T.J. Secker

Doped diamond-like carbon coatings for surgical instruments reduce protein and prion-amyloid biofouling and improve subsequent cleaning.

Doped diamond-like carbon (DLC) coatings offer potential antifouling surfaces against microbial and protein attachment. In particular, stainless steel surgical instruments are subject to tissue protein and resilient prion protein attachment, making decontamination methods used in sterile service departments ineffective, potentially increasing the risk of iatrogenic Creutzfeldt-Jakob disease during surgical procedures. This study examined the adsorption of proteins and prion-associated amyloid to doped DLC surfaces and the efficacy of commercial cleaning chemistries applied to these spiked surfaces, compared to titanium nitride coating and stainless steel. Surfaces inoculated with ME7-infected brain homogenate were visualised using SYPRO Ruby/Thioflavin T staining and modified epi-fluorescence microscopy before and after cleaning. Reduced protein and prion amyloid contamination was observed on the modified surfaces and subsequent decontamination efficacy improved. This highlights the potential for a new generation of coatings for surgical instruments to reduce the risk of iatrogenic CJD infection.

A rapid dual staining procedure for the quantitative discrimination of prion amyloid from tissues reveals how interactions between amyloid and lipids in tissue homogenates may hinder the detection of prions

Transmissible spongiform encephalopathies (TSEs) are fatal neurodegenerative diseases with no cure to this day, and are often associated with the accumulation of amyloid plaques in the brain and other tissues in affected individuals. The emergence of new variant Creutzfeldt-Jakob disease, an acquired TSE with a relatively long asymptomatic incubation period and unknown prevalence or incidence, which could potentially be iatrogenically transmitted, has prompted the need for sensitive and rapid methods of detection of the pathology indicator, the protease-resistant prion protein (PrP(Sc)), in tissues and on surgical instruments. To discriminate between common tissue proteins and amyloid-rich aggregates such as those formed by abnormal prion, we developed a quantitative thioflavin T/SYPRO Ruby dual staining procedure, used in combination with episcopic differential interference contrast/epifluorescence (EDIC/EF) microscopy for rapid scanning of samples. The detection limit of this direct observation technique applied to brain homogenates was greatly enhanced by the addition of Tween 20, as demonstrated in double-blind studies using various proportions of ME7-infected brain mixed with normal brain homogenate. The characteristic thioflavin T signal correlated with the relative amount of prion amyloid and proved at least 2-log more sensitive than the classic Western blot using the same prepared samples. This new sensitive microscopy procedure, which can be easily applied in instrument decontamination surveys, is likely to be more sensitive that Western blot in practice since it does not rely on the elution of resilient PrP(Sc) bound to the instrument surfaces. Our study also demonstrates how interactions between prion and lipid-rich tissue homogenates may reduce the sensitivity of such detection assays.

Application of a fluorescent dual stain to assess decontamination of tissue protein and prion amyloid from surgical stainless steel during simulated washer-disinfector cycles

Current World Health Organization guidelines pertaining to the reprocessing of surgical instruments in the face of potential iatrogenic transmission of Creutzfeldt-Jakob disease (iCJD) are incompatible for the vast majority of devices. This has led to the advent of a range of new decontamination measures. Even without the implementation of these new procedures, the incidence of proven iCJD through surgery remains low. In this study, existing decontamination processes in sterile service departments have been evaluated using simulated washer-disinfector cycles on surgical grade stainless steel wires inoculated with ME7 scrapie homogenate. The consequence of varying the soil drying times and choice of cycle pre-treatment on prion removal were evaluated. Assessment of residual contamination at each cycle phase was carried out with the application of a sensitive fluorescent staining procedure to identify both total protein and prion-associated amyloid. The study confirmed that immediate reprocessing following contamination was beneficial during the pre-treatment phase with either an enzymatic or pre-soak wetting agent. Final total protein levels at the end of the cycles, were not significantly different from those where the soil was allowed to dry. In addition, cycles involving a pre-treatment with either an enzymatic cleaner or pre-soak, whether the soil was allowed to dry or not, showed complete removal of detectable prion amyloid. The results suggest that current decontamination procedures, combined with immediate processing of surgical instruments, have the potential to be highly effective alone at reducing the risk of surgical transmission of CJD.

Ultrasonic activated stream cleaning of a range of materials

Despite decades of routine use (starting from the industrial setting but now also with domestic products available), ultrasonic cleaning faces technical challenges that have never been overcome, and the root of many of these lies with an understanding of the interaction between the bubble population and the sound field. Ultrasonically Activated Stream (UAS) technology is designed to produce ultrasonic cleaning, and in this paper it does so for scenarios for which an ultrasonic cleaning bath would be unsuitable, e.g., removing key contaminants (such as biofilms) from delicate substrates (tissues, etc.), without damaging that substrate.

Bubbles vs biofilms: a novel method for the removal of marine biofilms attached on antifouling coatings using an ultrasonically activated water stream

The accumulation of marine organisms on a range of manmade surfaces, termed biofouling, has proven to be the Achilles’s heel of the shipping industry. Current antifouling coatings, such as Foul Release Coatings (FRCs), only partially inhibit biofouling, since biofilms remain a major issue. Mechanical ship hull cleaning is commonly employed to remove biofilms, but these methods tend to damage the antifouling coating and often do not result in full removal. Here, we report the effectiveness of biofilm removal from FRCs through a novel cleaning device that uses an Ultrasonically Activated Stream (UAS). In this device, ultrasound enhances the cleaning properties of microbubbles in a freely flowing stream of water. The UAS was applied on two types of commercial FRCs which were covered with biofilm growth following twelve days immersion in the marine environment. Biofilm removal was quantified in terms of reduction in biovolume and surface roughness, both measured using an optical profilometer, which were then compared with similar measurements after cleaning with a non-ultrasonically activated water stream. It was found that the UAS significantly improves the cleaning capabilities of a water flow, up to the point where no detectable biofilm remained on the coating surfaces. Overall biofilm surface coverage was significantly lower on the FRC coatings cleaned with the UAS system when compared to the coatings cleaned with water or not cleaned at all. When biofilm biomass removal was investigated, the UAS system resulted in significantly lower biovolume values even when compared to the water cleaning treatment with biovolume values close to zero. Remarkably, the surface roughness of the coatings after cleaning with the UAS was found to be comparable to that of the blank, non-immersed coatings, illustrating that the UAS did not damage the coatings in the process.

Efficacy of humidity retention bags for the reduced adsorption and improved cleaning of tissue proteins including prion-associated amyloid to surgical stainless steel surfaces

Increasing drying time adversely affects attachment of tissue proteins and prion-associated amyloid to surgical stainless steel, and reduces the efficacy of commercial cleaning chemistries. This study tested the efficacy of commercial humidity retention bags to reduce biofouling on surgical stainless steel and to improve subsequent cleaning. Surgical stainless steel surfaces were contaminated with ME7-infected brain homogenates and left to dry for 15 to 1,440 min either in air, in dry polythene bags or within humidity retention bags. Residual contamination pre/post cleaning was analysed using Thioflavin T/SYPRO Ruby dual staining and microscope analysis. An increase in biofouling was observed with increased drying time in air or in sealed dry bags. Humidity retention bags kept both protein and prion-associated amyloid minimal across the drying times both pre- and post-cleaning. Therefore, humidity bags demonstrate a cheap, easy to implement solution to improve surgical instrument reprocessing and to potentially reduce associated hospital acquired infections.

Acquisition of proteinaceous contamination through the handling of surgical instruments by hospital staff in sterile service departments

Using Episcopic Differential Interference Contrast (EDIC) microscopy, this study has investigated the potential reapplication of prote ina ceouscontami napotential reapplication of proteinaceous contamination onto surgical instruments following a washer-disinfector cycle through the handling of staff within the clean room. The deposition of 0.51 ng/mm2 of protein onto surgical grade stainless steel by one finger print alone has been demonstrated. Moreover, using a previously described contamination index, a 5 to 10-fold increase in protein present on surgical instruments was noted following handling by clean-room staff under current departmental practices, relative to instruments handled by staff wearing gloves. While unlikely to pose a direct risk to patient health, subsequent sterilisation will fix protein to an instrument surface thereby decreasing the effectiveness of further decontamination cycles. Current guidelines make no recommendations surrounding the use of gloves by staff working within the clean room. However it is clear that this matter must be reviewed to limit the unnecessary transference of protein to surgical instruments.