. In the simulated-use study 100% of the Olympus colonoscopes, duodenoscopes and bronchoscopes evaluated met or surpassed the cleaning endpoints set for protein, and bioburden residuals (hemoglobin was not evaluated).

CONCLUSIONS

The ECR cleaning cycle provides an effective automated approach that ensures surfaces and channels of flexible endoscopes are adequately cleaned after having only a bedside flush but no manual cleaning. It is crucial to note that endoscopes used for emergency procedures or where reprocessing is delayed for more than one hour MUST still be manually cleaned prior to placing them in the ECR.

A study of the efficacy of bacterial biofilm cleanout for gastrointestinal endoscopes

AIM

To compare the influence and clearance effect of enzymatic and non-enzymatic detergents against Escherichia coli (E. coli) biofilm on the inner surface of gastroscopes.

METHODS

Teflon tubes were incubated in a mixture of different detergents and E. coli culture (10(6) CFU/mL) for 72 h at 15 degrees C, and biofilms on the inner surface of the teflon tubes were analyzed by bacterial count and scanning electron microscopy. To evaluate the clearance effect of detergents, after biofilms were formed on the inner surface of Teflon tubes by 72 h lavage with E. coli culture, tubes were lavaged by enzymatic and non-enzymatic detergents at a speed of 250 mL/min, then biofilms on the inner surface were analyzed by bacterial count and scanning electron microscopy.

RESULTS

Non-enzymatic detergent had a better inhibition function on biofilm formation than enzymatic detergent as it reduced bacterial burden by 2.4 log compared with the control samples (P = 0.00). Inhibition function of enzymatic detergent was not significantly different to that of control samples and reduced bacterial burden by 0.2 log on average (P > 0.05). After lavaging at 250 mL/min for 3 min, no living bacteria were left in the tubes. Scanning electron microscopy observation showed biofilms became very loose by the high shear force effect.

CONCLUSION

Non-enzymatic detergent has a better inhibition effect on biofilm formation at room temperature. High speed pre-lavage and detergents are very important in temporal formed biofilm elimination.

Modeling microbial survival in buildup biofilm for complex medical devices

Background

Flexible endoscopes undergo repeated rounds of patient-use and reprocessing. Some evidence indicates that there is an accumulation or build-up of organic material that occurs over time in endoscope channels. This "buildup biofilm" (BBF) develops as a result of cyclical exposure to wet and dry phases during usage and reprocessing. This study investigated whether the BBF matrix represents a greater challenge to disinfectant efficacy and microbial eradication than traditional biofilm (TBF), which forms when a surface is constantly bathed in fluid.

Methods

Using the MBEC (Minimum Biofilm Eradication Concentration) system, a unique modelling approach was developed to evaluate microbial survival in BBF formed by repetitive cycles of drying, disinfectant exposure and re-exposure to the test organism. This model mimics the cumulative effect of the reprocessing protocol on flexible endoscopes. Glutaraldehyde (GLUT) and accelerated hydrogen peroxide (AHP) were evaluated to assess the killing of microbes in TBF and BBF.

Results

The data showed that the combination of an organic matrix and aldehyde disinfection quickly produced a protective BBF that facilitated high levels of organism survival. In cross-linked BBF formed under high nutrient conditions the maximum colony forming units (CFU) reached ~6 Log₁₀ CFU/peg. However, if an oxidizing agent was used for disinfection and if organic levels were kept low, organism survival did not occur. A key finding was that once established, the microbial load of BBF formed by GLUT exposure had a faster rate of accumulation than in TBF. The rate of biofilm survival post high-level disinfection (HLD) determined by the maximum Log₁₀CFU/initial Log₁₀CFU for E. faecalis and P. aeruginosa in BBF was 10 and 8.6 respectively; significantly different compared to a survival rate in TBF of ~2 for each organism. Data from indirect outgrowth testing demonstrated for the first time that there is organism survival in the matrix. Both TBF and BBF had surviving organisms when GLUT was used. For AHP survival was seen less frequently in BBF than in TBF.

Conclusion

This BBF model demonstrated for the first time that survival of a wide range of microorganisms does occur in BBF, with significantly more rapid outgrowth compared to TBF. This is most pronounced when GLUT is used compared to AHP. The data supports the need for meticulous cleaning of reprocessed endoscopes since the presence of organic material and microorganisms prevents effective disinfection when GLUT and AHP are used. However, cross-linking agents like GLUT are not as effective when there is BBF. The data from the MBEC model of BBF suggest that for flexible endoscopes that are repeatedly used and reprocessed, the assurance of effective high-level disinfection may decrease if BBF develops within the channels.

Using detachment-promoting agents for the prevention of chronic peritoneal dialysis-associated infections

Biofilms are known to be responsible for chronic peritoneal dialysis (PD)-related infections. Such infections are still frequent among patients in PD. The aim of this study was to develop a new approach in the prevention of chronic PD-related infection by regular injection of specific formulations containing detachment-promoting agents. A biofilm reactor system reproducing PD-like operating conditions was developed. A first set of experiments allowed the assessment of the anti-biofilm efficacy of various formulations. Then, experiments were performed for a longer duration and selected formulations were tested and compared with taurolidine. Biofilm removal was quantified by calculating the percentage of coverage reduction compared with an untreated control. A regular weekly treatment led to a 97% reduction of the surface coverage although a daily treatment with taurolidine still left 48% of the biomass on the surface. Such treatment is recommended to reduce the frequencies of chronic PD-related infections.

Biofilms in wounds: management strategies

Biofilms probably induce a chronic and/or 'quiet' inflammation in the chronic wound and so delay healing. This paper reviews current strategies that can be used to suppress biofilms in chronic wounds until better options are available.

Endoscopy-related infection: relic of the past?

PURPOSE OF REVIEW

Recent outbreaks of nosocomial infection and pseudoinfection have been linked to contaminated endoscopes. This review summarizes the recent literature, analyzes the latest published information related to the epidemiology, examines potential causes for the outbreaks, and discusses current alternatives for preventing infection.

RECENT FINDINGS

A systematic follow-up of patients revealed that the risk of infection attributed to inadequate endoscope reprocessing was very low. Nevertheless, inadequate reprocessing practices are still considered the main culprit underlying contamination from endoscopy procedures. Moreover, standards of care are difficult to maintain given the numerous inconsistencies that exist among reprocessing guidelines and manufacturer's recommended practices. Exposure to contaminated equipment could be prevented through better reprocessing practices and adherence to decontamination guidelines. Recent literature reinforces the need for endoscopy drying after each reprocessing cycle, endoscope reprocessing after short periods of disuse, surveillance, and for a coordinated approach to handle postcontamination responses. Additional analyses such as health technology assessment and cost analysis are needed to identify control alternatives that are most effective.

SUMMARY

Although the risk of endoscopy-related infection is very low, continued efforts are needed to ensure that quality is maintained during endoscope reprocessing to reduce the incidence of endoscopy-related infections.

[Five years of the Robert Koch Institute guidelines for reprocessing of flexible endoscopes. A look back and a look forward]

In a short review the national and international reception of the German guidelines for reprocessing flexible endoscopes is presented. The recommendations of the guidelines are discussed in view of recent knowledge on old problems such as prion inactivation and new infectious diseases and new microorganisms such as SARS, avian influenza and C. difficile. New disinfectants and new methods for endoscope disinfection are mentioned, the importance of careful cleaning is underlined. The German guidelines of the Robert Koch Institute and the US Multi-Society guidelines, published in 2003, are compared. The discrepancies concerning recommendations for water quality for final rinsing and need of microbiological controls of endoscope reprocessing are stressed. Aspects not mentioned in the German guidelines, e.g. duration of storage after reprocessing and risk of infection transmission by the endo-washer, are discussed.

Quantification of lipids and protein in thin biofilms by fluorescence staining

The efficiency of removing unwanted biofilm from surfaces in industrial water systems was examined by fluorescence microscopy and image analysis. A quantitative assay for in situ determination of biofilm components was developed and tested on thin biofilms grown in reactors as well as real biofilms sampled from a fish processing factory. Different fluorescent dyes for in situ detection of protein, lipid and total organic matter were tested. It was possible to determine the approximate amounts, concentrations and coverage of the different components by correlating the fluorescent intensity of the biofilm components to standard solutions immobilised as a biofilm. The quantification methods were evaluated as a strategy for determining the efficiency of different disinfection/cleaning procedures, showing that quantification of these biofilm components was fast and reliable for optimisation of cleaning in place procedures. However, the approach also showed that bacterial cells, as investigated by culture-independent procedures, were killed but not removed by most disinfection procedures tested, potentially leading to surfaces which are easily recolonised.

Microplate fluorescence assay for measurement of the ability of strains of Listeria monocytogenes from meat and meat-processing plants to adhere to abiotic surfaces

Listeria monocytogenes is a significant food-borne pathogen that is capable of adhering to and producing biofilms on processing equipment, making it difficult to eliminate from meat-processing environments and allowing potential contamination of ready-to-eat (RTE) products. We devised a fluorescence-based microplate method for screening isolates of L. monocytogenes for the ability to adhere to abiotic surfaces. Strains of L. monocytogenes were incubated for 2 days at 30 degrees C in 96-well microplates, and the plates were washed in a plate washer. The retained cells were incubated for 15 min at 25 degrees C with 5,6-carboxyfluorescein diacetate and washed again, and then the fluorescence was read with a plate reader. Several enzymatic treatments (protease, lipase, and cellulase) were effective in releasing adherent cells from the microplates, and this process was used for quantitation on microbiological media. Strongly adherent strains of L. monocytogenes were identified that had 15,000-fold-higher levels of fluorescence and 100,000-fold-higher plate counts in attachment assays than weakly adherent strains. Strongly adherent strains of L. monocytogenes adhered equally well to four different substrates (glass, plastic, rubber, and stainless steel); showed high-level attachment on microplates at 10, 20, 30, and 40 degrees C; and showed significant differences from weakly adherent strains when examined by scanning electron microscopy. A greater incidence of strong adherence was observed for strains isolated from RTE meats than for those isolated from environmental surfaces. Analysis of surface adherence among Listeria isolates from processing environments may provide a better understanding of the molecular mechanisms involved in attachment and suggest solutions to eliminate them from food-processing environments.