'Secondary biofilms' could cause failure of peracetic acid high-level disinfection of endoscopes

Evaluation of novel disinfection methods for the remediation of heavily contaminated TMVs and water systems with Pseudomonas aeruginosa biofilm: considerations for new and existing healthcare water systems

BACKGROUND

Pseudomonas aeruginosa is a leading cause of nosocomial Gram-negative bacteraemia. Water systems are a well-documented source of P. aeruginosa and established biofilms are difficult to remove.

AIM

To evaluate the efficacy of regular flushing, peracetic acid disinfection, in-tap thermal disinfection and in-line thermal disinfection to eradicate P. aeruginosa biofilm in a colonised tap model.

METHODS

A simulated tap system was constructed and inoculated with a reference and an environmental strain of P. aeruginosa to form biofilm. Water samples were collected from the taps and P. aeruginosa levels enumerated following disinfection methods. To simulate regular flushing, taps were flushed for 5 minutes, 5 times per day with water tested daily. Peracetic acid (4000 PPM) was manually injected into the system and flushed through the system with a pump. Thermal flushing at 60°C was performed in-line and with an in-tap bypass valve. Tests were conducted with cross-linked polyethylene (PEX) piping and repeated with copper piping.

FINDINGS

Regular flushing and peracetic acid applied with a pump did not reduce P. aeruginosa levels. A limited reduction was observed when manually injecting peracetic acid. In-tap thermal flushing eradicated P. aeruginosa in copper piping but not PEX. In-line thermal flushing was the most effective at reducing P. aeruginosa levels; however, did not eradicate the biofilm.

CONCLUSION

In-line thermal flushing was the most effective method to remove P. aeruginosa biofilm. Results vary significantly with the strain of bacteria and the composition of the plumbing. Several methods used in combination may be necessary to remove established biofilm.

Effect of household pipe materials on formation and chlorine resistance of the early-stage biofilm: various interspecific interactions exhibited by the same microbial biofilm in different pipe materials

Microbial community biofilm exists in the household drinking water system and would pose threat to water quality. This paper explored biofilm formation and chlorination resistance of ten dual-species biofilms in three typical household pipes (stainless steel (SS), polypropylene random (PPR), and copper), and investigated the role of interspecific interaction. Biofilm biomass was lowest in copper pipes and highest in PPR pipes. A synergistic or neutralistic relationship between bacteria was evident in most biofilms formed in SS pipes, whereas four groups displayed a competitive relationship in biofilms formed in copper pipe. Chlorine resistance of biofilms was better in SS pipes and worse in copper pipes. It may be helped by interspecific relationships, but was more dependent on bacteria and resistance mechanisms such as more stable extracellular polymeric substance. The corrosion sites may also protect bacteria from chlorination. The findings provide useful insights for microbial control strategies in household drinking water systems.

Comparison of two endoscope channel cleaning approaches to remove cyclic build-up biofilm

INTRODUCTION

Biofilm contributes significantly to bacterial persistence in endoscope channels. Enhanced cleaning methods capable of removing biofilm from all endoscope channels are required to decrease infection risk to patients. This head-to-head study compared cyclic build-up biofilm removal of an automated endoscope channel cleaner (AECC) with standard manual cleaning according to instructions for use (IFU) in polytetrafluorethylene channels.

METHODS

Cyclic build-up biofilm was grown in 1.4-mm (representing air/water and auxiliary channels) and 3.7-mm (representing suction/ biopsy channels) inner diameter polytetrafluorethylene channels. All channels were tested for residual total organic carbon, protein, and viable bacteria. Internationally recognized ISO 15883-5:2021 alert levels were used as cleaning benchmarks for protein (3 μg/cm2) and total organic carbon (6 μg/cm2).

RESULTS

The automated cleaner significantly outperformed manual cleaning for all markers assessed (protein, total organic carbon, viable bacteria) in 1.4-mm and 3.7-mm channels representing air/water/auxiliary and suction/biopsy channels, respectively. Manual cleaning failed to remove biofilm from the air/water and auxiliary channels. According to the IFU, these channels are not brushed, suggesting a potential root cause for a portion of the numerous endoscopy-associated infections reported in the literature.

CONCLUSION

AECC shows potential to deliver enhanced cleaning over current practice to all endoscope channels and may thereby address infection risk.

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.

Preparations of antibacterial yellow-green-fluorescent carbon dots and carbon dots-lysozyme complex and their applications in bacterial imaging and bacteria/biofilm inhibition/clearance

The preparation of functional long-wavelength-emitting nanomaterials and the researches on their applications in antibacterial and antibiofilm fields have important significance. This paper reports the preparation of yellow-green-fluorescent and high- quantum yield carbon dots (4-ACDs) with 4-aminosalicylic acid and polyethylene imine as raw materials through one-step route, and the impacts of raw material structure and the reaction conditions upon the optical properties of the products have been investigated. 4-ACDs exhibit excellent broad-spectrum antibacterial activity, and their good biocompatibility ensures them as ideal fluorescent nano-probe for cell imaging. However, 4-ACDs could not effectively eliminate the biofilm of Staphylococcus aureus (S. aureus). CDs-LZM complex was prepared through the coupling between 4-ACDs and lysozyme (LZM) and the complex showed strong antibacterial activity against Gram-positive bacteria, particularly with MIC against S. aureus at 5 μg mL^-1. Besides, CDs-LZM showed excellent ability against the biofilm of S. aureus. At the concentration of 60 μg mL^-1, its inhibition rate against the growth of biofilm was 86 %, and elimination rate against biofilm reached 76 %. CDs-LZM exhibited obvious antibiofilm ability through removing extracellular matrix of biofilm, greatly reducing the thickness of biofilm under confocal microscopy. The application of novel long-wavelength-emitting nanomaterial in eliminating pathogenic bacteria is of great significance.

Listeria monocytogenes Biofilms Are Planktonic Cell Factories despite Peracetic Acid Exposure under Continuous Flow Conditions

Listeria monocytogenes biofilms are ubiquitous in the food-processing environment, where they frequently show resistance against treatment with disinfectants such as peracetic acid (PAA) due to sub-lethal damage resulting in biofilm persistence or the formation of secondary biofilms. L. monocytogenes serovar ½a EGD-e biofilms were cultivated under continuous flow conditions at 10 °C, 22 °C, and 37 °C and exposed to industrially relevant PAA concentrations. The effect of PAA on biofilm metabolic activity and biomass was monitored in real-time using the CEMS-BioSpec system, in addition to daily measurement of biofilm-derived planktonic cell production. Biofilm-derived planktonic cell yields proved to be consistent with high yields during biofilm establishment (≥10⁶ CFU.mL^-1). The exposure of biofilms to the minimum inhibitory PAA concentration (0.16%) resulted in only a brief disruption in whole-biofilm metabolic activity and biofilm biomass accumulation. The recovered biofilm accumulated more biomass and greater activity, but cell yields remained similar. Increasing concentrations of PAA (0.50%, 1.5%, and 4.0%) had a longer-lasting inhibitory effect. Only the maximum dose resulted in a lasting inhibition of biofilm activity and biomass-a factor that needs due consideration in view of dilution in industrial settings. Better disinfection monitoring tools and protocols are required to adequately address the problem of Listeria biofilms in the food-processing environment, and more emphasis should be placed on biofilms serving as a "factory" for cell proliferation rather than only a survival mechanism.

Biofilm Degradation by Seashell-Derived Calcium Hydroxide and Hydrogen Peroxide

Microbial cells and self-produced extracellular polymeric substances assembled to form biofilms that are difficult to remove from surfaces, causing problems in various fields. Seashell-derived calcium hydroxide, a sustainable inorganic material, has shown high bactericidal activity even for biofilms due to its alkalinity. However, its biofilm removal efficacy is relatively low. Herein, we report a biofilm degradation strategy that includes two environmentally friendly reagents: seashell-derived calcium hydroxide and hydrogen peroxide. A biofilm model of Escherichia coli was prepared in vitro, treated with calcium hydroxide-hydrogen peroxide solutions, and semi-quantified by the crystal violet stain method. The treatment significantly improved biofilm removal efficacy compared with treatments by calcium hydroxide alone and hydrogen peroxide alone. The mechanism was elucidated from calcium hydroxide-hydrogen peroxide solutions, which suggested that perhydroxyl anion and hydroxyl radical generated from hydrogen peroxide, as well as the alkalinity of calcium hydroxide, enhanced biofilm degradation. This study showed that concurrent use of other reagents, such as hydrogen peroxide, is a promising strategy for improving the biofilm degradation activity of seashell-derived calcium hydroxide and will contribute to developing efficient biofilm removal methods.

Assessment of postmanual cleaning adenosine triphosphate tests to prevent the use of contaminated duodenoscopes and linear echoendoscopes: the DETECT study

BACKGROUND AND AIMS

We investigated whether the use of postmanual cleaning adenosine triphosphate (ATP) tests lowers the number of duodenoscopes and linear echoendoscopes (DLEs) contaminated with gut flora.

METHODS

In this single-center before-and-after study, DLEs were ATP tested after cleaning. During the control period, participants were blinded to ATP results: ATP-positive DLEs were not recleaned. During the intervention period, ATP-positive DLEs were recleaned. DLEs underwent microbiologic sampling after high-level disinfection (HLD) with participants blinded to culture results.

RESULTS

Using 15 endoscopes of 5 different DLE types, we included 909 procedures (52% duodenoscopes, 48% linear echoendoscopes). During the intervention period, the absolute rate of contamination with gut flora was higher (16% vs 21%). The main analysis showed that contamination was less likely to occur in the intervention period (odds ratio, .32; 95% credible interval [CI], .12-.85). A secondary analysis showed that this effect was based on 1 particular duodenoscope type (estimated probability, 39% [95% CI, 18%-64%] vs 9% [95% CI, 2%-21%]), whereas no effect was seen in the other 4 DLE types. In detail, of the 4 duodenoscopes of this type, 2 had lower contamination rates (69% vs 39% and 36% vs 10%). During the control period, both these duodenoscopes had multiple episodes with ongoing contamination with the same microorganism that ended weeks before the start of the intervention period (ie, they were not terminated by ATP testing).

CONCLUSIONS

Postmanual cleaning ATP tests do not reduce post-HLD gut flora contamination rates of DLEs. Hence, postcleaning ATP tests are not suited as a means for quality control of endoscope reprocessing.

Thermal and chemical disinfection of water and biofilms: only a temporary effect in regard to the autochthonous bacteria

Thermal and chemical disinfection of technical water systems not only aim at minimizing the level of undesired microorganisms, but also at preventing excessive biofouling, clogging and interference with diverse technical processes. Typically, treatment has to be repeated in certain time intervals, as the duration of the effect is limited. The transient effect of disinfection was demonstrated in this study applying different treatments to water and biofilms including heat, chlorination, a combination of hydrogen peroxide and peracetic acid and monochloramine. Despite the diverse treatments, the reduction in live bacteria was followed by regrowth in all cases, underlining the universal validity of this phenomenon. The study shows that autochthonous bacteria can reach the concentrations given prior to treatment. The reason is seen in the nutrient concentration that has not changed and that forms the basis for regrowth. Nutrients are released by disinfection from lysed cells or are still fixed in dead biomass that is subsequently scavenged by necrotrophic growth. Treatment cycles therefore only provide a transient reduction of water microbiology if nutrients are not removed. When aiming at greater sustainability of the effect, biocidal treatment has to be equally concerned about nutrient removal by subsequent cleaning procedures as about killing efficiency.