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Management of Neurosurgical Instruments and Patients Exposed to Creutzfeldt-Jakob Disease

Published online by Cambridge University Press:  02 January 2015

Ermias D. Belay ,
Jennifer Blase ,
Lynne M. Sehulster ,
Ryan A. Maddox  and
Lawrence B. Schonberger
Ermias D. Belay*
Affiliation:
Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Jennifer Blase
Affiliation:
Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Lynne M. Sehulster
Affiliation:
Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Ryan A. Maddox
Affiliation:
Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Lawrence B. Schonberger
Affiliation:
Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
*
1600 Clifton Road, Mailstop A-30, Atlanta, GA 30333 (ebelay@cdc.gov)
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Abstract

Objective.

To summarize the approaches used to manage exposure of patients to inadequately sterilized neurosurgical instruments contaminated as a result of Creutzfeldt-Jakob disease (CJD).

Methods.

Information on past CJD exposure incidents reported to the Centers for Disease Control and Prevention (CDC) was aggregated and summarized. In addition, inactivation studies were reviewed, and data from selected publications were provided for reference.

Results.

Nineteen incidents of patient exposure to potentially CJD-contaminated instruments were reported to the CDC, including 17 that involved intracranial procedures and 2 that involved ophthalmologic procedures. In more than 50% of incidents, the neurosurgical procedures were performed for diagnostic work up of the index patients. At least 12 of the hospitals had multiple neurosurgical sets, and the CJD-contaminated instruments could not be identified in 11 of 19 hospitals. In 12 of 15 hospitals with neurosurgical incidents, a decision was made to notify patients of their potential exposure.

Conclusions.

Neurosurgical instruments used for treatment of patients with suspected or diagnosed CJD or patients whose diagnosis is unclear should be promptly identified and sterilized using recommended CJD decontamination protocols. Inability to trace instruments complicates appropriate management of exposure incidents. The feasibility of instituting instrument tracking procedures should be considered.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 34 , Issue 12 , December 2013 , pp. 1272 - 1280
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2013

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