An Analysis of the Effectiveness of High-level Disinfection for Surgical Instruments Used by Department of Defense Austere Surgical Teams

Effect of prolonged exposure to disinfectants in the antimicrobial resistance profile of relevant micro-organisms: a systematic review

BACKGROUND

Antimicrobial resistance (AMR) constitutes a major global health threat, to a very large extent due to the inadequate use of antibiotics. Additionally, the misuse of disinfectants can also trigger the selection of resistant clones, where micro-organisms develop an adaptative response and progress to resistance mechanisms. Cross-resistance may occur when a biocide's selective pressure induces antimicrobial resistance.

AIM

To acknowledge the potential relationship between repeated and/or prolonged exposure to disinfectants and antimicrobial resistance profile adjustment.

METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published until December 2023 that were related to the interaction between disinfectants and antimicrobials were included. Further selection was based on the methodology of exposure.

FINDINGS

Selected studies included testing about 'exposure to sublethal concentrations' for seventeen disinfectants. The mechanism of action for the majority of the disinfectants involved interactions with the cell membrane. Chlorhexidine was the most studied disinfectant.

CONCLUSION

Adaptation phenomena related to disinfectant exposure were documented and development of cross-resistance to antimicrobials was verified for several species, including Streptococcus spp., Klebsiella pneumoniae, Acinetobacter baumannii, Staphylococcus aureus, Pseudomonas aeruginosa, and Candida spp. Changes associated with disinfectant exposure also influenced biofilm formation, colony morphology, and efflux pump activity - three relevant determinants of loss of antibiotic efficacy.

Point of Use Treatment for Medical Devices: From Bedside to Battlefield

INTRODUCTION

Point of use (POU) treatment is a critical first step of medical device reprocessing. Reusable instruments and flexible endoscopes require a minimum of terminal sterilization or high-level disinfection, neither of which can be guaranteed if POU is performed incorrectly. Compliance considerations for POU include hospital accreditation readiness, unique austere surgical mission requirements, and the transition of future conflict towards Large Scale Combat Operations. This integrative review aims to describe POU for reusable instruments and endoscopes, and extrapolate implications for Military Health System policies and future considerations.

MATERIALS AND METHODS

The authors performed an integrative review and comprehensive literature search in PubMed and CINAHL with the keywords "point of use," "point of use cleaning," "POU," "instrument," "high-level disinfection," "endoscope," and "clean." Articles were limited to "English" and "human" from 2017 to 2023. The authors also performed a thorough review of the Defense Health Agency and service-specific doctrine, as well as national guidelines regarding POU adherence.

RESULTS

The literature review yielded 18 articles that discussed the transport and reprocessing of reusable medical devices. Regulatory standards and national guidelines were used to supplement the literature. Seventeen evidence-based criteria were extrapolated from the literature to generate two step-by-step guides for the POU treatment of endoscopes and reusable instruments (Tables I and II). Despite increased morbidity and mortality rates linked to inadequate device reprocessing, compliance with POU procedures remains low. Barriers to practice included complex POU processes, intricately designed surgical instruments and endoscopes, lack of healthcare worker (HCW) knowledge and competency, and inadequate or ambiguously written policies. Training, competency assessments, and clearly written policies and procedures can be cost-effective, evidence-based, and feasible solutions.

CONCLUSION

Completing POU treatment is critical to a successful surgical mission in both the hospital and austere environment. Implications to practice include implementing evidence-based POU programs that improve patient outcomes and readiness while decreasing costs.