[Evaluation of aseptic measures in the performance of epidural catheterization and perception of its risk of infection. Results of a survey in Languedoc-Roussillon]

Post spinal meningitis and asepsis

BACKGROUND

Post spinal meningitis (PSM) is a complication still currently being reported. After two PSM cases in our hospital an epidemiological study was initiated, which included a survey of techniques for asepsis that are applied in our department.

METHODS

Cases defined as PSM comprised meningitis within a week after spinal anesthesia. Anesthesia records, anesthesia complication files and the records of the Hospital Commission for Infection Control from 1997 to 2000 were reviewed. Asepsis techniques applied were surveyed by a questionnaire answered by all our department's anesthesiologists. The equipment and procedures for spinal anesthesia were listed. Current anesthesia textbooks were reviewed for recommendations regarding asepsis techniques in conjunction with spinal anesthesia.

RESULTS

Three cases of PSM were identified following 38,128 spinal anesthesias whereas none was observed in 12,822 patients subjected to other types of regional or general anesthesia (P>0.05). Culture of cerebrospinal fluid yielded Streptococcus in two patients and was negative in the other patient. The asepsis technique applied by the anesthesiologists varied considerably. The literature review showed that aspects on asepsis for spinal anesthesia are poorly covered.

CONCLUSION

The incidence of meningitis was similar in patients subjected to spinal anesthesia and in those subjected to other anesthetic techniques. Asepsis techniques were found to differ considerably among our staff members, reflecting the lack of well-defined published standards for this procedure. We recommend that asepsis for spinal anesthesia should not be less rigorous than for surgical asepsis.

[Evaluation of antibacterial filters for peridural obstetrical anesthesia]

OBJECTIVES

To assess the antibacterial efficiency of filters used in obstetrics when epidural top-ups are performed.

STUDY DESIGN

Observational prospective study.

PATIENTS AND METHODS

We aseptically collected 201 antibacterial filters that had been used for top-ups with ropivacaine +/- sufentanil for epidural analgesia during labour. We flushed them first with 2 mL of saline and then with 2 mL of a solution containing 1.5 x 10(6) Staphylococcus epidermidis/mL. The filtrates were incubated at 37 degrees C for 72 h. Number of top-ups and duration of epidural analgesia are expressed as median (extremes).

RESULTS

3 (1-10) top-ups were performed for labour analgesia over a period of 6.5 h (1.8-18). After filtering, all the solutions were found to be sterile. Especially, when using Staphylococcus epidermidis solutions, bacteria were not found beyond any filter. These results suggest the integrity of the filter membrane after several boluses. No infection related to epidural analgesia was reported.

CONCLUSION

Antibacterial filters provide a good protection against a potentially contaminated procedure during epidural top-ups.

[Meningitis after locoregional spinal anesthesia]

OBJECTIVE

Meningitis is a severe and an uncommon complication of both spinal and epidural anaesthesia. This review summarizes the knowledge on epidemiology, clinical and microbiological diagnosis and the ways to prevent them.

DATA SOURCES

Articles published in English and French language since 1989 has been collected on Medline database, using "meningitis", "spinal anaesthesia" and "epidural anaesthesia" as keywords.

DATA SYNTHESIS

Bacterial meningitis are usually in relation with Gram positive bacterias which is a clue for an exogenous contamination. Another unusual ways of contamination are blood circulating bacterias and spreading of local infection. Aseptic meningitis has been described, in relation to introduction of irritant agents in subarachnoid space. Lumbar puncture must be done each time meningitis suspected so that it can assert the diagnosis and guide antibiotherapy. Easy hygienic guidelines has been widely published to prevent meningitis. Usually, antibiotherapy alone is sufficient to treat meningitis but with an unjustified cost and sometimes severe persistent neurologic sequelae.

CONCLUSION

The unexpected appearance of meningitis during the wearing-off of a spinal anesthesia is exceptional; the possibility of death or serious sequela must be taken into account. The sources of contamination are quite frequently exogenous, the germs coming most often from the patient's cutaneous flora or the anesthetist's ENT flora. Prevention of this risk involves a rigorous respect for cutaneous disinfection and hygiene procedures. The anesthetist's medico-legal responsibilities will be called upon in case of exogenous contamination.

[Surveillance of nosocomial infections related to anesthesia. A multicenter study]

OBJECTIVES

To determine incidence rate, main characteristics and risk factors of nosocomial infections associated with anesthesia (NIAA).

STUDY DESIGN

Prospective, descriptive multicentre survey.

PATIENTS

All patients aged more than 15 years and undergoing surgery (except cardio-thoracic, ENT or ambulatory surgery) under general or regional anaesthesia.

METHODS

Voluntary participation of surgical units from public or private hospitals. Use of pre-established definitions of infections and a 72 hours postanesthetic follow-up. Anaesthesia and operation related risk factors collected. End point based on occurrence, or not, of clinical infection. Record, control, treatment and analysis of the data by Epi Info--5.0 software. Statistics used: Fischer's exact test, Mantel-Haenszel test, Anova method, Kruskall-Wallis test.

RESULTS

Among 7,300 patients belonging to 13 hospitals, 25 developed an infection (nine vascular catheter related infections, 12 respiratory tract infections, two infections of the eye and two of the mouth). Only two infections have been bacteriologically documented. The overall incidence of NIAA was 3.4 per 1,000 patients. It was significantly higher after an anaesthetic of more than 2 hours and after transfusion.

CONCLUSIONS

This first prospective survey of NIAA confirmed that nosocomial infections are a real problem in the practice of anaesthesia and the necessity to use preventive measures. A survey with a larger sample size would allow to specify the respective part of the various risk factors and to develop a risk index.