Innovations of Lister, Fleming still critical in contemporary infection prevention

Though the industry and technology has changed, the prevention of infection has remained the same.

Looking at the history of infection prevention is an effective way to prepare one’s mind for the reduction of infection risk in the modern operating room.

Such was the conclusion of a presentation by Keith R. Berend, MD, at the 2009 Current Concepts in Joint Replacement spring meeting.

Berend spoke about the innovations of Joseph Lister and Alexander Fleming, their work in the field of reducing infection rates and their impact on medicine all the way through the modern day. In addition, he outlined numerous ways that surgeons may reduce infection rates in their own operating rooms.

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“We use those things today to reduce our risk of infections in the operating room, and it is important to take those historical lessons and apply them to today’s medicine,” he said.

Focused to avoid infection

Berend began by discussing Lister’s antiseptic environment and Fleming’s “serendipitous” discovery of the antibiotic penicillin.

“I want to introduce the concepts discovered within the last couple hundred years that we still use today and focus our minds on understanding those, such that we will be prepared to try and avoid infection,” he said.

Lister’s creation of the clean-air environment through the use of carbolic acid was revolutionary. He used it on bandages to treat open fractures, which reduced both the amputation and death rates during war. He also used it for washing his own hands, preparing the wound, washing instruments and reduced the infection rate in the operating room.

“If you look at the antiseptic method today, we really haven’t come that far,” Berend said. “We scrub, we wear gowns and gloves, the instruments are sterile, the handling is different, the wounds are prepped and draped and we try to achieve a clean-air operating environment.”

Fleming’s use of penicillin as an antibiotic drastically reduced deaths caused by staph infections, open fractures and war wounds. According to Berend, antibiotics are still used in much the same way as they were.

“The prepared mind needs to know the facts,” Berend said. “Prolonged operative time increases risk. … We don’t need to be fast, we need to be efficient.”

“The prepared mind needs to know the facts. Prolonged operative time increases risk. … We don’t need to be fast, we need to be efficient.” — Keith R. Berend, MD

Among the things Berend said surgeons can do to prevent infection included a sterile-gowned person prepping the area to be operated on, which he said reduces the bacterial count within the operating room by fourfold. A plastic drape with or without iodine lowers the risk of deep wound contamination tenfold. Draping gloves that are then changed reduces contamination of the wound, as does double-gloving. In addition, suction tips can become contaminated within thirty minutes of skin incision. Splash basins become contaminated around 75% of the time.

“A door open to the hallway contaminates the operating room,” Berend said. “The number of people within the room can increase the bacteria count fifteen-fold. Additionally, there are certain personnel — including ourselves as surgeons — that are high skin-shedders or bacteria-shedders. Identifying those personnel and decontaminating them may decrease the risk of infection.”

Airflow systems

Berend addressed airflow systems, including laminar air flow and personalized isolation suits which have been shown in previous studies to reduce the infection rates for total knee or hip arthroplasty. Furthermore, he said, UV lights have been shown to take infection rates down from almost 2% to 0.5%.

“The question is: does it actually work?” Berend said. “There are some interesting data that has come up recently that shows there is actually a significantly higher risk of infection in total hip and total knee with the use of airflow alone … there is a paradoxically increased infection rate with total knee within laminar flow, and it probably relates to whether or not you are using vertical laminar flow or horizontal laminar flow.”

The smoking-gun in most of this evidence is actually the use of antibiotics, he continued. “The use of antibiotics alone actually decreases the infection rate much more significantly than the use of laminar flow alone,” he said.

Regarding the use of antibiotics in cement, Berend referred to the data as “mixed.” He stated, however, that in looking at the data and large meta-analyses there is clearly a relative risk reduction in infection with the use of antibiotic cement both within hips and knees.

Panel discussion

Moderator Joshua J. Jacobs spent part of the discussion after Berend’s presentation discussing the topic of antibiotic cement.

“Keith, you brought up this issue of using antibiotics in cement, and I’d like to poll the panel,” Jacobs said. “Do you routinely use antibiotics in cement, and if you don’t, when would you use it routinely?”

Five out of six panel members agreed that they use antibiotics in cement, though several clarified by saying that they only use cement for certain purposes.

For more information:

• Keith R. Berend, MD, can be reached at Joint Implant Surgeons, 7277 Smith’s Mill Road, Ste. 200, New Albany, Ohio 43054; 614-221-6331; e-mail: BerendKR@joint-surgeons.com. He has no direct or financial interest in any companies or products mentioned in this article.
• Joshua J. Jacobs, MD, is the Crown Family Professor and Chairman of the Department of Orthopaedic Surgery at Rush University Medical Center in Westchester, Illinois. He can be reached at One Westbrook Corporate Center, Ste. 240, Westchester, Illinois 60154; 708-236-2600; e-mail: joshua.jacobs@rushortho.com. He has no direct or financial interest in any companies or products mentioned in this article.

Reference:

• Berend, KR. Minimizing infection risk: fortune favors the prepared mind. Paper #79. Presented at Current Concepts in Joint Replacement Spring 2009 Meeting. May 17-20, 2009. Las Vegas, Nevada.