Contamination Of Surgical Instruments Research Articles

Detecting contamination events during robotic total joint arthroplasty

Robot-assisted total joint arthroplasty (robotic-TJA) has become more widespread over the last 20 years due to higher patient satisfaction and reduced complications. However, robotic TJA may have longer operative times and increased operating room traffic, which are known risk factors for contamination events. Contamination of surgical instruments may be contact- or airborne-related with documented scalpel blade contamination rates up to 9%. The robot arm is a novel instrument that comes in and out of the surgical field, so our objective was to assess whether the robot arm is a source of contamination when used in robotic TJA compared to other surgical instruments. This was a prospective, single-institution, single-surgeon pilot study involving 103 robotic TJAs. The robot arm was swabbed prior to incision and after closure. Pre- and postoperative control swabs were also collected from the suction tip and scalpel blade. Swabs were incubated for 24hours on tryptic soy agar followed by inspection for growth of any contaminating bacteria. A contamination event was detected in 10 cases (10%). The scalpel blade was the most common site of contamination (8%) followed by the robot arm (2%) and suction tip (0%). Robotic TJA is contaminated with bacteria at a rate around 10%. Although the robot arm is an additional source of potential contamination, the robot arm accrues bacterial contamination infrequently compared to the scalpel blade. Contamination of the robot arm during robotic TJA is minimal when compared to contamination of the scalpel blade.

Bacterial Contamination of Surgical Instruments Used at the Surgery Department of a Major Teaching Hospital in a Resource-Limited Country: An Observational Study.

Surgical instruments, be they disposable or reusable, are essential in any surgical procedure. Reusable surgical instruments should be properly sterilized or disinfected before use. However, the protocols are not always followed accordingly. This results in sterilization and disinfection failures, leading to a possible increase in the incidence of surgical site infections. This observational study report on bacterial contaminants identified instruments used for surgical procedures in a major teaching hospital in a resource-limited country. In total, 207 pre-sterilized surgical instruments and instrument parts used at three units—the general surgical theater, and the gastrointestinal (GI) endoscopy and urology endoscopy (uro-endoscopy) units—within the surgical department were randomly sampled and examined for bacterial contamination. Bacteria isolates were identified, and their antimicrobial susceptibility patterns were determined. Bacteria isolates that were identified included Citrobacter spp., Citrobacter freundii, Bacillus cereus, Staphylococcus hominis, and Staphylococcus aureus. Bacillus cereus was the most predominant bacteria isolated (30/61, 49.1%), and Staphylococcus hominis the least (1/61, 1.6%). In terms of the number of isolates from the three units examined, the uro-endoscopy unit recorded the highest followed by the general surgical theater and the GI endoscopy. However, there was no association between the various units and bacteria isolated, and no significant difference between the number of isolates among the various units (p = 0.9467, χ2 = 0.1095). In this study, even though CFU per device or device part counted was less than 20, bacteria isolated from the instruments used for a surgical procedure is of great concern considering that the setting of the study is a major teaching hospital. Multi-drug resistance was observed in almost all the isolated bacteria. Sterilization processes should be strictly adhered to, taking into consideration the length and temperature in order to reduce the risk of using contaminated instruments in these environments. It is therefore recommended that similar studies should be carried out in surgical departments at different levels of hospitals to ascertain the extent of this problem.

Infection control standards and its benefits on operative theater safety management

Working in the operating room (OR) is a very demanding job, it needs very skillful persons working in harmony to give the patient undergoing surgery the care he deserves. The OR staff should react to any abrupt situation very fast and pay attention to each detail to carry out surgical operations safely. Working in the operating room (OR) is a very demanding job, it need very skillful persons working in harmony to give the patient undergoing a surgery the care he deserves. The OR staff should react to any abrupt situation very fast and pay attention to each detail to carry out surgical operations safely. Operating Room Protocol includes Hand hygiene and wearing personal barriers. Various methods of getting rid of contamination of surgical instruments include cleaning, purification of the water used, ultrasonic removal of derbies, disinfection and sterilization. Recommendations include the formation of an infection control committee, Create, apply and follow up an annual strategy to ensure medical safety measures and continuous learning for medical staff.

Glove and instrument changing to prevent bacterial contamination in infected wound debridement and closure procedures: A prospective observational study.

Many surgeons use a single table of instruments for both excisional debridement and coverage/closure of infected wounds. This study investigates the effectiveness of a two‐table set‐up of sterile instruments, in addition to glove exchange, to reduce instrument cross‐contamination during these procedures. This is a prospective, single‐site, institutional review board‐approved observational study of surgical debridements of infected wounds over a 17‐month period. Two separate sterile surgical tables were used for each case: Table A for initial wound debridement (debridement set‐up) and Table B for wound coverage/closure (clean set‐up). Swabs of each table and its respective instruments were taken after debridement but prior to coverage/closure. The primary outcome of interest was bacterial growth at 48 hours. There were 72 surgical cases included in this study. Culture results of Table A demonstrated bacterial growth in 23 of 72 (32%) cases at 48 hours compared with 5of 72 (7%) from Table B (P = .001). These data suggest that there is significant bacterial contamination of surgical instruments used for debridement of infected wounds. Use of a two‐table set‐up reduced instrument cross‐contamination by 78%, suggesting avoidable re‐contamination of the wound.

The Influence of Iodine-Impregnated Incision Drapes on the Bacterial Contamination of Scalpel Blades in Joint Arthroplasty

BackgroundProsthetic joint infections (PJI) are a disastrous and feared complication in arthroplasty. Over the past decades, surgeons have tried to lower infection rates through all sorts of improvements. At present, it is impossible to reduce the risk to zero. As the contamination of surgical instruments and the surgical field has been identified as a remaining gap prone for infection, scalpel blades among others have become a focal point of several studies. This study is the first to compare the effect of adhesive incision drapes on contamination rates of scalpel blades in primary arthroplasty of the hip and knee. MethodsA total of 344 microbiologic blade culture results from 2 study groups with and without drape usage and 1 group with known PJI were analyzed and compared to histopathologic and microbiologic tissue results. ResultsIn 78% of all positive cultures, the bacteria were part of the local skin flora. The contamination rate for the skin blades with a drape was 3.81% vs 12.19% without drape usage. A significant difference was determined between positive skin blade culture results incision drape usage (P = .031). The different pathogens likely responsible for the PJI correlated with the deep blade cultures (P ≤ .01). The overall contamination rate of surgical blades (1.37%) is comparatively low to the results obtained from other surgical equipment in literature. None of those blade-positive patients developed a surgical site infection during 12-month follow-up. ConclusionIodine-impregnated incision drapes are able to reduce surgical skin blade contamination. Further studies may be needed to assess the relationship between blade contamination and surgical site infections.

Female Cat Intravesical Sequestration after Ovariosalpingohisterectomy Using Nylon Clamp

Background: The nylon clamp, marketed as an accessory of electrical devices, has been used as an alternative method for definitive surgical hemostasis by ligature of arteriovenous vessels in ovariosalpingohisterectomy (OSH) in bitches and female cats. However, since May 2015, the Brazilian Veterinary Statutory Body (CFMV - Conselho Federal de Medicina Veterinária) banned its application, once it is a material still not regulated to be used in animals, in addition to the numerous reports of postoperative complications. This paper reports the migration of the clamp used in the OSH to the urinary bladder of the cat and the implications of the presence of the foreign body, in addition to discussing the use of this device in surgeries.Case: A 1-year-old Persian female cat, which, three months after an elective OSH in a private veterinary clinic, presented polyuria and hematuria. The patient presented pain at abdominal palpation; in the WBC were observed leucopenia and eosinophilia, indicating a chronic inflammatory process installed; the urinalysis showed the presence of crystals, increased urinary density, milky aspect indicating presence of pus, proteinuria and hematuria; on ultrasound were observed the presence of two amorphous mobile structures inside the bladder, producing acoustic shadow, measuring approximately 0.4 and 0.6 cm in diameter, suggesting the presence of bladder urolithiasis. Considering the results, the patient was sent for a cystotomy. The association of acepromazine (0.02 mg/kg), midazolam (0.2 mg/kg), morphine (0.2 mg/kg) and ketamine (10 mg/kg) was used intramuscularly as preanesthetic medication. For anesthetic induction, 5 mg/kg of propofol was applied intravenously, in addition to epidural anesthesia with 1 mL/4 kg of lidocaine along 0.1 mg/kg of morphine and, for maintenance, isoflurane in oxygen at 100% was used. Then, a four-centimeter retro-umbilical incision was performed to exhibit the bladder. After the incision on the ventral aspect of the bladder wall, a nylon clamp with approximately 0.8 cm, present in the lumen was found and removed. The seromuscular synthesis of the bladder was with a 3-0 mononylon simple continuous suture, the muscle with a 2-0 mononylon sultan pattern, and in the skin an interrupted simple suture using 2-0 nylon was performed. Postoperative care comprised by amoxicillin with potassium clavulanate (15 mg/kg, orally, 8/8 h, 7 d), meloxican (0.15 mg/kg, orally, 24/24 h, 4 d) and tramadol (12 mg/kg, orally, 12/12 h, 4 d). After ten days, surgical stitches were removed, with good healing and clinical improvement, as well as remission of the symptomatology reported on anamnesis and physical examination.Discussion: The pathophysiology of the nylon clip migration probably occurred in a similar way to the intravesical migration of intrauterine devices (IUDs) to the abdominal cavity, bladder and intestine, in women. According to reports, it is a progressive event, in which several factors may be involved, mainly: inadequate implantation of devices, uterine infections, use of contaminated medical instruments, among others, followed by an inflammatory process, perforation of the uterine wall by the device, adhesions and migration to adjacent structures. In the present report, it is believed that the clamp lock failed in the procedure performed by the veterinarian responsible for OSH, with subsequent loosening and detachment, and migration to the urinary bladder, an organ located ventrally to the uterine body. However, the following hypotheses can also be raised: pregnancy at the moment of castration, followed by uterine stump retraction and release of the clamp; contamination of surgical instruments; postoperative infections and adhesions involving the bladder.

Chronic osteomyelitis as a complication from mycobacteriosis after breast implant

Introduction: Infection is one of the most feared complications in surgeries with the inclusion of breast implants, associated with the need for new procedures and aesthetic compromise. The agents that are most associated with this conditions are the ones that colonize the skin, such as Staphylococcus aureus and Coagulase-negative staphylococci. Case Report: We described the case of a 25-year old patient, who came to our service after an augmentation mammoplasty performed about 60 days before in a hospital in the countryside. She reported bilateral seroma and extrusion of the right breast implant on the 14th postoperative day, being submitted to antibiotic therapy and a new procedure for site review, with the placement of new implants, bilaterally. When she came to our service, on the 45th day after the exchange of implants, she presented with pain, fever, hyperemia and drainage of the purulent secretion in the operative wounds with extrusion of the implants. In the transoperative period, after the changes were identified, on the 3rd, 4th and 5th costal arches to the right, suggestive of osteomyelitis, associated with partial necrosis of the intercostal muscles and pectoralis minor. The bacteriological test of the periprosthetic secretion was bilaterally positive for mycobacteruim abscessus, and the anatomopathological study of the right costal arch biopsy was compatible with chronic osteomyelitis. The patient presented favorable clinical evolution after the removal of the implants and antibiotic therapy. Discussion: Mycobacteria are opportunistic organisms, which hardly cause diseases in human beings. Despite being uncommon, the infection of breast implants by mycobacteria can be associated with the contamination of surgical instruments and immunosuppression of the host. The infection can be similar to those caused by more common agents. In many cases, it presents with the later onset of symptoms. Prophylaxis and antisepsis, including special care regarding the protocols of sterilization of surgical instruments, are still the main factors associated with the impact of this type of complication in surgeries with breast implants.

Time-dependent surgical instrument contamination begins earlier in the uncovered table than in the covered table.

Time-dependent surgical instrument contamination and the effect of covering during arthroplasty have not been investigated. This study aimed to evaluate time-dependent contamination of surgical instruments and the effect of covering on contamination as well as to perform bacterial typing of contaminated samples. The hypothesis was that covering the surgical instruments would decrease contamination rates. Sixty patients who underwent total knee arthroplasty were randomized and divided into two groups: surgical instruments covered with a sterile towel or surgical instruments left uncovered. K-wires were used to extract microbiological samples. The K-wires were placed in a liquid culture medium at 0, 15, 30, 60, 90, and 120min. After 24-h incubation period, samples from liquid cultures were cultured on blood agar using swabs. Samples with growth after 48h were considered contaminated. Microscopic, staining, and biochemical properties were used for bacterial typing. Bacterial growth started after 30 and 60min in the uncovered and covered groups, respectively. An increase in the number of K-wires contaminated with time was detected. At least 10,000CFU/mL bacterial load was observed in the culture samples. Contamination was more significant in the uncovered group. A statistically significant difference in contamination was found between the uncovered and covered groups at 30-, 60-, 90-, and 120min (p = 0.035, p = 0.012, p = 0.024, and p = 0.037, respectively). The most common bacteria on the contaminated instruments were coagulase-negative Staphylococci (60.4%), Staphylococcus aureus (22.9%), and Streptococcus agalactia (16.7%), respectively. The risk of contamination increases with time. However, it may decrease if surgical instruments are covered. In the clinical practice, empiric antibiotic regimens based on the type of identified microorganisms in this study may be developed for postoperative periprosthetic joint infection prophylaxis. Prognostic, Level II.

Intestinal bacterial contamination of surgical instruments used for wound closure during intestinal surgery

Intestinal bacterial contamination of surgical instruments used for wound closure during intestinal surgery

Anterior subcapsular cataract caused by forceful irrigation during implantation of a posterior chamber phakic intraocular lens with a central hole

To report the rare entity of anterior subcapsular cataract after implantation of a posterior chamber phakic intraocular lens (pIOL) with a central hole. Department of Ophthalmology, Goethe-University, Frankfurt, Germany. Retrospective case series. Medical reports were reviewed of patients with vision loss caused by anterior subcapsular cataract after implantation of the V4c Visian Implantable Collamer Lens with a central hole. Patients were identified during regular follow-up visits between January and September 2015. Possible causative factors, such as microbial contamination of surgical instruments, type of ophthalmic viscosurgical device (OVD) and irrigation substance, intracameral application of mydriatics and antibiotics, duration of surgeries, and surgical technique were analyzed. Eleven eyes of 8 patients showed white opacification behind the anterior capsule of the crystalline lens 1day postoperatively. Opacification led to a significant loss of corrected distance visual acuity in all eyes. In 9 eyes, the pIOL was explanted and in 8 eyes, phacoemulsification with IOL implantation was performed. All other analyzed possible causative factors were excluded; thus, the opacification was attributed to the surgical technique of OVD removal by irrigation with a cannula in the presence of a central hole in the pIOL. After the surgical technique was adapted, no further cases of anterior subcapsular cataract occurred. Anterior subcapsular cataract was induced during implantation of a pIOL with a central hole by cannula irrigation with enforced stream onto the capsule through that hole. This entity can be avoided by a change in surgical technique.

Microbial contamination of surgical instruments used for laparotomy

The aim of this study was to determine the risk of contamination of surgical instruments according to the type of instrument and the surgical procedure. Microbiologic examination was conducted on 140 pairs of forceps used in 24 elective laparotomies. These included 60 pairs of tissue forceps and 80 pairs of DeBakey forceps. Microbes on their surface were recovered using a membrane filter method. Adenosine triphosphate assay was also performed simultaneously in each pair of forceps. A total of 66 strains of microbes was recovered from 44 collected instruments (31%), with microbial counts ranging from 0 to 296 colony-forming units. Among the recovered microbes, gram-positive cocci were dominant [corrected]. The remaining microbes included 6 strains of gram-positive rods and 4 strains of gram-negative rods. The most common organism was Staphylococcus epidermidis, followed by S hominis and S warneri. Residual adenosine triphosphate was not correlated with the number of recovered microbes. Surgical instruments tend to be contaminated during operations by microbes that inhabit the skin and organs. Surgical instruments could act as fomites for the pathogens of surgical site infection even if the surgical field is not apparently contaminated, through application of appropriate practices adhering to surgical site infection guidelines.

Evaluation of residual protein on unprocessed and decontaminated dental extraction forceps

Research into protein contamination of surgical instruments has received increasing attention and has focused on a quantitative analysis, without subsequent identification of these proteins. This study aimed to validate methods for the isolation and identification of instrument protein contamination using extraction forceps as a model. The working ends of used, unclean and decontaminated forceps were boiled in 1% (v/v) SDS and samples precipitated using StrataClean™ resin and Amicon® filtration. Proteins were visualised using SDS-PAGE and identified by mass spectrometry and Western blot. A total of 17 proteins were identified from used, unclean forceps, including blood and bacterial proteins and 2 protein bands from decontaminated forceps samples which could not be accurately identified. The methods described, when used in conjunction with quantitative and surface analysis of instruments, can aid development of cleaning processes by identifying contaminants on used devices that have been removed following cleaning.

Spiroplasma spp. biofilm formation is instrumental for their role in the pathogenesis of plant, insect and animal diseases

Spiroplasma spp. are important phyto and insect pathogens, and candidate causal agent/s of transmissible spongiform encephalopathies (TSE) in man and animals. These filterable wall-less bacteria are widely distributed in nature with an unspecified environmental reservoir. In this study we showed by scanning electron microscopy that spiroplasma form biofilm on an assortment of hard surfaces including mica, nickel and stainless steel. Spiroplasma were stuck to the surfaces by fibrillar threads consistent with curli fibers (an amyloid protein found in bacterial biofilms). After a lengthy time in cultures (6weeks), spiroplasma in biofilm bound to mica disks lost their spiral shapes and formed coccoid forms interconnected by long (>2μm) branched membranous nanotubules, therein representing direct conjugate connections between the cells. The affinity of spiroplasma biofilms for mica and nickel, and the membrane communications suggest that soil could be a reservoir for these bacteria. The persistence of clay bound spiroplasma in soil could serve as the mechanism of lateral spread of TSEs by ingestion of soil by ruminants. Spiroplasma binding to stainless steel wire supports bacterial contamination of surgical instruments following surgery on dementia patients as a mechanism of iatrogenic transmission of TSEs, especially with resistance of spiroplasma in biofilms to drying or exposure to 50% glutaraldehyde. The discovery of biofilm formation by spiroplasma addresses questions regarding environmental persistence of these organisms in nature and suggests novel mechanisms of intercellular communication and transmission.

Highly sensitive rapid fluorescence detection of protein residues on surgical instruments

There is a risk of contamination of surgical instruments by infectious protein residues, in particular, prions which are the agents for Creutzfeldt-Jakob Disease in humans. They are exceptionally resistant to conventional sterilization, therefore it is important to detect their presence as contaminants so that alternative cleaning procedures can be applied. We describe the development of an optimized detection system for fluorescently labelled protein, suitable for in-hospital use. We show that under optimum conditions the technique can detect ∼10 attomole/cm2 with a scan speed of ∼3−10 cm2/s of the test instrument's surface. A theoretical analysis and experimental measurements will be discussed.

Proteolytic inactivation of the bovine spongiform encephalopathy agent

Thermostable proteases have been investigated for their ability to provide a novel biological solution to decontamination of prion agents responsible for transmissible spongiform encephalopathies (TSEs). Proteases were identified that digested total mouse brain homogenate (MBH) protein from uninfected mice. These proteases were then evaluated for digestion of BSE (301V) infectious MBH over a range of pH and temperatures, screened for loss of anti-prion antibody 6H4 immunoreactivity and protease-treated infectious MBH assessed in mouse bioassay using VM mice. Despite a number of proteases eliminating all 6H4-immunoreactive material, only the subtilisin-enzyme Properase showed a significant extension in incubation period in mouse bioassays following a 30-min incubation at 60 °C and pH 12. These results demonstrate the potential of the method to provide a practical solution to the problems of TSE contamination of surgical instruments and highlight the inadequacy of using Western blot for assessment of decontamination/inactivation of TSE agents.

Creutzfeldt-Jakob Disease and Infection Control

Over the past year, several situations have occurred in Canada in which patients who had recently undergone a surgical procedure were subsequently diagnosed with confirmed or suspected Creutzfeldt-Jakob disease (CJD). This raised concerns over contamination of surgical instruments: which instruments might have been contaminated from direct exposure to tissues; can instruments become cross-contaminated by exposure to other contaminated instruments; what assessment is necessary to determine cross-contamination; and what should be done with instruments that have been contaminated. Additionally, should there be a patient traceback in the face of potential but unproven exposure? Unfortunately, there are no easy answers to most of the above questions. Australia, the United Kingdom and the World Health Organization have developed guidelines for the infection control management of patients with CJD, as well as instruments and devices that come into contact with them and their tissues (1-3). Health Canada's draft CJD infection control guidelines, withdrawn from the Health Canada Web site until safety concerns regarding sodium hydroxide can be addressed, closely mirrored recommendations made in those documents. The Centers for Disease Control and Prevention guidelines for CJD are under revision. However, a recent American publication made recommendations on what procedures should be used for reprocessing items that have been in contact with the prion protein (PrP) (4). These recommendations differ substantially from the draft Canadian guidelines. This article reviews current knowledge about CJD, and highlights some of the infection control concerns and controversies.

Microbial Contamination of Surgical Instruments After Washing

Microbial Contamination of Surgical Instruments After Washing

Levels of naturally occurring microorganisms on surgical instruments after clinical use and after washing

Surgical instruments exposed to sterile body sites should be contaminated with relatively low levels of microbial contamination or bioburden; however, few studies in the literature have determined the quantitative level and types of contamination. A study was conducted at 2 clinical sites to determine the level of microbial contamination of surgical instruments after clinical use and after washing. Quantitative assays showed that bioburden levels were in the range of 0 to 4415 colony forming units per instrument after clinical use, and 88% of the instruments had bioburden levels lower than 1000. As expected, a reduction in counts occurred after washing; however, in some cases, higher counts were found on the instruments after the washing process. Although the washing procedure is effective in reducing the microbial levels deposited on the surgical instruments during use, a recon-tamination process occurs that results in increased counts after washing. The low bioburden level after washing consists of predominantly vegetative microorganisms that present a relatively low challenge to sterilization and disinfection systems. (AJIC Am J Infect Control 1999;27:315-9)

Sterile hypopyon secondary to ultrasonic cleaning solution

During a 20-week period, 21 cases of sterile hypopyon occurred 24 hours after uncomplicated extracapsular cataract extraction and in-the-bag posterior chamber intraocular lens implantation at the Valley Eye Institute. While all cases responded to steroid treatment and exhibited no residual ocular effects, the cause of the hypopyon remained a mystery despite an on-going reevaluation of the surgical procedure and sterilization techniques. Several suspected causes were investigated and eliminated. It was clinically determined that surgical instruments placed in older ultrasonic cleaning solution caused the hypopyons. Further analysis at the Center for Intraocular Research at the University of Utah revealed that the instruments were contaminated by a heat-stable endotoxin that remained on the instruments through the autoclaving process. Surgeons currently using ultrasonic instrument cleaners should be aware that, with some models, following the manufacturer's recommended fluid changing procedures could result in endotoxic contamination of surgical instruments which could, in turn, cause severe inflammatory reactions in the immediate postoperative period.

Disinfection of surgical instruments

The degree of bacterial contamination of surgical instruments after operations and its reduction by cleaning and/or disinfection has been determined. Approximately 60 per cent of used instruments carried <10 1 micro-organisms, 80 per cent <10 2 and 90 per cent <10 3; and whether the operations were clean, clean-contaminated, contaminated or dirty did not significantly affect the microbial load. The contamination was not reduced by soaking instruments for 1 h in detergent, but an hour's immersion in a phenolic disinfectant reduced the levels to 80 per cent with <10 1 organisms and 98 per cent with <10 2. Similar reductions were obtained with a washer/ disinfector with a final rinse of water at >85 °C; and even better results with a different washer/disinfector without the final hot water rinse. The latter machine presumably had a better cleaning action. Instruments for manual processing should be disinfected before cleaning to minimize contamination of the cleaners' hands. However, they should preferably be processed in an efficient instrument-washer, which may not need a specific disinfection cycle, but must remain tightly closed to prevent contaminated splashes or aerosols.