Infection Control Today

APR 2019

ICT delivers to infection preventionists & their colleagues in the operating room, sterile processing/central sterile, environmental services & materials management, timely & relevant news, trends & information impacting the profession & the industry

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32 ICT April 2019 www.infectioncontroltoday.com feature T h e late s t p ro s p e c t i ve co h o r t by McClelland, et al. (2016) demonstrated that surgical site infections (SSI) occur at the higher end of 2 percent to 13 percent (i.e., 12.7 percent) and are egregiously underestimated largely based on retrospective data not subjected to the inclusivity of SSI as defned by the Centers for Disease Control and Prevention (CDC). 1 Furthermore, the widespread and indis- criminate use of local vancomycin powder has raised concerns of near-term antibiotic resistance, leading to establishment of global alliances against overuse of antibiotics taskforces. Despite concerns associated with vancomycin application immediately before surgical site closure, there is still no way to irrigate the screw-bone interface post-im- plantation. 2 Therefore, in cases where the bio-dose of natural or administrated immunity is limited, any contamination present from implantation is permanent. This leads to deep bone infection, or hardware loosening due to encapsulation of bioflm between the bone and the screw. 3-7 Nevertheless, if an opportunity presents to nullify the contamination of pedicle screws altogether, before the implantation, shouldn't become the standardized practice for the sake of patient's safety? The current communication seeks to provide well-quantified results through peer-reviewed data available in the literature, for spine surgeons to make an educated and ethical choice. Recent literature review has shown that both reprocessing (preoperative) and handling (intraoperative) of implants seem to lead to contamination of sterilized implants. 8 Furthermore, Agarwal, et al. demonstrated in their two-staged approach research, the pedicle screws are being contaminated in two phases: preoperative phase and intraoperative phase, both of which could be mitigated by employing newer methodologies or standard of care. 9-12 In the first phase, i.e. preoperative contamination, the pedicle screws undergo repeated bulk-cleaning with dirty instruments By Aakash Agarwal, PhD from the operating room (OR), leading to residue build up at the interfaces and possibly on the surfaces too. This, due to its concealed nature, remains unnoticed by the sterile processing department (SPD) or other hospital staff. 9 Nevertheless, this can be avoided by using single-use pre-sterilized screws, which are becoming popular these days, with many countries issuing a ban on repeated implant reprocessing. 13 In the second phase, i.e., intraoperative contamination, the sterile pedicle screw shafts (in the sterile feld) are directly touched by the scrub tech with soiled (assisting the surgeon dispose the tissues from the instruments in use) gloves for loading onto an insertion device/screw driver. 10 It is then kept exposed on the working table (either separately or next to the used instruments as the pedicles' holes are being prepared). Their investigation shows that by the time it is implanted in the patient, it can harbor up to 10e7 bacterial colony forming units. 10 -12 The study also included a treatment group, which in essence is a functional impermeable sterile-sheath around the sterile-implant, which shields the pedicle screws intraoperatively until it is implanted into the patient. 10-12 Use of the sheath resulted in zero contamination, thereby establishing itself as a precautionary measure against possible SSI or subclinical and chronic sepsis leading to screw loosening and pain. There also exists an analogous study from three years ago where the surgical team showed signifcant reduction in SSI rate by changing gloves every time before anyone touched the screw. 14 In theory, adoption of this practice would require universal education and is dependent upon the consistency and compliance of every individual surgeon. Even then, a pedicle screw is held by a scrub tech during unwrapping and attachment to an insertion device, followed by its placement next to other dirty surgical instruments, surfaces or open-air. In contrast, the use of intraoper- ative-sheath provides uninterrupted protection from all the aforementioned elements. Figure 1 shows a schematic of the process and the data. Figure 2 shows the schematics for pathogenesis of SSI. Figure 1: Schematic showing the binary nature of bacterial dose on the pedicle screw, from using or not using the intraoperative-implant-guard Implanting Pedicle Screws Without Bacteria: How Do We Keep Track of Invisibles?

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