A new dry-surface biofilm model: An essential tool for efficacy testing of hospital surface decontamination procedures

The role of air relative humidity on the wettability of Pseudomonas fluorescens AR11 biofilms

Biofilms are complex porous materials formed by microorganisms, polysaccharides, proteins, eDNA, inorganic matter, and water. They are ubiquitous in various environmental niches and are known to grow at solid-liquid, solid-air and air-liquid interfaces, often causing problems in several industrial and sanitary fields. Their removal is a challenge in many applications and numerous studies have been conducted to identify promising chemical species as cleaning agents. While these substances target specific components of biofilm structure, the role of water content in biofilm, and how it can influence wettability and detergent absorption have been quite neglected in the literature. Estimating water content in biofilm is a challenging task due to its heterogeneity in morphology and chemical composition. In this study, we controlled water content in Pseudomonas fluorescens AR 11 biofilms grown on submerged glass slides by regulating environmental relative humidity after drying. Interfacial properties of biofilm were investigated by measuring wetting of water and soybean oil. The morphology of biofilm structure was evaluated using Confocal Laser Scanning Microscopy and Scanning Electron Microscopy. The results showed that biofilm water content has a significant and measurable effect on its wettability, leading to the hypothesis that a preliminary control of water content can play a crucial role in biofilm removal process.

Bacterial viability in dry-surface biofilms in healthcare facilities: a systematic review

BACKGROUND

Bacteria are known to live inside architectural structures called biofilms. Though standard biofilms have been studied extensively for more than 50 years, little is known about dry-surface biofilms (DSBs). Since 2012, DSBs have been described in several scientific papers, but basic knowledge about the viability and culturability of bacteria remains limited.

AIM

To conduct a systematic review to determine whether bacteria inside DSBs are viable, culturable, and enumerable.

METHODS

Eligible articles had to deal with DSBs containing at least one bacterial species involved in healthcare-associated infections, which developed in actual healthcare environments (in-situ) or with the help of any biofilm model (in-vitro).

FINDINGS

Twenty-four articles were included in the review. Whereas most of them isolated viable bacteria (87% in situ; 100% in vitro), no in-situ study quantified culturable bacteria in the biofilm per unit area. Conversely, 100% of in-vitro studies cultured the bacteria from controls and 94.4% supplied an enumeration of them. Culturable bacteria also grew after 78% of the cleaning, disinfection, or sterilization protocols tested. Microscopic observations after staining the samples with live/dead fluorescent probes (Baclight®) showed large amounts of viable cells in culture-negative samples.

CONCLUSION

Our study questions the efficacy of current methods for microbiological monitoring of surfaces, since these methods are only based on bacterial culturability. To improve both surface monitoring and cleaning and disinfection protocols, it is necessary to integrate the concept of DSBs which appears to contain a significant amount of viable but non-culturable bacteria.

Bacillus-based probiotic cleansers reduce the formation of dry biofilms on common hospital surfaces

In the absence of liquid suspension, dry biofilms can form upon hard surfaces within a hospital environment, representing a healthcare-associated infection risk. Probiotic cleansers using generally recognized as safe organisms, such as those of the Bacillus genus, represent a potential strategy for the reduction of dry biofilm bioburden. The mechanisms of action and efficacy of these cleaners are, however, poorly understood. To address this, a preventative dry biofilm assay was developed using steel, melamine, and ceramic surfaces to assess the ability of a commercially available Bacillus spp. based probiotic cleanser to reduce the surface bioburden of Escherichia coli and Staphylococcus aureus. Via this assay, phosphate-buffered saline controls were able to generate dry biofilms within 7 days of incubation, with the application of the probiotic cleanser able to prevent >97.7% of dry biofilm formation across both pathogen analogs and surface types. Further to this, surfaces treated with the probiotic mixture alone also showed a reduction in dry biofilm across both pathogen and surface types. Confocal laser scanning microscopy imaging indicated that the probiotic bacteria were able to germinate and colonize surfaces, likely forming a protective layer upon these hard surfaces.

Modelling hospital disinfectant against multi-drug-resistant dry surface biofilms grown under artificial human sweat

BACKGROUND

Dry surface biofilms (DSBs) have been found abundantly across hospital surfaces within intensive care units and may explain how nosocomial pathogens can remain virulent and persist on surfaces for extended periods. Testing standards governing the performance of disinfectant products employ planktonic models under routine growth conditions, which are known to be less tolerant than their biofilm counterpart.

AIM

To evaluate biofilm models cultured under artificial human sweat (AHS), a source of nutrient expected on touch surfaces, to assess the antimicrobial performance of common cleaning agents, including a quaternary ammonium, hydrogen peroxide and active chlorine.

METHODS

Five single-species biofilms, using pathogenic bacteria such as Acinetobacter baumannii, Pseudomonas aeruginosa, Staphylococcus aureus and Enterococcus faecalis, were generated on stainless-steel substrates using a sedimentation protocol under both AHS and nutrient-rich conditions for a direct comparison of phenotypic tolerance. The biofilm models were grown over five days followed by desiccation cycles, before being submerged into the disinfectant solutions for up to 25 min. Epifluorescence (EF) microscopy using LIVE/DEAD™ stain was used to visualize microcolony viability.

FINDINGS

The results revealed biofilms cultured under AHS exhibited a greater antimicrobial tolerance and reduced speed of kill for all cleaning agents compared with the routine media; an average reduction of 72.4% vs 96.9%, respectively. EF microscopy revealed traces of viable bacteria across all coupons after disinfection indicating a potential opportunity for regrowth and recontamination.

CONCLUSION

The notable difference in biocidal performance between the two growth conditions highlights potential pitfalls within current antimicrobial test standards, and the importance of accurate representation of the microbial challenge.

An automated contact model for transmission of dry surface biofilms of Acinetobacter baumannii in healthcare

BACKGROUND

Dry surface biofilms (DSBs) have been recognized across environmental and equipment surfaces in hospitals and could explain how microbial contamination can survive for an extended period and may play a key role in the transmission of hospital-acquired infections. Despite little being known on how they form and proliferate in clinical settings, DSB models for disinfectant efficacy testing exist.

AIM

In this study we develop a novel biofilm model to represent formation within hospitals, by emulating patient to surface interactions.

METHODS

The model generates a DSB through the transmission of artificial human sweat (AHS) and clinically relevant pathogens using a synthetic thumb capable of emulating human contact. The DNA, glycoconjugates and protein composition of the model biofilm, along with structural features of the micro-colonies was determined using fluorescent stains visualized by epifluorescence microscopy and compared with published clinical data.

RESULTS

Micrographs revealed the heterogeneity of the biofilm across the surface; and reveal protein as the principal component within the matrix, followed by glycoconjugates and DNA. The model repeatably transferred trace amounts of micro-organisms and AHS, every 5 min for up to 120 h on to stainless-steel coupons to generate a biofilm model averaging 1.16 × 103 cfu/cm2 falling within the reported range for clinical DSB (4.20 × 102 to 1.60 × 107 bacteria/cm2).

CONCLUSION

Our in vitro DSB model exhibits many phenotypical characteristics and traits to those reported in situ. The model highlights key features often overlooked and the potential for downstream applications such as antibiofilm claims using more realistic microbial challenges.

Klebsiella pneumoniae survives on surfaces as a dry biofilm

BACKGROUND

Dry surface biofilms (DSB) are widespread in healthcare settings presenting a challenge to cleaning and disinfection. Klebsiella pneumoniae has been a focus of attention due to antibiotic resistance and the emergence of hypervirulent strains. Few studies have demonstrated K pneumoniae survival on surfaces following desiccation.

METHODS

DSB were formed over 12 days. Bacterial culturability and transfer were investigated following DSB incubation up to 4 weeks. Bacterial viability in DSB was investigated with live/dead staining using flow cytometry.

RESULTS

K pneumoniae formed mature DSB. After 2 and 4 weeks of incubation, transfer from DSB was low (<55%) and reduced further (<21%) following wiping. Culturability at 2 and 4 weeks varied although viability remained high indicating viable but non culturable state (VBNC).

DISCUSSION

K pneumoniae was removed from surfaces by mechanical wiping as shown with DSB of other species. Although culturability was reduced over time, bacteria remained viable up to 4 weeks incubation, proving the need for robust cleaning regimens.

CONCLUSIONS

This is the first study confirming K pneumoniae survival on dry surfaces as a DSB. The presence of VBNC bacteria indicated that K pneumoniae can for extended periods, raising questions about its persistence on surfaces.

How biofilm changes our understanding of cleaning and disinfection

Biofilms are ubiquitous in healthcare settings. By nature, biofilms are less susceptible to antimicrobials and are associated with healthcare-associated infections (HAI). Resistance of biofilm to antimicrobials is multifactorial with the presence of a matrix composed of extracellular polymeric substances and eDNA, being a major contributing factor. The usual multispecies composition of environmental biofilms can also impact on antimicrobial efficacy. In healthcare settings, two main types of biofilms are present: hydrated biofilms, for example, in drains and parts of some medical devices and equipment, and environmental dry biofilms (DSB) on surfaces and possibly in medical devices. Biofilms act as a reservoir for pathogens including multi-drug resistant organisms and their elimination requires different approaches. The control of hydrated (drain) biofilms should be informed by a reduction or elimination of microbial bioburden together with measuring biofilm regrowth time. The control of DSB should be measured by a combination of a reduction or elimination in microbial bioburden on surfaces together with a decrease in bacterial transfer post-intervention. Failure to control biofilms increases the risk for HAI, but biofilms are not solely responsible for disinfection failure or shortcoming. The limited number of standardised biofilm efficacy tests is a hindrance for end users and manufacturers, whilst in Europe there are no approved standard protocols. Education of stakeholders about biofilms and ad hoc efficacy tests, often academic in nature, is thus paramount, to achieve a better control of biofilms in healthcare settings.

Staphylococcus aureus Cell Wall Phenotypic Changes Associated with Biofilm Maturation and Water Availability: A Key Contributing Factor for Chlorine Resistance

Staphylococcus aureus biofilms are resistant to both antibiotics and disinfectants. As Staphylococci cell walls are an important defence mechanism, we sought to examine changes to the bacterial cell wall under different growth conditions. Cell walls of S. aureus grown as 3-day hydrated biofilm, 12-day hydrated biofilm, and 12-day dry surface biofilm (DSB) were compared to cell walls of planktonic organisms. Additionally, proteomic analysis using high-throughput tandem mass tag-based mass spectrometry was performed. Proteins involved in cell wall synthesis in biofilms were upregulated in comparison to planktonic growth. Bacterial cell wall width (measured by transmission electron microscopy) and peptidoglycan production (detected using a silkworm larva plasma system) increased with biofilm culture duration (p < 0.001) and dehydration (p = 0.002). Similarly, disinfectant tolerance was greatest in DSB, followed by 12-day hydrated biofilm and then 3-day biofilm, and it was least in the planktonic bacteria--suggesting that changes to the cell wall may be a key factor for S. aureus biofilm biocide resistance. Our findings shed light on possible new targets to combat biofilm-related infections and hospital dry surface biofilms.

A comprehensive comparison of biofilm formation and capsule production for bacterial survival on hospital surfaces

Biofilm formation and capsule production are known microbial strategies used by bacterial pathogens to survive adverse conditions in the hospital environment. The relative importance of these strategies individually is unexplored. This project aims to compare the contributory roles of biofilm formation and capsule production in bacterial survival on hospital surfaces. Representative strains of bacterial species often causing hospital-acquired infections were selected, including Acinetobacter baumannii, Klebsiella pneumoniae, Staphylococcus aureus, Staphylococcus epidermidis and Pseudomonas aeruginosa. The importance of biofilm formation and capsule production on bacterial survival was evaluated by comparing capsule-positive wild-type and capsule-deficient mutant strains, and biofilm and planktonic growth modes respectively, against three adverse hospital conditions, including desiccation, benzalkonium chloride disinfection and ultraviolet (UV) radiation. Bacterial survival was quantitatively assessed using colony-forming unit (CFU) enumeration and the 2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide (XTT) assay and qualitatively by scanning electron microscopy (SEM). Correlations between capsule production and biofilm formation were further investigated. Biofilm formation contributed significantly to bacterial survival on hospital surface simulators, mediating high resistance to desiccation, benzalkonium chloride disinfection and UV radiation. The role of capsule production was minor and species-specific; encapsulated A. baumannii but not K. pneumoniae cells demonstrated slightly increased resistance to desiccation, and neither showed enhanced resistance to benzalkonium chloride. Interestingly, capsule production sensitized K. pneumoniae and A. baumannii to UV radiation. The loss of capsule in K. pneumoniae and A. baumannii enhanced biofilm formation, possibly by increasing cell surface hydrophobicity. In summary, this study confirms the crucial role of biofilm formation in bacterial survival on hospital surfaces. Conversely, encapsulation plays a relatively minor role and may even negatively impact bacterial biofilm formation and hospital survival.

A new spray-based method for the in-vitro development of dry-surface biofilms

The inanimate environment immediately surrounding the patient in healthcare facilities is a reservoir of microorganisms embedded in dry-surface biofilms (DSB). These biofilms, first highlighted in 2012, are increasingly studied, but currently available in-vitro models only allow for the growth of semi-hydrated biofilms. We developed a new in-vitro method under actual dehydration conditions based on the hypothesis that surface contamination is mainly due to splashes of respiratory secretions. The main objective of this study was to show that the operating conditions we have defined allowed the growth of DSB with a methicillin resistant Staphylococcus aureus strain. The second objective was to show that extended-spectrum beta-lactamase-producing Enterobacteriaceae, that is, Klebsiella pneumoniae and Enterobacter cloacae were also able to grow such biofilms under these conditions. Monobacterial suspensions in sterile artificial saliva (SAS) were sprayed onto polyethylene surfaces. Nutrients and hydration were provided daily by spraying SAS enriched with 20% of Brain Heart Infusion broth. The primary outcome was mean surface coverage measured by image analysis after crystal violet staining. The method applied to S. aureus for 12 days resulted in reproducible and repeatable DSB consisting of isolated and confluent microcolonies embedded in extracellular polymeric substances as shown in scanning electron microscopy images. Similar DSB were obtained with both Enterobacteriaceae applying the same method. No interspecies variation was shown between the three strains in terms of surface coverage. These first trials are the starting point for a 3-year study currently in process.

Evaluating the environmental microbiota across four National Health Service hospitals within England

Hospital surfaces contaminated with microbial soiling, such as dry surface biofilms (DSBs), can act as a reservoir for pathogenic micro-organisms, and inhibit their detection and removal during routine cleaning. Studies have recognized that such increases in bioburden can hinder the impact of disinfectants and mask the detection of potential pathogens. Cleanliness within healthcare settings is often determined through routine culture-based analysis, whereby surfaces that exhibit >2.5 colony-forming units (CFU) per cm² pose a risk to patient health; therefore, any underestimation could have detrimental effects. This study quantified microbial growth on high-touch surfaces in four hospitals in England over 19 months. This was achieved using environmental swabs to sample a variety of surfaces within close proximity of the patient, and plating these on to non-specific low nutrient detection agar. The presence of DSBs on surfaces physically removed from the environment was confirmed using real-time imaging through episcopic differential interference contrast microscopy combined with epifluorescence. Approximately two-thirds of surfaces tested exceeded the limit for cleanliness (median 2230 CFU/cm²), whilst 83% of surfaces imaged with BacLight LIVE/DEAD staining confirmed traces of biofilm. Differences in infection control methods, such as choice of surface disinfectants and cleaning personnel, were not reflected in the microbial variation observed and resulting risk to patients. This highlights a potential limitation in the effectiveness of the current standards for all hospital cleaning, and further development using representative clinical data is required to overcome this limitation.

Essential oils and their active components applied as: free, encapsulated and in hurdle technology to fight microbial contaminations. A review

Microbial contaminations are responsible for many chronic, healthcare, persistent microbial infections and illnesses in the food sector, therefore their control is an important public health challenge. Over the past few years, essential oils (EOs) have emerged as interesting alternatives to synthetic antimicrobials as they are biodegradable, extracted from natural sources and potent antimicrobials. Through their multiple mechanisms of actions and target sites, no microbial resistance has been developed against them till present. Although extensive documentation has been reported on the antimicrobial activity of EOs, comparisons between the use of whole EOs or their active components alone for an antimicrobial treatment are less abundant. It is also essential to have a good knowledge about EOs to be used as alternatives to the conventional antimicrobial products such as chemical disinfectants. Moreover, it is important to focus not only on planktonic vegetative microorganisms, but to study also the effect on more resistant forms like spores and biofilms. The present article reviews the current knowledge on the mechanisms of antimicrobial activities of EOs and their active components on microorganisms in different forms. Additionally, in this review, the ultimate advantages of encapsulating EOs or combining them with other hurdles for enhanced antimicrobial treatments are discussed.

Technologies to decontaminate bacterial biofilm on hospital surfaces: a potential new role for cold plasma?

Healthcare-associated infections (HCAIs) are a major challenge and the near patient surface is important in harbouring causes such as methicillin-resistant Staphylococcus aureus (MRSA) and Clostridioides difficile. Current approaches to decontamination are sub-optimal and many studies have demonstrated that microbial causes of HCAIs may persist with onward transmission. This may be due to the capacity of these microbes to survive in biofilms on surfaces. New technologies to enhance hospital decontamination may have a role in addressing this challenge. We have reviewed current technologies such as UV light and hydrogen peroxide and also assessed the potential use of cold atmospheric pressure plasma (CAPP) in surface decontamination. The antimicrobial mechanisms of CAPP are not fully understood but the production of reactive oxygen and other species is believed to be important. CAPP systems have been shown to partially or completely remove a variety of biofilms including those caused by Candida albicans, and multi-drug-resistant bacteria such as MRSA. There are some studies that suggest promise for CAPP in the challenge of surface decontamination in the healthcare setting. However, further work is required to define better the mechanism of action. We need to know what surfaces are most amenable to treatment, how microbial components and the maturity of biofilms may affect successful treatment, and how would CAPP be used in the clinical setting.

Mild Positive Pressure Improves the Efficacy of Benzalkonium Chloride against Staphylococcus aureus Biofilm

Current protocols using liquid disinfectants to disinfect heat-sensitive hospital items frequently fail, as evidenced by the continued isolation of bacteria following decontamination. The contamination is, in part, due to biofilm formation. We hypothesize that mild positive pressure (PP) will disrupt this biofilm structure and improve liquid disinfectant/detergent penetration to biofilm bacteria for improved killing. Staphylococcus aureus biofilm, grown on polycarbonate coupons in the biofilm reactor under shear at 35 °C for 3 days, was treated for 10 min and 60 min with various dilutions of benzalkonium chloride without PP at 1 atmosphere (atm), and with PP at 3, 5, 7, and 10 atm. The effect on biofilm and residual bacterial viability was determined by standard plate counts, confocal laser scanning microscopy, and scanning electron microscopy. Combined use of benzalkonium chloride and PP up to 10 atm significantly increased biofilm killing up to 4.27 logs, as compared to the treatment using disinfectant alone. Microscopy results were consistent with the viability plate count results. PP improved disinfectant efficacy against bacterial biofilm. The use of mild PP is possible in many flow situations or if equipment/contaminated surfaces can be placed in a pressure chamber.

Dual species dry surface biofilms; Bacillus species impact on Staphylococcus aureus survival and surface disinfection

Aims

Dry surface biofilms (DSB) survive on environmental surfaces throughout hospitals, able to resist cleaning and disinfection interventions. This study aimed to produce a dual species DSB and explore the ability of commercially available wipe products to eliminate pathogens within a dual species DSB and prevent their transfer.

Methods and Results

Staphylococcus aureus was grown with two different species of Bacillus on stainless steel discs, over 12 days using sequential hydration and dehydration phases. A modified version of ASTM 2967–15 was used to test six wipe products including one water control with the Fitaflex Wiperator. Staphylococcus aureus growth was inhibited when combined with Bacillus subtilis. Recovery of S. aureus on agar from a dual DSB was not always consistent. Our results did not provide evidence that Bacillus licheniformis protected S. aureus from wipe action. There was no significant difference of S. aureus elimination by antimicrobial wipes between single and dual species DSB. B. licheniformis was easily transferred by the wipe itself and to new surfaces both in a single and dual species DSB, whilst several wipe products inhibited the transfer of S. aureus from wipe. However, S. aureus direct transfer to new surfaces was not inhibited post‐wiping.

Conclusions

Although we observed that the dual DSB did not confer protection of S. aureus, we demonstrated that environmental species can persist on surfaces after disinfection treatment. Industries should test DSB against future products and hospitals should consider carefully the products they choose.

Significance and Impact of the Study

To our knowledge, this is the first study reporting on the production of a dual species DSB. Multispecies DSB have been identified throughout the world on hospital surfaces, but many studies focus on single species biofilms. This study has shown that DSB behave differently to hydrated biofilms.

Artificial Human Sweat as a Novel Growth Condition for Clinically Relevant Pathogens on Hospital Surfaces

The emergence of biofilms on dry hospital surfaces has led to the development of numerous models designed to challenge the efficacious properties of common antimicrobial agents used in cleaning. This is in spite of limited research defining how dry surfaces are able to facilitate biofilm growth and formation in such desiccating and nutrient-deprived environments. While it is well established that the phenotypical response of biofilms is dependent on the conditions in which they are formed, most models incorporate a nutrient-enriched, hydrated environment dissimilar to the clinical setting. In this study, we piloted a novel culture medium, artificial human sweat (AHS), which is perceived to be more indicative of the nutrient sources available on hospital surfaces, particularly those in close proximity to patients. AHS was capable of sustaining the proliferation of four clinically relevant multidrug-resistant pathogens (Acinetobacter baumannii, Staphylococcus aureus, Enterococcus faecalis, and Pseudomonas aeruginosa) and achieved biofilm formation at concentration levels equivalent to those found in situ (average, 6.00 log₁₀ CFU/cm²) with similar visual characteristics upon microscopy. The AHS model presented here could be used for downstream applications, including efficacy testing of hospital cleaning products, due to its resemblance to clinical biofilms on dry surfaces. This may contribute to a better understanding of the true impact these products have on surface hygiene. IMPORTANCE Precise modeling of dry surface biofilms in hospitals is critical for understanding their role in hospital-acquired infection transmission and surface contamination. Using a representative culture condition which includes a nutrient source is key to developing a phenotypically accurate biofilm community. This will enable accurate laboratory testing of cleaning products and their efficacy against dry surface biofilms.

Hydrogen peroxide, sodium dichloro-s-triazinetriones and quaternary alcohols significantly inactivate the dry-surface biofilms of Staphylococcus aureus and Pseudomonas aeruginosa more than quaternary ammoniums

Globally, healthcare-associated infections (HAI) are the most frequent adverse outcome in healthcare delivery. Although bacterial biofilms contribute significantly to the incidence of HAI, few studies have investigated the efficacy of common disinfectants against dry-surface biofilms (DSB). The objective of this study was to evaluate the bactericidal efficacy of seven Environmental Protection Agency (EPA)-registered liquid disinfectants against DSB of Staphylococcus aureus and Pseudomonas aeruginosa. We hypothesized that overall, there will be significant differences among the bactericidal efficacies of tested disinfectants by product type and active ingredient class. We also hypothesized that depending on the species, higher bactericidal efficacies against DSB will be exhibited after 24 h of dehydration compared to 72 h. Wet-surface biofilms of S. aureus and P. aeruginosa were grown following EPA-MLB-SOP-MB-19 and dehydrated for 24 and 72 h to establish DSB. Seven EPA-registered disinfectants were tested against dehydrated DSB following EPA-MLB-SOP-MB-20. Overall, quaternary ammonium plus alcohol, sodium dichloro-s-triazinetrione and hydrogen peroxide products were more efficacious against DSB than quaternary ammoniums for both tested species. While there was no significant difference in the log₁₀ reductions between 24 and 72 h S. aureus biofilms, significantly higher log₁₀ reductions were observed when products were challenged with 24 h P. aeruginosa DSB compared to 72 h P. aeruginosa DSB. Species type, active ingredient class and dry time significantly impact disinfectant efficacy against DSB of S. aureus or P. aeruginosa.

Supplemental nutrients stimulate the amplification of carbapenemase-producing Klebsiella pneumoniae (CPKP) in a sink drain in vitro biofilm reactor model

Liquid wastes (LW) disposed in hospital handwashing sinks may affect colonization of sink P-traps by carbapenemase-producing Klebsiella pneumoniae (CPKP), causing CPKP dispersal into the patient care environment. This study aimed to determine the effect of LW on biofilm formation and CPKP colonization in a P-Trap model (PTM). PTMs containing polymicrobial biofilms grown in autoclaved municipal tap water (ATW) supplemented with 5% dextrose in water (D5W), nutritional shake (Shake), sugar-based soft drink (Soda), or ATW were inoculated with K. pneumoniae ST258 KPC+ (ST258) or K. pneumoniae CAV1016 (CAV1016) and sampled after 7, 14, and 21 d. Biofilm bio-volume, mean thickness, and heterotrophic plate counts were significantly reduced and roughness coefficient significantly increased by Soda compared with D5W, Shake, or ATW. CPKP were significantly reduced by Soda but significantly amplified by D5W (ST258; CAV1016, 7 d) and Shake (ST258) suggesting that reducing LW disposal in sinks may reduce CPKP dispersal into patient care environments.

Is a reduction in viability enough to determine biofilm susceptibility to a biocide?

OBJECTIVE

The abundance and prevalence of dry-surface biofilms (DSBs) in hospitals constitute an emerging problem, yet studies rarely report the cleaning and disinfection efficacy against DSBs. Here, the combined impact of treatments on viability, transferability, and recovery of bacteria from DSBs has been investigated for the first time.

METHODS

Staphylococcus aureus DSBs were produced in alternating 48-hour wet-dry cycles for 12 days on AISI 430 stainless steel discs. The efficacy of 11 commercially available disinfectants, 4 detergents, and 2 contactless interventions were tested using a modified standardized product test. Reduction in viability, direct transferability, cross transmission (via glove intermediate), and DSB recovery after treatment were measured.

RESULTS

Of 11 disinfectants, 9 were effective in killing and removing bacteria from S. aureus DSBs with >4 log10 reduction. Only 2 disinfectants, sodium dichloroisocyanurate 1,000 ppm and peracetic acid 3,500 ppm, were able to lower both direct and cross transmission of bacteria (<2 compression contacts positive for bacterial growth). Of 11 disinfectants, 8 could not prevent DSB recovery for >2 days. Treatments not involving mechanical action (vaporized hydrogen peroxide and cold atmospheric plasma) were ineffective, producing <1 log10 reduction in viability, DSB regrowth within 1 day, and 100% transferability of DSB after treatment.

CONCLUSIONS

Reduction in bacterial viability alone does not determine product performance against biofilm and might give a false sense of security to consumers, manufacturers and regulators. The ability to prevent bacterial transfer and biofilm recovery after treatment requires a better understanding of the effectiveness of biocidal products.

A rapid model for developing dry surface biofilms of Staphylococcus aureus and Pseudomonas aeruginosa for in vitro disinfectant efficacy testing

Background

Bacterial biofilms persistent on dry environmental surfaces in healthcare facilities play an important role in the occurrence of healthcare associated infections (HAI). Compared to wet surface biofilms and planktonic bacteria, dry surface biofilms (DSB) are more tolerant to disinfection. However, there is no official method for developing DSB for in vitro disinfectant efficacy testing. The objectives of this study were to (i) develop an in vitro model of DSB of S. aureus and P. aeruginosa for disinfectant efficacy testing and (ii) investigate the effect of drying times and temperatures on DSB development. We hypothesized that a minimum six log₁₀ density of DSB could be achieved on glass coupons by desiccating wet surface biofilms near room temperatures. We also hypothesized that a DSB produced by the model in this study will be encased in extracellular polymeric substances (EPS).

Methods

S. aureus ATCC-6538 and P. aeruginosa ATCC-15442 wet surface biofilms were grown on glass coupons following EPA MLB SOP MB-19. A DSB model was developed by drying coupons in an incubator and viable bacteria were recovered following a modified version of EPA MLB SOP MB-20. Scanning electron microscopy was used to confirm the EPS presence on DSB.

Results

Overall, a minimum of six mean log₁₀ densities of DSB for disinfectant efficacy were recovered per coupon after drying at different temperatures and drying times. Regardless of strain, temperature and dry time, 86% of coupons with DSB were confirmed to have EPS.

Conclusion

A rapid model for developing DSB with characteristic EPS was developed for disinfectant efficacy testing against DSB.

Development of a high throughput and low cost model for the study of semi-dry biofilms

The persistence of microorganisms as biofilms on dry surfaces resistant to the usual terminal cleaning methods may pose an additional risk of transmission of infections. In this study, the Centre for Disease Control (CDC) dry biofilm model (DBM) was adapted into a microtiter plate format (Model 1) and replicated to create a novel in vitro model that replicates conditions commonly encountered in the healthcare environment (Model 2). Biofilms of Staphylococcus aureus grown in the two models were comparable to the biofilms of the CDC DBM in terms of recovered log₁₀ CFU well^-1. Assessment of the antimicrobial tolerance of biofilms grown in the two models showed Model 2 a better model for biofilm formation. Confirmation of the biofilms' phenotype with an extracellular matrix deficient S. aureus suggested stress tolerance through a non-matrix defined mechanism in microorganisms. This study highlights the importance of conditions maintained in bacterial growth as they affect biofilm phenotype and behaviour.

Impacts of a changing earth on microbial dynamics and human health risks in the continuum between beach water and sand

Although infectious disease risk from recreational exposure to waterborne pathogens has been an active area of research for decades, beach sand is a relatively unexplored habitat for the persistence of pathogens and fecal indicator bacteria (FIB). Beach sand, biofilms, and water all present unique advantages and challenges to pathogen introduction, growth, and persistence. These dynamics are further complicated by continuous exchange between sand and water habitats. Models of FIB and pathogen fate and transport at beaches can help predict the risk of infectious disease from beach use, but knowledge gaps with respect to decay and growth rates of pathogens in beach habitats impede robust modeling. Climatic variability adds further complexity to predictive modeling because extreme weather events, warming water, and sea level change may increase human exposure to waterborne pathogens and alter relationships between FIB and pathogens. In addition, population growth and urbanization will exacerbate contamination events and increase the potential for human exposure. The cumulative effects of anthropogenic changes will alter microbial population dynamics in beach habitats and the assumptions and relationships used in quantitative microbial risk assessment (QMRA) and process-based models. Here, we review our current understanding of microbial populations and transport dynamics across the sand-water continuum at beaches, how these dynamics can be modeled, and how global change factors (e.g., climate and land use) should be integrated into more accurate beachscape-based models.

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.

Artificial dry surface biofilm models for testing the efficacy of cleaning and disinfection

Dry surface biofilms (DSB) harbouring pathogens are widespread in healthcare settings, are difficult to detect and are resistant to cleaning and disinfection interventions. Here, we describe a practical test protocol to palliate the lack of standard efficacy test methods for DSB. Staphylococcus aureus DSB were produced over a 12-day period, grown with or without the presence of organic matter, and their composition and viability were evaluated. Disinfectant treatment was conducted with a modified ASTM2967-15 test and reduction in viability, transferability and biofilm regrowth post-treatment were measured. Dry surface biofilms produced over a 12-day period had a similar carbohydrates, proteins and DNA content, regardless of the presence or absence of organic matter. The combination of sodium hypochlorite (1000 ppm) and a microfiber cloth was only effective against DSB in the absence of organic load. With the increasing concerns of the uncontrolled presence of DSB in healthcare settings, the development of effective intervention model in the presence of organic load is appropriate for the testing of biocidal products, while the use of three parameters, log₁₀ reduction, transferability and regrowth, provides an accurate and practical measurement of product efficacy. SIGNIFICANCE AND IMPACT OF THE STUDY: The widespread presence of biofilms on dry surfaces in healthcare settings has been recently documented. These dry surface biofilms (DSB) present an unprecedented challenge to cleaning and disinfection processes. Here, we describe a practical efficacy protocol based on an in vitro Staphylococcus aureus DSB model. The protocol measures reduction in viability, transferability and biofilm regrowth post-treatment to provide altogether a practical assessment of product efficacy against dry surface biofilms.

Carbapenem resistance in Acinetobacter baumannii is associated with enhanced survival on hospital fabrics

The success of Acinetobacter baumannii as an emerging organism is probably linked to its high resistance to adverse environmental conditions. This study was conducted to analyze the association between some factors that may favor the dissemination of A. baumannii clinical isolates. A total of 47 clinical strains of A. baumannii were evaluated to carbapenem, the ability to produce biofilm, the susceptibility to some antiseptics, and the survival time on cotton fabrics. Most of the isolates were resistant to carbapenem (72.3%), produced biofilm (83%), and survived more than 7 (51%) days on fabrics. A significant association between decreased susceptibility to antiseptics containing chlorhexidine or triclosan and carbapenem resistance and survival on fabrics could be observed. The resistance to carbapenem was significantly associated with survival on fabric, but not with the ability to form biofilm. The survival of the isolates on fabric was not associated with the ability to produce biofilms. Characteristics, such as resistance to antibiotics, ability to form biofilm, and survival on dry surfaces, probably contribute to the proliferation of this organism when selected in the hospital environment and can partly explain its success as responsible for nosocomial infection.

Transmission of Staphylococcus aureus from dry surface biofilm (DSB) via different types of gloves

Background

Pathogens can survive for extended periods when incorporated into biofilm on dry hospital surfaces (ie, dry-surface biofilm, DSB). Bacteria within biofilm are protected from desiccation and have increased tolerance to cleaning agents and disinfectants.

Objective

We hypothesized that gloved hands of healthcare personnel (HCP) become contaminated with DSB bacteria and hence may transmit bacteria associated with healthcare-associated infections (HAIs).

Method

Staphylococcus aureus DSB was grown in vitro on coupons in a bioreactor over 12 days with periodic nutrition interspersed with long periods of dehydration. Each coupon had ~107 DSB bacterial cells. Transmission was tested with nitrile, latex, and surgical gloves by gripping DSB-covered coupons then pressing finger tips onto a sterile horse blood agar surface for up to 19 consecutive touches and counting the number of colony-forming units (CFU) transferred. Coupons were immersed in 5% neutral detergent to simulate cleaning, and the experiment was repeated.

Results

Bacterial cells were readily transmitted by all 3 types of gloves commonly used by HCP. Surprisingly, sufficient S. aureus to cause infection were transferred from 1 DSB touch up to 19 consecutive touches. Also, 6 times more bacteria were transferred by nitrile and surgical gloves than to latex gloves (P <.001). Treating the DSB with 5% neutral detergent increased the transmission rate of DSB bacteria 10-fold.

Conclusion

Staphylococcus aureus incorporated into environmental DSB and covered by extracellular polymeric substances readily contaminates gloved hands and can be transferred to another surface. These results confirm the possibility that DSB contributes to HAI acquisition.

Cross-transmission in the Dental Office: Does This Make You Ill?

PURPOSE OF REVIEW

Recently, numerous scientific publications were published which shed new light on the possible risks of infection for dental healthcare workers and their patients. This review aimed to provide the latest insights in the relative risks of transmission of (pathogenic) micro-organisms in the dental office.

RECENT FINDINGS

Of all different routes of micro-organism transmission during or immediately after dental treatment (via direct contact/via blood-blood contact/via dental unit water and aerosols), evidence of transmission is available. However, the recent results put the risks in perspective; infections related to the dental office are most likely when infection control measures are not followed meticulously.

SUMMARY

The risk for transmission of pathogens in a dental office resulting in an infectious disease is still unknown; it seems to be limited in developed countries but it cannot be considered negligible. Therefore, maintaining high standards of infection preventive measures is of high importance for dental healthcare workers to avoid infectious diseases due to cross-contamination.

Modelling vaporised hydrogen peroxide efficacy against mono-species biofilms

This pilot study investigates a novel approach towards efficacy testing of antimicrobial cleaning agents; focusing primarily on hydrogen peroxide vapour (HPV). Contaminated surfaces are recognised modes of pathogen transmission within healthcare environments and increase the risk of pathogen acquisition in newly admitted patients. Studies have shown these pathogens can survive on surfaces for extended periods of time in spite of cleaning. This resilience is characteristic of biofilm formation and recent publications have identified their presence in hospitals. In this study, biofilm models comprised of multidrug-resistant organisms (MDROs) were generated using a drip flow reactor and exposed to HPV decontamination. The MDROs included Acinetobacter baumannii, Enterococcus faecalis, Klebsiella pneumoniae, Pseudomonas aeruginosa and Staphylococcus aureus. Upon exposure, samples were periodically removed and enumerated to generate kill curves for each species. Consequently revealing any inherent resistances; such as catalase-producing organisms which expressed reduced susceptibility. Epifluorescence microscopy revealed an abundance of viable and non-viable microcolonies before and after decontamination, respectively. Greater than 6-Log₁₀ reduction was achieved within a 100 minutes exposure time. This pilot study puts forward a potential methodology for testing antimicrobial agents against biofilms and supports the efficacy of HPV.

Staphylococcus aureus dry-surface biofilms are more resistant to heat treatment than traditional hydrated biofilms

BACKGROUND

The importance of biofilms to clinical practice is being increasingly realized. Biofilm tolerance to antibiotics is well described but limited work has been conducted on the efficacy of heat disinfection and sterilization against biofilms.

AIM

To test the susceptibility of planktonic, hydrated biofilm and dry-surface biofilm forms of Staphylococcus aureus, to dry-heat and wet-heat treatments.

METHODS

S. aureus was grown as both hydrated biofilm and dry-surface biofilm in the CDC biofilm generator. Biofilm was subjected to a range of temperatures in a hot-air oven (dry heat), water bath or autoclave (wet heat).

FINDINGS

Dry-surface biofilms remained culture positive even when treated with the harshest dry-heat condition of 100°C for 60min. Following autoclaving samples were culture negative but 62-74% of bacteria in dry-surface biofilms remained alive as demonstrated by live/dead staining and confocal microscopy. Dry-surface biofilms subjected to autoclaving at 121°C for up to 30min recovered and released planktonic cells. Recovery did not occur following autoclaving for longer or at 134°C, at least during the time-period tested. Hydrated biofilm recovered following dry-heat treatment up to 100°C for 10min but failed to recover following autoclaving despite the presence of 43-60% live cells as demonstrated by live/dead staining.

CONCLUSION

S. aureus dry-surface biofilms are less susceptible to killing by dry heat and steam autoclaving than hydrated biofilms, which are less susceptible to heat treatment than planktonic suspensions.

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.

Staphylococcus aureus dry-surface biofilms are not killed by sodium hypochlorite: implications for infection control

BACKGROUND

Dry hospital environments are contaminated with pathogenic bacteria in biofilms, which suggests that current cleaning practices and disinfectants are failing.

AIM

To test the efficacy of sodium hypochlorite solution against Staphylococcus aureus dry-surface biofilms.

METHODS

The Centers for Disease Control and Prevention Biofilm Reactor was adapted to create a dry-surface biofilm, containing 1.36 × 10(7)S. aureus/coupon, by alternating cycles of growth and dehydration over 12 days. Biofilm was detected qualitatively using live/dead stain confocal laser scanning microscopy (CLSM), and quantitatively with sonicated viable plate counts and crystal violet assay. Sodium hypochlorite (1000-20,000parts per million) was applied to the dry-surface biofilm for 10min, coupons were rinsed three times, and residual biofilm viability was determined by CLSM, plate counts and prolonged culture up to 16 days. Isolates before and after exposure underwent minimum inhibitory concentration (MIC) and minimum eradication concentration (MEC) testing, and one pair underwent whole-genome sequencing.

FINDINGS

Hypochlorite exposure reduced plate counts by a factor of 7 log10, and reduced biofilm biomass by a factor of 100; however, staining of residual biofilm showed that live S. aureus cells remained. On prolonged incubation, S. aureus regrew and formed biofilms. Post-exposure S. aureus isolates had MICs and MECs that were not significantly different from the parent strains. Whole-genome sequencing of one pre- and post-exposure pair found that they were virtually identical.

CONCLUSIONS

Hypochlorite exposure led to a 7-log kill but the organisms regrew. No resistance mutations occurred, implying that hypochlorite resistance is an intrinsic property of S. aureus biofilms. The clinical significance of this warrants further study.