Correspondence Iatrogenic Intraocular Infections

Correspondence Iatrogenic Intraocular Infections

156 CORRESPONDENCE CORRESPONDENCE IATROGENIC INTRAOCULAR INFECTIONS Some suggested prophylactic measures for fungal and hospital-induced infections...

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CORRESPONDENCE IATROGENIC INTRAOCULAR INFECTIONS

Some suggested prophylactic measures for fungal and hospital-induced infections In presenting this paper, I speak both as a scientist and a patient, having been hospi­ talized five times in five different leading New York City hospitals for surgery. New York City is considered one of the world's lead­ ing medical centers and some of my own experiences and observations in our finest hospitals leaves no doubt in my mind that the same or similar conditions, and probably even worse, prevail in other hospitals all over the country. It seems paradoxical that the more sci­ entific we become, the less we seem to re­ member some basic scientific principles. Cou­ pled with this is an astonishing forgetfulness of simple fundamentals of hygiene and cleanliness. The result is evident in many of our hospitals, unsuspecting patients being subjected to bacterial abscesses, septicemia, fungus infections, loss of eyes and death. It is not enough to do searching scientific investigations after a disease appears, nor is it enough to write papers on one's findings, nor is it enough to continue searching for another antimicrobial or chemotherapeutic agent. The time-lag between misplaced con­ fidence in and uses of various devices and measures must now be closed quickly. Our ultrascientific approach must be radically changed and we must learn to use new tools properly as well at too remember not to dis­ card the "old" methods and procedures in favor of the new. No tools should be used haphazardly and without the basic principles and knowledge of these at the command of the user. The indiscriminate and incorrect usage of peni­ cillin should always stay in our minds, for this "wonder drug" lost its full potentials in a short space of time with the unnecessary development of resistant strains of bacteria. Today we have "viruses looking for a dis­

ease" and we shall unwittingly supply the diseases for these orphaned viruses, unless we radically change our ways and our think­ ing. From time to time, a useful purpose is served by focusing on some facts, observa­ tions and inferences and reviewing some basic fundamentals. By critically scrutinizing and questioning, we are better able to place emphasis on pertinent information and ob­ servations, postulate and evaluate. We know that there are three basic meth­ ods for achieving sterilization—heat, physi­ cal and chemical agents. It seems self-evident that one does not discard a method of proven sterilization for something new, merely be­ cause a new method seems to be less timeconsuming and more convenient. The num­ ber of variables which must be controlled in evaluating the germicidal activity of chemical agents is too great to permit uniformity of results under all conditions. Unfortunately, this is lost sight of and one of our problems today is our lack of application of scien­ tifically established principles as part of hos­ pital usage. In 19351 quaternary ammonium com­ pounds assumed importance as disinfectants and antiseptics. In 1939, Castellani2 inocu­ lated tubes of sterile distilled water (boiled on three successive days or autoclaved) and plugged with absorbent cotton wool, with varying types of fungi, and tubes were left alone at room temperature for 12 months. After 12 months, he found all the fungi alive and they readily grew on being transplanted to solid media. As a matter of fact, he now recommends this procedure for maintaining pathogenic fungi in mycologie collections. He also noted that "a number of bacteria, es­ pecially intestinal bacteria such as Salmonella typhosa, S. schottmulleri and S. asiatica re­ main viable (and some of them multiply) for one year and longer in distilled water." In 19513 there was a report on solutions (soap, calamine lotion, one-percent cetrimide solution) used on skin injuries, those treated becoming infected with Ps. pyocyanea, the

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same organism being found in the "cleansing solutions" employed. In 19574 five open-heart surgical cases were reported with fatal septicemia due to Pseudomonas aeruginosa, directly traceable to the outer column of heavy acrylic plastic of the oxygenator used during surgery, the column having been cold sterilized with benzalkonium chloride (Zephiran) solution. In 19585 40 instances of septicemia due to Pseudomonas sp. were reported, resulting from the use of needles and catheters stored in Zephiran. In I9606 another report ap­ peared concerned with abscesses and septi­ cemia due to Aerobacter cloacae, resulting from use of gauze sponges which were kept soaking in a solution of Zephiran, and used to cleanse the skin before injections and venipunctures. The same organism was also recovered from the rubber hose attached to the aspirator used in clearing mucus from newborn babies, the rubber hose being pe­ riodically cleaned with benzalkonium chlo­ ride. We can draw some obvious conclusions from these reports: (a) fungi and bacteria can live in sterile distilled water in tubes plugged with cotton; (b) various solutions used in treating skin abrasions are capable of becoming infected and the infecting organ­ ism transmitted to patients under treatment ; (c) septicemia and bacterial abscesses result­ ing from use of gauze (cotton) sponges soaked in a solution of Zephiran and used to cleanse the skin prior to injection and venipunctures, from use of needles and cath­ eters stored in Zephiran and from use of part of an oxygenator cold sterilized in Zephiran. We can note the presence of some com­ mon factors involved—solutions, organic ma­ terial (cotton plugs with the possibility exist­ ing of enough cotton fibers falling into tubes of sterile distilled water to support growth of fungi and bacteria, cotton gauze soaked in Zephiran thereby reducing effectiveness of this germicide, cotton gauze dipped directly into cleansing or therapeutic agents) and

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variations in room temperatures. Luria, in 1962/ noted "reports of Candida endocarditis and disseminated moniliasis have appeared with increasing frequency in recent years. Many of the patients develop­ ing infection of the heart valves have had recent cardiac surgery. In the remaining pa­ tients developing Monilia endocarditis, and in the majority of those with disseminated candidiasis without endocardial involvement, the fungus had direct access to the blood stream through in-dwelling vascular cath­ eters, continuous or intermittent intravenous infusions, or the use of narcotic drugs intra­ venously. Duhig and Mead recorded four in­ stances of disseminated moniliasis in children with acute gastroenteritis in whom they were able to demonstrate the fungus in the center of blood clots in thrombosed veins through which fluids and medicaments had been ad­ ministered. They adduced convincing evi­ dence that the fungus disseminated from the intravascular site." Since no details of sterilization techniques employed are noted in this paper, might we not ask the following questions? (a) Were needles, in-dwelling catheters, intravenous in­ fusion set-ups, and oxygenator parts prop­ erly sterilized by moist heat or by cold liquid sterilization? (b) Was the skin cleansed, prior to injection, with gauze pads soaked in Zephiran? (c) Did any of the female staff attending patients have a vaginal trichomonas infection which is frequently associated with monilia infestation ? I have recently been confined to a hos­ pital, which I shall designate as Hospital X, for eye surgery, a hospital devoted largely to eye cases. My ophthalmologist spoke to me about a problem at this hospital, that of blindness due to postoperative fungus infec­ tions of eyes operated on for cataract extrac­ tion. On returning to this hospital after my release, to observe my surgeon perform the same operative procedure as was done on me, I was truly shocked at the primitive condi­ tions I encountered in the operating rooms. The air-conditioning system had been non-

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functioning for a long time, ordinary stand­ ards of cleanliness were sadly lacking, dust was visibly present in many parts of the operating room, doors to the operating rooms were left wide open with much traffic in and out of operating rooms, operating room doors opened directly from the corridor, old, wooden storage closets and cupboards formed part of an operating room, material was present in operating rooms which had no business being there and so forth. Shortly thereafter, I changed ophthalmolo­ gists. My present ophthalmologist who is the professor of ophthalmology at New York Hospital, also spoke to me about the same problem, postoperative fungus infections and subsequent loss of eyes subjected to cataract extraction, a problem not encountered at New York Hospital itself, but nevertheless one assuming great proportions elsewhere. Being a surgical patient also at New York Hospital, I had a chance to see its operating rooms which were quite in contrast to those of Hospital X—clean, air-conditioned rooms, no doors leading directly into operating rooms from outside corridor, no traffic in and out of operating rooms, and so forth. Having now been made cognizant of this problem by two ophthalmologists, I decided to look into some literature on fungus for a clue that might be applicable to eye work and obtained the papers of Miller, et al. 8 · 9 from the Boyce Thompson Institute for Plant Re­ search, Inc., Yonkers, New York, on their work on fungi and fungicides. They had worked with various metal ions, testing them against fungus spores. They found that sil­ ver ions, one part per million, were effective in releasing cell contents of fungus spores and in inhibiting germination of spores. I knew that in past years silver com­ pounds had been employed extensively in ophthalmologic work for treatment of con­ junctivitis due to a variety of organisms and for prophylaxis against the gonococcus or­ ganism in the eyes of newborn babies. Silver compounds have not been used for fungus infections, either for treatment or for

prophylaxis. With the advent of antimicro­ bials, there was an enormous decrease in the use of silver compounds, just as there was an enormous decrease in the use of heat sterilization with the advent of cold liquid sterilization. Interestingly, the U. S. Pharmacopeia X listed as an official test for silver prepara­ tions, the power of silver ions to inhibit the growth of yeast fungus, but this test was later dropped. On the basis of past use of silver com­ pounds in ophthalmologic work, plus the knowledge gained from the Miller, et al. re­ ports, I thought it might be feasible to utilize a silver compound in eyes as a preoperative prophylactic agent against fungi. Not being a clinician, I posed many questions to my oph­ thalmologist concerning the effect of silver on eyes. I then told him of the work of Mil­ ler, et al. and that I was seeking an applica­ tion of their findings for use as a preopera­ tive prophylactic in eyes scheduled for cat­ aract extraction. At this point my ophthal­ mologist perked up and told me that all eyes scheduled for surgery at New York Hos­ pital, regardless of the type of surgery to be performed, were preoperatively prepared with instillation of various solutions, one of these being argyrol. Argyrol is a mild silver protein preparation containing 20-percent sil­ ver. It was being instilled for its eye staining effect to check on proper preoperative eye preparation by the nursing staff. I then noted that while at Hospital X, I had not received any preoperative treatment to my eye. Yet, for the same surgery per­ formed at New York Hospital, I did have preoperative preparation and had even re­ marked about this at the time. Hospital X has no preoperative prepara­ tion of eyes scheduled for surgery and it is plagued with postoperative fungus infections in cataract extraction cases. New York Hos­ pital has routine preoperative preparation for all eyes scheduled for surgery and has had no postoperative fungus infections in cata­ ract extraction çasçs. At New York Hospi-

CORRESPONDENCE tal, one of the solutions used routinely in preoperative preparation of eyes is a silver preparation, 20-percent argyrol. Miller, et al. found silver ions effective in releasing cell contents of fungus spores as well as inhibit­ ing germination of spores. Can we not de­ duce immediately, without waiting for "ex­ perimental evidence" and more blindness, that 20-percent argyrol appears to be an ex­ cellent antif ungal prophylactic in eye surgery and institute its preoperative use immediately in all eye surgical cases? Might it not also be worth trying in eyes already infected with fungi to see if these eyes can be saved ? Since we have no effective antifungal agents for internal fungus infections, might we not con­ sider the intravenous or intramuscular use of an appropriate silver-containing preparation ? It is, of course, obvious that there are other variables present in both hospitals, one being different operating room conditions. While this should be corrected, I feel that it is not necessary to wait for correction of all variables, nor is it necessary to wait for ex­ perimental evidence to prove that a mild sil­ ver protein preparation is or is not an anti­ fungal prophylactic in cataract extraction surgery, but immediately to institute its use as such, evidence pointing strongly to this qual­ ity. No harm will accrue to patients and the benefits may be tremendous. Intraocular infections are directly trace­ able to (1) surgery, (2) perforating eye in­ jury, (3) presence of a fungus infection elsewhere in patient. A postoperative intra­ ocular fungus infection may begin a few days after cataract extraction or even months later. Examination of enucleated eyes may not even yield enough information to identify the specific invading fungus. The intent of this communication is not to review the available literature but to focus attention on what, to me, seems self-evident. I cannot supply experimental data to prove that silver proteinate is unequivocally a prophylactic agent in cataract extraction sur­ gery. Since the natural protective defense mechanisms against infections in laboratory

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animals are different from those in man, the limitations of gathering "evidence" are ap­ parent. May we not utilize established usage procedure vs. lack of same as confirmatory proof for substantiating my hypothesis as to the prophylactic value of silver proteinate? Interestingly, the Massachusetts Eye and Ear Infirmary of Boston, Massachusetts, also using a silver proteinate preoperatively, has never encountered an intraocular fungus infection following cataract extraction.10 The coincidence of use of silver proteinate at the New York Hospital and the Massachusetts Eye and Ear Infirmary, and the absence of intraocular fungus infections in both these institutions, is very significant, in spite of the fact that silver proteinate was not being consciously used as a prophylactic agent. Compare this with Hospital X and the sig­ nificance becomes even greater. Might we not even consider using a silver proteinate in eyes of all patients having any fungus infection at any site of the body, as a possible barrier to the spread of the fungus to eyes ? There are other fundamental principles that we should not lose sight of in patient care. The common sense of ordinary sanita­ tion and application of basic principles for hospital cleanliness seems evident, but, too frequently is sadly lacking. We know that dust particles carry organisms and that fungi like moist surfaces. It follows, therefore, that there should not be any dry dusting or sweep­ ing in any portion of a hospital, especially in operating rooms and in patients' quarters, and wet floor washing should be eliminated. Vacuum cleaners should be substituted and used constantly on floors, walls, furniture, and so forth. All dust collectors in patients' rooms should be eliminated, as for example, window drapes, window blinds, etc. Prior to the days of air conditioning and vacuum cleaners, photographers vaseline coated walls of dark rooms to eliminate dust and even today they still coat negatives with vaseline to keep them dust free. Should not this sim­ ple precaution be adopted in hospitals to pro-

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tect patients in operating rooms by entrap­ ping dust particles with subsequent death to airborne organisms, with application of vase­ line coating to all walls, woodwork, ceilings and the area under operating table ? Is it not elementary to insist that all fe­ male personnel having direct patient contact be checked for presence of Trichomonas vaginalis? Should we not revert to the use of iodine for skin sterilization prior to injec­ tion, infusion or puncture? Should we not insist that all injection material be prepared at the bedside? I have seen nurses fill sy­ ringes, wet a gauze pad with a fluid, insert the sterile needle into wet gauze pad and carry this through the hallway to the patient's room. What is on that gauze pad? Could it be unsterile alcohol, or Zephiran which will now contaminate the needle as well as the skin of person who is to receive the injection? The insistence on utmost care must be in­ stilled in all involved in patient care. Human life is more important than "time saving de­ vices" which may kill the patient. The instal­ lation and use of a properly controlled airconditioning system in operating rooms is a self-evident necessity. Where operating rooms are not equipped with air-condition­ ing, the use of a desiccant, such as Drierite (anhydrous calcium sulfate), to absorb ex­ cess moisture in operating rooms should be instituted. Hospital bathrooms, whether they be floor facilities or private facilities, should also be permanently equipped with a desic­ cant. We are aware that all is not as it should be at many hospitals, with the resultant dire effects on patients. I propose the following as a plan of action to be instituted at all hos­ pitals as prophylactic and protective meas­ ures: I. Eye surgery. Preoperative preparation of eyes with instillation of argyrol prior to moving patient to operating room. II. Operating rooms, (a) Removal of all but essential objects. Operating table, instru­ ment tray, metal stools when needed by sur­

geons and anesthesia equipment should be the only items in operating rooms, (b) Vaseline coating of all walls, woodwork, ceilings, feet of operating table and floor space under­ neath operating table, (c) Properly con­ trolled air-conditioning, (d) Properly con­ trolled desiccant where no air-conditioning is available, (e) Floor cleaning by vacuum cleaner. III. Sterilization procedures, (a) Autoclaving of all instruments and implements used in patient care, (b) Use of an iodine preparation for skin disinfection, (c) All solutions used in patient care to be supplied to dispensing quarters in small bottles, bot­ tles and contents sterilized by autoclave, bot­ tles with a narrow mouth and a screw cap (to assure that no one can dip a piece of gauze or cotton into bottle), and to be han­ dled with sterile precautions at all times, (d) Application of vaseline to skin after punc­ ture for withdrawal or injection, around skin area surrounding in-dwelling catheter and around skin area surrounding stationary needle insertion. IV. Patients' quarters, (a) All cleaning by vacuum cleaner only, (b) Desiccant in all bathroom facilities, (c) Removal of all dustcollecting items, (d) Coating with vaseline of walls, ceilings, woodwork and under bed area. V. Hospital personnel, (a) Routine check­ ing of all female personnel involved in pa­ tient care and service for Trichomonas vagi­ nalis and the immediate removal of infected personnel from patient care until cure in es­ tablished. (b) A thorough review for all personnel involved in patient care and serv­ ice, of elementary hygienic measures, that is, washing of hands between patients, after use of toilet, and so forth, and techniques of sterility in handling medication, skin disin­ fection, injections. In conclusion, inasmuch as hospital-ac­ quired infections are on the rise, and we know how the contaminating organisms gain entry, the active institution of obvious

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prophylactic measures is of immediate ur­ gency. (Signed) Rose L. Berman, 200 West 57th Street, New York 19, New York. REFERENCES

1. Domagk, G.: Eine neue Klasse von Desinfek­ tionsmitteln. Deutsche Med. Wochschr., 61:829832 (May 24) 1935. 2. Castellani, A.: The viability of some patho­ genic fungi in sterile distilled water. J. Trop. Med. Hyg., 42:225-229 (Aug.) 1939. 3. Lowbury, E. J. L.: Contamination of cetrimide and other fluids with Pseudomonas pyocyanea. Brit. J. Indus. Med., 8:22-25 (Jan.) 1951. 4. Keown, K., Gilman, R. and Bailey, C : Open heart surgery. Anesthesia and surgical experiences. J.A.M.A., 165:781-787 (Oct. 19) 1957. 5. Plotkin, S. A. and Austrian, R.: Bacteremia caused by Pseudomonas sp. following the use of materials stored in solutions of a cationic surfaceactive agent. Am. J. M. Se, 235:621-627 (June) 1958. 6. Malizia, W. F., Gangarosa, E. J. and Goley, A. F. : Benzalkonium chloride as a source of infection. New Eng. J. Med., 263:800-802 (Oct. 20) 1960. 7. Luria, D. B.: Experiences with and diagnosis of diseases due to opportunistic fungi. Ann. N. Y. Ac. Sei., 98:617-627 (Aug.) 1962. 8. Miller, L. P. and McCallon, S. E. A.: Toxic action of metal ions to fungus spores. Agric. & FoodChem., 5:116-122 (Feb.) 1957. 9. Miller, L. P. and McCallon, S. E. A.: Use of radioisotopes in tracing fungicidal action. Proc. Intern. Conf. Peaceful Uses Atomic Energy., 12: 170-176,1956. 10. Allen, Henry F.: Personal communication.

BOOK REVIEWS TUMORS OF T H E E Y E . By Algernon B.

Reese, M.D., D.Sc (Hon.), M.D. (Hon.), LL.D. (Hon.). New York, Hoeber Medi­ cal Division, Harper and Row, edition 2, 1963. 577 pages, 734 illustrations, 110 in full color, bibliography and index. Price: $30.00. Twelve years (has it really been that long ?) later, 200 more illustrations, 20 more pages, one pound heavier and 10 dollars more in price than its predecessor, the second edition of one of the world's choicest books in ophthalmic literature makes its thunderous appearance. It is an indispen­

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sable item for the library of every ophthal­ mologist, anywhere. For that matter, few general pathologists can do very well in their line without it. At first glance the text and illustrations are familiar, but even a cursory study re­ veals that the text has largely been rewritten, incorporating knowledge that has accumu­ lated in these 12 years. Many of the illustra­ tions are new, all are superb. Adding to his enormous personal experi­ ence and great authority in the field of ocular tumors, Dr. Reese has enriched his book by including important contributions from many others. Thus, the second edition is a better, bigger and broader book than is the first, impossible as this would seem. The printing of the text, and particularly of the illustrations, is a work of art. The author and publishers have every right to be proud of this production and it is a joy to us lesser mortals to welcome this distinguished scientific work in its new edition. Derrick Vail. TREATMENT OF L I D AND EPIBULBAR

MORS.

By

Merrill

J.

Reeh,

TU­

M.D.,

F.A.C.S., Springfield, 111., Charles C Thomas, 1963. 327 pages, 471 figures, index. Price: $15.50. This is an excellent monograph describing a field in which the author has had a special interest and a wide experience for many years. The numerous illustrations are well selected, pertinent, and indicate both the clinical and histologie appearance of common and uncommon benign and malignant new growths of the lid, conjunctiva and cornea. The introductory chapter, written by Lester T. Jones, M.D., describes the anat­ omy and physiology of the lids and lacrimal tissues. This discussion emphasizes his re­ cent morphologic studies rather than surgical anatomy as such. The physiology of lacrimal drainage is discussed in detail, although this topic is but minimally presented in the chap­ ter on treatment.