Surgical Instrument Reprocessing in LMICs: A Scoping Review of Existing Methods, Policies, and Barriers

Author(s):
Brittany Powell; Jared Forrester; Joseph Forrester; Christina Fast; Thomas Weiser

Background:

Surgical infections are a major cause of morbidity and mortality in low- and middle-income countries (LMICs). Improperly reprocessed surgical instruments can be a vector for pathogens. Little is known about the current state of surgical instrument decontamination and sterilization (IDS) practices in low-resource settings.

Methods:

We performed a scoping review of English-language articles in PubMed, Web of Science, and Google Scholar databases describing current methods, policies, and barriers to IDS in LMICs. We conducted qualitative analysis of all studies to categorize existing practices and barriers to successful IDS. Barriers were non-exclusively categorized by theme: education/training, resource availability, environment, and lack of policies/procedures. Studies associating surgical infections with IDS practices were separately evaluated to assess this relationship.

Results:

Nine-hundred seventy-two abstracts were identified. Forty studies met criteria for qualitative analysis and three studies associated patient outcomes with IDS. Most studies (n=28, 70%) discussed institution-specific policies/procedures for IDS; half discussed shortcomings in staff training. Sterilization (n=38, 95%), certification in sterilization (n=16, 40%), and instrument cleaning and decontamination (n=16, 40%) were the most common instrument reprocessing practices examined, with poor resource availability, lack of education/training, and lack of policies/procedures cited as common barriers. Of the case series associating IDS with patient outcomes, improperly cleaned and sterilized neurosurgical instruments and contaminated rinse water were linked to Pseudomonas aeruginosa ventriculitis and Mycobacterium chelonae port site infections, respectively.

Conclusions:

Large gaps exist between instrument reprocessing practices in LMICs and recommended policies/procedures. Areas for improvement identified include instrument cleaning and decontamination, certification in sterilization, and other sterilization related aspects of instrument reprocessing. Education and training of staff responsible for reprocessing instruments and realistic, defined policies and procedures are critical, and lend themselves to improvement interventions.