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Control of an outbreak of postoperative bone mucormycosis: An intervention study of contiguous cohorts
Marcelo S Chaves1, Diego Franco2, Juan C Nanni3
1Quality Improvement Area, Sanatorio La Entrerriana, Paraná, Entre Ríos, Argentina.
Abstract:
An outbreak of postoperative bone mucormycosis following arthroscopic anterior cruciate ligament reconstruction in a tertiary referral center in Paraná, Argentina, could have been transmitted through an arthroscopic anterior cruciate ligament reconstruction-exclusive contaminated item. The outbreak was controlled after changing from a system of direct delivery of implants and instruments to the operating room without proper verification, to a controlled and centralized process; specifically, the institution's pharmacy verified the quality and traceability of implants, and instruments were processed only by the institution's central sterile services department.
Insights
A bone infection outbreak after anterior cruciate ligament reconstruction was linked to contaminated surgical items. Implementing a centralized sterile processing system effectively controlled the mucormycosis transmission in orthopedic surgery.
Area of Science:
- Orthopedics
- Infectious Diseases
- Surgical Site Infections
Background:
- An outbreak of bone mucormycosis occurred post-arthroscopic anterior cruciate ligament reconstruction.
- The infection was suspected to be linked to contaminated surgical items used exclusively for the procedure.
Purpose of the Study:
- To identify the source of the mucormycosis outbreak.
- To implement and evaluate control measures for surgical site infections.
Main Methods:
- Investigated an outbreak of postoperative bone mucormycosis.
- Assessed the surgical supply chain and instrument processing protocols.
- Implemented a revised system involving pharmacy verification of implants and central sterile services for instruments.
Main Results:
- The outbreak was successfully controlled after implementing a centralized and verified system for implants and instruments.
- The change in protocol shifted from direct delivery without verification to a controlled, centralized process.
Conclusions:
- Contaminated items used in arthroscopic anterior cruciate ligament reconstruction can transmit mucormycosis.
- Centralized quality control and sterile processing are crucial for preventing surgical site infections.
