Biofilm: Undercover Assassin

A career in medicine can be a fascinating one. It provides a format for continual learning, especially for those who choose to read articles, go to conferences, participate in webinars, etc. Those are the nurses who will know the latest techniques, research, medications, medical equipment, and procedures. Knowledge accumulates in our memory just like biofilm builds up in the plaque on our teeth, inside a pipe, in river streams, and inside medical equipment. It does not matter where you work as a nurse or if you are a nursing student; biofilm can affect your patients.

In your education whether at school or in the workplace you will begin to see the word biofilm. It can be a threat to a patient's health and the healing process once it begins to form and grow under its protective shield. It is important to be informed and aware of the properties of biofilm in order to effectively treat patients and prevent infections. Biofilm is a relatively new concept, so let's take a look at what we are dealing with.

What is Biofilm?

In order to prevent or treat biofilm, an understanding of it's foundation is crucial. Biofilm is a community made up of social bacteria. The article "Center for Biofilm Engineering Biofilm basics: Section 1" tells us that they can form from one single type of bacteria or a mixture of bacteria, fungi, algae, and protozoa. In fact, over five hundred types of bacteria has been identified in dental biofilm. The cells are held together by a sticky gluey polysaccharide ( complex carbohydrates, starches or cellulose) substance that begins forming once enough cells are attached to an indwelling medical device, industrial/potable water piping, and natural water such as streams (Donlan).

This matrix of cells mix with noncellular materials such as clay particles, blood components, or mineral crystals to help in the bonding process (Donlan). The result of this marriage between noncellular and cellular materials is a three dimensional and potentially harmful biofilm. The life cycle of biofilm begins with its attachment to free floating bacteria in just minutes on a wet surface. The second stage is the secretion of the glue that holds it all together. Within hours there can be a complex community that in the third stage can multiply to other areas with the detachment of seeds to attach in other sites (Center).

Where Does Biofilm Live?

With what we know about biofilm, it seems intelligent with survivalist instincts. The first person to document the presence of biofilm was Anton van Leeuwenhoek as stated in the article "The Marshall Protocol Knowledge Base". He simply scraped some plaque off his own teeth and looked under a microscope at it. However it wasn't until the 1980s and 90s that microbiologists began to realize how organized biofilm can be. Isolating bacteria and studying the effects of antibiotics on them helped scientist find that biofilm formed in the right conditions (Center). They found that " microbial biofilms are naturally tolerant of antibiotics in doses up to 1,000 times greater than doses that kill planktonic bacteria" (Center).

Finding biofilm in plaque was just the beginning. It was then found on the interior of pipes, on floors and counters, making commercial food preparation more difficult (Marshall). In a concerted effort, microbial ecologists, environmental engineers, and mathematicians over the years have collaborated in their study of this thing called biofilm.

The colonized bacteria can change forms several times to adapt to the environment in order to get the nutrients needed to grow. This adaptation results in less competition accomplished by "chemical vocabulary" allowing biofilm to thrive (Marshall).

Finding biofilm in the environment can cause issues but in the human body it can cause serious infections and even death. It has been found in patients with cystic fibrosis, mitral valve endocarditis, otitis media, prostatitis, indwelling medical devices, kidney stones, prosthetic joints, heart valves, and diabetic foot wounds (Marshall).

How can biofilm be treated and prevented?

The extraordinary properties of biofilm make it immune to antibiotics too because of their special set of genes, a fact studied by Lawrence Muscarella M.D. Muscarella gives a presentation available on the SGNA website learning link providing information of the properties of biofilm. They cling to the inside of scopes used in colonoscopy, EGD scopes, orthopedic implants, and central venous catheters, thriving and multiplying resulting in high mortality and morbidity rates.

The only treatment to rid patients of biofilm in some cases is to remove the prosthetic or catheter. In diabetic foot ulcers, the only way to resolve the infection that is involved with biofilm is debridement (Neut). Researchers are looking into genetic relations to the biofilm in order to find ways to prevent it. They will also be focusing on controlling biofilm formation on medical devices. Regarding reusable medical equipment, such as endoscopy scopes, the only way to prevent formation of biofilm is to manually clean the scopes as soon as they are used following SGNA guidelines.

Duodenoscopes have been in the news lately for their link to severe illness and even deaths in patients who have undergone an ERCP - Endoscopic Retrograde Cholangiopancreatography. The purpose of the ERCP is to evaluate the bile and pancreatic duct for stones and tumors then treat to allow bile drainage. The duodenoscope has an elevator on it's tip that moves up and down and this is where the CRE - Carbapenem-Resistant Enterobacteriaceae has been found according to the article, "Design of Endoscopic Retrograde Cholangiopancreatography (ERCP) Duodenoscopes May Impede Effective Cleaning: FDA Safety Communication" published by the FDA.

Over 500,000 ERCPs are done annually with 135 patients between January 2013 and December 2014 reported to have possibly contracted CRE during the procedure. The FDA has published updated recommendations in cleaning the scopes, focusing on the elevator area, as well as testing the scopes weekly for contaminates by infection control in each facility. All three manufacturers of the scopes , Fujifilm, Olympus, and Pentax have reported related infections.

The latest model of duodenoscope by Olympus has gotten a lot of attention because they have not received final approval from the FDA, however, there have been no confirmed infections linked to that lack of clearance . The FDA did not require cancelling ERCPs in which these models of scopes would be used (Design).

The FDA is working with the CDC and the manufacturers of the scopes to find ways of preventing further infections (Design).

Since the February release of information regarding CRE related infections, a more recent report shows that the biofilm is still going strong. On March 5, 2015 ,a California hospital Cedars-Sinai released a statement that four confirmed cases of CRE has developed with one death (Another). A total of 67 patients could have been exposed, so the hospital has stopped doing ERCPs until further notice (Another).

There will be a lot of media attention and speculation regarding the duodenal scope related infections. For the most accurate and current information, read what the FDA and CDC release.

When you next encounter a patient that has a chronic infection, consider the undercover assassin you now know as biofilm. If you want to read more about biofilm use my references as links. Hopefully there will be more information soon regarding the research on prevention and treatment of biofilm. Look for further articles updating our knowledge of biofilm.

References

"Another California Superbug Outbreak Linked to Endoscopes". CaliforniaHealthline The Daily Digest of News, Policy &Opinions. 5 March, 2015. 12 March, 2015. Web.

"Biofilm bacteria". The Marshall Protocol Knowledge Base. Autoimmunity Research Foundation. 14 Feb. 2014. 8 Oct. 2014. Web.

Bjarnsholt T. "The role of bacterial biofilms in chronic infections." Pubmed. 2013 May: 136. 8 Oct. 2014. Web.

"Design of Endoscopic Retrograde Cholangiopancreatography (ERCP) Duodenoscopes May Impede Effective Cleaning: FDA Safety Communication". FDA.gov. 4 March, 2015. 12 March, 2015. Web.

Donlan, Rodney M. "Biofilms and Device-Associated Infections". Emerging Infectious Diseases. Centers for Disease Control and Prevention Atlanta, Georgia, USA. Vol 7, n 2 (March-April 2001). 5 February, 2015. Web.

Donlan, Rodney M. "Biofilms: Microbial Life on Surfaces". Emerging Infectious Diseases. Vol. 8, No. 9 (Sept. 2002). 5 February, 2015. Web.

Muscarella, Lawrence F. Ph.D. "GI Endoscopes and the Risk of Transmission of Biofilms, Clostridium Difficile and Other Epidemiologically Important Infectious Agents." SGNA Society of Gastroenterology Nurses and Associates, Inc. 5 February, 2015. Web.

Neut, Danielle. Tijdens-Creusen, Elvira JA. Bulstra, Sjoerd K. Van der Mei, Henny C. Busscher, Henk J. "Biofilms in Chronic diabetic foot ulcers - a study of 2 cases". Acta Orhopaedica The Official Publication of the Nordic Orthopedic Federation. 8 Jul. 2011. 21 Jan. 2015. Web.

"What are biofilms?". Center for Biofilm Engineering Biofilm basics: Section 1. Montana State University. 8 Oct. 2014. Web.