Infection- The Last Bony Frontier

Eugene Sherry (Univ. Sydney)

Patrick H Warnke (Univ.Kiel,Germany)
Suresh Sivananthan (Univ. Malaya).

to operate you need:

• the right team

• the right tools

• and a sterile zone

 OR=sacred place of trust
?deserves our best efforts

INFECTION CONTROL

• Critical for the Success of Surgery

 the COST
• to the hospital (Nepean-500 cases@yr.)
• to the economy-Aust $300M@ yr., AUD
20,000/patient)
• The additional cost imposed on the US health system
annually by antibiotic resistance has been estimated to
range between US $100 million and US $30 billion.
[Hellinger WC, Confronting the problem of Increasing Antibiotic
Resistance, South Med J 93(9): 842-848, 2000

MRSA

learn to ‘live with it’

(MRSA and beyond…. Marshall et al. ANZ J
Surg 2004 74: 465-469)
-suggested hand washing and nasal mupirocin

or ‘GET RID OF IT’

 Sterile(Operating)Zone
Key Concept
= area between incision&surgical team
- the surgical workplace
- must be ultraclean
build (wash/gown/drape)
maintain (intra-op)
dismantle (?after you leave the OR)

Challenge to:
restructure what’s already there
• Looked at:
- hand wash
- mask
- gloving
- gowning
- draping
- handling the scalpel
-
 yeS-WIPE
your hands
naturally

• SQUEEZE
• WASH
• DRY

Clinical Results
• Soap & Water: <10% clean hands
• Hibicol: 50% clean hands
• yeS-WIPE: >90% clean hands

reproduced the surgical scrub with

yeS-Wipe (72cc device replaces sink area);
>99% saving on:water,soap and space

•
 Pooled data
Overall mean Colony Counts SE

Baseline 225,979 51,900

F.Surg Scrub 6,487 4,706

yeS-WIPE 478 94

(Int J Environ Res -accepted for pub 2004)

Gloving
Errors seen:
- opening
- donning
- glove/sleeve interface

Challenge:
- is to make easier and safer
 Gowning
- violations related to final flap tie
- <8% are properly applied
- multi-center trial underway in Australia

Challenge is to
to free scrub and surgeon for their work
S-Gown is
Taking the Spin out of the OR

S-Gown robing process Solution

1.Pull

Perform neck &

mid-back tie as
normal.
1. Unfold sterile flap & pull across back

2.Press 3.Peel

2. Press flap onto gown 3. Peel S-Gown device off

Robing complete
- No visible ties
 Multi-Centre Clinical trial
Sydney March 2000
5 x Hospitals (Development of a new

surgical gown: a multicenter study. Surg Today. 2006;36(5):490.

200 gowns tested

Faster to don in 75%(90%)
Remained closed 92%(vs. 8%)(100%)
Infection control improved 75%(82%)
Use again 70%(100%)
i.e.. Faster to don/remains closed/infection
t l/ i

Draping

- 100 cases examined

- 4 violations of sterile technique
(one major) per operation
- slow
- surgeon & scrub dependent

Challenge:
Make easier & free surgeon & scrub to work
 Face Masks
March 2003

Found air levels of bugs

and that masks did NOT function as barriers
Staph epidermidis

new mask design..TRIALS

FACEMASK POLLUTION OF THE OPERATING ROOM AIR

INTRODUCTION: A clean Operating Room (OR) is essential for successful surgical outcomes.
To date little is known about the biological load of the OR air. We decided to investigate this
during a knee replacement operation.
METHOD: Air samples were taken, using a vacuum pump drawing air sample through sterile
0.42 micron filters, at the beginning of the operation, and for every 30 minutes until the end.
Two sets of samples were taken. All micron filters were transferred onto Tryptic Soy Agar
and Malt Agar plates immediately. At the end (3.5 hours) all plates were incubated for 24
hours and the results tabulated. All surfaces in the OR were cultured. Also, all facemasks
used were collected and checked, both back and front. These microorganisms were
identified.
Then we introduced a new facemask(infiltrated with a phytochemical) and tested same( x
5).
RESULTS: The biological profile showed increased bacteria and mold in the air of the OR
from 10x1 to 10x4. All OR surfaces remained sterile. However, all masks were found to be
contaminated at 15 mins., both back and front, with the same high levels of throat and nasal
flora. In contrast, the new facemasks remained sterile for 3.5 hrs. (13x longer).
DISCUSSION AND CONCLUSIONS: It is postulated that this increased bio load was
introduced into the OR by the masks of the surgeons and nurses. Our new facemask may
solve this problem and prevent pollution of the OR air.
 Scalpel Blade Pick-up

- slow/dangerous
Challenge:
- make easier and faster
- met
S-Foam

S-Foam TM
Scalpel Held Perpendicular to
Bottom of Dish - Easy Pick Up

Handle End Up

Large Tactile Body – For

Easy Blind Location, Also for
Scraping Debris Off Blade

V- Shaped Slot - Provides Added Grip

NEW
Available in Sterile
Packaging

Easy Peel - Backing Paper

Blade End Down Low Tack Adhesive - Leaves no

Residue

An Important Infection Control Device...

...for the safe and efficient handling of sharps in the Operating Theatre
Designed and Made in Australia Distributed & Packaged by DEFRIES INDUSTRIES Patent Pending
 id.S id.S

old
crowded

id.S(2)
 id.S(2)

Phytochemicals

-plant derived substance with active

hydrocarbons for :
• antisepsis(high MRSA activity)
• wound healing problems
• biological sealant(tissue healing problems)
• treatment of TB/Malaria
 Phytochemical papers
• Sherry E, Warnke PH, Boeck H.
• Percutaneous treatment of chronic MRSA osteomyelitis with a novel plant-derived antiseptic.
BMC Surg. 2001;1(1):1. Epub 2001 May 16.

• Sherry E, Boeck H, Warnke PH

• Topical application of a new formulation of eucalyptus oil phytochemical clears methicillin-resistant
Staphylococcus aureus infection.
Am J Infect Control. 2001 Oct;29(5):346. No abstract available.

• Sherry E, Warnke PH.

• Alternative for MRSA and Tuberculosis (TB): Eucalyptus and Tea-Tree Oils as New Topical
Antibacterials
• AAOS, Dallas.Feb 2002 Sherry E , Warnke PH, Boeck H.

• Sherry E, Sivananthan S, Warnke PH, Eslick G.

• Topical phytochemicals used to salvage the gangrenous lower limbs of type 1 diabetic patients.
Diabetes Res Clin Pract. 2003 Oct;62(1):65-6. No abstract available.

Phytochemical papers (ctd)

• Warnke PH, Terheyden H, Acil Y, Springer IN, Sherry E, Reynolds M, Russo PA, Bredee JP,
Podschun R. Related Tumor smell reduction with antibacterial essential oils.
Cancer. 2004 Feb 15;100(4):879-880.

• E Sherry , PH Warnke
• Successful use of an inhalational phytochemical to treat pulmonary tuberculosis: A case report.
• Phytomedicine vol 11/issue 2-3, Feb.,p95. 2004.

• Antibacterial essential oils reduce bad smell in cancer patients

P.H. WARNKE1, E. SHERRY2, R. PODSCHUN1, H. TERHEYDEN1, Y. ACIL1, and I.N.
SPRINGER1, 1 University of Kiel, Germany, 2 University of Sydney, Penrith, Australia. 4026
• The IADR/AADR/CADR 82nd General Session (March 10-13, 2004)
Honolulu, HI

•
E Sherry S Sivananthan PH Warnke Inhalational phytochemicals to treat pulmonary tuberculosis;
• tyo case reports AJIC Oct 2004
MRSA case
 Tumour work

Papers- Palliative Care

SINUS

Further tumour/pallaitive care work

 Papers-TB
28F, first case

Treatment costs around US $2500 per patient,

rising to US $250,000 in multi drug resistant TB,
with the overall potential cost of lost productivity due to
TB is in the order of 4%-7% of GDP

‘new’ era of...

local treatment with:

debridement & local antiseptic

the new OR:
-yeS-WIPE → Surgical Scrub
-S-Gown → Gowning
-id.s → Draping
-new masks → clean air
-phytos to seal wound

But need to CONVINCE industry?????????

to make all these changes

Basics:
Swedish Hip Registry, 2003

Critical issues are:

-surgical technique- OPTIMIZED

-implant design- NO CHANGE

 ? < 4% soft tissue problems
vol=(1/3(¶r2)(height)
-Assume cone of dissection;
- vol=(1/3(¶r2)(height)

-Then 5 cm versus 25 cm incision

means 1/25 volume of Incision
5cm
soft tissue trauma or
and ? <1/25(or <4%) of soft tissue 25cm
complications (infection, DVT…)

Technique Highlights

„ NO “significant” DVTs
DVTs// NO pulmonary
embolus

„ NO Infections

„ Hospital stays one third

 MIS Hip Surgery

the end of:

-Surgeons taking control and working

INSIDE the body
Hospitals( as we know them)
-Day surgery or outpatient procedures
Strategy
-reduce size frontier(incisio
-in vivo tissue engineering(
-surgeon in control