American Journal of Infection Control 51 (2023) A114–A119

Contents lists available at ScienceDirect

American Journal of Infection Control

journal homepage: www.ajicjournal.org

Major Article

Biofilms on medical instruments and surfaces: Do they interfere with

instrument reprocessing and surface disinfection ]]
]]]]]]
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⁎
David J. Weber MD, MPH a,b, , William A. Rutala PhD, MS a, Deverick J. Anderson MD, MPH c,
Emily E. Sickbert-Bennett PhD, MS a,b
a
Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC
b
Department of Infection Prevention, UNC Medical Center, Chapel Hill, NC
c
Division of Infectious Diseases, School of Medicine, Duke University, Durham, NC

Key Words: Background: Biofilms are surface-attached communities of bacteria embedded in an extracellular matrix.
Endoscopy This matrix shields the resident cells from desiccation, chemical perturbation, invasion by other bacteria,
Medical devices and confers reduced susceptibility to antibiotics and disinfectants. There is growing evidence that biofilms
Environental surfaces
on medical instruments (especially endoscopes) and environmental surfaces interfere with cleaning and
disinfection.
Methods: The English literature on the impact of biofilms in medicine was reviewed with a focus on the
impact of biofilms on reusable semicritical medical instruments and hospital environmental surfaces.
Results: Biofilms are frequently present on hospital environmental surfaces and reusable medical equip­
ment. Important health care–associated pathogens that readily form biofilms on environmental surfaces
include Staphylococcus aureus, Pseudomonas aeruginosa, and Candida auris. Evidence has demonstrated that
biofilms interfere with cleaning and disinfection.
Discussion: New technologies such as “self-disinfecting” surfaces or continuous room disinfection systems
may reduce or disrupt biofilm formation and are under study to reduce the impact of the contaminated
surface environment on health care–associated infections.
Conclusions: Future research is urgently needed to develop methods to reduce or eliminate biofilms from
forming on implantable medical devices, reusable medical equipment, and hospital surfaces.
© 2023 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All
rights reserved.

BACKGROUND properties of the biofilm matrix constituents coupled with their

particular interactions give rise to the global biofilm mechanical
Biofilms are surface-attached communities of bacteria embedded properties.2 These properties allow the matrix to shield the resident
in an extracellular matrix. A defining feature of a biofilm is the cells from desiccation, chemical perturbation, invasion by other
presence of the extracellular matrix, made up of extracellular poly­ bacteria, and killing by predators. The matrix also provides the
meric substances (EPS) secreted by the cells dwelling inside.1 The mechanical properties necessary to protect the cells from external
EPS is usually a mixture of polysaccharides, proteins, extracellular forces such as fluid shear and to ensure the biofilm community re­
DNA, and other minor components. The physical and chemical mains attached to a surface2 Biofilms are found in nature adhering to
a variety of surfaces including rocks in streams (slime), water pipes,
and plant roots.
⁎
Prinzi and Rohde have described the steps and time course of
Address correspondence to DJ Weber, MD, MPH, Division of Infectious Diseases,
Bioinformatics Building, University of North Carolina at Chapel Hill, Suite 3101, CB
bacterial biofilm development as follows: (1) reversible attachment
7030130 Mason Farm Road, Chapel Hill, NC 27599-7030. of planktonic cells (seconds); (2) first colonizer becomes irreversibly
E-mail address: [email protected] (D.J. Weber). attached (seconds to minutes); (3) growth and cell division (hours to
Conflicts of interest: None to report. This article was published as part of a sup­ days); (4) production of EPS and formation of water channels (hours
plement supported by STERIS Corporation, Advanced Sterilization Products, Inc., GOJO
to days); and (5) attachment of secondary colonizers and dispersion
Industries, Inc., and IDEATE Medical, Inc. The opinions or views expressed in this
article are those of the authors and do not necessarily represent the official position of of microbes to new sites (days to months).3 Further, once the mi­
the funders. croorganisms mature, they can shed and move from the matured

https://doi.org/10.1016/j.ajic.2023.04.158
0196-6553/© 2023 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
 D.J. Weber et al. / American Journal of Infection Control 51 (2023) A114–A119 A115

biofilm to join another biofilm community or pioneer a new one. Implanted medical devices
Importantly, biofilms may involve only a single bacterial species or
be polymicrobial. Medical implants are artificial devices partly or entirely inserted
Importantly, studies have shown that viruses can secondarily co­ into the human body and intended to remain after the procedure for
lonize preexisting biofilms, and viral biofilms have been described.4,5 diagnostic, therapeutic, and rehabilitation purposes. Implanted
medical devices include intrauterine devices as a contraceptive,
breast implants, cerebrospinal fluid shunts, dental implants, cardi­
ROLE OF BACTERIAL BIOFILMS IN HUMAN INFECTION ovascular implants (eg, prosthetic heart valves, implantable cardio­
verters, pacemakers), gastrointestinal implants (eg, biliary stents),
When biofilm-associated microbes are pathogenic, the ability of urologic implants (eg, stents), orthopedic devices (ie, prosthetic
microbes to aggregate into biofilms becomes a significant virulence knees and hips, rods), and intravascular implants (eg, vascular grafts,
factor.3 As noted by Prinzi and Rohde, “the vast majority of human intravenous ports).11 Microbial biofilms may form on contaminated
infections are actually biofilm mediated. Biofilm infections are often implanted medical devices. Biofilms lead to increased resistance to
related to medical devices (e.g., knee replacements, catheters, im­ phagocytosis and biocides, which, in a clinical context, implies re­
plants, contact lenses, prosthetic valves and joints, screws and pins) sistance to host defense mechanisms.11 In addition, biofilms confer
or tissue related (e.g., chronic wounds, “staph” skin infections, en­ decreased susceptibility to antibiotic therapy.
docarditis, chronic otitis media, cystic fibrosis lungs).” Biofilm-re­
lated infections reoccur in ∼65%-80% of cases.6 Importantly, biofilms Pathogens asscociated with biofilms
can impact antimicrobial efficacy, as well as the immune response,
contributing to antimicrobial resistance and allowing the establish­ Pathogens frequently associated with biofilm formation on
ment of persistent or chronic infections.”3,6 implanted medical devices include Staphylococcus spp. (in parti­
cular Staphylococcus aureus), Acinetobacter spp. (especially
Acinetobacter baumannii), Enterobacteriales such as Escherichia
Antimicrobial resistence coli and Klebsiella pneumoniae, Pseudomonas spp. (in particular
Pseudomonas aeruginosa and P fluorescens), Enterococcus spp., and
The mechanisms by which biofilms reduce the effectiveness of Cutibacterium acnes.11 Staphylococcus lugdunensis is of increasing
antimicrobials have been reviewed.3,6,7 As described by Prinzi and concern.11 A more complete list of biofilm-forming microbes that
Rohde “In bacteria, common antibiotic resistance mechanisms include includes bacteria, fungi, and prostists has been published.12
point mutations, enzymes and efflux pumps. However, these me­ Biofilm formation is an important survival mechanism for health
chanisms are unlikely to be responsible for the resistance seen in care–associated pathogens that exhibit prolonged environmental
biofilm organisms. Various components work in tandem within a survival including Staphylococcus spp.,13–15 Pseudomonas spp.,16–20
biofilm to reduce, or fully prevent, antibiotic effectiveness and further Klebsiella,21 Candida aureus.22–29 Staphylococcus spp., especially
drive resistance. In combination, these mechanisms allow for the S aureus, are capable of forming biofilms that promote survival on
survival of organisms within the biofilm in the presence of high implantable medical devices and environmental surfaces. S capitus is
concentrations of antibiotics, a phenomenon known as recalci­ an emerging pathogen that has emerged as a worldwide public
trance.”3 Prinzi and Rohde further described 3 important mechanisms health problem, especially in neonatal intensive care units (ICU)
for antibiotic resistance of bacteria: (1) resistance at the biofilm sur­ where it is responsible for severe nosocomial sepsis in preterm
face (ie, impairment of antibiotic penetration); (2) resistance within neonates.15 The ability of S capitus to produce biofilm under nutrient
the biofilm microenvironment (ie, impairment of bactericidal effects stress and to resist desiccation on environmental surfaces explains
due to low oxygen, and accumulation of metabolic byproducts, waste why it is able to colonize and persist on neonatal ICU surfaces.15
and nutrient accumulation); and (3) resistance of bacterial “persister P aeruginosa produces a robust biofilm.16,17 Clinical isolates of P aer­
cells” (ie, bacteria existing in a dormant state may avoid antibiotic uginosa demonstrate a high prevalence of multidrug-resistance,
activity).3 Venkkatsan and colleagues divided factors affecting bac­ biofilm formation, and alginate production.18 Six strains of P aerugi­
terial resistance in biofilm into 3 groups: biochemical factors (exo nosa found in hospital water systems all demonstrated biofilm for­
polysaccharides, antibiotic degrading enzymes, extracellular DNA, mation after inoculation on polystyrene and glass surfaces, although
efflux pumps, and quorum sensing); molecular mechanisms (lateral with different growth kinetics.19 Some, but not all, strains of P aer­
and horizontal gene transfer and mutation); and altered host factors uginosa demonstrated desiccation tolerance on plastic and stainless-
(sub-MIC (Minimum inhibitory concentration) antibiotics, oxidative steel surfaces, a necessary feature to produce dry biofilms.20
stress, chemical signals, toxin-antitoxin modules, nutrients, tem­ The Centers for Disease Control and Prevention considers Candida
perature, pH, cell density, and osmolarity).6 auris to be an emerging fungus that presents a serious global health
Prevention strategies have been described.6,8–10 These include threat for the following reasons: (1) it is often multidrug resistant,
coating the surface with bactericides, quorum-sensing molecules or meaning that it is resistant to multiple antifungal drugs commonly
peptides, or creating nanostructures.6 As noted by Roy, a major focus used to treat Candida infections. Some strains are resistant to all 3
for improving the efficacy of treating biofilm-associated infections is available classes of antifungals; (2) it is difficult to identify with
the development of antibiofilm molecules that include herbal active standard laboratory methods, and they can be misidentified in labs
compounds, chelating agents, peptide antibiotics, and synthetic without specific technology. Misidentification may lead to in­
chemical compounds.8 Rather divided antibiofilm strategies into 3 appropriate management; and (3) It has caused outbreaks in health
groups: biological (natural products like plant extract, honey, and care settings30. For this reason, it is important to quickly identify
others; antiquorum sensing compounds, bacteriophages, antibiofilm C auris in a hospitalized patient so that health care facilities can take
peptides, capsular polysaccharides, biosurfactants, and matrix in­ special precautions to stop its spread.30 An important feature of
hibiting enzymes), physical (photodynamic therapy, bioelectric ap­ C auris is the ability to produce a robust biofilm that confers survival
proach, and ultrasonic treatment), and chemical (chelating agents, to disinfectant challenge, desiccation, and high-saline environ­
chemical modifications of surface coatings, chemical uncouplers, ments.22 These features allow C auris to readily colonize human skin
and other such as peracetic acid, hydrogen peroxide, and neutral and persist in the environment for prolonged periods of time.23
electrolyzed water).10 Biofilm formation in C auris has been reported to be a strain-
A116 D.J. Weber et al. / American Journal of Infection Control 51 (2023) A114–A119

dependent trait that is strongly associated with the type and phe­ Impact of biofilms on environmental surface microbe survival and
notypic behavior of the isolates.25 Sherry reported in 2017 that disinfection
C auris had the capacity to form antifungal-resistant biofilms that
were sensitive to chlorhexidine in vitro.26 Ledwoch assessed the The impact of biofilms on dry environmental surfaces in hospitals
susceptibility of C auris dry surface biofilms to 12 commercially has been reviewed.35,38,39, Biofilm formation, may in part, explain
wipe-based disinfectants and sodium hypochlorite (1,000 ppm) and how microbes may persist on environmental surfaces for days to
reported that a peracetic acid (3,500 ppm) and 2 chlorine-based months.38 Importantly, microbes attached to surfaces and in biofilms
products (1,000 ppm available chlorine) were successful in reducing are less susceptible to biocides and physical stress.38 Compared with
C auris viability and delaying biofilm regrowth.26 However, 50% of planktonic cells, microbes attached to surfaces are up to 10-fold less
the products tested failed to decrease C auris viability, 58% failed to susceptible to biocides, and mature biofilms up to 1,000-fold less
prevent its transferability, and 75% did not delay biofilm regrowth.26 susceptible to biocides.38 In general, bacteria in planktonic culture
In contrast, another study reported that C auris clinical isolates are more susceptible to biocides than attached cells, which are in
evaluated on different surface environments were tolerant to clini­ turn more susceptible than established biofilms as demonstrated in
cally relevant concentrations of sodium hypochlorite and peracetic multiple studies.38
acid in a surface-dependent manner.27 Rutala and colleagues using a Studies have assessed the epidemiology (location, microbial load,
disc-based quantitative test to assess the activity of 21 germicides presence or absence of biofilm and pathogens) of bacterial con­
against C auris and reported that chlorine-based products, a phe­ tamination of hospital room surfaces.40–43 Room surfaces in an in­
nolic, 1.4% improved hydrogen peroxide, and alcohol-quaternary tensive care unit that were sampled after 2 “terminal cleans” with a
ammonium compounds) were effective against C auris.31 Health care 500 ppm free chlorine solution revealed multidrug-resistant bac­
facilities should use a surface disinfectant on the Environmental teria were cultured from 52% (23/44) of the samples cultured.40
Protection Agency’s (EPA) List P for disinfection of surfaces housing a Biofilm was demonstrated in 93% (41/44) of samples and pyr­
patient with known or suspected C auris colonization or infection.32 osequencing demonstrated that the biofilms were polymicrobial and
C auris biofilms also reduce antifungal activity.28 A genomic contained multidrug-resistant strains.40 A study of 61 terminally
analysis of 2 C auris isolates with increased biofilm-forming capacity cleaned items from 3 different hospitals revealed that multispecies
revealed that amplification of the subtelomeric adhesion gene ALS4 dry biofilms were recovered from 95% of samples. A study of hospital
was the reason behind the strain’s enhanced adherence and biofilm- surfaces in different ICU revealed many intensive care surfaces (61%)
forming capacity.29 Ultraviolet-C room disinfection devices are also were highly contaminated by biological soil as determined by ATP
effective against C auris, but should be run on a cycle time that is bioluminescence testing but that the degree of biological soiling was
effective against Clostridioides difficile.33,34 not associated with bacterial contamination as detected by qPCR.41
Bacterial load ranged from 78.21 to 3.71 × 108 (median = 900) bac­
teria/100 cm2. Overall, 75% (71/95) of surface swabs were culture-
INFECTION PREVENTION IMPACT OF MICROBIAL BIOFILMS positive; of these, 22.5% contained multidrug-resistant organisms.
Biofilm was visually confirmed by microscopy on 70% (14/20) of
Microbial biofilms may impair infection prevention for several samples. A study of “high-touch” surfaces in the ICU of 2 Brazilian
main reasons.35 First, biofilms may develop on dry environmental hospitals reported that the average bacterial load was 1.32 × 104
surfaces impairing cleaning and disinfection. Second, biofilms may bacteria per cm2, container for newborn feeding bottles, stretcher
develop on reprocessed surgical instruments and medical devices mattress, humidicrib mattress filling, and computer keyboards pre­
(especially lumened endoscopes) impairing cleaning and disinfec­ sented the higher bioburdens.43 Overall, 45.6% (26/57) of surfaces
tion. Third, biofilms may develop on wet surfaces such as water sampled were culture-positive, including 4/26 with multidrug-re­
pipes, showers, taps, sinks, tubs, and drains and may serve as re­ sistant pathogens. Further, biofilm was present on all surfaces sub­
servoirs and/or source for microbial contamination of a patient’s jected to microscopy (n = 56), demonstrating that current cleaning
skin or the hands of health care providers. Biofilms have divided into practices are suboptimal and reinforcing that multidrug-resistant
several forms: (1) traditional biofilms that form under continuously organisms are incorporated into hospital surfaces biofilm.
hydrate conditions (eg, water pipes, taps, sinks, lumened endo­ Multiple studies have assessed the effectiveness of chemical
scopes); (2) build-up biofilm which form following exposure to disinfectants and heat against bacterial biofilms.44–49 Using the
chemicals (eg, high-level disinfectants or sterilants) or heat that can Centers for Disease Control and Prevention biofilm reactor, Alma­
fix organic residues onto the medical device surface; and (3) dry troudi tested the effectiveness of sodium hypochlorite (1000-
surface biofilms that represent a heterogeneous accumulation of 20,000 ppm) applied for 10 minutes to eliminate S aureus dry surface
organisms and other material in a dry matrix.35 biofilm.44 Hypochlorite exposure reduced plate counts by a factor of
Importantly, bacteria imbedded in dry surface biofilms may 7-log10 and reduced biofilm biomass by a factor of 100; however,
contaminate the hands or gloves of health care personnel. One staining of residual biofilm showed that live S aureus cells remained
study demonstrated that between 5.5% and 6.6% of S aureus dry and on prolonged incubation, S aureus regrew and formed biofilms at
surface biofilm bacteria were transferred to hands with one touch all concentrations tested.44 In a later study, Almatroudi reported that
and ∼20% were then transferred to blood agar plates with one dry-surface biofilms remained culture positive even when treated
touch, giving an overall transfer rate of 1.26% and 1.04% for with the harshest dry-heat condition of 100 °C for 60 minutes.45
polycarbonate and glass coupons, respectively.36 Another study Further, dry-surface biofilms subjected to autoclaving at 121 °C for
reported that S aureus imbedded in a dry surface biofilm was up to 30 minutes recovered and released planktonic cells.45 Ledwoch
readily transmitted by all 3 types of gloves (ie, nitrile, latex, and using an S aureus dry surface biofilm that the combination of sodium
surgical gloves) commonly used by health care providers.37 Fur­ hypochlorite (1,000 ppm) and a microfiber cloth was only effective
ther, sufficient S aureus to cause infection was transferred from 1 against biofilm in the absence of organic load.46 In a similar set of
dry surface biofilm touch up to 19 consecutive touches.37 Also, 6 experiments using S aureus dry surface biofilm, Chowdhury reported
times more bacteria were transferred by nitrile and surgical that biofilm viability was reduced by 2.8-log10 for the chlorine-based
gloves than to latex gloves (P < 0.001). Treating the dry surface products and by 2 log10 for Proxitane, but these products failed to kill
biofilm with 5% neutral detergent increased the transmission rate any biofilm in the presence of soil. In contrast, Surfex completely
of dry surface biofilm bacteria 10-fold.37 inactivated biofilm (6.3-log10 reduction) in the presence of soil. H2O2
 D.J. Weber et al. / American Journal of Infection Control 51 (2023) A114–A119 A117

products had little effect against the biofilm.49 Also, detergent effective even in the presence of blood.56 In fact, steam sterilization
treatment before disinfection had no effect. is the most effective sterilization technology with the largest margin
Lineback assessed the efficacy of 8 registered disinfectants (6 of safety, followed by ethylene oxide and hydrogen peroxide gas
registered by the US EPA and 2 products registered in by the plasma.56,57
European Chemical Agency) against S aureus and P aeruginosa and
reported that sodium hypochlorite and hydrogen peroxide disin­ Endoscopes
fectants had significantly higher bactericidal efficacies than qua­
ternary ammonium chloride disinfectants.47 They also found that all Semicritical items are those that come in contact with mucous
tested disinfectants except for quaternary ammonium chloride dis­ membranes or nonintact skin. Respiratory therapy and anesthesia
infectants met and exceeded the EPA standard for bactericidal effi­ equipment, gastrointestinal endoscopes, bronchoscopes, laryngo­
cacy against biofilms. Similarly, Chaggar used S aureus and scopes, transesophageal probes, tonometers, endocavitary probes,
P aeruginosa dry surface biofilms to assess the effectiveness of 7 EPA- transrectal ultrasound-guided prostate biopsy probes, cystoscopes,
registered disinfectants and reported quaternary ammonium plus hysteroscopes, infrared coagulation devices, and diaphragm fitting
alcohol, sodium dichloro-s-triazinetrione, and hydrogen peroxide rings are included in this category.58 These medical devices should
products were more efficacious against dry surface biofilms than be free of all microorganisms (ie, mycobacteria, fungi, viruses, and
quaternary ammoniums for both tested species.48 It was concluded bacteria), although small numbers of bacterial spores may be pre­
that species type, active ingredient class, and dry time significantly sent. Semicritical items represent the greatest risk of disease
impact disinfectant efficacy against dry surface biofilm of S aureus or transmission, as far more health care–associated infections have
P aeruginosa. been caused by reusable semicritical items than critical or non­
At the present time, there are no recommendations with regard critical items. Lumened endoscopes, especially gastrointestinal en­
to choosing a surface disinfectant based on the studies of their doscopes, have the highest potential for biofilm formation in the
ability to disrupt biofilms and/or inactivate microbes present in lumen to interfere with cleaning and disinfection, resulting in a
biofilms. Rather, hospital epidemiologists and infection preven­ substantial risk of health care–associated infections in patients. In
tionists should choose EPA-registered disinfectants based on the fact, gastrointestinal endoscopes and bronchoscopes have been as­
products antimicrobial claims as provided in the EPA-specific pa­ sociated with far more outbreaks of infections (> 130 outbreaks)
thogen lists,50 and a review of the advantages and disadvantages of than any other reusable medical or surgical device in health
specific types of disinfectants used for low-level disinfection.51 care.54,58,59 Importantly, gastrointestinal endoscopes), by virtue of
the body cavities they enter, may contain 107-10 (7-10-log10) enteric
Impact of biofilms on disinfection of surgical instruments and medical microorganisms. Because of this high microbial burden, the margin
devices of safety associated with cleaning and high-level disinfection of
gastrointestinal endoscopes is minimal or nonexistent (level of
Biofilms may interfere with the cleaning and disinfection of contamination: 4-log10 [maximum contamination, minimal cleaning
reusable surgical equipment and medical devices (eg, endoscopes).35 and high-level disinfection] to −5-log10 [minimum contamination,
maximum cleaning and high-level disinfection]).54,58,59 Especially
Surgical equipment important are the multiple outbreaks of carbapenem-resistant En­
terobacterales in patients who have undergone endoscopic retro­
Surgical instruments are considered critical items because they grade cholangiopancreatography despite the endoscopic retrograde
enter sterile body tissues or the vascular system, and if con­ cholangiopancreatography scope having undergone cleaning and
taminated with any microorganism, including bacterial spores, this high-level disinfection per the manufacturer’s instructions or use
could result in infection.51 A study of the bioburden of used surgical (MIFU).60,61
instruments reported that approximately 70% of the used instru­ As noted above, there is substantial evidence for the accumu­
ments obtained after cleaning were contaminated with 10 or less lation of organic material and microbial survival despite MIFU
colony-forming units (CFU).52 Fourteen percent were contaminated reprocessing of flexible endoscopes.35,60,61 As noted by Alfa, the
with 11-100 CFU and 14% were contaminated with greater than 100 key question is whether the existing validated MIFU for endoscope
CFU. Overall, 30% of the instruments yielded no growth. The low reprocessing can eliminate traditional biofilm. A study of 66 en­
bioburden on used surgical instruments was demonstrated in a doscope suction and biopsy channels and 13 water and air chan­
subsequent study, which reported that the microbial load on used nels revealed that obvious biofilm growth was detected on 36
surgical instruments before cleaning was generally low; 58% had 10 suction and biopsy channels (36/66, 54.6%) and 10 water and air
CFU or less, and 78% had 100 CFU or less.53,54 However, despite the channels (10/13, 76.9%).62 The formation of endoscopic biofilm
bioburden on used surgical instruments, decontamination is re­ during clinical practice was related to the reuse of detergent,
commended for the following 2 reasons: (1) it protects the staff manual cleaning, and incomplete drying.62 One study which as­
handling the instruments from acquiring infection in the event of a sessed the impact between not-aged and accelerated-aging of
percutaneous injury; and (2) it reduces the microbial contamination research material that mimicked the surfaces of scopes, reported
on instruments as well as protein and salt before sterilization and that significant differences between the 2 sample groups (ie, not-
thereby enhances the reliability of the sterilization process. Protein aged and aged) were observed in the pattern of physical surface
and salt have been shown to interfere with the sterilization pro­ alterations.63 A study that evaluated a dismantled duodenoscope
cesses, especially low-temperature sterilization processes.53 In ad­ reported that alterations were noticed on both the coating and
dition to immediate decontamination, surgical instruments should working channel polymers, with external alterations increasing
be cleaned in a washer-disinfector prior to sterilization. One study progressively from the proximal sample to the distal sample near
demonstrated a washer-disinfecter was extremely effective in the tip of the scope.64 Primo and colleagues studied new gastro­
eliminating microorganisms (> 7-log10 reduction), including vege­ intestinal endoscopes and reported that after an average of 60
tative and spore-forming bacteria, from experimentally con­ uses, extensive biofilm was detected in air, water, and air-water
taminated instruments.55 As steam sterilization is the most robust junction channels (18/28, 64%).65 In addition, all channels (28 of
sterilization technology, all instruments unless heat sensitive should 28) showed residual matter, and structural damage was identified
undergo standard steam sterilization.51 Steam sterilization is in most of them (20 of 28). A systematic review of 12 studies that
A118 D.J. Weber et al. / American Journal of Infection Control 51 (2023) A114–A119

evaluated the impact when there was a lack of drying reported the 15. Chavignon M, Coignet L, Bonhomme M, et al. Environmental persistence of
following: 4 studies microbial growth with mainly cocci and ba­ Staphylococcus capitis NRCS-A in neonatal intensive care units: role of biofilm for­
mation, desiccation, and disinfectant tolerance. Microbiol Spectr. 2022;10:e0421522.
cilli (ie, Staphylococcus, E coli, Bacillus maltophilia, and P aerugi­ 16. Lee K, Yoon SS. Pseudomonas aeruginosa biofilm, a programmed bacterial life for
nosa) and 2 studies reported that drying could effectively reduce fitness. J Microbiol Biotechnol. 2017;27:1053–1064.
biofilm regeneration.66 17. Skariyachan S, Sridhar VS, Packirisamy S, Kumargowda ST, Challapilli SB. Recent
perspectives on the molecular basis of biofilm formation by Pseudomonas aeru­
Given the failure of current cleaning and high-level disinfection, ginosa and approaches for treatment and biofilm dispersal. Folia Microbiol.
in part due to biofilm formation in the lumens of the duodenoscope, 2018;63:413–432.
a number of remedies have been proposed. These include: (1) using 18. Davarzani F, Saidi N, Besharati S, Saderi H, Rasooli I, Owlia P. Evaluation of anti­
biotic resistance pattern, alginate and biofilm production in clinical Isolates of
alternative methods to diagnose gastrointestinal pathology (eg,
Pseudomonas aeruginosa. Iran J Public Health. 2021;50:341–349.
capsule endoscopy); (2) using disposable end caps; (3) moving to a 19. Iseppi R, Sabia C, Bondi M, Mariani M, Messi P. Virulence factors, drug resistance
low-temperature sterilization method; and (4) using a single-use and biofilm formation in Pseudomonas species isolated from healthcare water
systems. Curr Microbiol. 2020;77:1737–1745.
disposable duodenoscope. The use of disposable end caps is now
20. Karash S, Yahr TL. Genome-wide identification of Pseudomonas aeruginosa genes im­
standard. Low-temperature sterilization methods hold promise (eg, portant for desiccation tolerance on inanimate surfaces. mSystems. 2022;7:e0011422.
ethylene oxide) but need validation that sterilization can be 21. Centeleghe I, Norville P, Hughes L, Maillard JY. Klebsiella pneumoniae survives on
achieved. Disposable scopes are now available, but additional data surfaces as a dry biofilm. Am J Infect Control. 2023;S0196-6553:00079–792.
22. Chakrabarti A, Sood P. On the emergence, spread and resistance of Candida auris:
on feasibility and cost-effectiveness would be useful. host, pathogen and environmental tipping points. J Med Microbiol.
2021;70:001318.
CONCLUSIONS 23. Egger NB, Kainz K, Schulze A, Bauer MA, Madeo F, Carmona-Gutierrez D. The rise
of Candida auris: from unique traits to co-infection potential. Microb Cell.
2022;9:141–144.
Biofilms are increasingly appreciated as an important impedi­ 24. Singh R, Kaur M, Chakrabarti A, Shankarnarayan SA, Rudramurthy SM. Biofilm
ment to cleaning and disinfecting environmental surfaces in formation by Candida auris isolated from colonising sites and candidemia cases.
Mycose. 2019;62:706–709.
hospitals and reusable medical devices, especially lumened en­ 25. Sherry L, Ramage G, Kean R, et al. Biofilm-forming capability of highly virulent,
doscopes. Important health care–associated pathogens that multidrug-resistant Candida auris. Emerg Infect Dis. 2017;23:328–331.
readily form biofilms on environmental surfaces include S aureus, 26. Ledwoch K, Maillard JY. Candida auris dry surface Biofilm (DSB) for disinfectant
efficacy testing. Materials. 2018;12:18.
P aeruginosa, and C auris. Biofilms contribute to prolonger survival 27. Kean R, Sherry L, Townsend E, et al. Surface disinfection challenges for Candida
and interfere with disinfection. In part because of biofilms, the auris: an in-vitro study. J Hosp Infect. 2018;98:433–436.
cleaning of reusable surgical instruments and medical devices (eg, 28. Chatzimoschou A, Giampani A, Meis JF, Roilides E. Activities of nine antifungal
agents against Candida auris biofilms. Mycoses. 2021;64:381–384.
endoscopes) should always precede disinfection. New technolo­
29. Bing J, Guan Z, Zheng T, et al. Clinical isolates of Candida auris with enhanced
gies that may remove or disrupt biofilm formation that are under adherence and biofilm formation due to genomic amplification of ALS4. PLoS
study to reduce the impact of biofilms on health care–associated Pathog. 2023;19:e1011239.
infections include “self-disinfecting” surfaces, continuously active 30. Centers for Disease Control and Prevention. Candida auris. Accessed March 30,
2023. https://www.cdc.gov/fungal/candida-auris/index.html.
surface disinfectants, new enzymatic detergents, and new disin­ 31. Rutala WA, Kanamori H, Gergen MF, Sickbert-Bennett EE, Weber DJ. Susceptibility
fectant systems. The development of validated methods of ster­ of Candida auris and Candida albicans to 21 germicides used in healthcare facil­
ilization of gastrointestinal endoscopes or single-use disposable ities. Infect Control Hosp Epidemiol. 2019;40:380–382.
32. United States Environmental Protection Agency. List P: Antimicrobial products
scopes is required to eliminate outbreaks despite appropriate registered with EPA for claims against Candida auris. Accessed 30 March, 2023.
cleaning and high-level disinfection. https://www.epa.gov/pesticide-registration/list-p-antimicrobial-products-
registered-epa-claims-against-candida-auris.
33. Rutala WA, Kanamori H, Gergen MF, Sickbert-Bennett EE, Weber DJ. Inactivation
References of Candida auris and Candida albicans by ultraviolet-C. Infect Control Hosp
Epidemiol. 2022;43:1495–1497.
34. Pearlmutter BS, Haq MF, Cadnum JL, Jencson AL, Carlisle M, Donskey CJ. Efficacy of
1. Hall-Stoodley L, Costerton JW, Stoodley P. Bacterial biofilms: from the natural
relatively low-cost ultraviolet-C light devices against Candida auris. Infect Control
environment to infectious diseases. Nat Rev Microbiol. 2004;2:95–108.
Hosp Epidemiol. 2022;43:747–751.
2. Yan J, Bassler BL. Surviving as a community: antibiotic tolerance and persistence
35. Alfa MJ. Biofilms on instruments and environmental surfaces: do they interfere
in bacterial biofilms. Cell Host Microbe. 2019;26:15–21.
with instrument reprocessing and surface disinfection? Review of the literature.
3. Prinzi A., Rohde R.E. The role of bacterial biofilms in antimicrobial resistance.
Am J Infect Control. 2019;47S:A39–A45.
American Society of Microbiology. Accessed March 30, 2023. 〈https://asm.org/
36. Chowdhury D, Tahir S, Legge M, et al. Transfer of dry surface biofilm in the
Articles/2023/March/The-Role-of-Bacterial-Biofilms-in-Antimicrobial-Re〉.
healthcare environment: the role of healthcare workers’ hands as vehicles. J Hosp
4. Von Borowski RG, Trentin DS. Biofilms and coronavirus reservoirs: a perspective
Infect. 2018;100:e85–e90.
review. Appl Environ Microbiol. 2021;87:e0085921.
37. Tahir S, Chowdhury D, Legge M, et al. Transmission of Staphylococcus aureus from
5. Besharati S, Farnia P, Farnia P, Ghanavi J, Velayati A. Investigation of the hy­
dry surface biofilm (DSB) via different types of gloves. Infect Control Hosp
pothesis of biofilm formation in coronavirus (COVID-19). Biomed Biotechnol Res J.
Epidemiol. 2019;40:60–64.
2020;4.
38. Otter JA, Vickery K, Walker JT, et al. Surface-attached cells, biofilms and biocide
6. Venkatesan N, Perumal G, Doble M. Bacterial resistance in biofilm-associated
susceptibility: implications for hospital cleaning and disinfection. J Hosp Infect.
bacteria. Future Microbiol. 2015;10:1743–1750.
2015;89:16–27.
7. Hall CW, Mah TF. Molecular mechanisms of biofilm-based antibiotic resistance
39. Abdallah M, Benoliel C, Drider D, Dhulster P, Chihib NE. Biofilm formation and
and tolerance in pathogenic bacteria. FEMS Microbiol Rev. 2017;41:276–301.
persistence on abiotic surfaces in the context of food and medical environments.
8. Roy R, Tiwari M, Donelli G, Tiwari V. Strategies for combating bacterial biofilms: a
Arch Microbiol. 2014;196:453–472.
focus on anti-biofilm agents and their mechanisms of action. Virulence.
40. Hu H, Johani K, Gosbell IB, et al. Intensive care unit environmental surfaces are
2018;9:522–554.
contaminated by multidrug-resistant bacteria in biofilms: combined results of
9. Koo H, Allan RN, Howlin RP, Stoodley P, Hall-Stoodley L. Targeting microbial
conventional culture, pyrosequencing, scanning electron microscopy, and con­
biofilms: current and prospective therapeutic strategies. Nat Rev Microbiol.
focal laser microscopy. J Hosp Infect. 2015;91:35–44.
2017;15:740–755.
41. Johani K, Abualsaud D, Costa DM, et al. Characterization of microbial community
10. Rather MA, Gupta K, Mandal M. Microbial biofilm: formation, architecture, anti­
composition, antimicrobial resistance and biofilm on intensive care surfaces. J
biotic resistance, and control strategies. Braz J Microbiol. 2021;52:1701–1718.
Infect Public Health. 2018;11:418–424.
11. Caldara M, Belgiovine C, Secchi E, Rusconi R. Environmental, microbiological, and
42. Ledwoch K, Mahenthiralingam E, Muir DD, et al. Beware biofilm! Dry biofilms
immunological features of bacterial biofilms associated with implanted medical
containing bacterial pathogens on multiple healthcare surfaces; a multi-centre
devices. Clin Microbiol Rev. 2022;35:e0022120.
study. J Hosp Infect. 2018;100:e47–e56.
12. Samrot AV, Abubakar Mohamed A, Faradjeva E, et al. Mechanisms and impact of
43. Costa DM, Johani K, Melo DS, et al. Biofilm contamination of high-touched sur­
biofilms and targeting of biofilms using bioactive compounds-a review. Medicina.
faces in intensive care units: epidemiology and potential impacts. Lett Appl
2021;57:839.
Microbiol. 2019;68:269–276.
13. Schilcher K, Horswill AR. Staphylococcal biofilm development: structure, reg­
44. Almatroudi A, Gosbell IB, Hu H, et al. Staphylococcus aureus dry-surface biofilms
ulation, and treatment strategies. Microbiol Mol Biol Rev. 2020;84:e00026-19.
are not killed by sodium hypochlorite: implications for infection control. J Hosp
14. Otto M. Staphylococcal biofilms. Microbiol Spectr. 2018;6.
Infect. 2016;93:263–270.
 D.J. Weber et al. / American Journal of Infection Control 51 (2023) A114–A119 A119

45. Almatroudi A, Tahir S, Hu H, et al. Staphylococcus aureus dry-surface biofilms are 56. Rutala WA, Gergen MF, Weber DJ. Does blood on "dirty" instruments interfere
more resistant to heat treatment than traditional hydrated biofilms. J Hosp Infect. with the effectiveness of sterilization technologies? Infect Control Hosp Epidemiol.
2018;98:161–167. 2022;43:1262–1264.
46. Ledwoch K, Said J, Norville P, Maillard JY. Artificial dry surface biofilm models for 57. Rutala WA, Weber DJ. Risk of disease transmission to patients from “con­
testing the efficacy of cleaning and disinfection. Lett Appl Microbiol. taminated” surgical instruments and immediate use steam sterilization. Am J
2019;68:329–336. Infect Control. 2023 in press.
47. Lineback CB, Nkemngong CA, Wu ST, Li X, Teska PJ, Oliver HF. Hydrogen peroxide 58. Rutala WA, Weber DJ. Reprocessing semicritical items: outbreaks and current
and sodium hypochlorite disinfectants are more effective against Staphylococcus issues. Am J Infect Control. 2019;47S:A79–A89.
aureus and Pseudomonas aeruginosa biofilms than quaternary ammonium com­ 59. Rutala WA, Weber DJ. Reprocessing semicritical items: an overview and an update on
pounds. Antimicrob Resist Infect Control. 2018;7:154. the shift from HLD to sterilization for endoscopes. Am J Infect Control. 2023 in press.
48. Chaggar GK, Nkemngong CA, Li X, Teska PJ, Oliver HF. Hydrogen peroxide, sodium 60. Rutala WA, Weber DJ. Outbreaks of carbapenem-resistant Enterobacteriaceae in­
dichloro-s-triazinetriones and quaternary alcohols significantly inactivate the fections associated with duodenoscopes: what can we do to prevent infections?
dry-surface biofilms of Staphylococcus aureus and Pseudomonas aeruginosa more Am J Infect Control. 2016;44(5 Suppl):e47–e51.
than quaternary ammoniums. Microbiology. 2022;168:001140. 61. Rutala WA, Kanamori H, Sickbert-Bennett EE, Weber DJ. What’s new in re­
49. Chowdhury D, Rahman A, Hu H, Jensen SO, Deva AK, Vickery K. Effect of disin­ processing endoscopes: are we going to ensure "the needs of the patient come
fectant formulation and organic soil on the efficacy of oxidizing disinfectants first" by shifting from disinfection to sterilization? Am J Infect Control.
against biofilms. J Hosp Infect. 2019;103:e33–e41. 2019;47S:A62–A66.
50. U.S. Environmental Protection Agency. Antimicrobial products registered with 62. Ren-Pei W, Hui-Jun X, Ke Q, Dong W, Xing N, Zhao-Shen L. Correlation between
EPA for claims against common pathogens. Accessed March 30, 2023. https:// the growth of bacterial biofilm in flexible endoscopes and endoscope reproces­
www.epa.gov/pesticide-registration/selected-epa-registered-disinfectants. sing methods. Am J Infect Control. 2014;42:1203–1206.
51. Rutala WA, Boyce JM, Weber DJ. Disinfection, sterilization and antisepsis: an 63. Lee DH, Kim DB, Kim HY, et al. Increasing potential risks of contamination from
overview. Am J Infect Control. 2023 in press. repetitive use of endoscope. Am J Infect Control. 2015;43:e13–e17.
52. Rutala WA, Gergen MF, Jones JF, Weber DJ. Levels of microbial contamination on 64. Balan GG, Rosca I, Ursu EL, et al. Duodenoscope-associated infections beyond the
surgical instruments. Am J Infect Control. 1998;26:143–145. elevator channel: alternative causes for difficult reprocessing. Molecules.
53. Rutala WA, Gergen MF, Weber DJ. Microbial contamination on used surgical in­ 2019;24:2343.
struments. Infect Control Hosp Epidemiol. 2014;35:1068–1070. 65. Primo MGB, Tipple AFV, Costa DM, et al. Biofilm accumulation in new flexible
54. Alfa MJ. Medical instrument reprocessing: current issues with cleaning and gastroscope channels in clinical use. Infect Control Hosp Epidemiol.
cleaning monitoring. Am J Infect Control. 2019;47S:A10–A16. 2022;43:174–180.
55. Rutala WA, Gergen MF, Weber DJ. Efficacy of a washer-disinfector in eliminating 66. Tian H, Sun J, Guo S, et al. The effectiveness of drying on residual droplets, mi­
healthcare-associated pathogens from surgical instruments. Infect Control Hosp croorganisms, and biofilms in gastrointestinal endoscope reprocessing: a sys­
Epidemiol. 2014;35:883–885. tematic review. Gastroenterol Res Pract. 2021;2021:6615357.