Microbial biofilms

Biofilms
Adherent microcolonies bacteria or fungi
Inherent lack of susceptibility to
antimicrobials
Differs from classical genetic resistance in
that its reduced susceptibility disappears
when the biofilm is returned to planktonic
growth
60% of human infections chronic,
recurrent and device-related infections

Biofilms in:
Nature
Food industry
Hospitals colonization of MRSA in
nasal passages
Medical devices healthcare
associated infections urinary tract,
respiratory tract, surgical sites,
bloodstream infections

Tolerance vs. resitsance

Tolerance is only demonstrated when
the isolate is in the biofilm mode of
growth; lost when the culture is
returned to planktonic growth
Tolerance implies that the biofilm is
not killed by the antimicrobial

Mechanisms of biofilm
tolerance
Biofilm structure by TEM/SEM, diffusion barrier renders
them resistant to antimicrobial treatment
CHO matrix
DNA gene pool for diversity seen w/in the biofilm
Penetration fluoroquinolones > aminoglycosides

Biofilm physiology
Targeting one member of the mixed population w/in the
biofilm may alter the suseceptibility patterns of other species

Cellular signalling quorum sensing & cyclic

deguanylate
Plasticity of biofilms
Perister cells pre-exists in the population
Subpopulation of cells - Insurance hypothesis combination
of diverse populations in the biofilm that contribute to
tolerance

Antibiotic prescribing and

stewardship (appropriate use)
Victims of their own success
ESKAPE pathogens E. faecium, S.
aureus, K. sp, A. baumannii, P.
aeruginosa, ESBL producing
organisms
Alternatives are more toxic than the
first line drugs

Principal goals of a
stewardship program:
Improve patient outcomes
Lessen the risk of adverse effects
Reduce resistance levels, or at least
slow the rate of resistance
development
Improve cost-effectiveness

Components of antimicrobial
stewardship program
ID MD
Clinical pharmacist w/ Infectious dx
training
Medical microbiologist
Infection control professional
Hospital epidemiologits
IT specialist

Monitoring of antibiotic
resistance
Antibiotic consumption and costs, both
in total and by specific drug class
Costs associated with prescribing
potentially toxic antibiotics
Rates of resistance to specific antibiotics
by problem pathogens
Pharmacy interventions to advise on
inappropriate antibiotic use.
The incidence of hospital-acquired
infections

Public health microbiology:

infection prevention and
control

Two infection control issues:

From where (or from whom) has the

infection come
How can we minimize the risk of it
spreading to others

HCAI Healthcare associated

infections:

Wound and soft tissue infections

Bloodstream infections
UTI
Respiratory tract infections
GI tract infections

Organisms that cause HCAI:

1. S. aureus and MRSA

2. S. epidermidis
3. Gram neg bacteria
4. glycopeptide-resistant enterococci
5. C. difficile
6. Norovirus explosive vomiting &
diarrhea

5 opportunities/requirements
for hand hygiene:

Before touching a patient

Before clean/aseptic procedures
After body fluid exposure/risk
After touching a patient
After touching patient surroundings

 Zero tolerance approach to avoidable

infections

SIGHT C. difficile
Suspect that a case of diarrhea
mabye infective
Isolate patient and contact ICC team
Gloves and aprons
Hand washing with soap
Test stool for C. difficile toxins

Biosafety
Ebola virus

Vaccination
Reinfections (rare):
When the infectious agent exhibits
antigenic plasticity such as common
colds/influenza
If patient is immunocompromised (due
to immunosuppressive therapy or
immunological disorders)
When a significant amount of time has
passed after the first infection.

Spread of Infection
Common-source
Transient source of infection (infected
drinking water, contaminated food)

Propagated-source
Direct transmission of an infective agent
from a diseased individual to a healthy,
susceptible one

Classes of Immunity
Passive (artificially acquired)
IgG
Provides passive protection to the
newborn
Preformed antibodies

Active (artificially acquired)

Attenuated
Non-living or inactivated vaccine

Types of vaccine
Live, infective attenuated
Advantages:
Immunization mimics the course of a natural
infection such that a single exposure is required
to render an individual immune.
Exposure maybe mediated through the natural
route of infection (oral)

Killed and component

Immunity may not reach optimal levels until
the course of immunization is complete

DNA vaccines

Microbial spoilage, infection

risk and contamination
control

Spoilage deterioration of
pharmaceuticals
GPMP Good Pharmaceutical
Manufacturing practice quality, safety,
efficacy, stability, acceptable to patients
Consequences of contamination:
Spoiled product
Threat of litigation
Health hazard to patients

Pharmaceutical ingredients
susceptible to attack
Therapeutic agents
Less potent/inactive; thalidomide

Surface-active agents
(anionic surfactant, soap)

Non-ionic surfactants
Increasing chain length and branching
decrease ease of attack; Pseudomonas in
quaternary ammonium antiseptics

Organic polymers
Thickening & suspending agent; agar

Pharmaceutical ingredients
susceptible to attack
Humectants
Glycerol / sorbitol to reduce water loss

Fats and oils

Hydropobic; fungal attack

Sweetening, flavouring & coloring agents

Pseudomonas

Preservatives and disinfectants

Gram negative; Pseudomonas in eye drops

Observable effects
of microbial attack
Smell, sour taste fatty acids and
their ketonic oxidation products
Discoloration by microbial pigments
Loss of viscosity & sedimentation
Gaseous metabolites seen as trapped
bubbles within viscous formulations

Factors affecting microbial

spoilage
Type / size of contaminant inoculum
Raw materials contaminated, lapse in
plant-cleaning protocol, biofilm, product
was grossly misused during
administration
Lag period before spoilage begins

Nutritional factors
Metabolic adaptability

Factors affecting microbial

spoilage
Moisture content water activity
The greater the solute concentration,
the lower is the water activity. Most
ogranisms grow best in dilute solutions
(high Aw).
Tablet film coating greatly reduces water
vapor uptake during storage while
allowing ready dissolution in bulk water.

Factors affecting microbial

spoilage
Redox potential
Ability of organism to grow in an environment

Storage temperature
Spoilage occurs over -20 to 60 degrees C
Deep freeze at -20C for long-term storage
Short term storage of dispensed TPN

pH
Bacterial spoilage more likely at neutral pH.

Factors affecting microbial

spoilage
Packaging design
Control entry during storage and use
Medicines rely on their low Aw to prevent
spoilage

Protection of microbes w/in pharmaceutical

products
Surfactants, suspending agents, proteins can
increase the resistantce of orgs to
preservatives

Hazard to Health
Salmonella in pacreatin and thyroid
extract
Loss of sight; burn patients
Surfactants increase resistance of
microorganisms.
Pseudomonas in TPN fluids
HIV infection infection of hemophiliacs
CJD from human growth hormone
Contaminated IV fluid; moral

Sources of control of
contamination
I. In manufacture
Raw materials, processing equipment, cleaning
equipment, area with filtered air, personal and
production hygiene, suitable packaging
Hospital manufacture
Water - > 80C & circulated a flow rate of 1-2 m/s to prevent
the build up of bacterial biofilms in the piping.
Environment - GMP
Packaging & re packaging

II. In use (human, environment &

equipment sources)

Sources of control of
contamination
II. In use cross infection (human,
environment & equipment sources)
improvements in packaging & changes in
nursing practices
Human- topical products are most at risk
Pseudomonas
environmental airborne; static level of 10^210^3/g or per mL
Equipment reuse, cosmetic products,
humidifier, incubators, ventilators, resuscitators

Extent of microbial
contamination
Specific product / Isolated incident
In manufacture
Thyroid tablets with Salmonella
Hydrocortisone eye ointment with
Pseudomonas

In use
Heavy contamination 18 % > 10^4
CFU/g or CFU/mL

Factors determining the

outcome of a medicamentborne infection

Type and degree of microbial

contamination
Route of administration
epidural

Resistance of the patient

 QMS
QA
QC