TTIMES WORLD: Health News Report

Friday, November 17, 2017
Washington, DC, USA


 

Surgical Instrument Proper Storage
Makes a Big Difference in Surgical Infection Rates

Storage.
Studies have suggested that wrapped surgical trays remained sterile for varying periods depending on the type of material used to wrap the trays. Safe storage times for sterile packs vary with the porosity of the wrapper and storage conditions (e.g., open versus closed cabinets). Heat-sealed, plastic peel-down pouches and wrapped packs sealed in 3-mil (3/1000 inch) polyethylene overwrap have been reported to be sterile for as long as 9 months after sterilization. The 3-mil polyethylene is applied after sterilization to extend the shelf life for infrequently used items967. Supplies wrapped in double-thickness muslin comprising four layers, or equivalent, remain sterile for at least 30 days. Any item that has been sterilized should not be used after the expiration date has been exceeded or if the sterilized package is wet, torn, or punctured.

Although some hospitals continue to date every sterilized product and use the time-related shelf-life practice, many hospitals have switched to an event-related shelf-life practice. This latter practice recognizes that the product should remain sterile until some event causes the item to become contaminated (e.g., tear in packaging, packaging becomes wet, seal is broken)968. Event-related factors that contribute to the contamination of a product include bioburden (i.e., the amount of contamination in the environment), air movement, traffic, location, humidity, insects, vermin, flooding, storage area space, open/closed shelving, temperature, and the properties of the wrap material966, 969. There are data that support the event-related shelf-life practice970-972. One study examined the effect of time on the sterile integrity of paper envelopes, peel pouches, and nylon sleeves. The most important finding was the absence of a trend toward an increased rate of contamination over time for any pack when placed in covered storage971. Another evaluated the effectiveness of event-related outdating by microbiologically testing sterilized items. During the 2-year study period, all of the items tested were sterile972. Thus, contamination of a sterile item is event-related and the probability of contamination increases with increased handling973.

Following the sterilization process, medical and surgical devices must be handled using aseptic technique in order to prevent contamination. Sterile supplies should be stored far enough from the floor (8 to 10 inches), the ceiling (5 inches unless near a sprinkler head [18 inches from sprinkler head]), and the outside walls (2 inches) to allow for adequate air circulation, ease of cleaning, and compliance with local fire codes (e.g., supplies must be at least 18 inches from sprinkler heads). Medical and surgical supplies should not be stored under sinks or in other locations where they can become wet. Sterile items that become wet are considered contaminated because moisture brings with it microorganisms from the air and surfaces. Closed or covered cabinets are ideal but open shelving may be used for storage. Any package that has fallen or been dropped on the floor must be inspected for damage to the packaging and contents (if the items are breakable). If the package is heat-sealed in impervious plastic and the seal is still intact, the package should be considered not contaminated. If undamaged, items packaged in plastic need not be reprocessed.

Reducing Hospital Blood Borne Infections
Surgical Central Lines

A central line is a tube that a doctor usually places
in a large vein of a patient’s neck or chest to give
important medical treatment. When not put in
correctly or kept clean, central lines can become
a freeway for germs to enter the body and cause
serious bloodstream infections. These infections
can be deadly. Of patients who get a bloodstream
infection from having a central line, up to 1 in 4 die.
Bloodstream infections in patients with central
lines are largely preventable when healthcare
providers use CDC-recommended infection control
steps. Medical professionals have reduced
these infections in hospital intensive care unit
(ICU) patients by 58% since 2001. Even so, many
still occur in ICUs, in other parts of hospitals,
and in outpatient care locations. In 2008,
about 37,000 bloodstream infections occurred
in hemodialysis* outpatients with central lines.

Case Report: Endocarditis after Tongue Piercing
By Hossein Akhondi MD and Ali R. Rahimi MD

Haemophilus aphrophilus Endocarditis after Tongue Piercing

Piercing invades subcutaneous areas and has a high potential for infectious complications. The number of case reports of endocarditis associated with piercing is increasing. We studied a 25-year-old man with a pierced tongue, who arrived at Memorial Health University Medical Center with fever, chills, rigors, and shortness of breath of 6 days duration and had an aortic valvuloplasty for correction of congenital aortic stenosis.

Body piercing poses a risk for serious disease. Because it invades subcutaneous areas, piercing has a high potential for infectious complications. Such complications result from introduction of skin or mucous membrane microflora into subcutaneous tissue or from the ongoing presence of colonies of these microflora at the piercing site. Pain, edema, and prolonged bleeding may occur immediately after piercing (1), and a cyst, scar, or keloid may form at the piercing site. In various surveys, the rate of earlobe piercing infections alone has been estimated at 11% to 24%. Skin lesions or anatomic abnormalities at the site of piercing, as well as valvular heart disease, are risk factors for complications (2). Staphylococcal endocarditis of the mitral valve after nasal piercing (3), Neisseria endocarditis after tongue piercing (4), and Staphylococcus epidermidis endocarditis and mastitis following nipple piercing have been reported (5). Even though a consistent correlation is not known between piercing and endocarditis, the number of case reports is increasing, and a correlation may well exist.

Persons at high risk for complications should be treated with preventive antibiotics, just as persons at high risk for complications receive antibiotic treatment before dental procedures. The correlation between dental procedures and endocarditis has been reviewed by Van der Meer et al., who prospectively examined all cases of infective endocarditis in the Netherlands over a 2-year period (6). Of 427 patients who had been hospitalized, 64 had previous dental or other procedures in the preceding 3 months. Using 48 of these 438 patients as study cases (only 48 patients met the qualification of having native-valve and cardiovascular anomalies that increased their risk of getting endocarditis, these researches found no significant difference in presence of dental procedures between patients and matched controls without endocarditis (odds ratio 1.2, 95% confidence interval 0.03 to 2.3). Two other studies (7,8) reported similar results. No study has examined the correlation between piercing and endocarditis.

In the United States, body piercing, which is becoming increasingly common, is mainly performed by unlicenced practitioners. Only 26% of states have regulatory authority over tattooing establishments, and only six of these states exercise authority over body-piercing establishments. Piercing occurs in regulated and unregulated shops, department stores, jewelry shops, homes, or physicians’ offices. Generally no antibiotic is used, and sterilization methods vary. Studies show that ear piercing can cause cephalic tetanus (a local form of tetanus caused by wounds or other head and neck infections) (8), Pseudomonas infections, or perichondrial auricular abscesses, especially with Pseudomonas aeruginosa. Tongue or oral piercing can cause Ludwig’s angina (2,9,10) or may be complicated by normal oral flora, such as Haemophilus aphrophilus, as in this case. Genital piercing may result in Escherichia coli infection and may increase the risk for sexually transmitted diseases through tissue damage and exposure and unwanted pregnancy because of condom rupture (11). Systemic infections, such as toxic shock syndrome or sepsis, have also been reported (10). Among noninfectious cases, granulomatous perichondritis of the nasal ala, sarcoidlike foreign body reaction from multiple piercing, paraphimosis from a distal penis pierce, and speech impairment, together with difficulty in chewing and swallowing from oral jewelry, have been reported (1,2,9,10). Metal-associated problems include allergy (especially to nickel), eczematous rash, and lymphocytoma (2,9,10,12). We describe an incidence of H. aphrophilus endocarditis following tongue piercing.

Case Report

Thumbnail of The tongue pierce of the man from the case study. The stud was bispherical metal inserted without anesthesia or preparation. Although the stud was removable, the patient had not removed it. The area around insertion was clean with no local sign of infection when the stud was removed; the tongue was not inflamed or painful.
Figure. The tongue pierce of the man from the case study. The stud was bispherical metal inserted without anesthesia or preparation. Although the stud was removable, the patient had not removed it....

A 25-year-old man arrived at Memorial Health University Medical Center with fever, chills, rigors, and shortness of breath of 6 days duration. He had a history of aortic valvuloplasty at 8 years of age for correction of congenital aortic stenosis. At admission, the patient had fever of 38.9°C and a grade III/VI ejection systolic murmur accompanied by a grade II/VI diastolic blowing murmur best heard in the left sternal border area. The oral cavity was pink, and no inflammation or exudates were noticed on the pharynx. The middle portion of the tongue had been pierced, and a bispherical stud was in place (Figure). The piercing was performed 2 months before onset of illness. Extensive tattoos on the shoulders, arms, and upper torso dated back 3 years. The patient had previous dental work done but always with antibiotic prophylaxis.

Laboratory tests showed erythrocyte sedimentation rate of 41 mm/hr (normal rate, 0–15 mm/hr) and elevated C-reactive protein of 5.1 mg/dL (normal level 0–1). Transthoracic echocardiography was not conclusive; a transesophageal echocardiogram showed remnants of a bicuspid and deformed aortic valve with multiple vegetative lesions. Blood cultures were obtained, and the patient was started on triple antibiotics (ampicillin, nafcillin, and gentamycin). Wet preparation and acridine orange stain of the blood specimen showed gram-negative pleomorphic rods. Two of the conventional chocolate-agar cultures turned positive approximately 4 days after incubation and were consistent with H. aphrophilus (β-lactamase negative, lactose fermenting, and Mannose fermenting). The stud culture was also positive for H. aphrophilus. Antibiotics were modified because of sensitivity to ceftriaxone and gentamycin, and the patient was discharged to complete the 6-week course through a peripherally inserted central catheter line at home. Aortic valve replacement was recommended after completion of antibiotic therapy, but the patient did not return for treatment.

Conclusions

Our case demonstrates H. aphrophilus endocarditis possibly caused by tongue piercing (or as a complication of the ongoing presence of the stud) in a patient with congenital heart disease. Colonization around the stud likely caused bacteremia and endocarditis. H. aphrophilus is commonly isolated from the upper respiratory tracts of humans and animals; however, its prevalence is unknown. In a previous study of piercing complications in patients with congenital heart disease (13), 43% of the study population had earlobe piercing; of these, 6% took antibiotics before piercing. Twenty-three percent of patients had piercing-related infections 1 week to 3 years after piercing. Most infections were local skin infections; no endocarditis was reported in that study.

Until prospective randomized studies shed light on the relationship between piercing and endocarditis, prophylactic measures are indicated and should be formulated, particularly for persons at high risk, e.g., those with structural heart diseases.

Dr. Akhondi is a first-year resident with the Department of Internal Medicine at Mercer University School of Medicine, Savannah Campus at Memorial Health University Medical Center in Savannah, Georgia.

Dr. Rahimi is the associate director of Internal Medicine Education, chief of the Geriatrics Division, and professor of medicine at Mercer University School of Medicine, Savannah campus.

Top Hosptals With Lowest C-Section Rates
List May Suprise You

The following 16 hospitals had C-section rates of 17 percent or less, according to Consumer Reports. These hospitals also delivered at least 3,500 babies or had at least 750 low-risk births or the nine months.

1.Crouse Hospital (Syracuse, N.Y.) — 7 percent

2.SSM St. Mary's Health Center (St. Louis) — 12 percent

3.Memorial Medical Center (Springfield, Ill.) — 12 percent

4.Lovelace Women's Hospital (Albuquerque, N.M.) — 13 percent

5.Bakersfield (Calif.) Memorial Hospital — 13 percent

6.Utah Valley Regional Medical Center (Provo, Utah) — 14 percent

7.WakeMed Raleigh Campus (Raleigh, N.C.) — 15 percent

8.Intermountain Medical Center (Murray, Utah) — 16 percent

9.Desert Regional Medical Center (Palm Springs, Calif.) — 16 percent

10.NorthShore University Health System (Evanston, Ill.) — 17 percent

11.Kaiser Permanente Panorama City (Calif.) Medical Center — 17 percent

12.Kaleida Health (Buffalo, N.Y.) — 17 percent

13.Northwestern Memorial Hospital (Chicago) — 17 percent

14.TMC HealthCare (Tucson, Ariz.) — 17 percent

15.University Medical Center (Lubbock, Texas) — 17 percent

16.Providence Regional Medical Center Everett (Wash.) — 17 percent

*Repeat numbers indicate organizations with the same ranking based on C-section rate.

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