Parks_EU Neurology 10/03/2010 10:19 Page 118
Surgery
Figure 2: Colony-forming Units Before and
duplicate, the plates incubated and colonies counted after 48 hours of
After Antisepsis
culture (72 hours for fungal organisms).
30
In a published study on the role of endogenous microflora on
Staphylococcus epidermidis counts (logarithm CFU):
povidone iodine antisepsis neurosurgical-site infections, no relationship was observed
5
between bacterial density before or after skin antisepsis and
subsequent infection.
31
3M™Ioban™2™ was used in all surgical
4
cases. In a prospective study,
32
bacterial densities were measured
3
using 3M™Ioban™2™ without disinfection prior to surgery and
compared with bacterial densities with standard antisepsis
2
(Betadine). 3M™Ioban™2™ reduced the bacterial density on the
after antisepsis
skin, although to a lesser extent than the standard antiseptic
Colony-forming units
1
agents. The data indicate that 3M™Ioban™2™ reduced the
bacterial skin count (measured as CFU) by approximately 0.70 logs.
0 Figure 2 illustrates the relationship between the post-antisepsis
021 34567
and pre-antisepsis bacterial densities, given as CFU (data courtesy
Colony-forming units before antisepsis
of Dr E Larson).
Bacterial count <100 (2 logs) and antisepsis incomplete
Bacterial counts >100 (2 logs) and antisepsis incomplete
Six hundred and one patients underwent craniotomy using iodophor
Bacterial counts <100 (2 logs) and antisepsis acceptable
antisepsis.
31
Fifty-eight patients had only Staphylococcus epidermidis
Bacterial counts >100 (2 logs) and antisepsis acceptable
remaining on their skin after antisepsis.
At present, the accepted antisepsis level of a given product is
Figure 3: Operative-site Image Demonstrating
determined by the tentative final monograph on antiseptic products.
33
Use of a Sterile Surface Associated with the
Antimicrobial-containing Incise Drape
The characteristic behaviour of an antiseptic appears as the diagonal
line. Every data point below and to the right of the diagonal line
indicates that antisepsis was acceptable by current definitions. This
situation is illustrated using circles. Failure to achieve acceptable
antisepsis is illustrated using squares.
The amount of bacteria necessary to lead to a prosthetic infection can
be estimated
34–36
at 2 logs (100 CFU), and any value that equals or
exceeds this number is illustrated with a filled symbol. As indicated,
22 (4%) patients failed to undergo acceptable antisepsis and 42 (7%)
patients had residual bacteria on their skin in excess of 200 CFU.
Using the results described, the application of 3M™Ioban™2™
reduces those individuals who have in excess of 2 logs of
Staphylococcus epidermidis on their skin to 19 (3% of all patients),
effectively reducing those subjects with sufficient organisms to lead
to a prosthetic infection by half.
Clinical neurosurgical experience supports the utility of
For the time-dependent in vitro kill rate, expressed in logarithms of 3M™Ioban™2™. For eight years it has been a standard approach to
colony-forming units (CFU) killed, for an antimicrobial-impregnated uniformly use 3M™Ioban™2™ for both spinal surgery and the
incise drape (3M™Ioban™2), values are given as an average ± 1 implantation of electrodes into the subthalamic nucleus for
standard deviation. Staphylococcus aureus and Staphylococcus Parkinson’s disease (see Figure 3). In a series of 125 patients given a
epidermidis, both methicillin-resistant, are accentuated by enclosure bilateral implantation for Parkinson’s disease in the subthalamic
(see Figure 1). nucleus, 250 electrodes were implanted and no infections of the
intracranial electrodes were noted after a median survey time of more
The adhesive surface of the test sample is inoculated with 50μl of a than one year. Given that the duration of the operation was
bacterial suspension (containing 5x10
8
[±0.5 log] CFU/ml) by approximately four hours, it is clear that additional protection beyond
dispensing 10–12 droplets across the surface. The petri dishes are the use of wide-spectrum antiseptics becomes necessary to maintain
covered and incubated at 35±2°C for 30 minutes plus one minute; a lower risk of surgical-site infection by reducing the cutaneous flora.
60 minutes plus two minutes; and 90 minutes plus two minutes Similarly, between January and June 2009, 182 patients underwent
(timing starts on contact with the total inoculum volume). disc repair, and there has been one case of discitis, yielding an
infection rate of 0.54% (GKN, unpublished data).
At the appropriate time, the sample is transferred to a blender jar
containing 100ml of Difco™ D/E neutralising broth. Samples are Conclusion
blended for two minutes at low speed. After blending, serial 10-fold As with other device-related infections, meticulous surgical methods
dilutions in phosphate-buffered water are plated for each dilution in must be coupled with a process of infection reduction, which can be
118 EUROPEAN NEUROLOGICAL REVIEW
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