• When surgical site infections are linked back to surgical instru-
ments, biofilm is likely a root cause.
• The infection outbreak spanned nearly 2 years, from July 21, 2016,
to April 5, 2018. Whatever was causing the infections was recurrent
and undetectable, telltale characteristics of biofilm.
• The hospital sent precautionary letters to about 5,300 patients who
underwent orthopedic or spinal surgery at the hospital during that
time. The letter explains that the sterilization issue revolved around
the first step in a multistep process: a pre-cleaning process that
occurs before instruments go through "an intense heat sterilization."
• Health officials determined that the infection control breach was due
to human error that occurred during "a gap" in the manual pre-cleaning
phase — before the tools underwent heat sterilization. Staff at Porter
Adventist wiped down, soaked and scrubbed certain spine and orthope-
dic instruments, but apparently not well enough. The instruments likely
still contained bioburden when they were sent along for automated
cleaning and heat sterilization.
• Since warning patients of the pre-cleaning breach, the hospital discov-
ered residue on instruments after sterilization. The hospital first suspect-
ed this was due to a water quality issue, but tests showed the water quali-
ty was well within the typical range found in drinking water. It turns out
that a mineral buildup in a cleaning machine caused the residue.
Bacteria's slimy fortress
The Porter Adventist incident hammers home the critical importance
of the first step in the instrument reprocessing process in the battle
against biofilm. The incident also illustrates biofilm's tolerance and
tenacity.
Biofilm forms when bacteria adhere to surfaces in some form
of watery environment and begin to excrete a slimy, glue-like
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