Difficulty in removing biofilm from dry surfaces.

Cleaning is fundamental to infection control. This report demonstrates that a Staphylococcus aureus biofilm is significantly more difficult to remove than dried planktonic bacteria. A single wiping action removed >99.9% (>3 log10) of dried planktonic bacteria, whereas only 1.4 log10 of biofilm (96.66%) was removed by 50 wiping actions with a standardized wiping process.

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.

Transfer of dry surface biofilm in the healthcare environment: the role of healthcare workers' hands as vehicles.

BACKGROUND: Dry surface biofilms (DSBs) persist for extended periods in hospital, and may play a significant role in transmission of healthcare-associated infections. AIM: To determine whether DSBs may be transferred from hospital surfaces to healthcare workers' hands. METHOD: Twelve-day Staphylococcus aureus DSB was grown on polycarbonate and glass coupons in a CDC Biofilm Reactor®. A total of 1.8 × 106 and 8.8 × 105 bacteria grew on the polycarbonate and glass coupons respectively. Transmission was tested by lifting the coupon with forefinger and thumb of ungloved hands to a height of 30 cm, then touching horse blood agar (HBA) plates 19 sequential times. Transferred bacterial number was determined by colony-forming units. The effect of DSB wetting on biofilm transfer was tested with 5% neutral detergent treatment for 5 s. FINDINGS: Between 5.5 and 6.6% of the DSB bacteria were transferred to hands with one touch and ∼20% were then transferred to HBA with one touch, giving an overall transfer rate of 1.26% and 1.04% for polycarbonate and glass coupons, respectively. Detergent treatment had little effect on bacterial removal from coupons, but, for biofilm grown on polycarbonate, significantly increased transferral to HBA (P < 0.001) to 5.2%. Large numbers of bacteria were transferred by bare hands to multiple fomites. One-third of polycarbonate coupons transferred >1000 colonies during the first five sequential touches. Sufficient bacteria to cause infection were transmitted up to 19 times following one touch of the DSB. CONCLUSION: DSB bacteria are transferred by hands from one fomite to multiple fomites, suggesting that DSB may serve as a persistent environmental source of pathogens.

Intensive care unit environmental surfaces are contaminated by multidrug-resistant bacteria in biofilms: combined results of conventional culture, pyrosequencing, scanning electron microscopy, and confocal laser microscopy.

BACKGROUND: Hospital-associated infections cause considerable morbidity and mortality, and are expensive to treat. Organisms causing these infections can be sourced from the inanimate environment around a patient. Could the difficulty in eradicating these organisms from the environment be because they reside in dry surface biofilms? AIM: The intensive care unit (ICU) of a tertiary referral hospital was decommissioned and the opportunity to destructively sample clinical surfaces was taken in order to investigate whether multidrug-resistant organisms (MDROs) had survived the decommissioning process and whether they were present in biofilms. METHODS: The ICU had two 'terminal cleans' with 500 ppm free chlorine solution; items from bedding, surrounds, and furnishings were then sampled with cutting implements. Sections were sonicated in tryptone soya broth and inoculated on to chromogenic plates to demonstrate MDROs, which were confirmed with the Vitek2 system. Genomic DNA was extracted directly from ICU samples, and subjected to polymerase chain reaction (PCR) for femA to detect Staphylococcus aureus and the microbiome by bacterial tag-encoded FLX amplicon pyrosequencing. Confocal laser scanning microscopy (CLSM) and scanning electron microscopy (SEM) were performed on environmental samples. FINDINGS: Multidrug-resistant bacteria were cultured from 52% (23/44) of samples cultured. S. aureus PCR was positive in 50%. Biofilm was demonstrated in 93% (41/44) of samples by CLSM and/or SEM. Pyrosequencing demonstrated that the biofilms were polymicrobial and contained species that had multidrug-resistant strains. CONCLUSION: Dry surface biofilms containing MDROs are found on ICU surfaces despite terminal cleaning with chlorine solution. How these arise and how they might be removed requires further study.

Use of the de Pezzer catheter to facilitate endoanal pull-through during ileal pouch-anal anastomosis.

Ileal pouch-anal anastomosis is now the treatment of choice for selected patients requiring proctocolectomy for benign mucosal disease of the large intestine. Pelvic sepsis continues to be a major postoperative complication. This is often subsequent to the technical complexity of the intestinal pull-through and ileal pouch-anal anastomosis. We report the use of the de Pezzer catheter to facilitate this often difficult reservoir pull-through during restorative proctocolectomy. This is an inexpensive and simple aid which has consistently helped to decrease operative difficulty, especially where pelvic access is restricted. By enabling the avoidance of clamps and tissue forceps, it has reduced the incidence of contamination and tissue trauma. It has enabled pull-through without undue tension on the reservoir and has facilitated postoperative drainage of the reservoir.

Deterioration of cold-stored tissue specimens due to lipid peroxidation: modulation by antioxidants at high subzero temperatures.

It is often necessary to store tissue specimens in subzero conditions for assay in batches. During storage at -20 degrees C we found that sufficient lipid peroxidation occurred in rat liver homogenates in phosphate-buffered saline to affect subsequent malondialdehyde assays. This peroxidation did not occur at -196 degrees C. The ratio of oxidized to reduced glutathione increased with storage at -20 degrees C and the level of conjugated dienes increased progressively. The addition of a specific free radical scavenger, superoxide dismutase (200 u/ml) reduced the level of malondialdehyde (P < 0.001) during -20 degrees C storage for periods of 28 days but failed to prevent the changes in the glutathione ratio or dienes. Storage in a less specific free radical scavenger, 0.25 molar sucrose/EDTA, instead of phosphate-buffered saline totally prevented the malondialdehyde production over similar storage periods.

Small intestinal perforation following minor trauma.

Small intestinal perforation occurred in two patients aged 70 years and 88 years who had experienced minor trauma by tripping or falling on the pavement. They both developed signs of generalized peritonitis and at laparotomy were found to have perforated the mid ileum. There was no sign of direct abdominal trauma but they had suffered minor facial trauma as a result of the fall.

Relaparotomy: a five-year review of indications and outcome.

Complications from abdominal surgery may necessitate reoperation and can be associated with significant morbidity and mortality. This review aims to analyse the incidence and outcome of relaparotomy for various indications. In a retrospective review of case notes of patients who had undergone one or more relaparotomies during the same hospitalisation between 1996 and 2000, 55 patients required relaparotomy. Indications included bleeding, infection, anastomotic leakage, wound dehiscence, necrotising pancreatitis, bowel necrosis, bowel obstruction and miscellaneous indications. Relaparotomy for dehiscence and obstruction carried minimal risk; for bleeding and infection entailed moderate risks; and for anastomotic leak had the highest mortality rate. The mortality rate increased in older age groups, multiple system and organ failure and multiple relaparotomies. The overall mortality rate was 38%. Twenty-nine per cent of patients had MRSA infection contributing to sepsis and multiple system and organ failure. Reintervention had brought to evidence technical errors, which could be corrected, and resulted in patient salvage in some cases. The mortality rate of relaparotomy has remained unchanged compared with data published previously, despite improvements in surgical techniques and critical care. Timely relaparotomy is valuable in the identification and treatment of complications following abdominal surgery.

Complications of percutaneous endoscopic enterostomy tubes.

Percutaneous endoscopic gastrostomy and jejunostomy tubes have been used clinically for approximately 10 years. They have been used predominantly in patients who cannot sustain their weight by oral intake, such as individuals with abnormalities of swallowing or intestinal peristalsis. The percutaneous endoscopic method of placement confers some advantages over classical surgical placement, especially in poor risk cases. Although several types of tube are commercially available, a substantial complication rate is still directly attributable to the tubes. In some series, complications are reported in 70% of cases. This report describes two complications of endoscopically introduced jejunostomy tubes used in patients with Roux-en-Y reconstructions after previous multiple gastric surgical procedures.

'Catastrophic' antiphospholipid syndrome.

When 'catastrophic' is applied as an adjective to the antiphospholipid syndrome, it implies a characteristic presentation due to predominantly small blood vessel thrombosis leading to rapidly progressive failure of multiple organs and a frequently fatal outcome. We present the case of a 48-year-old woman who presented with the 'catastrophic' antiphospholipid syndrome without previous history of coagulation disorder or connective tissue disease that illustrates the difficulties in diagnosing and managing this disorder. We also review the factors that have been reported to have a role in the development of this condition and show how this case throws light on its pathogenesis.

Neonatal and adult copper-64 metabolism in the pig and the possible relationship between the ontogeny of copper metabolism and Wilson's disease.

The copper profiles of neonatal mammals differ from those of the adult; in man they are similar to those found in people with Wilson's disease (WD). WD patients handle an intravenous bolus of radioactive copper in a characteristic manner which aids diagnosis. In view of the similarity between neonatal mammals and WD patients, we have studied the fate of an intravenous bolus of 64Cu injected into neonatal and adult pigs. In adult pigs, plasma 64Cu activity fell for 10 h and then slowly increased over the next 14 h as newly synthesised caeruloplasmin was secreted. In the neonate a secondary rise in 64Cu activity was not observed. Gel filtration of the soluble supernatant revealed significant differences in the association of 64Cu with hepatic copper proteins. In adults 64Cu associated predominantly with superoxide dismutase whilst in the neonate the 64Cu associated with metallothionein and a protein of high molecular weight. This study indicates that 64Cu export from the neonatal pig liver is in many ways similar to that found in WD. Additionally, there are similarities in the profile of hepatic 64Cu-binding proteins.