The importance of infection control and prevention in anesthesiology

Zorrilla-Vaca, Andrés; Escandón-Vargas, Kevin; Zorrilla-Vaca, Andrés; Escandón-Vargas, Kevin

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Colombian Journal of Anestesiology

Print version ISSN 0120-3347

Rev. colomb. anestesiol. vol.45 supl.2 Bogotá Dec. 2017

Essay

The importance of infection control and prevention in anesthesiology^{^☆}

Andrés Zorrilla-Vaca^a^*

Kevin Escandón-Vargas^a

^{^a} Program of Medicine and Surgery, School of Medicine, Universidad del Valle, Cali, Colombia

ABSTRACT

The key role of the field of infectious diseases in other medical specialties, including anesthesiology, is currently well known. The anesthesiologist faces a potential risk of con tributing to the development of healthcare associated infections in the operating rooms; however, the infectious complications derived from anesthesia have been underestimated. It is important to acknowledge that there are some deficiencies in research, notification, and publication of reports on anesthesia-associated infectious events in developing countries, particularly in Colombia, which is the focus of our attention in this article. As far as we know, only five countries 一 most of them developed 一 have carried out studies on the practices and knowledge of the anesthesiology personnel with regards to universal recommendations for the prevention and control of anesthesia-associated infections. This document discusses the importance of infections in the area of anesthesiology and at present in Colombia. Fur thermore, the need to comply with basic infection prevention and control precautions and of creating awareness of safe injection practices is recognized.

Keywords: Patient safety; Anesthesiology; Communicable diseases; Anesthesia; Colombia

RESUMEN

Actualmente es bien conocido el protagonismo que el campo de las enfermedades infecciosas desempeña en otras especialidades médicas, incluyendo la anestesiología. El anestesiologo tiene un riesgo potencial de contribuir al desarrollo de infecciones asocia das a la atención en salud en los quirófanos; sin embargo, las complicaciones infecciosas derivadas de la anestesia han sido subestimadas. Es importante reconocer que existen deficiencias en la investigación, notificación y publicación de reportes de eventos infecciosos asociados a la anestesia en países en vías de desarrollo, en particular en Colombia, en el cual nos hemos enfocado en el presente artículo. Hasta donde se sabe, solo 5 países, la mayoría de ellos desarrollados, han realizado estudios sobre prácticas y conocimientos del personal de anestesiología respecto a las recomendaciones universales para la prevención y el control de infecciones asociadas a la anestesia. En el presente documento se discute la importancia de las infecciones en el campo de la anestesiología y el panorama actual de su situación en Colombia. Además, se resalta la necesidad de adherencia a precauciones básicas de prevención y control de infecciones y de concientización sobre las prácticas seguras de inyección.

Palabras clave: Seguridad del paciente; Anestesiología; Enfermedades transmisibles; Anestesia; Colombia

Introduction

The leading role of the field of infectious disease in other med ical specialties is currently widely known. There is a growing need each year to do research on infectious diseases, in view of the increasing implications of infectious diseases for the world population, making it an exciting public health area. Infectious complications are relevant, both in developed as in developing countries, with impact at the community and hospital level.

In particular, healthcare-associated infections (HCAI) are relevant because they present in multiple healthcare envi ronments and cause considerable morbidity, mortality, hospitalization, and costs.¹^,² In developed countries, 3.5-12% of hospitalized patients develop at least one HCAI, while in the developing countries this percentage varies from 5.7% to 19.1%.²

Today, the prevention and control of HCAIs in the surgical environment, including the anesthesiology staff, are mostly based on the understanding and practice of hand hygiene, hospital cleaning and disinfection (Ex., asepsis of the surgical site, sterilization of medical equip ment), adequate implementation of invasive procedures, safe practices in the parenteral administration of med ications, and use of sterile or new supplies³^,⁵; how ever, these recommendations and standards are frequently forgotten, ignored or infringed by the healthcare staff. Preventing nosocomial infections is essential nowadays, considering the increase in the number of multiple drug resistant organisms.²^,⁵^,⁶

For a long time the HCAIs in the operating room were associated to a large extent with general asepsis failures in the surgical environment, the type of surgical proce dure, and surgeon practices, forgetting the potential risk for the anesthesiology staff during surgery.³^,⁶ The relevance of HCAIs in the area of anesthesiology has been evidenced for decadesノ⁹ This document discusses the importance of infections in anesthesiology and the outlook of this situa tion in Colombia, based on the available scientific evidence. Furthermore, emphasis shall be placed on the need to adhere to the basic recommendations regarding infection prevention and control, and to raise awareness about safe injection practices.

Risk factors associated with pre-surgical preparation

Just as other branches in medicine, Anesthesiology is con sidered a dynamic medical specialty in terms of research and its professional practice focuses on the comprehensive care and safety of the patient. The prevention and control of HCAIs is one of the key pillars of an ideal anesthetic practice.

Anesthesiologists often invade the body's physiological and mechanical barriers when doing respiratory tract invasive procedures (tracheal intubation) and the cardiovascular sys tem (venous or arterial accesses), or when performing local or neuraxial blocks. These procedures are potential sources for the transmission of microorganisms to patients and may lead to infection in the presence of gaps in the univer sal precautions of infection control or non-compliance with the recommended healthcare practices by the staff.³^,¹⁰^,¹³

Historically, a large number of common medical prac tices have been reported as risky, though they were originally intended to do good. These previously established practices have been reassessed in the light of new knowledge and so they have been banned or advised against because the cur rent evidence suggests considerable risk for patients. In the area of anesthesiology it was for instance acceptable to reuse syringes for administering drugs to multiple patients, as long as the needle was changed, or to prepare intravenous injec tions using the same bag and administration channels for patients receiving the same therapy in one day.¹⁴^,¹⁸ The risk of pathogen transmission among patients due to these prac tices is high, but we know it is totally preventable when these practices are abandoned.¹⁹ Unfortunately, it has been shown that anesthesiologists often are unaware ofthe impor tance of being compliant with all hygiene precautions and of the fact that they are actually mechanical vectors of pathogens everyday, since they are frequently in contact with infected patients.⁸^,²⁰

Although the cause-effect relationships in the practice of anesthesia and post-surgical infections are difficult to establish,¹¹ multiple publications since 1972 have asso ciated anesthetic practices and equipment or contami nated anesthetic products with bacterial, viral, and fungal infections.¹⁰^,²¹^,³³ Unfortunately, in some of these cases there have been hospital outbreaks, resulting in considerable mor bidity or mortality.^(10,22,23,26 一 ^28,30,32,33) However, it is thought that outbreaks are just a proportion of the true burden of disease derived from unsafe drug injection practices and hospital gaps in infection control.³⁴ Specifically, infections from Hepatitis B Virus (HBV), Hepatitis C Virus (HCV) and Human Immunodeficiency Virus (HIV) may go undetected since these are initially asymptomatic, mildly symptomatic or unspecific.⁴

Risky behaviors in the operating room

Some of the mechanisms of transmission of frequently indis criminate microorganisms in cases of anesthesia-associated infection include: reuse of single-use vials,²³^,²⁶ reuse of vials or multidose vials in multiple patients,²⁴^,²⁵^,²⁷^,³⁰^,³²^,³³ reuse of syringes or needles in multiple patients.²²^,²³

Propofol in particular is the anesthetic drug more often involved in infectious events due to its lipid emulsion that promotes bacterial growth and due to its frequent wrongful manipulation (for example, reusing syringes or vials in multiple patients, poor external disinfection of the vial,³⁵ and continuous propofol infusion) that facilitates its contamination.³⁶ As we documented in a recent systematic review of the risk of infections with the use of propofol,³⁶⁾ all propofol-associated HCAIs have been reported in devel oped countries. This difference in scientific evidence does not seem to be different with other anesthetic products and practices studied with regards to microbial contamination or infection. Moreover, a recent systematic review on sep tic meningitis associated with regional anesthesia, showed the absence of clinical evidence in developing countries (Zorrilla-Vaca A., et al. Clinical occurrence of septic meningitis after spinal and epidural anesthesia, 1900-2015: a system atic review and peer reviewed). Although both anesthetic techniques show risks of infectious complications, accord ing to a recent meta-analysis general anesthesia seems to be more closely associated.³⁷ In general, our literature search suggests that developing countries lack scientific evidence of anesthesia-associated complications or specific anesthetic practices.

One of the most researched topics is the compliance of the anesthesiologist with the recommended hygiene, preven tion, and control measures, including safe injection practices involving the set of measures implemented in order to administer injections in a safe manner for the patient, the healthcare staff and third parties. Table 1 illustrates the main findings of world cross-sectional trials aimed at identifying the level of compliance with the practice and the knowledge of hygiene and biosafety of the anesthesiology staff.³^,⁶^,¹¹^,¹²^,¹⁹^,³⁸^-⁴⁶ Sev eral of these practices have been involved in the perioperative transmission of microorganisms and anesthesia-associated risk of post-surgical infection. It is concerning to find high percentage of reuse of single-use vials (50%-59.6%), reuse of multi dose in multiple patients (41.3%), reuse of syringes in the same patient (46.4-82%) and reuse of syringes in multiple patients (39.8-59.2%). While there is evidence that the reuse of syringes in different patients has decreased in the most recent studies, other unsafe injection practices have remained con stant or increased. Hand hygiene and the use of gloves and facemask, show a higher percentage of compliance in the most recent trials.

Table 1 Findings of studies done in anesthesiology staff on hygiene practices and biosafety knowledge for the prevention of transmission of microorganisms.

Source: Authors.

Woodbury et al. determined that among the 89 pro fessionals involved in anesthesia, the primary factors preventing them from using brand new materials under certain circumstances in their clinical practice was costs (71%), convenience/efficiency (36%), environmental impact (16%), time (12%) or negligence (4%).⁶ Gounder et al. also determined among 522 anesthesiologists that the major bar riers to use vials of new medicines for multiple patients were the shortage of drugs (44%), the intention to reduce wastage (44%), in addition to high costs (27%).⁴⁵ None of these factors, including cost savings, justifies reuse prac tices against the current recommendations; for instance, the cost of a iatrogenic infection case is certainly higher than the cost of using new materials, not to mention the ethical implications involving human distress and harmful consequences.⁶^,⁴²

Few studies have been completed on epidemiological surveillance of anesthesia-associated infections. A Japanese trial reported that 8.3% of6,437 patients undergoing surgery in a two-year period were infected with a virus (HBV, HCV or HIV) prior to surgery.²⁰ Another multicenter trial in France deter mined a 3.4 per every 1000 patients of anesthesia-associated hospital acquired infections.⁴⁷

Overall, the findings herein presented emphasize the need for further education and the importance of adhering to the universal recommendations and basic infection control guide-lines. However, some professionals, despite their knowledge of the information fail to change their practice habits if they are not fully convinced about the impact and the reasons behind the recommendations. Consequently, stressing the negative outcomes associated with unsafe injection practices may have a positive effect.⁶ A poor hygiene practice by one single anes thesiologist, may result in catastrophic infectious events for multiple patients in a healthcare institution, not only placing patients at risk, but also jeopardizing the professional's job performance.⁴² Anesthesia providers have the responsibility and the opportunity to give patients good healthcare, so they most ensure the safe administration of medications and suit able performance of anesthetic procedures.⁶ The difficulties in developing countries 一 still unknown 一 should be considerably more severe as compared to the developed countries. It is then absolutely necessary to undertake national trials to validate the injection and manipulation practices of anesthetic agents by the anesthesiology staff. Fig. 1 illustrates the hierarchy of risk factors for anesthesia-associated infectious complica tions.

Source: Authors.

Fig. 1 Pyramid illustrating the hierarchy of risk factors for anesthesia-associated infectious complications (from top to bottom: surgical asepsis, biosecurity (gloves and facemask), reuse of vials in multiple patients, reuse of syringes in multiple patients).

Surveillance and control in Colombia

At the end of our literature search, no studies were found on infections in anesthesia in Colombia, which suggests big gaps in the knowledge and awareness about the issue. In Colom bia, probably the only paper on the topic was a study we recently published, showing that 6.1% of propofol vials used in the operating rooms in a third level hospital were contami nated after being used for anesthesia.⁴⁸ Although the clinical impact of this finding was not measured, surprisingly enough we found that only26.1%ofthe vials used were punctured just once. A recent cross-sectional research at the national level established that the level of reuse of vials and syringes was 37.9% and 6.2%, respectively.⁴⁹

Apparently Colombia has no specific published recom mendations on anesthetic handling or guidelines for the prevention and control of anesthesia-related infections. In contrast, countries such as the United States, the United Kingdom, Canada, Australia, New Zealand, Spain, Hong Kong, and South Africa do have protocols and hygiene guidelines for the prevention and control of anesthesia-associated infections.⁵⁰^-⁵⁶

Despite the low research interest of anesthesiology in infectious disease at the national level, it is important to highlight some of the activities sponsored by the Colom bian Society of Anesthesiology and Resuscitation (S.C.A.R.E.) such as the "Revised-Comprehensive Surgical Risk Measure ment" program (MIRQ-R) implemented by the promotion and prevention area, the XXXI Colombian Congress of Anesthesiology that focused on "Patient Safety" and a recent publication in the Colombian Journal of Anesthesiology entitled "Evidence-based Clinical Practice Manual: patient preparation for surgery and transfer to the operating room".⁵⁷

Various strategies and educational advances have been implemented in other countries. In June 2008, the Coalition of Safe Injection Practices was founded with the aim of stop ping unsafe injection practices in the United States.⁵⁸ This coalition, together with the US Centers for Disease Control and Prevention (CDC), launched the "One and Only Campaiqn” with a view to raise awareness among the healthcare profes sionals and the general public about safe injection practices (Fig. 2). The name of the campaign addresses the use of a needle and a syringe for a single injection in one patient. Table 2 illustrates the key recommendations for safe injection practices.⁵⁹

Source:http://www.oneandonlycampaign.org/.

Fig. 2 Advertising campaign image "One and Only Campaign".

Table 2 Key recommendations for safe injection practices.

Recommendation	Recommended practices	Level of evidence
Use of the aseptic	• Avoid contaminating the sterile injection	I-A
technique	Equipment
	• Use alcohol to disinfect the outer surface (plug,	_-a,b
	rubber, glass) of vials or ampoules (in particular
	propofol ampoules) before use.
Single use of sterile	• Syringes, needles and cannulas are sterile and	I-A
syringes, needles	single use. Should not be reused in the same or in a
and cannulas	different patient.
	• Do not administer medications from a syringe to	I-A
	multiple patients, even if changing the needle or
	cannula.
	• Prefilled propofol syringes are single use and the
	infusion shall be administered within the first 6h of
	opening the syringe.
Use of vials	• Do not use single use vials in multiple patients, or	I-A
indicated for single	mix the residual contents of used vials.
use of parenteral	• Propofol vials shall be used in one single patient
medications -	and the infusion shall be administered within the
whenever possible	first12 h after opening of puncturing the vial.
Use of multidose	• In case of using multidose vials, syringes, needles	I-A
vials in one single	and cannulas shall be sterile.
patient - whenever	• Do not store multidose vials in treatment areas;	I-A
possible	store according to the manufacturer's
	recommendations; dispose of any contaminated of
	under suspicion of being contaminated vials.
Use of infusion lines	• Do not use IV solution bags or bottles as a source	I-B
and equipment for	of anesthesia for more than one patient.
one single patient	• Consider syringes, needles or cannulas as	I-B
	contaminated upon contact with a patient or after
	use to connect the infusion equipment.
Level I-A: strongly recommended practice for implementation and with strong evidence based on well designed experimental, clinical or epidemiological studies. Level I-B: strongly recommended practice for implementation and evidence-based on some experimental, clinical or epidemiological studies and a strong theoretical foundation. ^a Harrison et al.⁽³⁸^{) b} Hajjar and Girard.⁽⁴⁷⁾	Source: Authors. Based on Siegel et al.⁽⁵⁹⁾ and adapted from King and Ogg,⁽⁴⁴⁾ Hemingway et al.⁽³⁵⁾

The interest of anesthesiology in infectious complications

There are several explanations for the lack of interest of anesthesiology in infectious diseases, particularly in develop ing countries such as Colombia: (1) limited knowledge about prevention and control guidelines in Health Care Associated Infections, (2) the lack of awareness regarding patient safety in surgical hospital environments, (3) minimal epidemiological follow-up and surveillance of HCAIs in the operating room, (4) little economic support for implementing research activi ties and doing a local analysis of healthcare centers relevant data, (5) research preferences favoring mechanical applica tions and physiological principles of anesthesia, instead of researching adverse events associated with anesthetics con tamination and basic cleansing and disinfection procedures, and (6) the perception that infectious diseases are beyond the scope or unfamiliar to anesthesiology.

We believe that the following aspects may generate increased interest:(1) the severe clinical consequences of a practice of anesthesia that fails to comply with the universal recommendations on hygiene and infections prevention and control, (2) the growing generalized interest of epidemiological surveillance to learn about the outcomes associated with anesthetic procedures, (3) the actions of professional anesthesiologists avoiding legal issues due to malpractice or medical negligence, and (4) the need to fight and prevent antimicro bial resistance.

Conclusions

The anesthesiologist faces the potential risk of contributing to the development of HCAIs in the OR; however, infectious complications from anesthesia have been underestimated. In our country, infectious diseases are not as significant in anesthesiology as in other medical specialties, but this is not due to lack of merits. Despite the strong bond between the anesthesiologist and patient safety, there are few studies that clearly depict the epidemiology of anesthesia-associated infections as one of the potential healthcare complications. It is important to acknowledge that there are some flaws in research, notification and reporting of anesthesia-associated infectious events in Colombia. The knowledge and practices of the anesthesiology staff in our country with regards to the universal recommendations for the prevention and control of anesthesia-associated infections are also unknown. Research in the area of anesthesia-associated infectious diseases would be a novelty for the healthcare staff.

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☆ Please cite this article as: Zorrilla-Vaca A, Escandon-Vargas K. La importancia del control y prevencion de enfermedades infecciosas en anestesiologia. Rev Colomb Anestesiol. 2017;45:69-77.

Funding Andres Zorrilla-Vaca received a research grant from S.C.A.R.E.

Received: May 21, 2016; Accepted: September 01, 2017

^*Corresponding author at: Facultad de Salud, Universidad del Valle, Calle 4B # 36-00, 760043 Cali, Colombia. E-mail address andres.zorrilla@correounivalle.edu.co (A. Zorrilla-Vaca).

^{Conflicts of interest}

The authors have no conflicts of interest to declare.

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