8 Tips to Prevent Periprosthetic Infections

“There are often bacteria, fungi and viruses present in our surgery-ready ORs just waiting for an opportunity to get access to the next patient’s open wound,” shares Wava Truscott, PhD, MBA, a recognized expert in microbiology and biofilm science.

She says approximately 20% of bacteria remain on the patient after the surgical site has been prepped—pathogens ready to contaminate any instrument, implant or glove that might touch the patient’s skin.

Prosthetic implants are an increasingly well-known safe haven for these bacteria to thrive, whether the implant is a joint replacement, spinal implant, plates, screws or dental implant.

Battling an Unseen Enemy

Truscott says the secrets of this thriving microbiological world in the OR continue to be uncovered.

For example, a small class of bacteria has recently been understood to dwell in the tissues around and even attached to gentamicin-containing temporary spacers used after revision surgery due to an initial infection.

These bacteria are referred to as small colony forming bacteria variants (SCV) and include Staphylococcus aureus, Pseudomonas aeruginosa, and a few other bacteria, Truscott explains. “SCV require special diagnostic and treatment approaches or they will lay in wait to continue re-infecting the patient.”

Taking Action in the OR

Here are Truscott’s top 8 steps perioperative team members can take today to prevent damaging and deadly implant infections:

1. Make time to sterilize the implant—Ensure the implant is ordered early enough and delivered soon enough to be properly sterilized and confirm sterilization parameters were met after reading the bio-indicator (BI) and Class 5 integrating indicator or BI and enzyme-only indicator contained within the process challenge device (PCD).  Ideally, there should be enough time to re-sterilize if needed.




2. Have anesthesia wipe down equipment between cases—It has been repeatedly shown that anesthesia equipment in the OR are usually contaminated and that the level of contamination increases throughout the surgical day. Recently, studies have demonstrated that wiping this equipment with a detergent (or cleaner/disinfectant wipe) significantly reduces the contamination of the patient injection ports as well, reducing a potential source of bacteremia.




3. Establish responsibility for who will clean the surgical tourniquet—This should preferably happen between each case because the tourniquet is a popular source for bacteria-harboring biofilm to build-up and the tourniquet is placed just inches from the surgical site.




4. Double glove—Activities during surgery can damage and tear surgical gloves that can serve as reservoirs for sweat and bacteria that remains in a team member’s pores after antisepsis. Although much bacterial regrowth is held at bay when scrubs with residual kill are used, these are no longer always used for every surgery. Even when they are, they do not keep hands sterile. Therefore when a glove is punctured or cut, sweat bacteria and endotoxin leak into the surgical site. Also, just before anyone handles the implant, the exterior glove should be replaced so as not to contaminate the implant.




5. Don’t rest implants on patient skin—Bacteria harboring in the safety of patient pores, even after the perfect skin prep, can be transmitted to an implant if the two come in contact. For example, it has been found that propionibacteria and corynebacteria that dwell within an implant are responsible for many delayed periprosthetic infections.




6. Keep all lint-generating materials away from the surgical site and implant—Even sterile particles such as cotton lint from surgical towel or cotton gowns can attach to an implant or fall in the open wound. These particles are recognized as a threat by the body and attacked by the patient’s immune cells, while they ignore the few bacteria that always contaminate the surgical site. This immune distraction allows bacteria to multiply and establish themselves.




7. Reprocess unused screws and plates to prevent biofilm development—Coordinate with sterile processing to understand the safe life-cycle for these orthopedic items. Repeated reprocessing can corrode and pit the outer protective layer of these devices and provide places for bacteria to hide and biofilm to form. 




8. Pre-treat instruments immediately after surgery to prevent biofilm development—The surgical technologist or nurse should immediately wipe down instruments and place them in water or cover with an enzyme foam because blood and organic debris damage the surfaces—providing niches for bacteria to adhere, making them extremely difficult to clean, and creating a nice protective armor for pathogens. This has been a serious problem with reamers and bone shavers, for example.

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