Understanding the

ANTIMICROBIAL
PROCESS
Richard Wills, MD, MBA, ACSM, Bobbie Hevner-Willey, Neal Hunter, CMA

The increasing number of antibiotic resistant strains of bacteria

and rising number of hospital acquired (nosocomial) infections

continue to stress the importance of sterile technique.

Approximately two million US patients each year in acute care

facilities suffer from nosocomial infections, costing approximately

$3.5 billion.According to the Centers for Disease Control’s Hospital

Infections Program approximately one-third of nosocomial

infections can be prevented through the use of well-organized

infection control programs, but only 6 percent to 9 percent are

actually prevented.1

Patients acquire infections through airborne contaminants,

ineffective hand-washing agents or technique, ineffective

sterilization or disinfection procedures, length of hospital stay, and

crowding in ICUs.2,3 The patient’s own suppressed immune system,

malnutrition or history of illness may contribute to susceptibility,

as well as the level of bacterial resistance to treatment.3

JUNE 2000 The Surgical Technologist

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s
183 JUNE 2000 CATEGORY 1

urgical site infection (SSI) is the second most Golgi apparatus, lysosomes) within the cytoplasm
common nosocomial infection (behind urinary are encased by the cell wall of the organism.8
tract infections). The primary cause of SSI is the There are three classifications of pathogenic
patient’s own endogenous flora, but other microorganisms:
sources include airborne contaminants or Type 1, Acellular, consists of prions, viroids,
exogenous flora from the surgical team and con­ and viruses. These are the smallest organisms
taminated or improperly sterilized instrumenta­ able to demonstrate pathogenic potential (Figure
tion. Environmental sources—such as unsterile 1).12 Viruses are obligated intracellular parasites
medications, contaminated antiseptic solutions that depend entirely upon the host cells’ synthet­
or wound dressings, and improper cleaning/ ic machinery for reproduction and energy pro­
decontamination of anesthesia equipment, IV duction. They contain either DNA or RNA. DNA
lines or fluids—also pose risks.2 viruses frequently mature in the host cell’s nucle­
The purpose of this article is to help the surgical us, while RNA viruses mature in the cytoplasm.
technologist understand types of pathogenic Type 2, Unicellular, are divided into prokary­
microorganisms, the environment in which they otic cells (chlamydiae, mycoplasmas, bacteria)
thrive, and the mechanisms of antimicrobial and eukaryotic cells (fungi, protozoa, algae, and
agents upon those organisms. An understanding plant, animal and human cells).12 Prokaryotes
of which could lead to more careful practice of lack a true cell nucleus (Figure 2). Instead, the
sterile technique and better protection for the genetic material of the cell lies within the cyto­
patient and the surgical team. plasm. Unlike acellular organisms, unicellular
forms contain both DNA and RNA and repro­
Classifications of microorganisms duce through binary fusion.
Microbial cells can best be understood by catego­ Eukaryotes are larger than bacteria and their
rizing their cellular organization into specific bio­ genetic material is separated from the cell cyto­
logic forms. These cells are divided into internal plasm by a nuclear membrane. Many reproduce
compartments by membrane systems. The com­ by budding (yeast) or grow in colonies (mold).
partments have specific activities for the mainte­ Type 3, Multicellular, consist of helminths
nance of the functions of the cell. The nuclear (adult worms, larvae, and ova) and arthropods
compartment (nucleus) contains the cells’ hered­ (lice, ticks, and fleas).12 Infections within this
itary material (DNA). Outside the nuclear mem­ category depend on specie, total number of
brane, the organelles of the cell (eg, ribosomes, helminths supported with the body of the host,

Do you know the difference?

Asepsis—the absence of pathogens in vivo Fungicide—an agent or process that kills fungi
Antisepsis—the prevention of infection in vivo Microbiocidal—an agent or process that kills microbes
Antiseptic—an agent or used to kill or remove microor­ Microbiostatic—an agent or process that inhibits growth
ganisms on living tissue or reproduction of microorganisms through drying, freez­
Bacteriostatic—an agent or method that inhibits metab­ ing, antibiotics, etc.
olism or reproduction of bacteria Sanitation—a method to reduce microorganisms to levels
Bacteriocidal/bacteriocide—an agent or method that deemed safe by public health standards
kills bacteria but not their spores Sterilization—complete destruction of all living organ­
Disinfection—a process of killing or removing microor­ isms, including cells, spores, and viruses
ganisms from fomites through chemical or physical means Virucide—kills viruses
Disinfectant—an agent used to kill or remove microor­
ganisms on fomites

The Surgical Technologist JUNE 2000

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 FIGURE 1
Types of
viruses

Dave Ludwig
Nucleic Acid
Envelope

ILLUSTRATION
A helical virus A polyhedral virus An enveloped helical virus Spikes

and the host’s defenses. The damage to the host outer layer of these bacterial membranes is
varies from species to species. An example is the thicker and is composed of lipoprotein and
hookworm, which attaches directly to the lipopolysaccharide attached to the peptidoglycan
intestinal mucosa and feeds on the blood often layer. This outer membrane contains the somatic
causing anemia within the host. 0 antigens and the endotoxin characteristic of
Arthropods are important medically because Gram-negative bacteria.10
they infest the human skin or serve as vectors in Gram-positive bacteria have a heavy, rigid
transmission of other pathogens. Table 1 classi­ layer of peptidoglycan and teichoic acid that is
fies common diseases by their type of pathogen. thicker than that of Gram-negative cells. Gram-
positive cells are most sensitive to the enzyme
Defense mechanisms of pathogens lysozyme, found in tears, saliva, and other body
fluids, which hydrolyzes peptidoglycan.
• CAPSULE A few organisms, including a number
of disease-producing bacteria, are able to • CYTOPLASM AND CYTOPLASMIC MEMBRANE Removal
manufacture a capsule that surrounds the entire of the cytoplasmic membrane surrounding the
exterior of the cell wall. The role of the capsule in entire cell will lead to bacterial lysis because the
the life of bacteria has yet to be discovered, but it cell is unable to withstand the osmotic pressures
does serve as a protective structure from found in nature.
phagocytosis. The cytoplasm contains ribosomes. Although
the ribosomes function in a similar manner, it is
• BACTERIAL CELL WALL The bacterial cell wall is possible to distinguish the ribosomes of
rigid, provides protection, and gives shape to prokaryotic cells from those of eukaryotic cells
the cell. The most abundant substance of the cell by their different sedimentation velocity in the
wall is peptidoglycan, a complex of short ultra centrifuge. Bacterial ribosomes have a
peptides and sugars.10 sedimentation value of 70s (svedberg units),
Bacteria are divided into Gram-negative and whereas eukaryotic ribosomes are larger and
Gram-positive groups based upon a reaction to a heavier with a sedimentation value of 80s.11
staining procedure, which is due to differences in
their cell wall structures (Figure 3). 10 Gram- • SPORES Approximately 150 types of bacteria
negative bacteria have a very thin peptidoglycan produce spores. These bacteria form a tough
layer next to the cytoplasmic membrane.10 The shell within the cell during a resting stage. This

JUNE 2000 The Surgical Technologist

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 FIGURE 2
Examples of
bacteria.
Escherichia coli
(transmission electron
micrograph) with flagella,
are Gram-negative
intestinal bacterium that

CDC/Elizabeth H White, MS, 1995

can cause diarrhea,
urinary tract infection,

CDC/Janice Carr
and surgical site infection.
Pseudomonas
aeruginosa (scanning
electron micrograph) are
Gram-negative bacteria
that are an opportunistic
pathogen in hospitals and
important in causing
lower respiratory and
urinary tract infections.
Streptococcus
pneumoniae (scanning
electron micrograph) are
Gram-positive bacteria
and a common respiratory
pathogen.
CDC/Janice Carr

CDC/Janice Carr
Bacillus anthracis are
rod-shaped, Gram-
positive bacteria that
cause anthrax.
The Enterococcus
species (scanning
electron micrograph) was
formerly in the
Streptococcus family.This
Gram-positive bacteria is
a common cause of
surgical site infections.
Legionella pneumophila
(transmission electron
micrograph) is Gram-
CDC/William A Clark, 1977

negative,rod-shaped
CDC/Janice Carr

bacteria that causes

Legionnaires’disease

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shell protects the bacteria from changes in its FIGURE 3
environment. During this stage, it can survive Gram-positive bacteria
without moisture or food, and even survive Differences in
extreme hot or cold temperatures. When
environmental conditions return to normal, the the cell walls
spore is able to grow and reproduce bacteria.2
of Gram-
• RESISTANCE Microorganisms have an incredible
ability to adapt to their environment. They are positive and
able to mutate in several ways to avoid the
negative effects of antimicrobial agents. They Gram-
may change their cell membranes, receptor cites,
or other aspects of their surfaces to keep the negative
agent from binding with or entering the cell. Or,
they may produce an enzyme that disables the bacteria
antimicrobial agent. Over time, these organisms
may become resistant to several agents typically Protein
used to kill them. 4 More about antimicrobial Teichoic Acids
resistance was published in the June 1999 issue of Peptidoglycan
The Surgical Technologist. Cytoplasmic
membrane
The antimicrobial process
Types of antimicrobial agents include antiseptic,
disinfectant, sterilant and pharmaceutical. The
use of these agents must be sufficient enough to
achieve a therapeutic effect against the invading
organisms. Knowledge of the biochemistry and
mechanism of action of the specific agent is nec­ Cell wall
essary when dealing with the surgical patient. By Outer membrane
combining knowledge of the antimicrobial Gram-negative bacteria Lipopolysaccharide
process with the structural function of the bacte­ Lipoprotein
rial cell wall, cell lysis or destruction of the
pathogen can be achieved effectively. FIGURE 4
The action of these agents on microorganisms
is more easily understood by analyzing the cellu­ Transmission
lar components of microorganisms and the speci­
fic effects on the microbe by the agent of choice.2,7 electron
This action can be physical, chemical, or radiation.
micrograph of
Antiseptic agents
Antiseptic agents are chemicals used on tissue to rotavirus.
either kill pathogenic organisms or inhibit their
growth during contact between the agent and the
organism.7 Examples include hexachlorophene,
1978 CDC/Erskine Palmer

iodophor, and benzalkonium (Zephiran chlo­

ride). Their effectiveness depends on both chem­
ical and physical methods.

JUNE 2000 The Surgical Technologist

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 TABLE 1 Diseases by type of pathogen4,6
FIGURE 5
Disease Virus (acellular)
Transmission Bronchitis Parainfluenza, RSV
Chickenpox Varicella-zoster
electron HIV/AIDS Human immunodeficiency (HIV)
Mononucleosis Epstein-Bar, cytomegalovirus
micrograph of Measles Parainfluenza
Meningitis Coxsackieviruses, echoviruses,
influenza A mumps, herpes simplex
Mumps parainfluenza
virus. Pneumonia Influenza, adenovirus, rhinovirus,
coronavirus, parainfluenza

CDC/Erskine Palmer
Disease Bacteria (unicellular)
Anthrax Bacillus anthracis
Cholera Vibrio cholerae
FIGURE 6 Diphtheria Corynebacterium diphtheriae
Meningitis Haemophilus influenzae,
Transmission Neisseria meningitidis
Pneumonia Haemophilus influenzae, Klebsiella
electron pneumoniae, Staphylococcus aureus,
Streptococcus pneumoniae
micrograph of Strep Throat Streptococcus pyogenes
Syphilis Treponema pallidum
Ebola virus. Tetanus Clostridium tetani
Typhoid fever Salmonella typhi

Disease Fungi (unicellular)

Athlete’s foot Trichophyton, Epidermophyton,
Microsporum
Meningitis Cryptococcus neoformans
CDC

Pneumonia Aspergillus fumigatus, Aspergillus

The physical action of rinsing and scrubbing favus, Aspergillus niger
is important in ridding the area of bacteria and Systemic mycosis Blastomyces, Histoplasma,
other debris. Chemical agents, such as antisep­ Cryptococcus, Coccidioides, Candida
tics, then affect pathogenic cells through disrup­ Ringworm infections Trichophyton, Epidermophyton,
tion of the cell membrane, inactivation of Microsporum
enzymes or damage to the genetic material. The Vaginal candidiasis Candida
effectiveness of the chemical in killing pathogens
depends on the following factors: exposure, Disease Protozoa (multicellular)
time, concentration, pH or acidity of the solu­ Gum Disease Entamoeba gingivalis
tion, temperature, and bioburden.2,4 Malaria Plasmodium falciparum, Plasmodium
Pharmaceutical agents ovale, Plasmodium ovale, Plasmodium
Pharmaceutical agents are chemicals used on liv­ vivax, Plasmodium malariae
ing tissue to destroy the microbe while preserv­ Pinworm Enterobius vermicularis
ing the tissue. These agents can be antibacterial Pneumonia Pneumocystis carinii
(antibiotics), antifungal, antiviral or antipara-

The Surgical Technologist JUNE 2000

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sitic. Examples of pharmaceutical agents include with AIDS (Figures 7 and 8).5 Antifungal agents
penicillin, aminoglycoside and miconazole such as Amphotericin B and the azoles cause
(Monistat).5 damage to the cell membranes of fungi, changing
Antibiotics can be classified on the basis of their permeability. 5-Fluorocytosine kills fungi
their action on the microbial cell: by interfering with nucleic acid synthesis.6
1. Inhibition of cell wall synthesis occurs with
penicillins, cephalosporins, bacitracin, and Disinfectants and sterilants
vancomycin. The mode of action is to inhibit Disinfectants and sterilants are chemical agents
peptidoglycan synthesis.11 used on fomites and are categorized by levels of
2. Action against the cell membranes occurs sterilization (Table 2). At the disinfectant level,
with polymyxin, nystatin, amphotericin B, the agents are effective on all microorganisms
and imidazoles. These agents inhibit normal except spores, killing bacteria, fungi, viruses, etc.2
function of the bacterial cell membrane.11 At higher levels, disinfectants may also be used as
3. Inhibitors of protein synthesis include sterilants to kill all organisms including spores.
aminoglycoside, tetracycline, chlorampheni­ Varying the time of exposure or concentration
col, erythromycin, and lincomycin. These
antimicrobials bind to a subunit of the bacte­
rial ribosome causing a blockage of the initi­
ation complex, meaning they cannot form FIGURE 7
peptide bonds, through interference with
attachment of tRNA to the ribosomes’ mRNA Asexual spores
complex and production of faulty proteins
through distortion of the mRNA code.11 of Histoplasma
4. Inhibition of transcription and nucleic acid
synthesis causing potent inhibition of bacter­ capsulatum.
ial DNA-dependent RNA polymerase occurs
with rifamycin, chloroquine, sulfonamides, Microconidia
and trimethoprim.11
In the hospital setting, most infections are are also
caused by bacteria and viruses (Figures 4, 5, and
6), although fungi and parasites occasionally are CDC
present.
involved. Because viruses are particles that live
inside the host’s cells, antiviral agents have been FIGURE 8
difficult to find. Cells that are infected with a virus
have some characteristics that differ from healthy Cryptococcosis of
cells. The action of pharmaceutical antiviral
agents is based on inhibiting division of infected lung in a patient
cells without affecting normal cells. Antiviral
treatments for HIV, AIDS, herpes, influenza, even with AIDS.
viral pneumonia are currently on the market.2,5
Antifungal agents can also be difficult to create Histopathology of lung shows
because fungal cells are similar enough to human widened alveolar septum
cells that the drugs used to treat their overgrowth containing a few inflammatory
can be toxic to humans. Fungi often live in the cells and numerous yeasts of
1984 CDC/Edwin P Ewing Jr

natural flora of the human body, but can become Cryptococcus neoformans. The
pathogenic, and sometimes life threatening, inner layer of the yeast capsule
when the immune system is impaired, such as stains red.

JUNE 2000 The Surgical Technologist

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 TABLE 2 Disinfectant classification and use
Level Effective Ineffective Use on Examples
against against
High All microorganisms Spores Critical Items - items Surgical instruments,
Glutaraldehyde except spores used in sterile tissue implants, hypoder­
(Soacide or Cidex) or body cavity mic needles
Hydrogen peroxide
solutions
Paracytic Acid
Chlorine compounds
(Chlorine dioxide and
chlorous acid)

Intermediate Fungi, bacteria, Spores Semicritical Items ­ Cystoscopes, colono­

Phenolic compounds hydrophilic viruses, items that come into scopes, laryngo­
Iodophors, 450 ppm M tuberculosis, and contact with mucous scopes
Isopropyl and ethyl HBV membranes or non-
alcohols intact skin but not
used in sterile tissue
or body cavity

Low Fungi, bacteria, Some viruses such as Noncritical items ­ Blood pressure cuff,
Chloride compounds hydrophilic viruses M tuberculosis and Items that contact OR furniture, OR
Iodophors, 100 ppm spores only environmental tables
Quaternary ammoni­ surfaces and unbro­
um compounds ken skin
(Quats)

Adapted from Surgical Technology for the Surgical Technologist: A Positive Approach to Education.

of the solution based on the type of fomite is nec­ material (DNA and nucleic acids respectively),
essary to achieve complete sterilization. Problems killing the microbials.4
with the strength, use, or contamination of disin­ Many chemical agents are hazardous to human
fectants or sterilants used in the OR could com­ skin or corrosive to equipment. When choosing a
promise the infection control process.2,4 chemical agent, the surgical technologist should
Chemical agents, such as iodophor and hexa­ take into consideration the type of pathogens pre­
chlorophene, concentrate on the cell surface sent, the toxicity to humans and the properties of
altering the physical and chemical properties of the objects needing disinfection.2
the pathogen’s cell membrane. This prevents Physical methods of sterilization effectively
normal cellular function and either destroys or disable or kill pathogens by physically altering
inhibits the pathogen. Alcohol and phenol are their environment. Temperature can affect a
examples of chemicals that inactivate the microbe’s ability to reproduce and to metabo­
pathogen’s enzymes. Chemicals, such as forma­ lize nutrients. The temperature at which an
lin and Pyridium, damage the cells’ genetic organism thrives differs, but for many, normal
body temperature is optimum. Thermal steril­

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