Case Studies in Infection
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Page updated 9 October 2007
Precautions to be taken from known, suspect or at-risk patients with TSE.
When procedures are undertaken which carry a risk of contamination with CSF, brain, blood or lymphoid tissue, the following precautions must be taken.
Access to CSF (eg by lumbar puncture)
All lumbar punctures and access to cerebrospinal fluid must be performed with "single use only" equipment. This applies to all procedures involving access to the subarachnoid space and, for example, access to ventriculo-peritoneal shunts. The rule includes spinal anaesthesia and diagnostic neuroradiology.
Lumbar puncture (including radiological and other procedures during which CSF is withdrawn)
Attending to extraventricular and lumbar drains
Venepuncture and administration of injections
Dressing wounds and bed sores
Wear disposable gloves, plastic aprons and eye protection
Use disposable drapes, instruments and other equipment
All used equipment must be incinerated after use (see below)
Biopsies (especially neural tissue)
Inform infection control nurse and theatre manager before ANY procedure. Warn the neuropathologists if a diagnostic brain biopsy is to be taken.
The greatest risk of transmission of prions from one patient to another arises from transplantation of tissue (eg cornea). There is also theoretically a high risk from re-using instruments on the brain and other neural tissue.
Biopsies of tissues such as nerve, muscle, skin or lymph nodes may also provide a risk for the transmission of variant CJD. Where there is any risk that the patient may have any form of prion disease, the biopsy should be performed with disposable instruments. Where this is not possible, or where the diagnosis is in doubt, the instruments must be quarantined until a definitive diagnosis is reached. A record of patient, pathological diagnosis and fate of instruments will be kept by the operating theatre manager. Formal notification of decisions regarding instruments should be made to the operating theatre manager.
Wherever possible, any surgical procedure on a patient known or suspected to be suffering from prion disease should be performed at the end of the list, to allow the theatre to be cleaned afterwards. The minimum number of staff possible should be present in theatre and proper personal protective equipment must be worn.
All brain biopsies for diagnostic purposes (whatever the clinical diagnosis) will be performed with a disposable set of instruments with the exception of the Pistol drill. Turbine drills must not be used.
The disposable instruments will be destroyed by incineration. The Pistol drill will be washed under water by a trained operative wearing full protective clothing (including domestic rubber gloves, apron and visor), and then sent for routine processing in CSSD.
Other surgery on patients with known or suspected CJD
Known cases of classical CJD (or GSS or FFI)
Known case of variant CJD
For surgical procedures on classical CJD patients involving brain or spinal cord, eye, and excluding invasive dental procedures and
For surgical procedures on vCJD patients involving CNS, brain, spinal cord, the eye and lympho-reticular system; (e.g. tonsillectomy, appendicectomy);
Members of the operating team should wear the following single use, disposable protective clothing:
A disposable plastic apron under the operation gown
Non-wettable operation gown
Gloves, masks, cap, over-shoes, and suitable eye protection (visor or goggles).
The procedure should be scheduled last on the list.
Instruments and drapes
Disposable drapes and dressings must be used and destroyed after use. All instruments must be disposed of in plastic sealable containers after use. These will be incinerated.
Where the surgical procedure involves the brain (e.g. cortical biopsy), spinal cord or eye, the following additional precautions should be taken:
The least possible number of persons should take part in the operation.
A one-way flow of instruments should be maintained.
Single use disposable instruments should be used whenever practical.
All instruments in contact with neural tissue must be destroyed by incineration.
These are sensible precautions in any event.
Suspected case of CJD (all forms including GSS or FFI)
The precautions above must be observed when neurological procedures, or procedures where lymphoreticular tissue is involved are carried out on patients in whom the possibility of any form of CJD enters into the differential diagnosis. All re-usable instruments must be placed in quarantine (see below) until a confirmed diagnosis is obtained.
Patients with classical CJD and inherited forms: the prion protein has not been found in reticulo-endothelial tissue so the instruments may be re-used after normal decontamination. However, it would be wise to check this before performing a procedure, then quarantining the instruments before re-use.