Reducing the risk of iatrogenic Creutzfeldt–Jakob disease by improving the cleaning of neurosurgical instruments

• Published in: The Journal of hospital infection Vol. 100; no. 3; pp. e70 - e76
• Main Authors: Smith, A., Winter, S., Lappin, D., Sherriff, A., McIvor, I., Philp, P., Suttner, N., Holmes, S., Stewart, A.
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 01.11.2018
• Subjects: Automated washer-disinfector; Cleaning; Creutzfeldt-Jakob Syndrome - epidemiology; Creutzfeldt-Jakob Syndrome - prevention & control; Creutzfeldt–Jakob disease; Decontamination - economics; Decontamination - methods; Humans; Iatrogenic Disease - epidemiology; Iatrogenic Disease - prevention & control; Infection Control - economics; Infection Control - methods; Neurosurgical instruments; Pre-cleaning; Proteins - analysis; Risk reduction; Surgical Instruments; United Kingdom - epidemiology; United Kingdom; Risk reduction; Neurosurgical instruments; Automated washer-disinfector; Cleaning; Pre-cleaning; Creutzfeldt–Jakob disease
• ISSN: 0195-6701; 1532-2939
• DOI: 10.1016/j.jhin.2018.03.001

In all, there have been 178 variant Creutzfeldt–Jakob disease (vCJD) patients diagnosed in the UK, with an estimated maximum 1:2000 carriage rate based on archived appendix and tonsil tissue, implying that infection may be rare but carriage relatively frequent. Previous workers have identified that maintenance of surgical instruments in a humid atmosphere after use and prior to cleaning assists cleaning efficacy. Recently the Department of Health/Advisory Committee on Dangerous Pathogens UK have recommended a surgical instrument cleanliness threshold post cleaning of <5 μg protein per instrument side. To quantify cleanliness of neurosurgical instruments and to investigate cost-effective measures for improved cleaning. Two instrument protein quantification methods were used: one based on the International Standard (15883 series) using sodium dodecyl sulphate elution and ortho-phthalaldehyde reaction, and a second in-situ protein fluorescence detection system (ProReveal) providing results per instrument side. In-vitro investigation of the efficacy of some commercial and in-house pre-clean wetting agents was undertaken using artificial test soil and stainless steel discs under standard conditions. In-vivo evaluation of best-performing in-vitro agents was undertaken on craniotomy sets. ProReveal technology demonstrated that 163 out of 187 (87%) neurosurgical instruments had <5 μg residual protein per instrument side. The use of proprietary National Health Service plastic bags and sterile water-soaked wound pads were equivalent in efficacy to commercial pre-cleaning wetting products and significantly less expensive. Although we demonstrate low in-situ protein levels on neurosurgical instruments and the beneficial effects of keeping instruments moist, other cleaning critical-control points such as instrument loading patterns should also be monitored.