As it cannot be denied that infection can result from environmental conditions and can be caught anywhere it is often forgotten that pathogenic microorganisms could have been planted in the patient during the actual surgical procedure. What is more in this case contamination is introduced directly to the sterile tissue what stipulates that it is entirely down to individual’s immune system to deal with it. In order to prevent the spread of infection and speed up recovery time antibiotics were used to support the body’s natural defences. Now more and more pathogens mutate and develop properties that allow them to resist these drugs.
It should not be a surprise then that this subject is being brought up into the decontamination sciences arena. The question we ought to as well is, what is the ultimate goal of decontamination of surgical instruments as in the context of drug resistant microorganisms. Is inactivation of pathogens enough? What risks are we truly facing considering contaminated surgical instruments?
For some time now I have been talking about the need for the shift in focus in decontamination sciences. From inactivation or simply killing microorganisms that reside on surfaces of surgical instruments we need to move towards their physical removal. There are two major issues that need to be addressed.
First of all there is a major problem with sterility of surgical instruments. Theoretically sterility is achieved based on an assumption there is less than a million microorganisms on a total surface are of an instrument and the fact that process delivers 12 log reduction of the population – that results in a one in a million or less chance of survival of a single viable organism. That is theory. In practice we often do not know how much contamination is really present when all surfaces of the instrument are included – think of box joints and lumen instruments and all that area that is hidden from our view. On top of that contamination is not usually evenly spread on the instruments but resides in areas hardest to clean like holes, dead ends, crevices. Inside of these features are difficult to penetrate by sterilising media – be it steam, gas or plasma – making them vulnerable.
Second issue is the dead organic matter that resides on the instruments after the decontamination process. This organic matter introduces to the sterile tissue will produce endotoxins putting yet more stress on the body to combat them. In the instance of consequent infection with antibiotic resistant bacteria will leave an individual in a much worse position to start with.
It is therefore necessary to reduce the initial bioburden before sterilisation much further. Shift in focus from sterilisation towards cleaning. This means increasing efficacy of cleaning processes. Making sure efficacy is measured against worst case scenario – instruments toughest to reprocess. We need efficacy that is proven and further monitored on a regular basis. Most of all, however, we need awareness and understanding of the importance of the cleaning process as facing drug resistant bacteria it seems the best line of defence.
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