Enzymes for surgical cleaners 4/13/2017 2009-08013-01

Surgical cleaners Enzymatic detergents Biofilm content 4/13/2017 NOVOZYMES PRESENTATION content Surgical cleaners Enzymatic detergents Biofilm

Challenges for surgical cleaners 4/13/2017 NOVOZYMES PRESENTATION Challenges for surgical cleaners "...in the absence of careful physical cleaning, most disinfection and sterilization processes are likely to be ineffective. …only steam autoclaving can overcome the barrier effects of residual organic matter." Source: Gastrointestinal Endoscopy Vol 50 no. 2 1999, pg 288 Removal of body tissue soils like blood, mucous, fats, and others Reduction of biofilms

Formulation types of surgical cleaners 4/13/2017 NOVOZYMES PRESENTATION Formulation types of surgical cleaners . Neutral pH Detergent (pH 6 – 8) Alkaline pH Detergent (pH 10-12) Enzymatic Detergent (~Neutral, pH 7-8) Single enzyme (e.g., protease or lipase) Multi-enzyme (protease, lipase, amylase, cellulase…)

Intended use of surgical cleaners 4/13/2017 NOVOZYMES PRESENTATION Intended use of surgical cleaners . High or low impingement washers Manual applications Ultrasonic Presoak Stain Removal

Example of process – endoscope cleaning 4/13/2017 NOVOZYMES PRESENTATION Example of process – endoscope cleaning Effective cleaning of endoscopes is essential Endoscopes have fragile parts and should not be exposed to high temperatures (>60°C) and autoclaving Flexible endoscope must be decontaminated by cleaning at low temperatures and disinfected by cold chemicals Cleaning of flexible endoscopes is classified as a semi-critical instrument since it penetrates skin and tissue. Must be disinfected with a high level disinfector (HLD)

Types of surgical instruments and their use 4/13/2017 NOVOZYMES PRESENTATION Types of surgical instruments and their use Flexible endoscopes Heat labile – can not be autoclaved Gastro-Intestinal inspections 10 million inspections/year in US (1995) Rigid endoscopes Laparoscopes Abdominal; minimum invasive surgery 4.4 million inspections/ year in US

The optimal process of endoscope cleaning (WGO) 13/04/201713/04/2017 NOVOZYMES PRESENTATION The optimal process of endoscope cleaning (WGO) Use of device Rinsing with water and manual cleaning with detergent Automatic cleaning with detergent Disinfection Rinsing with bacteria-free water or alcohol Drying Storage

The optimal process of endoscope cleaning (WGO) 13/04/201713/04/2017 NOVOZYMES PRESENTATION The optimal process of endoscope cleaning (WGO) Room 1 - The Operating room Room 2 - The dirty room Room 3 The reprocessing room Room 4 - The storage room Step 2 Rinsing with water And manual cleaning Step 1 Use of the Device Step 3-6 Washing, disinfection, rinsing with bacteria-free water or alcohol & drying Step 7 Storage

Washing with detergents 13/04/2017 NOVOZYMES PRESENTATION Washing with detergents This is the part of the cleaning process where enzymes are applicable This part of the reprocessing process is very important, since inadequate cleaning and removal of biofilm inhibits disinfection as defined by AAMI There are two methods of washing/cleaning: manual and automatic Disinfection is defined as: “The process of removing as much of the contamination as possible, but not necessarily killing the microorganism.” Source: TIR 30 – A Compendium of cleaning of medical devices” by AAMI (2003) (TIR 30)

4/13/2017 NOVOZYMES PRESENTATION Enzymatic detergents Enzymatic detergents are recommended in both Europe (ESGE), in the US (Multi-society guidelines) and globally (WGO) Can be positioned as a environmental friendly and more safe to handle substitute to more harsh detergents They are often the detergent of choice since they are effective at dissolving proteins and operate at low temperatures in a neutral environment The majority of the guidelines recommend that the health care facility uses the detergent recommended by the manufacturer of the AER The majority of the enzymatic detergents are multi-purposed and can be used in almost all the automatic cleaners and as a manual cleaner The manufacturers of the detergents use the enzymes as a selling point in their brochures using between one to four different enzymes in their detergents (protease, lipase, amylase, and cellulase)

Complete blood removal with proteases 4/13/2017 NOVOZYMES PRESENTATION Complete blood removal with proteases Test stopped Time taken in min. to clean Get faster blood removal with enzymatic detergents Blood is the main and most critical contaminant of surgical instruments and it is used in the international standard ISO15883 as chosen test soil (TOSI test) to check the efficacy of cleaning procedures for surgical instrumentation reprocessing

4/13/2017 NOVOZYMES PRESENTATION Reasons for cleaning Blood fixation by sterilizing agents (glutaraldehyde, peracetic acid)

Endoscope cleaners in Brazil contain three to four enzymes 4/13/2017 NOVOZYMES PRESENTATION Endoscope cleaners in Brazil contain three to four enzymes Endoscope cleaners launched in Brazil containing only one enzyme Endoscope cleaners launched in Brazil containing more than one enzyme

Examples of enzymatic cleaners 4/13/2017 NOVOZYMES PRESENTATION Examples of enzymatic cleaners . Asepti-zyme from Ecolab is marketed as a multi-purpose detergent that can be used for manual decontamination, scope washer/disinfectors, ultrasonics, washers and sterilizers, and washer decontaminators, and as a detergent that delivers: Rapid action Dissolves proteinacious matter Super-concentrated Low foaming - saves time

Examples of enzymatic cleaners 4/13/2017 NOVOZYMES PRESENTATION Examples of enzymatic cleaners Kimberly Clark’s multi–enzyme detergent for manual Cleaning is marketed as: Effective; rapidly removes all types of soils (fats, carbohydrate and protein) Compatible; can be used with a wide range of devices Low-Foaming; appropriate for manual and small washer use Easy-To-Use; pump dispenses consistent 1 ounce dose User-Friendly; pleasant fragrance in an ergonomically designed package Process-Friendly; easily integrates into your current practices Environment-Friendly; biodegradable and phosphate-free

Examples of enzymatic cleaners 4/13/2017 NOVOZYMES PRESENTATION Examples of enzymatic cleaners Korsolex Endo-cleaner from Bode is marketed as: Excellent solving capacity for oil, dirt, blood and biofilm High degree of material compatibility for machine and endoscope Little foaming Economical Phosphate-free Environmentally friendly Compatible with Korsolex® Endo-Disinfectant

Examples of enzymatic cleaners 4/13/2017 NOVOZYMES PRESENTATION Examples of enzymatic cleaners PRO EZ 2 from Certol is marketed as: Dual enzymatic action dissolves both protein and starch containing soils. Superior surfactants remove loosened soils and emulsify fats Use as a presoak Multipurpose: used in manual, ultrasonic, or automated systems Reduces unpleasant odors Gentle, neutral pH and non-corrosive The dispensing pump takes the guess work out of measuring

Novozymes’ positioning in I&I surgical cleaner market 4/13/2017 NOVOZYMES PRESENTATION Novozymes’ positioning in I&I surgical cleaner market Segment Novozymes preferred products Selling points Competitor product NZ product discriminator Surgical instrument reprocessing Alcalase / Esperase/ Alcalase Ultra Stainzyme Lipex Viscozyme Enables improved cleaning at low temperatures Attacks all food residue and body soils efficiently Extended equipment lifetime Less hazardous chemicals to handle Cleaning and hygiene in 1 step Ultra to offset MPG costs Mainly competing with Peroxyacetic acid and surfactants and glutaraldehyde based detergents Better overall performance, milder conditions Less toxic chemicals

The problem with biofilms 4/13/2017 NOVOZYMES PRESENTATION The problem with biofilms Biofilms are ubiquitous in nature and cause a variety of problems including: Fouling of membranes Biological fouling in medical instruments, oil field injection wells, and cooling towers Infections and disease in people (e.g., contamination of drinking water and dental unit water) Oral care/plaque buildup Corrosion of metal surfaces by sulfur-reducing bacteria (SRB’s) Companies are attempting to address most of these areas using detergent-type Cleaners.

Typical enzyme dosages 4/13/2017 NOVOZYMES PRESENTATION Typical enzyme dosages For initial formulation trials, in an endoscope cleaner used at a 5% concentration in the cleaning bath, the recommended dosage levels of liquid enzymes are: Enzyme Category Typical enzyme dosage in the detergent, wt% Proteases 10% (Savinase 16 L, Everlase 16 L, Alcalase 2.5 L, Esperase 8.0 L, Liquanase 2.5 L) Amylases 8% (Termamyl 300 L, Duramyl 300 L) 6% (Stainzyme 12 L, Stainzyme Plus 12 L) Lipases 5% (Lipex 100 L, Lipolase 100 L) Cellulases 5 % (Novozym 342, Celluzyme, Viscozyme)

Polysaccharides produced by bacteria in biofilms 4/13/2017 NOVOZYMES PRESENTATION Polysaccharides produced by bacteria in biofilms EPS Polymer Linkage Bacteria Alginates b-1,4 mannuronic acid a-1,4 guluronic acid Pseudomonas Amylopectin a-1,4 & a-1,6 glucose Ecoli Celluloses b-1,4 glucose Acetobacter Colanic Acids Glucose, galactose, fucose, glucuronic acid, pyruvic acid Salmonella, Ecoli Dextrans a-1,6 & a-1,4 glucose Streptococcus, Acetobacter Glycogen Bacillus, Pneumococci Levans b-2,6 fructose Pseudomonas, Bacillus, Aerobacter Polymannans b-1,4 mannose Desulfovibrio desulfuricans

4/13/2017 NOVOZYMES PRESENTATION How can enzymes help . Enzymes are able to facilitate biofilm removal from surfaces in an environmentally-friendly manner Enzymes enable targeted removal of contaminants from surfaces without causing deleterious effects to the surface (e.g., pH-sensitive membranes and temperature-sensitive surgical instruments) Enzymes may be able to bypass bacterial defense mechanisms that can inactivate common cleaning agents (e.g., bacterial catalases for H2O2)

Typical biofilm screening methodology 13/04/2017 NOVOZYMES PRESENTATION Typical biofilm screening methodology Grow biofilms of relevant organism(s) in minimal media on polycarbonate or stainless steel coupons in CDC reactors (stirred cell, batch mode (non-CSTR) – typically for 2 days) Treat biofilm-coated coupons with various cleaning products with and without enzymes Stain coupons with crystal violet solution Measure the biofilm removal index (BRI) instrumentally ((based on ASTM D4265-98) BRI = 100 – [(Lclean-Ltreated)2 + (aclean – atreated)2 + (bclean – btreated)2]1/2

Multi-enzyme solution can help detergents remove biofilm 4/13/2017 NOVOZYMES PRESENTATION Multi-enzyme solution can help detergents remove biofilm , The surgical instruments were soaked for 60 min at 40°C This data is based on the removal of Model Pseudomonas auerginosa biofilm, a common microbe found on surgical instruments Unsoaked Soaked in detergent Soaked in detergent + multi-enzyme solution L* Values for Soaked Coupons Containing Pseudomonas Auerginosa biofilm 12 14 16 18 20 Detergent+E2 Detergent+E1 Detergent only No Soaking Treatment L*

Comments on disinfection 4/13/2017 NOVOZYMES PRESENTATION Comments on disinfection Disinfection is a separate step of the reprocessing of the flexible Endoscope The specific substance used for disinfection varies around the world due to different recommendations in the different countries One of the most commonly used disinfectors globally for endoscopes is Glutaraldehyde followed by Peracetic acid Glutaraldehyde is an asthmagen and there is a rising concern, especially in the West, about the use of this substance Glutaraldehyde is still the most used disinfector in the rest of the world**, while the US authorities recommend that you do not use unless its absolutely necessary*** NHS statement on disinfection “It is not considered acceptable to use Glutaraldehyde for endoscope disinfection in the United Kingdom.” * A program under the British health authorities. ** Danish recommendations from SSI ( Statens Serum Insititut) and statistics from ESGE and WGO ***Recommendations from the Center for Disease control (CDC), the Association for the Advancement of Medical Instrumentation (AAMI) and Association of practitioners in infection control (APIC) and WGO.

The different disinfectors – categorized 4/13/2017 NOVOZYMES PRESENTATION The different disinfectors – categorized Disinfectant base Properties Examples Alkylating agents Superior materials compatability Tend to be in a higher COSHH Essentials hazard group than oxidising agents Their ability to fix protein may limit use of some products (e.g glutaraldehyde) Glutaraldehyde (Cidex, ASEP, Totacide) Ortho-phthalaldehyde (OPA, Cidex-OPA) Mixtures (Gigasept rapid, Septo DN) Oxidising agents Superior sponcidal activity Tend to be in a lower COSHH Essentials hazard group than oxidising agents May be incompatible with some endoscopes Chlorine-containing compounds (Sterilox, Tristel) Peroxygen compounds (Virkon S) Perasetic acid (Nu Cidex, Steris, Aperlan)

Learn more about our I&I solutions at www.novozymes.com 4/13/2017 NOVOZYMES PRESENTATION Thank you Learn more about our I&I solutions at www.novozymes.com