0:03

Hi everyone and welcome back to

0:05

The Joint Approach, the official podcast of

0:07

the Musculoskeletal Infection Society and the European

0:09

Bone and Joint Infection Society. We

0:12

would like to introduce our hosts for this podcast. I'm

0:15

Jesse Seidelman and I'm an infectious disease

0:17

physician at Duke University. And

0:19

I'm Johannes Plata, total joint surgeon at the

0:21

University of Pittsburgh. The goal

0:24

of this podcast is really to

0:26

have both infectious disease physicians and

0:28

orthopedic surgeons sit down to discuss

0:30

the joint prevention, diagnosis and management

0:32

of musculoskeletal infections. We

0:35

will break down the existing data and

0:37

open up the lines of communication between

0:39

the medical and surgical subspecialties to help

0:41

navigate these challenging clinical cases. This

0:48

episode is sponsored by Bone Support,

0:50

makers of Ceramet G with Gentamicin.

0:53

Ceramet G is an FDA

0:55

designated breakthrough device offering proven

0:57

bone remodeling with reliable elution

0:59

of broad spectrum Gentamicin. Ceramet

1:02

G has a 96% success rate

1:04

and eradication of infection in

1:06

a single stage for patients

1:08

with fracture related infections and

1:11

chronic osteomyelitis. To learn more

1:13

and review Ceramet G cases,

1:15

visit their website at bonesucord.com.

1:19

Welcome to the conclusion of our series

1:22

on surgical site infection prevention with Tobias

1:24

Cromer and Keith Kay. Let's

1:26

return to the conversation. I'm

1:29

going to take a little bit of a

1:31

right turn here to bring us to another

1:33

really important topic that I think is a

1:35

little bit less understood, but something that I

1:37

think listeners and other clinicians

1:40

alike will be interested in. Talk

1:42

to us about exogenous sources

1:44

of infection. When

1:46

we are addressing things like

1:49

spacesuits and appropriate

1:51

headgear and how many people are

1:53

in the OR, how many doors

1:55

are opening, how significant is this?

2:00

And where is the

2:02

data pointing? Are

2:04

there clear links to surgical site infections

2:07

or are we talking more about increasing

2:10

particle counts and increasing CFUs?

2:15

So I will address this first if that's okay.

2:19

I do believe there are several

2:21

aspects in that question that we

2:24

need to discuss not separately, but

2:27

after each other. So I think the

2:29

behavioral aspect and how many people are

2:32

in the OR, how many times the

2:34

doors open is a surrogate more or

2:36

less on how much traffic there is

2:38

in the OR. And I don't really

2:40

believe that this

2:43

has to do with exogenous

2:45

contamination with particles flying in

2:47

the air, but rather

2:49

with the concentration aspects and

2:51

the behavioral aspects during

2:54

surgery itself. However, there will

2:57

be contamination, of course, through

2:59

exogenous sites. And I think

3:02

there are some very nice,

3:04

interesting studies highlighting potential contamination

3:07

of so to speak sterile

3:09

environments, be the suction tip

3:12

or being inter-operatively taking samples where

3:14

you can in some studies find

3:16

up to 40% a

3:19

positivity rate with coagulase

3:21

negative staphylococci, micrococci, bacilli

3:23

and so forth and so on. I

3:25

don't really believe that they always

3:28

translate into an infection altogether,

3:30

but that they are part

3:32

of the entire OR experience,

3:35

unfortunately. And I don't think

3:37

we yet fully understand and

3:39

grasp the importance of the

3:42

particles and this exogenous

3:44

contamination. If you go back to

3:46

the skin preparation, there's some very

3:48

nice investigations from Zurich. Yvonne Akerman

3:51

did that with Herstaltic Group back

3:53

a couple of years prior to

3:55

the pandemic. They looked at how

3:57

deep the skin had established. really

4:00

goes into the lower or deeper

4:02

more profound skin levels

4:04

and how you could culture

4:06

and identify cutobacterium agonist from

4:08

the from the deeper skin

4:12

skin areas and I do think

4:14

there is much more to be

4:17

investigated on the patient side and

4:19

the potential of

4:21

preventing infections

4:23

with the endogenous than there is

4:26

really from the action exogenous contamination

4:28

but however of course there are

4:31

certain aspect that need to be

4:33

fulfilled the the the sterilized

4:36

equipment filtered

4:38

air I don't really see the point

4:40

from from my training and the institution

4:42

where I come from for a laminar

4:44

airflow and the benefit of that as

4:46

well and at

4:48

least in in Germany as far as I understand

4:50

the the the helmets and

4:53

the the pressure suits or the

4:55

the spacesuits are rather uncommon but

4:57

I don't know if that is

4:59

still the case and maybe Johannes

5:01

can can talk about the feeling

5:03

of performing surgery in such

5:05

a setting with a with a helmet

5:07

and a spacesuit as well but I

5:10

don't really see the benefit

5:12

of using such a technical

5:15

approach to really reduce further reduce

5:18

SSI rates in my opinion but maybe

5:21

there's a different different view on

5:23

the topic from Keith oh yeah I

5:25

just want to add on to you know

5:28

I really like what Tobias had

5:30

to say about these exogenous sources you

5:32

know there are the classic exogenous

5:35

sources that lead to outbreaks or

5:37

infections that are due to a

5:40

colonized surgeon or

5:42

anesthesiologist or a sterilization

5:44

breakdown and you know

5:47

equipment causing infection but

5:50

I think when you're talking about room entries

5:52

the number of people in the OR and

5:54

I would expand this to garb in the

5:57

OR and I probably would expand this even

5:59

to things like how rates of flash sterilization.

6:03

It really ties into the culture of the OR.

6:07

I think when things get loose and

6:10

lax and the

6:13

OR isn't really treated as a sacred

6:15

space and as a very high risk

6:18

important area and things get

6:21

too casual, there's a

6:23

tipping point where I think there's enough

6:25

small things that are

6:27

lax and not optimally hygienic

6:30

that you do start seeing

6:32

infection risk increase. It's not

6:34

any one measurable smoking

6:37

gun, but I think breakdowns

6:40

in crowded

6:42

rooms and frequent

6:45

entries into the OR,

6:48

suboptimal turnover of the room or

6:50

not optimal cleaning of the room,

6:53

tons of flash sterilization and rushing

6:55

equipment back and forth and back

6:57

to ORs without

6:59

standard checks and balances, these

7:02

all tie to a chaotic, non-controlled,

7:07

suboptimal, risky

7:09

environment. I

7:12

think that's where we start seeing

7:15

risk increase. I

7:18

would also say one thing I really like

7:20

this podcast is I like that we have

7:22

a surgeon and an ID person who are

7:24

leading this. I think surgery

7:26

more so than any other safety

7:29

issue in the hospital, even outside

7:31

of just infection control and HAI,

7:34

it really is multidisciplinary. I

7:38

think an infection control person can have the

7:40

best prevention plan in the

7:42

world, but if it's not implementable or

7:45

surgery or anesthesia or pharmacy, if they're

7:47

not on board or they're the weak

7:49

link in the chain, it ain't

7:52

going to work. So I

7:54

think in the multidisciplinary aspects, and

7:56

this ties into our culture as

7:58

well, respect Willingness

8:01

to speak up when there's an issue and

8:05

really fostering teamwork

8:08

and multifaceted expertise

8:10

around protocols and

8:12

processes is

8:14

so important for SSI prevention.

8:19

These are all very good points. I'll comment

8:21

on the spacesuit real quick because you asked me.

8:24

I do use the spacesuit, but you have to be

8:26

careful. You have a false

8:28

sense of security when you're wearing one of

8:30

those suits. They're really just another layer of

8:32

PPE. They

8:34

are, you know, quote, unquote

8:37

sterile, but as soon

8:39

as you put them on, they're not anymore. So

8:41

there are folks that touch the front of the

8:43

screen, which is then

8:45

not a not sterile anymore. The exhaust goes

8:47

out the back of the gown if you're

8:49

not wearing a toga gown or a vest

8:52

so it can contaminate the field behind

8:54

you. So there are several

8:58

aspects about these gowns,

9:00

these spacesuits that are

9:03

quite worrisome. So I

9:06

completely agree with your sentiment. To

9:08

talk about something else, we

9:10

like our OR to be very, very cold. We

9:13

like to see our breath, so we say,

9:15

but, you know, obviously we don't want any

9:18

bacterial growth during the operation and that's what

9:20

we like to keep the OR cold. However,

9:23

sometimes do we do harm to our

9:25

patients by making our patients cold? Is

9:29

there a reason to

9:31

have a patient's normal thermic with some

9:34

form of a heating device? And why

9:36

is that important? And are there specific

9:38

devices that we should

9:40

use? What are your thoughts on

9:42

that? It's a really good

9:44

question, Johannes, and it does seem that maintaining

9:47

normal thermia for as long

9:49

and as much as possible

9:52

for the patient during surgery

9:55

is very important in reducing SSI risk.

10:00

you know, keeping the core

10:02

temperature for the patient, increased,

10:04

increases blood flow, increases

10:06

oxygenation of the tissues, all these

10:08

things can help prevent SSI. Getting

10:12

back to what I was saying about multidisciplinary

10:14

approaches, there

10:17

are different approaches to warming

10:19

the patient. And, you know,

10:21

you gotta make sure that your

10:23

anesthesiologists are on board, that your preoperative nursing

10:25

is on board, but it

10:28

seems that the two most common

10:30

methods for warming, one is forced

10:32

air warming, which

10:34

usually has to do with certain blankets or

10:36

devices that go right around the patient. And

10:39

the other is warming through

10:41

infusion, intravenous

10:44

infusion of warm fluids. I

10:46

think the forced air warming seems to

10:49

be more commonly used at places where

10:51

I've been. And it seems

10:53

that one of the

10:55

regimens that's recommended, that seems to be

10:57

particularly effective, is preoperative warming

11:00

right before they go into the OR, typically

11:02

for somewhere around 20 to 30 minutes before

11:05

they go in the OR. The goal is to

11:07

maintain body

11:10

temperature above 35.5 degrees Celsius. But,

11:14

you know, again, you have to get

11:16

your nursing on board, your anesthesia on

11:18

board, your surgeons on board, to

11:21

make sure that you have the right equipment, that

11:23

you have the right flow for the patient and

11:25

pre-op to the OR, and

11:28

that, you know, everyone's on board for

11:31

what equipment you're gonna use, for

11:33

how long and, you know, where it's

11:35

gonna happen, and that, you know, once

11:37

the patient's in, you're ready to

11:39

get going in the OR

11:41

to try to minimize any sort

11:44

of hypothermic time period.

11:47

Tobias, anything on your side of the

11:49

pond, so to speak? Yeah, that's pretty

11:51

much the same as

11:53

we currently practice it in Germany as

11:55

well. The warmed infusions

11:57

are rarely used. unfortunately,

12:00

and I do believe that when

12:02

implementing such an improvement and really

12:05

trying to keep normothermia that people

12:07

need to understand the reason behind

12:09

it, not only the physicians and

12:11

the surgeons but also of course

12:13

nurses and the entire the entire

12:16

chain of the process really needs

12:18

to understand why it is necessary

12:20

to keep the patient at a

12:22

normothermic level

12:25

and then I think implementation

12:27

and adhesion or compliance to

12:29

those rules and those

12:31

sets really is much more effective

12:34

and way better than

12:36

without that knowledge of course. All

12:40

right and I know that this we've been

12:42

going on because there are just so many

12:44

important aspects of SSI prevention but one of

12:47

the things I'm really curious to ask both

12:49

of you is about perioperative

12:51

glucose control. You know

12:54

I think that and I'll have maybe

12:56

one of you explain the pathophysiology behind

12:58

it why this is so important in

13:00

diabetics and non-diabetics but the other thing

13:02

that I think is really challenging and

13:05

again like you said another good reason

13:07

why we have multidisciplinary groups like this

13:09

to discuss the issues is that

13:12

you know someone a lot of our patients

13:14

who are coming out of orthopedic surgery are

13:16

doing so as an outpatient. So if you

13:19

take a glucose value when they

13:21

come out of the OR how

13:23

do you respond to that right?

13:25

Is this someone that needs to

13:28

get sliding-scale insulin like how can

13:30

we best monitor and then respond

13:32

to episodes of hyperglycemia particularly in

13:35

a specialty where so much of the

13:37

surgery is done same day or where

13:40

patients are only staying one night? Well

13:44

in Germany at least or in Europe the

13:47

control of the blood glucose level

13:50

prior to surgery is implemented

13:53

and is quite common and of

13:55

course the the post surgical phase

13:57

is important as you can can

14:00

read in the literature in order

14:02

to really decrease SSI rates altogether.

14:04

But I don't believe that we

14:06

are really there yet in controlling

14:10

the post-surgical glucose level as we

14:13

should. I mean, there are protocols

14:15

implemented in order to really get

14:18

the patient at a certain aspect,

14:20

but I think still some colleagues

14:22

are still scared

14:25

of managing that

14:27

hyperglycemia too

14:30

aggressively and

14:33

decreasing the value too fast

14:35

and too intense. Therefore,

14:37

I would be really interested in

14:40

hearing your perspective and the current practices

14:42

that you use in the U.S. A

14:47

really great topic, and I

14:50

think glucose control in the

14:53

perioperative period has really emerged over

14:55

the past 25 years. I think

14:59

initially the strongest literature, and a

15:01

lot of the strongest literature is

15:03

the cardiothoracic literature where insulin drips

15:05

were used during surgery

15:07

in the post-operative period. Targets

15:10

have changed from less than 200 to

15:12

less than 180,

15:14

and depending on what guidelines you're looking at,

15:17

sometimes they'll go even lower. I

15:20

think now we're focused more

15:22

on the glucose control in the

15:25

immediate post-operative period. I

15:28

think if you're keeping it under

15:30

200, I think you're doing a

15:32

good job. If that can be done with

15:34

a sliding scale insulin, that's great. I think

15:36

if you require an insulin drip, and a

15:38

lot of times endocrine has gotten

15:41

a lot of business from

15:43

places that do a lot of either

15:46

prosthetic joint surgery or cardiothoracic surgery, and

15:49

aggressively trying to keep levels

15:51

below 200, some guidelines

15:53

are recommending below 180. I think the data

15:56

would say the lower

15:59

that you safely go down

16:02

to 130, 120, 110

16:05

would be better, but then your

16:07

hypoglycemia risk starts increasing. So

16:10

that's why I think people are a little

16:12

hesitant to be too aggressive in terms of

16:14

glucose targets. I do

16:16

think there's pretty good convincing data. As

16:20

glucose goes up, white blood cell function

16:23

functions less well. Hypoglycemia

16:27

is somewhat of an

16:29

immune suppressant to a

16:31

degree. And

16:33

I think aggressively controlling the glucose

16:36

is associated with decreased risk. So

16:39

a place where I've worked, I think

16:41

it shifted more toward the immediate post-operative

16:44

period. There

16:46

are some places I know that are still pretty

16:48

aggressively go after

16:50

intraoperative glucose control.

16:54

Especially when you're screening people before they

16:56

go in the OR, things like hemoglobin

16:58

A1c can give you an idea of

17:01

risk and how poorly

17:03

controlled or how well controlled blood sugars

17:05

have been. But regardless

17:08

of prior history of diabetes,

17:10

keeping that glucose below 200 or below 180 in

17:16

the immediate post-operative period, if possible,

17:19

in the OR as well, will

17:21

decrease infection risk. But again, it's

17:23

being on board with nursing, on

17:25

board with endocrine on

17:28

board as well

17:30

obviously with surgery and anesthesia. So

17:34

it is one of those areas that sounds good.

17:36

You have some targets to keep the glucose down.

17:39

But when the rubber hits the road, sometimes it's

17:41

complicated and you don't want to cause harm. You

17:44

don't want to make a mistake and

17:46

cause someone to bottom out their glucose

17:48

in the perioperative

17:50

period. I'm kind of interested

17:52

in Johannes, what's the practice at Pittsburgh

17:55

around this? We

17:57

have established an A1c cutoff for

17:59

occasions. at 7.5 preoperatively and there's

18:01

data that supports 7.5, there's data

18:03

that supports below 8.

18:07

I think ideally maintain

18:10

glucose control prior to surgery

18:13

is best.

18:16

Our cutoff preoperatively for

18:18

glucose is 200. So

18:21

anybody over a glucose on the day of

18:23

surgery over 200 gets cancelled the day

18:26

of surgery. And I think there's some good literature

18:28

to support all of that as you pointed that

18:30

out. But this has been a great

18:33

podcast. We've been talking about a

18:35

lot of things regarding SSI and

18:38

PJI. However, if we

18:40

look at the numbers, the numbers I think are

18:42

stacked against us still as

18:44

the numbers of total joint replacements is

18:46

going to rise in the next decades.

18:48

So is the number of PJI and

18:51

most likely SSI as well. Any

18:54

innovative inventions, new

18:58

methods that you have

19:00

come across that you could share with us that

19:02

could help us in the future? Let's

19:05

start with Tobias. Well, thank you,

19:07

Johannes. There's always the question, of course, if

19:09

you can code any

19:11

surfaces with antibacterial

19:14

or anti-pathogenic substances

19:17

using silver or copper, what

19:20

some combination of the above. I

19:24

do believe that not

19:26

really one silver

19:28

bullet is available in the future, but

19:30

rather the combination, the

19:32

bundle, as well

19:35

as the implementation science behind

19:37

IPC is the real way

19:40

forward and the communication and

19:43

interdisciplinary approach as we do here.

19:45

But as we also practice on

19:47

a daily basis will be the improved

19:51

future for reducing SSI and

19:53

PJI's altogether. Of course, there's

19:55

always certain strategies and potential

19:57

intervention that are being evaluated

20:00

at different centers

20:02

worldwide, talking about

20:04

lavage, for example, using local

20:07

antibiotics as a strategy. I

20:13

do believe there is potential room

20:15

for investigation in all of those

20:18

strategies, but I do firmly believe

20:20

that implementation science and really doing

20:22

the interdisciplinary approach is really the

20:24

way forward and discussing

20:27

potential flaws or

20:29

strategies in a team and

20:35

onsite together with surgeons, with physicians, with

20:37

IPC personnel, but also within nursing staff

20:40

to really further improve strategies and bundle

20:42

strategies that can be implemented and can

20:44

be adhered to. Yeah,

20:47

I think that's to buy some things up really

20:49

well. The one thing I'll say, Johannes, is the

20:52

movement towards more robotic

20:54

surgeries, also hip

20:57

resurfacing, avoiding prostheses,

21:00

some of these less invasive procedures, smaller

21:04

incisions, less blood

21:07

loss. These are

21:09

all preventive modalities that

21:14

I think are gonna help. While the total

21:16

number of PGIs may go up, I think

21:18

we're gonna continue to see rates drop. I

21:23

think rapid diagnostics, if we can do

21:25

point of care testing

21:28

for Staph aureus colonization or MRSA

21:30

colonization, I think that that could

21:32

be very helpful. If

21:35

we really wanna be targeted

21:37

in how we manage antibiotic

21:39

prophylaxis or advanced or

21:42

uber decolonization protocols, I

21:45

think that that could be helpful. And

21:48

I do think there's, as Tobias mentioned, I'll put

21:51

a plug in for the shake and pandium. There

21:54

is a big focus on implementation now.

22:00

making sure that all the cooks are at the

22:02

table and that you

22:05

have a real team approach

22:09

that is

22:11

smooth and efficient without

22:13

redundancies or unnecessary steps

22:16

or unneeded complications. So

22:18

I think a lot of the technology preventive

22:20

methods are going to come on

22:23

the surgical side and I do

22:25

think sort of a lot of this behavioral and

22:29

qualitative type

22:31

of improvements around process

22:34

implementation are going to help

22:36

us protect our patients

22:38

as much as possible before they get

22:42

in the OR. Keith,

22:44

you couldn't have rounded out our

22:46

multidisciplinary podcast any better with the

22:48

emphasis on the team approach or

22:50

the joint approach as we are

22:52

called. I really want

22:54

to thank both of our distinguished guests for

22:57

being on the podcast with us. Again, this

22:59

is such a critical topic of conversation and

23:01

we so appreciate all the work that both

23:03

of you have done in this field. Thank

23:07

you so much for listening. This episode has been

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23:28

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23:30

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23:32

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23:34

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23:43

as always, if you

23:45

have any questions, comments,

23:47

or suggestions for future

23:49

episodes or guests, please

23:51

reach out to us

23:53

at jointapproachpodcast@gmail.com. Again, that's

23:55

one word, jointapproachpodcast@gmail.com. And

23:57

be sure to subscribe on Spotify or Apple

23:59

podcast. Thanks again and

24:01

we hope you tune in again soon.