Preventing the risk of prion transmission via neurosurgical instruments: a case report

Abstract

U posljednjih 10 godina Hrvatskom zavodu za javno zdravstvo prijavljeno je 15 bolesnika oboljelih od Creutzfeldt-Jakobove bolesti (CJB). Tijekom lipnja 2012. godine u Općoj bolnici Varaždin (OBV) preminuo je 58-godišnji bolesnik premješten s Klinike za neurologiju KBC Zagreb pod sumnjom na sporadični oblik CJB. Nakon obdukcije bolesnika, koja je provedena u našoj ustanovi, dijagnoza CJB potvrđena je patohistološkom analizom mozga u Kliničkom institutu za neurologiju Medicinskog fakulteta u Beču. Povjerenstvo za sprječavanje i suzbijanje bolničkih infekcija OBV izradilo je upute o mjerama i načinu postupanja s prostorima, opremom i instrumentima koji su bili potencijalno kontaminirani prionima. Obzirom da se radilo o bolesniku koji je 2,5 mjeseca prije postavljene dijagnoze bio neurokirurški operiran u našoj ustanovi, a upotrijebljeni neurokirurški instrumenti nisu bili tretirani po principu dekontaminacije priona, postavljeno je pitanje potencijalnog prijenosa priona kontaminiranim instrumentima na 29 bolesnika koji su naknadno neurokirurški operirani. Analizom neurokirurškog zahvata utvrdili smo da su neurokirurški instrumenti bili u kontaktu s kožom, potkožjem, fascijama mišića, kostima i intervertebralnom hrskavicom bolesnika, ali ne i s tvrdom moždanom ovojnicom, niti je za vrijeme operacije bilo likvoreje. Zaključili smo da tijekom neurokirurškog zahvata nije došlo do kontakta instrumenata s tkivima visokog i srednjeg rizika za prijenos priona te je rutinski postupak s neurokirurškim instrumentima (rutinsko čišćenje i sterilizacija) bio dostatan za sprječavanje prijenosa priona, sukladno smjernicama britanske i kanadske grupe za kontrolu CJB. Naknadnim praćenjem nije registriran niti jedan slučaj sekundarne CJB u 29 bolesnika operiranih nakon ovog bolesnika u našoj bolnici.In the last 10 years there have been 15 cases of Creutzfeldt-Jakob disease (CJD) reported to the Croatian Institute of Public Health/Department of Epidemiology. In June 2012, a 58-year-old patient that had been relocated from the Department of Neurology of the University Hospital Centre Zagreb to General Hospital Varaždin, died from a suspected sporadic form of Creutzfeldt-Jakob disease. After autopsy was performed in our hospital, CJD was confirmed by histopathological analysis of the brain in the Clinical Institute of Neurology/Medical University of Vienna. The Hospital Infection Control Committee drafted guidelines for infection control measures regarding work areas, equipment and instruments that were potentially contaminated with prions. Since the patient had undergone a neurosurgical operation in our institution 2.5 months prior to CJD diagnosis, and the neurosurgical instruments used during this procedure were not processed according to the prion decontamination principles, a question was raised regarding a potential prion transmission via contaminated instruments to the 29 patients who subsequently underwent neurosurgical operation. By analyzing the neurosurgical procedure that the patient underwent, we established that neurosurgical instruments were in contact with the patient\u27s skin, subcutaneous tissue, fascia muscle, bones and intervertebral cartilage and not with the dura mater and that there was no cerebrospinal fluid drainage during surgery either. Therefore, we concluded that during neurosurgery the instruments did not come into contact with tissues of higher or medium risk for transmission of prions and that routine procedure for cleaning and sterilization of neurosurgical instruments was sufficient for preventing prion transmission, which is in accordance with the British and Canadian CJD infection control guidelines. Subsequent follow-up recorded not a single case of secondary CJD among the 29 patients who underwent surgery after the infected patient in our hospital