Renewed awareness of infection control during surgery

Media reports of possible exposure to Creutzfeldt-Jakob disease (CJD) continue to occur because some health care facilities are reportedly not following recommended guidelines for the decontamination, sterilization, and quarantine of neurosurgical equipment. Routine sterilization practices have proven ineffective against the CJD organism and exposure may occur when a surgeon operates on a patient using instruments that have been used previously on a different patient with undiagnosed CJD without having undergone CJD-specific sterilization.

CJD is extremely rare—only one in 1 million people worldwide are diagnosed with the disease.* However, recent incidents signal the need for renewed awareness and implementation of preventative measures to address infection control during surgery. It is essential that surgeons and other health care providers, as well as sterile processing staff, take all necessary measures to prevent the transmission of CJD.

To that end, The Joint Commission recently issued an addendum to its 2001 Sentinel Event Alert on the recommended practice of quarantining surgical equipment. The addendum encourages health care institutions to use specific CJD-related, evidence-based sterilization guidelines provided by the Centers for Disease Control and Prevention, the World Health Organization (WHO), and the American National Standards Institute with the Association for the Advancement of Medical Instrumentation.

CJD case study and sentinel event

The 2001 Sentinel Event Alert explains how a Joint Commission-accredited hospital performed a brain biopsy on a patient who did not present with symptoms of CJD. Three weeks later, a pathology report confirmed CJD in the patient. In the meantime, six other patients had undergone brain biopsies using the same instruments. A manual instrument tracking system was in place that helped the hospital identify and inform patients of their possible exposure to CJD.

The hospital reported the event to The Joint Commission and conducted its own root-cause analysis, which yielded three important findings:

  • A CJD or prion disease patient may present without symptoms of CJD.
  • The time interval between biopsy and pathology report should be monitored and reviewed to ensure the shortest time from biopsy to results.
  • Instruments used in brain biopsy procedures should not be reused when a patient’s diagnosis is uncertain at the time of the procedure.

These results caused the hospital to revise its policies and procedures. The hospital now requires follow-up with pathology reports within one week, and it also quarantines instruments used in neurosurgery—including brain biopsies—for patients with an unknown or uncertain diagnosis until a confirmation of diagnosis is determined.

Quarantining surgical equipment

The Joint Commission encourages health care providers to establish policies for the cleaning, disinfection, sterilization, and disposal of instruments used in neurosurgery, as well as with loaner instrumentation practices. In 1999, WHO developed CJD infection control guidelines that stated, “Items for quarantine should be cleaned by the best non-destructive method as per Section 6 and Annex III, sterilized, packed, dated and ‘Hazard’ labeled, and stored in specially marked rigid sealed containers.”

If a CJD diagnosis is negative, the instruments can be routinely sterilized and returned to use. However, if a CJD diagnosis is positive, the instruments should be incinerated or sterilized using stringent sanitization methods for heat-resistant instruments. These methods are described in Annex III of the WHO guidelines and include the use of 1N sodium hydroxide (NaOH).

When surgeons and other health care providers consistently remind their colleagues about infection prevention measures—including the appropriate cleaning, decontamination, and sterilization of surgical instruments—they will help to improve the safety and quality of patient care.

For more information on CJD and infection control during surgery, visit

*The Joint Commission. Sentinel Event Alert. Issue 20. 2001. Available at: Accessed May 2, 2014.
World Health Organization. WHO infection control guidelines for transmissible spongiform encephalopathies. March 23-26, 1999:9. Available at: Accessed May 21, 2014.

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