Efficacy of preoperative antimicrobial skin preparation
solutions on biofilm bacteria.(Home Study Program)

From: AORN Journal |

    Date: 3/1/2005 |

    Author: Paulson, Daryl S.

* RESEARCH ON THE MEDICAL EFFICACY of topical antimicrobials and antibiotics against infections has focused largely on the effect
on free-floating, planktonic bacteria.

* IN THE PRESENCE OF nonbiological surfaces (eg, catheters, prosthetic devices, biomaterials), however, bacteria form highly
complex biofilm systems that resist traditional medical treatment.

* BACTERIAL PATHOGENS commonly found in chronic infections in both the planktonic and biofilm state were challenged with a
variety of commonly used topical antimicrobial formulations.

* BIOFILM BACTERIA were shown to be more resistant to killing than planktonic bacteria. Antimicrobial skin preparation times were
adequate to significantly reduce bacterial populations protected in biofilms.

The article "Efficacy of preoperative antimicrobial skin preparation solutions on biofilm bacteria" is the basis for this AORN Journal
independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR,
clinical editor, with consultation from Susan Bakewell RN, MS, BC, education program professional, Center for Perioperative Education.

Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of
completion. The deadline for submitting this study is March 31, 2008.

Complete the examination answer sheet and learner evaluation found on pages 505-506 and mail with appropriate fee to

AORN Customer Service

c/o Home Study Program

2170 S Parker Rd, Suite 300

Denver, CO 80231-5711

BEHAVIORAL OBJECTIVES

After reading and studying the article on biofilms and the efficacy of antimicrobial skin preparation solutions on biofilm bacteria, nurses
will be able to

1. describe how biofilm matrices develop,

2. identify at least three implanted devices at risk for being infected with biofilms that are commonly encountered by perioperative
nurses,

3. explain how an evaluation was performed to determine efficacy of topical skin antiseptics against biofilm infections, and

4. discuss recommendations for preventing development of biofilm matrices.

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

A minimum score of 70% on the multiple-choice examination is necessary to earn 2.4 contact hours for this independent study.

Purpose/Goal: To educate perioperative nurses about biofilms and the effect of antimicrobial skin preparation solutions on biofilm
bacteria.

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Until recently, perioperative professionals were taught that microbial infections (eg, bacterial, viral, fungal) were caused by free-moving,
individual microorganisms or small isolated groups of microorganisms. Microorganisms causing infections

* entered the body via a wound or by direct invasion;

* spread through the body;

* multiplied in the body;

* evaded immunological defenses (ie, T lymphocyte, B lymphocyte, and phagocytic activity); and

* were shed from the body to infect new hosts. (1)

Although it is true that in acute infections, bacteria generally are found in a free-floating (ie, planktonic) form, if bacteria (ie, prokaryotes)
establish a presence of any duration in the body, they generally form a highly complex, self-regulating, bacterial community known as a
biofilm matrix. (2) Bacterial biofilm complexes cause challenging infections that generally are both difficult and expensive to treat and
manage. Terms relevant to biofilm bacteria are defined in Table 1.

Through a process termed "quorum-sensing," bacteria in a biofilm matrix can chemically communicate system-level needs for the well-
being of the entire biofilm community. Quorum-sensing between bacteria enables a biofilm community to induce or repress specific gene
expressions regulating such activities as

* cell division,

* metabolic rates,

* production of virulence factors,

* plasmid transfer for antibiotic resistance, and

* release of planktonic bacteria from the biofilm. (3-5)

Biofilm infections often begin during surgical procedures, such as insertion of vascular catheter lines, pacemakers, heart valves,
permanent biomaterials for repair of aneurysms, or prosthetic joint replacements. Other medical procedures associated with biofilm
establishment are intratracheal intubation needed for ventilators and protracted use of indwelling urinary catheters. (6) It is important for
perioperative staff members to recognize that implantation of devices or biomaterials may lead to the formation of biofilms, which
increases the risk of difficult-to-treat infections in postoperative patients.

BIOFILM GENESIS

To form a clinically significant biofilm, bacteria must attach to tissue or an inanimate surface (eg, titanium, stainless steel,
polytetrafluoroethylene, polyester fiber) in a patient's body and then attract and attach to other bacterial cells. (4-7) Typically, direct
attachment of bacteria to tissue elicits such a strong immunological response (eg, high fever, malaise) that it becomes apparent, and
patients are treated immediately, according to standard protocols, before a biofilm is able to develop. In comparison, implanted
biomaterials, prosthetics, and devices have inanimate surfaces. Bacteria adhering to these inanimate surfaces do not elicit an immune
response. The lack of an immune response results in patients not being treated for infection; thus, normal skin bacterial residents (eg,
Staphylococcus epidermidis) attaching to implanted materials can lead to the development of a biofilm.

Bacterial attachment to inanimate surfaces generally requires that a surface be conditioned by organic deposits, such as collagen,
laminin, fibrin, and fibrinogen. The bacterial cells and organic deposits are mutually attracted via noncovalent forces, including vander
Waal's forces and hydrophobic interactions. (7-9) Bacteria with receptor sites for these organic compounds can attach directly to the
compounds by primary adhesion (Figure 1), divide, and produce an exopolysaccharide biofilm matrix. This establishes a bacterial
presence that is protected from the body's natural immunological surveillance, including phagocytosis and antibiotic treatments. (7)

[FIGURE 1 OMITTED]

The conditioning layer influences which organisms will be the primary colonizers of the biofilm (Figure 2). For example, specific organic
substances (ie, collagen, laminin, fibrinogen, fibrin) are deposited on the inanimate surface for Staphylococcus aureus to produce an
exopolysaccharide biofilm matrix. Similarly, for Staphylococcus epidermidis to produce a biofilm matrix, fibrinogen binding protein is
deposited on the inanimate surface.

[FIGURE 2 OMITTED]

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Biofilms also contain bacteria that are attached to other bacteria and not to organic debris (Figure 3). Different bacterial species that
cannot attach to organic material themselves are able to attach to bacteria already adhering to the organic material. Specific and
compatible attachment sites are required of both bacteria; this attachment process is called coadhesion. The exact extent of this
phenomenon and its process are not well-understood at this time, but much anecdotal knowledge derives from oral biofilms (ie, plaque),
for which the coadhesive process is understood more fully. (10,11)

[FIGURE 3 OMITTED]

Individual bacterial cells can form an elaborate matrix of exopolysaccharide and interstitial fluid consisting of

* 95% to 99% water,

* 2% bacterial content, and

* 1% to 2% exopolysaccharide content. (2) A biofilm matrix may appear as depicted in Figure 4 or as a thin layer of bacteria in an
exopolysaccharide matrix. To date, no universal configuration has been determined for medical biofilms.

[FIGURE 4 OMITTED]

A biofilm matrix offers bacterial protection and, thereby, increases resistance to the immunological responses of both humoral and
cellular derivation, as well as from the phagocytic activities of neutrophils and tissue macrophages. (2-4) This facilitates growth of the
biofilm matrix (eg, on a venous catheter), and allows the biofilm to slough off planktonic bacteria that can produce septic conditions
throughout a patient's body. Biofilm matrices often are slow-growing and localized, however, affecting only an implant and surrounding
tissues, and this may require surgical removal of the implant and debridement of associated tissues. (12-15)

Bacteria in a biofilm are 500 to 1,500 times more resistant to antibiotic therapy than are planktonic bacteria. (16,17) Initially, researchers
believed that the exopolysaccharide matrix provided a barrier that protected the bacteria from direct exposure to antibiotics. (2,3) It now
appears that the reason is more complex. (16,17) Bacteria in biofilm are more metabolically efficient, which limits their uptake of
antibiotics. Although bacteria in a biofilm generally do not replicate as rapidly as they do in the planktonic state, different biofilm sections
are in various stages of growth (ie, static, stationary, exponential) at any given time. (18,19) On average, however, the entire growth rate
of the biofilm community appears quiescent. (15,16) Bacteria in the biofilm that are most susceptible to antibiotics are in the exponential
growth phase because antibiotics require high metabolic rates and active cellular division to be effective. Antibiotics

* inhibit synthesis of the bacterial cell wall or cell membrane,

* block protein synthesis at the 30s or 50s ribosome subunit,

* block DNA replication, or

* block folate coenzymes needed in DNA synthesis. (18)

Destroying biofilm sections in the exponential growth phase does not destroy bacteria in the biofilm that are in the static and stationary
growth phases.

Resistance to some disinfectants (eg, hydrogen peroxide) is related directly to bacterial density in a biofilm. Degradation of hydrogen
peroxide via catalase produced by bacterial cells, including nonviable cells, requires a concerted systems effort by a group of bacteria. A
single bacterium is not able to produce enough catalase to overcome the debilitating effects of hydrogen peroxide. (19,20)

PERIOPERATIVE IMPLICATIONS

Implanted devices (eg, hemodialysis grafts, genitourinary prosthetics, pacemaker leads, prosthetic heart valves, vascular grafts) have
significant potential for incurring biofilm infection. (8) For example, polyester fiber grafts that are used to replace and repair stenotic
thoracic arteries and abdominal aortic aneurysms are prone to biofilm infections from coagulase-negative Staphylococcus species,
Staphylococcus aureus, and other microorganisms.

VASCULAR CATHETERIZATION. Biofilms are a serious concern for patients who have vascular catheters. Microorganisms, particularly
normal skin flora, colonize and form biofilms quickly on catheter surfaces; however, contaminative exogenous microorganisms from
health care personnel, contaminated infusion fluid, and distal infections transported via hematogenous routes also have been implicated.
(7,12,21) Many of the millions of patients who undergo vascular catheterization procedures in the United States every year become
infected via biofilms. (16) Four percent to 14% of patients who have a central venous catheter experience septicemia. (15) Central
venous catheter infections most commonly are caused by normal skin bacteria, including Staphylococcus epidermidis or other catalase-
negative Staphylococcus species. Other common bacteria cultured from these catheters include Staphylococcus aureus, Pseudomonas

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aeruginosa, and Enterococcus species. (21)

Local biofilm infections, which are very common at catheter-insertion sites, include tunnel infections (ie, cellulitis along the subcutaneous
catheter route) and frank catheter-tip colonization. These can lead to life-threatening septicemias.

The current trend for topical antimicrobials is to demonstrate antimicrobial persistence for longer periods of time to limit injury to veins
from multiple insertions; however, patients with catheters may have an increased risk for acquiring biofilm infections when the catheter
remains at a specific site for a longer time. To counteract this threat, some catheter manufacturers are partnering with manufacturers of
topical antimicrobials to produce tubing, cannulas, and catheter insertion tips treated with antimicrobial products, such as silver
sulfadiazine or chlorhexidine gluconate. (22)

Nearly 100% of superior vena cava catheters become locally infected within two to three days of placement. (16) Many of these
infections are caused by coagulase-negative Staphylococcus species, especially Staphylococcus epidermidis. A high proportion of these
bacteria demonstrate resistance to multiple antibiotic medications, especially to methicillin and oxacillin. (16)

Devices exposed to direct blood flow, such as vascular catheters and heart valves, pose a serious risk for both local and systemic
infections. It is important for perioperative nurses to understand Virchow's triad (ie, surface area, blood contact, and flow rate), and that
the greater the surface area, the more probable it is that bacteria can colonize it. Direct blood flow offers a continuous source of
conditioning material that coats a device in preparation for bacterial attachment. The blood flow also exerts a shearing effect that can
transport planktonic bacteria and biofilm clumps to other areas in the body. (8,23) Finally, ventricular-peritoneal shunts used to reduce
intracranial pressure almost always become biofilm-contaminated with Staphylococcus epidermidis and Staphylococcus aureus. (15)

ORTHOPEDICS. Joint replacements (eg, hip, knee) pose the threat of postoperative biofilm infections with particularly devastating
effects, including osteomyelitis. Staphylococcus epidermidis, Staphylococcus aureus, and Pseudomonas aeruginosa commonly are
cultured from these implants. (13) In many situations, biofilm-infected joints require revisional surgery with a second implant, and this
can be expensive and traumatic. Special precautions with topical skin antiseptics may be valuable because Staphylococcus epidermidis
is prevalent in these infections.

ENDOTRACHEAL TUBES. Patients who remain intubated after a surgical procedure are prone to ventilator-associated pneumonia,
Endotracheal tubes bypass the body's normal pulmonary clearing responses (eg, coughing, mucociliary clearance), increase mucus
secretions because of irritation and inflammation, and tend to denude cilia from the tracheal epithelium. This allows secretions to enter
the lungs through the stented glottis. (8) Biofilms quickly develop on the endotracheal tube and can pass easily into the lungs,
particularly during suctioning procedures.

ARE TOPICAL ANTIMICROBIALS EFFECTIVE?

It is pertinent to determine the effectiveness of topical antimicrobials that are used to remove germs from the skin before catheter
insertions or preoperative skin preparation or when challenged with bacteria in a biofilm matrix. Currently; antimicrobial efficacy testing is
performed almost exclusively on bacteria in the planktonic state. An evaluation to determine efficacy against biofilms was performed
using a number of common topical skin antiseptics to challenge pathogenic bacterial species prevalent in biofilm infections. The
evaluation determined the resistance to killing provided by a biofilm matrix compared to the bacteriocidal effectiveness of each antiseptic
versus the bacteria in a planktonic state.

MATERIALS AND METHODS. The bacterial species and strains used were supplied by the American Type Culture Collection. These
included

* methicillin-resistant Staphylococcus areus,

* methicillin-resistant Staphylococcus epidermidis,

* Pseudomonas aeruginosa,

* Staphylococcus aureus,

* Staphylococcus epidermidis, and

* vancomycin-resistant Enterococcus faecium.

The topical antimicrobial compounds evaluated are used commonly to prepare patients' skin before surgery or vascular catheter
insertion. The active ingredients in these antimicrobial compounds include

* 70% isopropanol + 2% chlorhexidine gluconate;

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* 72% isopropanol + 7.5% povidone iodine;

* 73% ethanol + 0.25% zinc pyrithione; and

* 62% ethanol + < 5%, isopropanol.

RESULTS

The results of the evaluation are presented in Table 2. Planktonic time kills were performed on bacterial solutions containing
approximately 1 x [10.sub.9] colony forming units (CFU)/mL. A 0.1 mL aliquot of the suspension was added to 9.9 mL of product to
result in a 99% concentration of the product. Exposure times were 15 seconds and two minutes. After each exposure, a 1-mL portion of
the product/bacterial solution was transferred to 9 mL of a phosphate-buffered solution with product neutralizers. It was serially diluted,
plated, and incubated at 35[degrees] C [+ or -] 2[degrees] C (95[degrees] F [+ or -] 3.6[degrees] F). Bio-films developed on microporous
membranes resting on agar nutrient medium. The membranes were inoculated with a cell suspension containing approximately 1 x
[10.sup.9] CFU/mL to generate the biofilms.

The membrane-supported biofilms were incubated at 35[degrees] C [+ or -] 2[degrees] C (95[degrees] F [+ or -] 3.6[degrees] F) for 48
hours, with transfers to fresh agar nutrient medium approximately every 10 to 12 hours. After approximately 48 hours, the membrane-
supported biofilms were exposed to each antimicrobial product in screw-capped containers for 15 seconds and for two minutes.
Neutralizing fluid was added to the jars after each designated exposure time, and a vortexing unit was used to agitate the contents to
disaggregate the biofilm. The neutralizer/product/disaggregated biofilm suspension then was serially diluted, plated, and incubated at 35
[degrees] C [+ or -] 2[degrees] C (95[degrees] [+ or -] 3.6[degrees] F).

For each antimicrobial compound tested, with the exception of Enterococcus faecium, biofilm-enclosed bacteria retarded the microbial
action of alcohol, alcohol and povidone iodine, alcohol and chlorhexidine gluconate, and alcohol and zinc pyrithione, relative to the
planktonic time-kill. Generally, however, the topical antimicrobials tested demonstrated high antimicrobial activity against the biofilms
within a time frame practical for site preparation. Unlike antibiotics that kill by interrupting bacterial replicative and synthesizing
mechanisms

* alcohols coagulate and denature bacterial proteins and leach membrane lipids;

* chlorhexidine gluconate punctures the cytoplasmic membrane so that low molecular weight cytoplasmic components, such as
potassium, leak out; and

* povidone iodine oxidatively blocks disulfide bridging, which is important in bacterial protein synthesis. (24-26)

RECOMMENDATIONS

An effective, persistently active antimicrobial formulation should be used to prepare skin sites thoroughly before performing vascular
catheterization procedures or surgeries requiring stents, biomaterial repairs, joint replacements, or orthopedic implants. It may be
prudent to have patients treat intended surgical sites with alcohol/ chlorhexidine gluconate, alcohol/zinc pyrithione, or a solution
containing only chlorhexidine gluconate at home for three to four consecutive days before surgery. (26) With repeated use, both
chlorhexidine gluconate and zinc pyrithione demonstrate residual antimicrobial properties that prevent skin colonization from rebounding
to baseline microbial population levels. (27) Approximately three days of repeated exposure, however, are necessary for the
chlorhexidine gluconate or zinc pyrithione to be adsorbed onto the stratum corneum. (28) It is important, therefore, to use antimicrobially
effective surgical scrub products labeled with both immediate and persistent antimicrobial properties. (29)

Prepping with alcohol and chlorhexidine gluconate, alcohol and povidone iodine, alcohol and zinc pyrithione, or chlorhexidine gluconate,
alone before vascular catheterization procedures may reduce catheter-associated infections. Using antimicrobially-treated bandaging
may improve prospects even more. Currently, catheters coated with antimicrobials are being evaluated for their value in preventing
bacterial attachment and biofilm formation. (8)

As in many surgeries, it is important to administer prophylactic antibiotics just before and during the surgical procedure. It is prudent to
employ antibiotics that can inactivate methicillin-resistant Staphylococcus aureus, methicillin-resistant Staphylococcus epidermidis, and
vancomycin-resistant Enterococci. (30) The goal is to eliminate planktonic bacteria before they can form a biofilm that is resistant to
antibiotics. (30)

Health care practitioners must take special care for orthopedic surgeries involving implants in joint replacements. Antimicrobial incision
drapes are recommended to isolate the surrounding skin surface from the incisional site. (31) An alcohol skin wipe also should be
performed before placement of an antimicrobial incision drape. (32)

It is important to take a proactive approach to preventing contamination of wounds and implants. Health care professionals should

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require vendors to provide published documentation demonstrating that products are effective against microorganisms in the biofilm
matrix, as well as in the planktonic state.

Editor's note: The author acknowledges Terri Eastman, manager of in vitro laboratories; John A. Mitchell, PhD, director of quality
assurance; and Karen Wesenburg-Ward, PhD, project manager of biofilm division, BioScience Laboratories, Inc, Bozeman, Mont, for
their assistance in producing this article.

BioScience Laboratories manufactures technologies described in this article. The evaluation described in this article was funded by
BioScience Laboratories, Inc. Publication of this article in no way implies AORN endorsement of products manufactured by BioScience
Laboratories, Inc.

TABLE 1
Definitions

Antimicrobial residual properties: When chlorhexidine
gluconate or zinc pyrithione solution is
used for at least two to three days before surgery
as a presurgical site wash, the medications are
adsorbed into the stratum corneum and prevent
normal microbial population regrowth. Then,
when the preoperative skin preparation is performed
just before a surgical procedure, the normal
microbial population numbers already have
been reduced greatly, and the preoperative skin
preparation is more effective.

Biofilm: A complex community of microorganisms
enclosed in an exopolysaccharide matrix
attached to tissue or an inanimate surface.

Coadhesion: The process of planktonic microorganisms
binding to microorganisms attached to
surfaces.

Exopolysaccharides: Polymerized material produced
by microorganisms that constitutes the
biofilm, providing protection and containment for
the microorganisms.

Laminin: Linking proteins of basal lamina, which
induce adhesion and enhance spreading of
microorganisms in a biofilm.

Planktonic: Free-floating microorganisms.

Quorum-sensing: Chemical communication
between microorganisms.

Van der Waal's force: Nonspecific attraction
between atoms that are 3 angstrom units ([Angstrom])
to 4 [Angstrom] apart.

TABLE 2
Time Kill Results

[Log.sub.10] reduction
from initial population

Planktonic

15 sec * 2 min *

Pseudomonas aeruginosa
62% ethanol + < 5% isopropanol > 5 > 5

Staphylococcus aureus
70% isopropanol + 2% chlorhexidine

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gluconate (CHG) > 6 > 6
72% isopropanol + 7.5% povidone iodine > 6 > 6
73% ethanol + 0.25% zinc pyrithione > 5 > 5
62% ethanol + < 5% isopropanol > 6 > 6

Methicillin-resistant Staphylococcus aureus
70% isopropanol + 2% CHG > 6 > 6
72% isopropanol + 7.5% povidone iodine > 6 > 6
62% ethanol + < 5% isopropanol > 6 > 6

Staphylococcus epidermidis
70% isopropanol + 2% CHG > 6 > 6
72% isopropanol + 7.5% povidone iodine > 6 > 6
73% ethanol + 0.25% zinc pyrithione > 5 > 5
62% ethanol + < 5% isopropanol > 6 > 6

Methicittin-resistant Staphylococcus epidermidis
72% isopropanol + 7.5% povidone iodine > 5 > 5
62% ethanol + < 5% isopropanol > 5 > 5

Vancomycin-resistant Enterococcus faecium
70% isopropanol + 2% CHG > 5 > 5

[Log.sub.10] reduction
from initial population

Biofilm

15 sec * 2 min *

Pseudomonas aeruginosa
62% ethanol + < 5% isopropanol 0.35 > 5

Staphylococcus aureus
70% isopropanol + 2% chlorhexidine
gluconate (CHG) 1.51 > 6
72% isopropanol + 7.5% povidone iodine 0.37 > 5
73% ethanol + 0.25% zinc pyrithione 0.10 > 5
62% ethanol + < 5% isopropanol 0.08 **

Methicillin-resistant Staphylococcus aureus
70% isopropanol + 2% CHG 3.14 > 6
72% isopropanol + 7.5% povidone iodine 0.75 > 6
62% ethanol + < 5% isopropanol 0.08 > 6

Staphylococcus epidermidis
70% isopropanol + 2% CHG 1.86 > 6
72% isopropanol + 7.5% povidone iodine 0.97 > 6
73% ethanol + 0.25% zinc pyrithione 0.28 > 5
62% ethanol + < 5% isopropanol 0.01 > 6

Methicittin-resistant Staphylococcus epidermidis
72% isopropanol + 7.5% povidone iodine 1.70 > 5
62% ethanol + < 5% isopropanol 0.36 > 5

Vancomycin-resistant Enterococcus faecium
70% isopropanol + 2% CHG > 5 > 5

* Exposure time

** Unable to validate because of several outliers in data

Examination

Efficacy of preoperative antimicrobial skin preparation solutions on biofilm bacteria

1. In acute infections, bacteria generally are found in the form of free--floating a. enzymes.

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b. plankton.

c. plaque.

d. toxins.

2. Biofilm matrices are

a. highly complex, self-regulating, bacteria[ communities.

b. dense, nonmineralized complexes that are composed of bacterial colonies embedded in a gelatinous matrix.

c. poisonous substances produced by bacteria that have the ability to destroy inorganic surfaces.

3. The ability of bacteria in a biofilm matrix to chemically communicate system-level needs for the well-being of the entire biofilm
community is known as

a. coadhesion.

b. quantum monitoring.

c. quorum-sensing. d. Van der Waal's force.

4. Bacteria adhering to inanimate surfaces elicit a strong immune response.

a. true

b. false

5. Bacterial attachment to inanimate surfaces generally requires that a surface be conditioned by organic deposits, such as

1. collagen.

2. fibrin.

3. fibrinogen.

4. laminin.

5. plasma.

a. 2 and 4

b. 1, 3, and 5

c. 1, 2, 3, and 4

d. 1, 2, 3, 4, and 5

6. Bacteria in biofilm are most susceptible to antibiotics when they are in which of the following growth phases?

a. exponential

b. hyperplastic

c. static

d. stationary

7. Endotracheal tubes

1. bypass the body's normal pulmonary clearing responses.

2. increase mucus secretions because of irritation and inflammation.

3. denude cilia from the tracheal epithelium.

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4. allow secretions to enter the lungs through the stented glottis. 5. allow biofilms to develop quickly and pass easily into the lungs.

a. 1 and 3

b. 2, 3, and 5

c. 1, 2, 3, and 4

d. 1, 2, 3, 4, and 5

8. In this article, the topical anti-microbial solutions that were evaluated 1. coagulated and denatured bacterial proteins and leached
membrane lipids.

2. interrupted bacterial replicative and synthesizing mechanisms.

3. oxidatively blocked disulfide bridging.

4. punctured the cytoplasmic membrane so that low molecular weight cytoplasmic components leaked out.

a. 1 and 3

b. 2 and 4

c. 1, 3, and 4

d. 1, 2, 3, and 4

9. To be adsorbed onto the stratum corneum, chlorhexidine gluconate or zinc pyrithione must be used repeatedly for approximately

a. three days.

b. five days.

c. one week.

d. two weeks.

10. Health care practitioners may consider implementing one or more of the following actions to prevent biofilm development.

1. Use antimicrobially-treated bandaging.

2. Use catheters coated with antimicrobials.

3. Administer prophylactic antibiotics that can inactivate antibiotic-resistant organisms just before and during surgical procedures.

4. Isolate surrounding skin surfaces from incisional sites with antimicrobial incision drapes during orthopedic procedures.

5. Perform an alcohol skin wipe before placing an antimicrobial incision drape during orthopedic procedures.

a. 1 and 2

b. 3 and 4

c. 2, 3, and 5

d. 1, 2, 3, 4, and 5

AORN Home Study

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on
Accreditation. AORN recognizes these activities as continuing education for RNs. This recognition does not imply that AORN or the
American Nurses Credentialing Center approves or endorses products mentioned in the activity. AORN is provider-approved by the
California Board of Registered Nursing, Provider Number CEP 13019. Check with your state hoard of nursing for acceptance of this
activity for relicensure.

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Goals and Agenda for Strengthening Hospitals Released

The American Hospital, Association (AHA) has unveiled its members advocacy agenda for 2005, which was developed with input from
hospital Leaders throughout the country, according to a Feb 4, 2005, news release from the AHA. Top priorities include protecting the
health care "safety net," making care more affordable, improving the quality of health care, and expanding health care coverage.

The AHA's board of trustees also has announced six Long-term goats for strengthening the nation's health care system. These include

* instituting public quality reporting by every hospital;

* developing information technology standards to achieve interoperability among hospitals and other health care settings;

* adding 300,000 new health care professionals to US hospitals;

* ensuring that every hospital is prepared for emergency situations and has the staff, equipment, and training to be self-sufficient for 48
hours after a mass casualty incident;

* maintaining affordable coverage for those who have it and increasing by 25 million the number of people with access to affordable
coverage; and

* improving the quality, coordination, and efficiency of care to the 20% of patients who are critically ill and on whom 80% of resources
are spent.

The achievement of these goals depends on cooperation by public and private leaders. The AHA also will pursue a broad-based
advocacy agenda that will work to

* help hospitals have the resources necessary to serve communities by ensuring adequate Medicare and Medicaid funding;

* expand coverage to the uninsured;

* pass federal legislation to limit medical liability insurance costs;

* permanently extend the moratorium on physician self-referral to new limited-service hospitals;

* improve the quality of patient care by passing patient safety legislation and sharing more information with the public; and

* improve coordination of care for all Americans, especially those who are critically ill.

AHA Opens 2005 With Agenda to Improve Health Care in America (news release, Washington, DC: American Hospital Association, Feb
4, 2005).

Answer Sheet

Efficacy of preoperative antimicrobial skin preparation solutions on biofilm bacteria

Please fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the
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Additionally, please verify by signature that you have reviewed the objectives and read the article, or you will not receive credit.

Signature

1. Record your AORN member identification number in the appropriate section below. (See your member card.)

2. Completely darken the spaces that indicate your answers to examination questions one through 10. Use blue or black ink only.

3. Our accrediting body requires that we verify the amount of time you required to complete this 2.4 contact hour (120-minute) program.

4. Enclose fee if information is mailed.

AORN (ID) # --

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Name --

Address --

City -- State -- Zip --

Phone number --

RN license # -- State --

Fee enclosed --

or bill the credit card indicated [] MC [] Visa [] American Express [] Discover

Card # -- Expiration Date --

Signature -- (for credit card authorization)

[ILLUSTRATION OMITTED]

Event #05033

Session #9173

Contact hours: 2.4

Fee:

Members $12

Nonmembers $24

Program offered March 2005

The deadline for this program is March 31, 2008

A score of 70% correct on the examination is required for credit.

Learner Evaluation

Efficacy of preoperative antimicrobial skin preparation solutions on biofilm bacteria

Objectives

To what extent were the following objectives of this Home Study Program achieved?

1. Describe how biofilm matrices develop.

2. Identify at least three implanted devices at risk for being infected by biofilms that are commonly encountered by perioperative nurses.

3. Explain how an evaluation was performed to determine efficacy of topical skin antiseptics against biofilm infections.

4. Discuss recommendations for preventing development of biofilm matrices.

Content

To what extent

5. did this article increase your knowledge of the subject matter?

6. was the content clear and organized?

7. did this article facilitate learning?

8. were your individual objectives met?

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9. did the objectives relate to the overall purpose/goal?

Test Questions/Answers

To what extent

10. were they reflective of the content?

11. were they easy to understand?

12. did they address important points?

Learner Input

13. Will you be able to use the information from this Home Study in your work setting? a. yes b. no

14. I learned of this Home Study via

a. the Journal I receive as an AORN member.

b. a Journal I obtained elsewhere.

c. the AORN web site.

d. SSM Online.

15. What factor most affects whether you take an AORN Journal Home Study?

a. need for contact hours

b. price

c. subject matter relevant to current position

d. number of contact hours offered What other topics would you like to see addressed in a future Home Study Program? Would you be
interested or do you know someone who would be interested in writing an article on this topic?

Topic(s): --

Author names and addresses: --

[ILLUSTRATION OMITTED]

This evaluation is used to determine the extent to which this Home Study Program met your learning needs. Rate these items on a scale
of 1 to 5.

Purpose/Goal: To educate perioperative nurses about biofilms and the effect of antimicrobial skin preparation solutions on biofilm
bacteria.

NOTES

(1.) C Mires, A Nash, J Stephen, Mim's Pathogenesis of Infectious Disease, fifth ed (San Diego: Academic Press, 2001).

(2.) M G Darby, G A O'Toole, "Microbial biofilms: From ecology to molecular genetics," Microbiology and Molecular Biology Reviews 64
(December 2000) 847-867.

(3.) A L Reysenbach, E Shock, "Merging genomes with geochemistry in hydrothermic ecosystems," Science 296 (May 10, 2002) 1077-
1082.

(4.) J Jass, S Surman, J T Waller, "Microbial biofilms in medicine," in Medical Biofilms: Detection, Prevention and Control, eds, H Jass,
S Surman, J Waller (West Sussex, UK: John Wiley & Sons, Inc, 2003) 1-28.

(5.) M Hentzer, M Givskov, L Eberl, "Quorum sensing in biofilms: Gossip in slime city," in Microbial Biofilms, eds, M Ghannoum, G A
O'Toole (Washington, DC: American Society of Microbiology, 2004) 118-140.

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(6.) S N Wai, Y Miztmoe, J Jass, "Biofilm-related infections on tissue surfaces," in Medical Biofilms: Detection, Prevention and Control,
eds, J Jass, S Surman, J Waller (West Sussex, UK: John Wiley & Sons, Inc, 2003) 1-28.

(7.) F Gotz, G Peterson, "Colonization of medical devices by coagulase-negative Staphylococci," in Infections Associated with Indwelling
Medical Devices, third ed, F A Waldvogel, A L Bisno, eds (Washington, DC: American Society of Microbiology, 20O0) 55-88.

(8.) J M Anderson, R E Marchant, "Biomaterials: Factors favoring colonization and infection," in Infections Associated with Indwelling
Medical Devices, third ed, F A Waldvogel, A L Bisno, eds (Washington, DC: American Society of Microbiology, 2000) 89-109.

(9.) S E Cramton, F Gotz, "Biofilm development in Staphylococcus," in Microbial Biofilms, eds M Ghannoum, G A O'Toole (Washington,
DC: American Society of Microbiology, 2004) 64-84.

(10.) D Spratt, "Dental plaque," in Medical Biofilms: Detection, Prevention and Control, eds J Jass, S Surman, J Waller (West Sussex,
UK: John Wiley & Sons, Inc, 2003) 1-28.

(11.) P E Kolenbrander, R J Palmer, "Human oral bacterial biofilms," in Medical Biofilms: Detection, Prevention and Control, eds J Jass,
S Surman, J Waller, (West Sussex, UK: John Wiley & Sons, Inc, 2004) 85-117.

(12.) J G Thomas, G Ramage, J L Lopez-Ribot, "Biofilms and implant infections," in Microbial Biofilms, eds M Ghannoum, G A O'Toole
(Washington, DC: American Society of Microbiology, 2004) 269-293.

(13.) J M Steckelburg, D R Osman, "Prosthetic joint infections," in Infections Associated with Indwelling Medical Devices third ed, F A
Waldvogel, A L Bisno, eds (Washington, DC: American Society of Microbiology, 2000) 173-209.

(14.) A Stein, M Drancourt, D Raoult, "Ambulatory management of infected orthopedic implants," in Infections Associated with Indwelling
Medical Devices third ed, F A Waldvogel, A L Bisno, eds (Washington, DC: American Society of Microbiology, 2000) 211-230.

(15.) N Phillips, Berry & Kohn's Operating Room Technique, 10th ed (St Louis: Mosby, 2000) 740-765.

(16.) G D Ehrlich, F Z Hu, J C Post, "Role for biofilms in infectious disease," in Microbial Biofilms, eds M Ghannoum, G A O'Toole
(Washington, DC: American Society of Microbiology, 2004) 332-358.

(17.) P S Stewart, P K Mukherjee, M A Ghannoum, "Biofilm antimicrobial resistance," in Microbial Biofilms, eds M Ghannoum, G A
O'Toole (Washington, DC: American Society of Microbiology, 2004) 250-268.

(18.) C Walsh, Antibiotics: Actions, Origins, Resistance (Washington, DC: American Society of Microbiology, 2003).

(19.) J Netting, "Sticky situations," Science News Online 160 (July 2001) 2. Also available at
http://www.sciencenews.org/articles/20010714 /bob12.asp (accessed 24 Jan 2005).

(20.) P S Stewart, "Multicellular resistance: Biofilms," Trends in Microbiology 9 (May 2001) 5, 204.

(21.) R Bayston, "Biofilm infections on implant surfaces," in Biofilms: Recent Advances in Their Study and Control, first ed, L V Evans,
ed (Amsterdam: Harwood Academic Publishers, 2000) 117-131.

(22.) L A Mermel, "Prevention strategies for intra-vascular catheter-related infections," in Infections Associated with Indwelling Medical
Devices, second ed, F A Waldvogel, A L Bisno, eds (Washington, DC: American Society of Microbiology, 2000) 407-425.

(23.) M R Brunstedt et al, "Bacteria/blood/ material interactions. I. Injected and pre-seeded slime-forming Staphylococcus epidermis in
flowing blood with biomaterials," Journal of Biomedical Materials Research 29 (April 1995) 455-466.

(24.) G W Dentin, "Chlorhexidine," in Disinfection, Sterilization and Preservation, fifth ed, S S Block, ed (Philadelphia: Lippincott,
Williams & Wilkins, 2001) 321-335.

(25.) Y Ali et al, "Alcohols," in Disinfection, Sterilization and Preservation, fifth ed, S S Block, ed (Philadelphia: Lippincott, Williams &
Wilkins, 2001) 229-253.

(26.) W Goltardi, "Iodine and iodine complexes," in Disinfection, Sterilization and Preservation, fifth ed, S S Block, ed (Philadelphia:
Lippincott, Williams & Wilkins, 2001) 159-184.

(27.) D W Hobson, L A Seal, "Antimicrobial bodywashes," in Handbook of Topical Antimicrobials, ed D S Paulson, (New York: Marcel
Dekker, Inc, 2003) 167-188.

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HighBeam™ Research, Inc. © Copyright 2008. All rights reserved.

(28.) D S Paulson, "Full body showerwash: Efficacy evaluation of a 4% chlorhexidine gluconate," in Handbook of Topical Antimicrobials,
ed D S Paulson, (New York: Marcel Dekker, Inc, 2003) 189-196.

(29.) D S Paulson, Topical Antimicrobial Testing and Evaluation (New York: Marcel Dekker, Inc, 1999).

(30.) S M Nettina, The Lippincott Manual of Nursing Practice, seventh ed (Philadelphia: Lippincott, Williams & Wilkins, 2001) 114115.

(31.) D M Fogg, "Infection prevention and control," in Alexander's Care of the Patient in Surgery, 12th ed, J C Rothrock, ed (St Louis:
Mosby, 2003) 817-930.

(32.) B Bowen, "Orthopedic surgery," in Alexander's Care of the Patient in Surgery, 12th ed, J C Rothrock, ed (St Louis: Mosby, 2003)
817-930.

Daryl S. Paulson, PhD, is president and chief executive officer of BioScience Laboratories, Inc, Bozeman, Mont.

COPYRIGHT 2005 Association of Operating Room Nurses, Inc.

For permission to reuse this article, contact

Copyright Clearance Center.

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