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The Horrors of Biofilm

This is a spooky little reminder that biofilm may be haunting your operating rooms, and you might not even know it. Think of it as a cauldron that contains a slimy matrix of extra cellular polymeric substances and prokaryotic organisms that, when mixed, combine to form a colony that multiplies and grows, becoming irreversible. We’re not sure about you, but that isn’t a potion we want mixed into our operating rooms now, is it?

Enough with the Halloween jargon; you get the point. It’s not ideal in any scenario to have this substance forming on our surgical instrumentation or devices. That said, what exactly is biofilm? We’ve all heard the term before, and it seems to be more and more normal in our sterile processing terminology these days. It’s a colony of clustered bacteria, or microorganisms that adhere to surfaces—a slimy matrix of extracellular polymeric substances produced by bacteria that aggregates. I’m not sure about you, but clustered bacteriapolymeric substance (a.k.a. glue-like), and slimy matrix are not words that I want associated with anything that will be entering any part of my body.

Biofilm can cause massive complications, and the threat is prevalent and relevant to anyone involved in working with surgical devices. Let’s break it down into a digestible form to better help you understand this threat, how to identify it, and how to manage it. No slimy bacteria colonies. Do we have a deal?

A microbial biofilm is made up of many prokaryotic organisms that combine to form a colony. The colony is adhered to a surface and coated with a polysaccharide layer (or slime layer). The slime consists of many porous layers with channels which allow the cells in the center of the colony to receive nutrients and remove waste products. The image below depicts how biofilm grows. 

Microbes can exist in two states: free floating or attached. Free floating bacteria encounter a surface and attach to it. This can only take minutes to do, so after a certain amount of time attachment is permanent and irreversible.

Negative outcomes
Some common infections that result from biofilm are otitis media (ear infection), cystic fibrosis (lung), surgical site infections (SSIs), and bloodstream infections.

For the sake of this article, surgical site infections and flexible endoscopes are paramount. Flexible endoscopes are reportedly associated with more documented cases of healthcare-acquired infections than any other type of reusable medical device (bronchosopes and duodenoscopes are the key offenders).

How to prevent formation
Now that we understand the anatomy of composition of biofilm, how free-floating bacteria finds a surface, attaches and adheres to it, and how that surface growth can rapidly transition from a single layer to a microcolony to multiple microcolonies (biofilm), it helps us paint a not-so-glorious story. It brings light to the fact that time is of the essence, and there is a reason. Spraying down instrumentation and maintaining moisture as soon as the patient exits the room (known as point of use) can help prevent this formation from beginning in the first place. Let’s delve a bit deeper into point of use and what governing agencies have to say about it.

Point of Use: “Decontamination of surgical instruments begins in the operating room. The Association of periOperative Registered Nurses (AORN) “Guideline for Cleaning and Care of Surgical Instruments,” and the Association for the Advancement of Medical Instrumentation (AAMI) Comprehensive guide to steam sterilization and sterility assurance in health care facilities ST79:2010 & A1:2010 & A2:2011 & A3:2012 & A4:2013, sections six and seven, recommend keeping instruments moist and wiped down at the point of use.”1

“The effectiveness of cleaning and decontamination is enhanced when the scrub personnel removes gross bioburden at the point of use both on surfaces and inside lumens. Therefore, during the surgical procedure, the scrub personnel should keep instruments and equipment free of gross soil by wiping the surfaces with a sterile surgical sponge moistened with sterile water (not saline). Lumens should also be irrigated with sterile water throughout the procedure in order to keep them clear and discourage the formation of biofilm.”1

Transport: To help prevent bioburden from drying and adhering, instruments should be kept moist until they are decontaminated.1

Containment: Occupational Safety and Health Administration (OSHA) regulations “require soiled instruments to be transported in a closed container or enclosed cart that is leakproof, puncture resistant, large enough to contain all of the contents, and labeled with a biohazard label.”1

After understanding the above knowledge and how serious this threat can be, your facility can take additional action by:

  • Performing a water test
  • Determining flow dynamics
  • Updating protocols/verifying competencies
  • Routine maintenance from professionals that have the tools, engineering, sterile efficacy testing capability, and manufacturing that will support patient safety and overall best outcome

Now that we understand the anatomy, formation, prevention methods, and actionable items your facility can take, let’s take the needed action to prevent biofilm from becoming a patient safety threat in your facility today.


  1. https://biosealnet.com/2015/08/cleaning-and-containment-prior-to-transportation

Rebecca Kinney has been working to improve patient safety in the medical arena for more than 13 years. She provides educational content on LinkedIn to help sterile processing and medical professionals gain knowledge as it relates to surgical devices, and her articles have appeared in Outpatient Surgery magazine. Her articles focus on the practical, hands-on knowledge operating room professionals can benefit from—never lacking in entertainment as she unfolds the true reality and struggles that are faced every day in the operating room setting. She is also a small business owner of a startup sales and marketing consulting agency.

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