Environment of care: Is it time to reassess microbial contamination of the operating room air as a risk factor for surgical site infection in total joint arthroplasty?

Moving toward point-of-care surgery in Ukraine: testing an ultra-portable operating room in an active war zone

PURPOSE

In conflict zones, providers may have to decide between delaying time-sensitive surgeries or performing operative interventions in the field, potentially subjecting patients to significant infection risks. We conducted a single-arm crossover study to assess the feasibility of using an ultraportable operating room (U-OR) for surgical procedures on a porcine cadaver abdominal traumatic injury model in an active war zone.

METHODS

We enrolled participants from an ASSET-type course designed to train Ukrainian surgeons before deployment to active conflict zones. They performed three standardized consecutive abdominal surgical procedures (liver, kidney, and small bowel injury repair) with and without the U-OR. Primary outcomes included surgical procedure completion rate, procedure time, and airborne particle count at the start of surgery. Secondary survey-based outcomes assessed surgery task load index (SURG-TLX) and perceived operative factors.

RESULTS

Fourteen surgeons performed 76 surgical procedures (38 with the U-OR, 38 without the U-OR). The completion rate for each surgical procedure was 100% in both groups. While the procedure time for the liver injury repair did not differ significantly between the two groups, the use of the U-OR was associated with a longer time for kidney (155 vs. 56 s, p = 0.002), and small bowel (220 vs. 103 s, p = 0.004) injury repair. The average airborne particle count within the U-OR was substantially lower compared to outside the U-OR (6,753,852 vs. 232,282 n/m3, p < 0.001). There was no statistically significant difference in SURG-TLX for procedures performed with and without the U-OR.

CONCLUSION

The use of the U-OR did not affect the procedure completion rate or SURG-TLX. However, there was a marked difference in airborne particle counts between inside and outside the U-OR during surgery. These preliminary findings indicate the potential feasibility of using a U-OR to perform abdominal damage-control surgical procedures in austere settings.

Operating Room Air May Harbor Pathogens: The Role of an Ultraviolet Air Filtration Unit

BACKGROUND

One important factor for the prevention of surgical site infections is ultraclean air in the operating room (OR). Still, the direct sterilization potential of most technologies, especially in a dynamic clinical setting, is not well understood. We aimed to determine and compare the microbial presence from the inlet and outlet flow of a filtration unit with crystalline ultraviolet-C (C-UVC) light.

METHODS

A prospective study was conducted at a single institution, where primary total joint arthroplasty and spine surgeries were performed. The OR was fitted with a positive ventilation system. In addition, a filtration unit with a C-UVC sterilizing light was placed in the OR. The inlet and outlet air flows were swabbed simultaneously and compared. Swabs were processed for culture and next-generation sequencing.

RESULTS

The mean length of the surgical procedures sampled was 68 ± 13 minutes. Overall, 19 out of 200 (9.5%) swabs isolated microorganisms. Inlet air swabs were positive at a higher rate (16 versus 3%; P < .01) compared to the outlet air swabs. A wide variety of Gram-positive, Gram-negative, and anaerobic bacteria were isolated, but fungi were only recovered from inlet air swabs. The detection of microorganisms was also higher when more door openings were performed (32.5 ± 7.1 versus 27.9 ± 5.6; P < .01).

CONCLUSIONS

Air swabs mainly isolated microorganisms from the inlet flow to the filtration unit with a C-UVC light. The sterilizing unit counteracted factors affecting the air quality in the OR, namely door openings, surgical personnel, and tissue combustion.

Risk Influence of Some Environmental and Behavioral Factors on Air Contamination in the Operating Room: An Experimental Study

Air contamination in operating rooms (ORs) depends on the conditions of the room and on activities therein performed. Methodologies of air quality assessment in ORs are often inadequately described in the scientific literature, and the time required for a change in status in air quality is never taken into account. The purpose of this study was to determine the influence of the state and the presence of human operators on air quality by implementing a precise measurement protocol that also took into account the time required for changes in the room to affect air pollution. As the main indicators of air pollution, bacterial load and concentration of airborne dust were measured. The results showed that: the use of surgical masks by operators in the OR did not significantly affect bacterial load within a distance of 2 m; keeping OR doors open did not induce a significant increase in bacterial load and of 5 μm particles while 10 μm particles concentration was positively affected; and air pollution measured with open doors was not significantly different from that due to the presence of two staff members, whether or not they were wearing masks. The results clarified the role of some factors on air pollution in ORs.

Distribution and the trend of airborne particles and bio-aerosol concentration in pediatric intensive care units with different ventilation setting at two hospitals in Riyadh, Saudi Arabia

OBJECTIVE

To examine the distribution and the trend of airborne particles and bio-aerosol concentration in pediatric intensive care units (PICUs) in two tertiary care hospitals with different ventilation setting.

METHODS

Hospitals A but not B is provided with a central HEPA filter. PICUs in both hospitals were categorized into protective environment (PE) with room HEPA filter, semi-protective environment (SPE) with portable air-purifier, and non-protective environment (NPE) with neither system. Fine particles (≤ 2.5 µm) and coarse particles (≤ 10.0 µm) were obtained using optical particle counter (Lighthouse Handheld 3016) and total bacterial (TBC) and fungal (TFC) counts were obtained using Andersen air sampler.

RESULTS

Hospital B had significantly higher levels of fine and coarse particles (in all room), TBC (in PE), but not TFC compared with matched rooms in hospital A. In hospital B, the levels of fine particles, coarse particles, and TBC were lowest in SPE (p < 0.001, p = 0.004, and p = 0.006, respectively) while TFC was lowest in NPE (p = 0.014). Airborne particles, TBC, and TFC had variable trends with some of the indoor peaks follow outdoor peaks. Gram-positive bacteria (69 %) were the predominant bacteria in hospital A while bacterial flora (70 %) were the predominant bacteria in hospital B (p < 0.001 for each).

CONCLUSIONS

The levels of airborne contaminants and microbial counts in PICUs are significantly affected by the ventilation system and to less extent by outdoor levels. The results indicated that advanced filtration system and central HEPA filters play a significant role in the reduction of indoor fine particulates and TBC.

The Role of the Gut Microbiome on the Development of Surgical Site Infections

Despite advances in antisepsis techniques, surgical site infection remains the most common and most costly reason for hospital readmission after surgery. Wound infections are conventionally thought to be directly caused by wound contamination. However, despite strict adherence to surgical site infection prevention techniques and bundles, these infections continue to occur at high rates. The contaminant theory of surgical site infection fails to predict and explain most postoperative infections and still remains unproven. In this article we provide evidence that the process of surgical site infection development is far more complex than what can be explained by simple bacterial contamination and hosts' ability to clear the contaminating pathogen. We show a link between the intestinal microbiome and distant surgical site infections, even in the absence of intestinal barrier breach. We discuss the Trojan-horse mechanisms by which surgical wounds may become seeded by pathogens from within one's own body and the contingencies that need to be met for an infection to develop.

Increased CO2 levels in the operating room correlate with the number of healthcare workers present: an imperative for intentional crowd control

The air in an operating room becomes more contaminated as the occupancy of the room increases. Individuals residing in a room can potentially emit infectious agents. In order to inhibit and better understand the epidemiology of surgical site infections, it is important to develop procedures to track room occupancy level and respiration. Exhaled CO₂ provides a respiratory byproduct that can be tracked with IR light and is associated with human occupancy. Exhaled CO₂ can also be used as an indirect measure of the potential release and level of infectious airborne agents. We show that non-dispersive infrared CO₂ sensors can be used to detect CO₂ in operating room air flow conditions of 20 air changes per hour and a positive pressure of 0.03 in. H₂O. The CO₂ concentration increased consecutively for occupation levels of one to four individuals, from approximately 65 ppm above the background level when one individual occupied the operating room for twenty minutes to approximately 300 ppm above the background when four individuals were present for twenty minutes. The amount of CO₂ detected increases as the number of occupants increase, the activity level increases, the residency time increases and when the ventilation level is reduced.

Comparison of Microbial Sampling Sites and Donor-Related Factors on Corneal Graft Contamination

Grafts used for corneal donation should be sterile to avoid transplantation failure and secondary infection. However, there are no clear and globally accepted specifications from eye banks on microbial sampling sites. The objective of this study was to analyze microbial contamination of corneal grafts collected from different sampling sites. We found that the contamination rates and strain compositions significantly differed at different sampling sites. To clarify the effect of the microbial sampling site on corneal graft contamination, microbial sampling was conducted using 30 corneal grafts at the extraocular and intraocular sides of the graft in 2020 from the National Eye Bank of Taiwan. Microbial contamination significantly differed (p < 0.05) between the different sampling sites on the graft according to McNemar’s test. Although the two sampling sites showed the same specificity (33.33%), the sensitivity of sampling on the extraocular side (82.35%) was higher than that on the intraocular side (17.65%) of the graft. Donor-associated factors, including the cause of death, operating place, and cold compression, were analyzed using chi-square statistics, which revealed no significant differences in microbial contamination. Thus, our data provide evidence for the microbial sampling site of donated grafts and clear specifications for maintaining the quality of corneal grafts.

Pre-Admission Use of Chlorhexidine-Impregnated Gauze for Skin Preparation Reduces the Incidence of Peri-Prosthetic Joint Infection after Primary Total Knee Arthroplasty: A Prospective Cohort with Retrospective Controls

Background: Peri-prosthetic joint infection (PJI) has long been a devastating complication after total knee arthroplasty (TKA), with native skin flora always identified as the causative agents. The aim of this study was to investigate the efficacy of pre-admission use of chlorhexidine-impregnated gauze for pre-operative skin preparation on infection rates after primary TKA surgeries. Patients and Methods: Patients undergoing TKAs performed from January 2017 until January 2021 were prospectively recruited. The experimental group included patients who used chlorhexidine-impregnated gauze the evening before surgery for skin preparation. These patients were compared with a retrospective cohort of TKAs performed during the previous four years without this step as control group. During a one-year follow-up, complications including PJI and superficial infections were collected as the primary outcomes for analysis. Results: A total of 1,218 TKAs in the experimental group and 1,033 TKAs in the control group were included in the study. A total of seven (0.6%) cases of PJI were identified in the experimental group, whereas 16 (1.5%) cases were diagnosed in the control group; a significant difference was detected (χ² = 5.245; p = 0.022). Eighteen (1.5%) cases of superficial infection were identified in the experimental group, and 28 (2.7%) cases were observed in the control group; a significant difference was found between groups (χ² = 4.243; p = 0.039). No significant differences were found on other wound-related complications. Conclusions: Pre-admission use of chlorhexidine-impregnated gauze for skin preparation was found to be an effective practice in reducing the incidence of PJI after TKA procedures, which has the potential of being utilized for patients undergoing TKA surgeries.

Effects of intra-articular D-amino acids combined with systemic vancomycin on an experimental Staphylococcus aureus-induced periprosthetic joint infection

BACKGROUND

The D-isoforms of amino acids (D-AAs) exhibit anti-biofilm potential against a diverse range of bacterial species in vitro, while its role in vivo remains unclear. The aim of this study was to investigate the effects of a combination of D-AAs and vancomycin on a PJI rat model.

METHODS

Eight-week-old male SD rats were randomized to the control group, sham group, vancomycin group, D-AAs-vancomycin group. After treatment for 6 weeks, we analysed the levels of inflammatory factors in serum, behavioural change, imaging manifestations. The anti-biofilm ability of D-AAs was detected by crystal violet staining and scanning electron microscope observation, and its ability to assist antibiotics in killing bacteria was assessed by culture of bacteria. Additionally, micro-CT and histological analysis were used to evaluate the impact of D-AAs combined with vancomycin on the bone remodelling around the prosthesis.

RESULTS

The group treated with a D-AAs-vancomycin combination sustained normal weight gain and exhibited reduced the serum levels of α2M, IL-1β, IL-6, IL-10, TNF-α and PGE2. Moreover, treated with D-AAs in combination with vancomycin improved the weight-bearing activity performance, increased the sizes and widths of distal femurs, and improved Rissing scale scoring. In particular, treatment using D-AAs enhanced the ability of vancomycin to eradicate Staphylococcus aureus, as demonstrated by the dispersion of existing biofilms and the inhibition of biofilm formation that occurred in a concentration-dependent manner. This treatment combination also resulted in a reduction in bacterial burden with in the soft tissues, bones, and implants. Furthermore, D-AAs-vancomycin combination treatment attenuated abnormal bone remodelling around the implant, as evidenced by an observed increase in BMD, BV/TV, and Tb.Th and the presence of reduced Trap⁺ osteoclasts and elevated osterix⁺ osteo-progenitors.

CONCLUSIONS

Combining D-AAs with vancomycin provides an effective therapeutic strategy for the treatment of PJI by promoting biofilm dispersion to enhance antimicrobial activity.

Reduction in Operating Room Airborne Particle Burden and Time-Dependent Contamination of Sterile Instrument Trays With the Use of a Novel Air Filtration System

Introduction

Postoperative infections represent a substantial burden to patients and healthcare systems. To improve patient care and reduce healthcare expenditures, interventions to reduce surgical infections must be employed. The crystalline C-band ultraviolet (UV-C) air filtration technology (Aerobiotix Inc., Miamisburg, OH, USA) has been designed to reduce airborne bioburden through high-quality filtration and germicidal irradiation. The purpose of this study was to assess the ability of a novel UV-C air filtration device to reduce airborne particle counts and contamination of surgical instrument trays in an operating room (OR) setting.

Materials and methods

Thirty sterile instrument trays were opened in a positive-air-flow OR. The trays were randomly assigned to one of two groups (UV-C or control, n=15 per group). In the UV-C group, the UV-C filtration device was used and in the control, it was not. All trays were opened with the use of a sterile technique and left exposed in the OR for four hours. Air was sampled by a particle counter to measure the numbers of 5µm and 10µm particles. Culture specimens were obtained from the trays to assess for bacterial contamination. Outcome data were collected at 30-minute intervals for the duration of the four-hour study period.

Results

Use of the UV-C device resulted in statistically significant reductions in the numbers of 5µm (average of 64.9% reduction when compared with the control, p<0.001) and 10µm (average of 65.7% reduction when compared with the control, p<0.001)-sized particles detectable in the OR. There was no significant difference in the overall rates of contamination (33.3% in the control group vs. 26.7% in the UV-C group, p=1.0) or the time to contamination (mean survival of 114 minutes in the control group vs. 105 minutes in the UV-C group, p=0.72) of surgical instrument trays with the use of the UV-C device.

Conclusions

The results demonstrate that the UV-C filtration device can successfully reduce airborne bioburden in standard ORs, suggesting that it may have the potential to reduce the risk for wound and hardware infections. Further clinical trials are necessary to better determine the effect of this air filtration system on postoperative infection rates.

The safety of a novel single-drape cover for sterile back tables in the operating room compared to the standard two-drape method: an experimental study

BACKGROUND

Covering the prepared sterile back tables (PSBTs) during periods of nonuse and during active surgeries may decrease contamination of sterile surgical instruments that have direct contact to surgical wound. The Association of periOperative Registered Nurses (AORN) declared that an easy method for covering and removing the drape will ultimately be most effective (e.g. standard two-drape method). Hence, this study was designed to test the hypothesis that using a novel single-drape cover had more efficiency and safety in decreasing airborne bacteria-carrying particles (ABCPs) settling on the PSBTs during static and dynamic periods than the standard two-drape method.

METHODS

This experimental study was conducted with using 918 agar plates to detect contamination of the PSBTs with ABCPs on two conditions (static and dynamic) at an academic medical center in Kashan, Iran, from September 25, 2021, to January 20, 2022. The contamination of PSBTs was evaluated by 6 agar settle plates (n = 918 in total) on each PSBT in static and dynamic operating room (OR) conditions. At each time-point, this set-up was repeated on two occasions else during data collection, establishing 81 PSBTs in total. Tested groups included the PSBTs covered with the standard two-drape method, the novel single-drape cover, or no cover. The plates were collected after 15, 30, 45, 60, 120, 180, 240 min and 24 h. The primary outcome measured was comparison of mean bioburden of ABCPs settling on covered PSBTs on two conditions by using agar settle plates. The secondary outcomes measured were to determine the role of covering in decreasing contamination of PSBTs and the estimation of time-dependent surgical instrument contamination in the uncovered PSBTs on two conditions by using agar settle plates.

RESULTS

Covering the PSBTs during static and dynamic OR conditions lead to a significantly decreased bioburden of ABCPs on them (P < 0.05). No differences were seen between the standard two-drape method and the novel single-drape cover (P > 0.05).

CONCLUSIONS

We found that there is no preference for using the novel single-drape cover than the standard two-drape method. Our results showed a significant decrease in bioburden of ABCPs on the PSBTs when those were covered during static and dynamic OR conditions, indicating the efficiency for covering the PSBTs during periods of nonuse and during active surgery.

An in vitro model of microbial contamination in the operating room

Infection associated with tissue-contacting biomedical devices is a compelling clinical problem initiated by the microbial colonization of the device surface. Among the possible sources of contaminating bacteria is the operating room (OR) itself, where viable bacteria in the atmosphere can sediment onto a device surface intraoperatively. We have developed an aerosolizing system that can reproducibly spray small quantities of aerosolized bacteria onto a surface to mimic OR contamination. This paper describes the design of the system and characterizes key aspects associated with its operation. The area density of sprayed bacteria is on the order of 10² /cm² . Using titanium (Ti) alloy coupons as test substrates contaminated by staphylococci, we quantify the fraction of bacteria that are well adhered to the substrate, those that can be removed by sonication, and those that are not recovered after spraying. Despite the relatively low levels of surface contamination, we furthermore show that such a model is able to demonstrate a statistically significant reduction in colonization of Ti coupons modified by antimicrobial quaternary ammonium compounds relative to unmodified controls.

Using a stacker crane for sterile storage in the operating theatre: initial environmental microbiological qualification

BACKGROUND

Adequate storage of sterile surgical devices must prevent contamination and the introduction of microbial contaminants inside the operating rooms. For functional and economic purposes, stacker cranes (STCs) could replace the traditional sterile storage room (TSSR). STCs are large multistage computer-assisted systems used to automatically store and retrieve loads from defined locations. However, their microbiological performance has not been evaluated AIM: As part of the opening of a new building that included an operating theatre, we qualified a new STC and compared its microbiological control performance to that of the previous TSSR.

METHODS

From December 2020 to March 2021, 590 environmental specimens (air, n=56; surfaces, n=534) were collected and interpreted according to the NF S90-351 French Association for Standardization standards.

FINDINGS

Thorough surface disinfection was not sufficient for controlling microbial contamination in the STC. Thus, the initial qualification testing was conducted following an aggressive aerial chemical decontamination of the STC. Despite the lack of a HEPA filtered air system, the overall non-conformity rates were lower in the STC than in TSSR (8.3% vs. 21.4%, p=0.33 for air, respectively, and 9.7% vs. 41.7% p<0.001 for surfaces). The air-controlled barrier in front of the loading zone appeared to be sufficient to prevent bacterial contamination. The presence of fungi must be carefully monitored.

CONCLUSION

This is the first study supporting the contribution of STCs in saving space and improving the maintenance of sterile surgical device storage and availability under acceptable environmental conditions. Further studies are needed to assess the long-term microbiological contamination inside the STC.

Analysis of the Application Effect of PDCA Cycle Management Combined With Risk Factor Management Nursing for Reducing Infection Rate in Operating Room

Purpose

To explore the application effect of plan-do-check-action (PDCA) cycle management combined with risk factor management nursing in an operating room.

Methods

A total of 150 surgical patients in our hospital from November 2020 to February 2021 were selected as the conventional group, and 150 surgical patients in our hospital from March 2021 to June 2021 were selected as the research group. The conventional group implemented routine infection management, and the research group implemented PDCA cycle management combined with risk factor management. Detection of pathogenic bacteria, incidence of incision infection, infection control, occurrence of irregular events, and nursing quality in the operating room were observed in the two groups.

Results

The detection rate of Gram-negative bacillus and Gram-positive cocci, infection rate of incision, and total incidence of irregular events in the research group were lower than those in the conventional group (P < 0.05). The qualified rate of disinfection of object surface, hands of medical staff and air, and nursing quality scores in the research group were higher than those in the conventional group (P < 0.05).

Conclusion

Plan-do-check-action (PDCA) cycle management combined with risk factor management nursing can reduce the detection rate of pathogenic bacteria and infection rate of incision in the operating room, reduce the incidence of irregular events, improve the qualified rate of disinfection, and greatly improve the quality of nursing, which can be considered to be widely used in clinical practice.

Systematic study on the relationship between particulate matter and microbial counts in hospital operating rooms

In this study, a systematic procedure for establishing the relationship between particulate matter (PM) and microbial counts in four operating rooms (ORs) was developed. The ORs are located in a private hospital on the western coast of Peninsular Malaysia. The objective of developing the systematic procedure is to ensure that the correlation between the PMs and microbial counts are valid. Each of the procedures is conducted based on the ISO, IEST, and NEBB standards. The procedures involved verifying the operating parameters are air change rate, room differential pressure, relative humidity, and air temperature. Upon verifying that the OR parameters are in the recommended operating range, the measurements of the PMs and sampling of the microbes were conducted. The TSI 9510-02 particle counter was used to measure three different sizes of PMs: PM 0.5, PM 5, and PM 10. The MAS-100ECO air sampler was used to quantify the microbial counts. The present study confirms that PM 0.5 does not have an apparent positive correlation with the microbial count. However, the evident correlation of 7% and 15% were identified for both PM 5 and PM 10, respectively. Therefore, it is suggested that frequent monitoring of both PM 5 and PM 10 should be practised in an OR before each surgical procedure. This correlation approach could provide an instantaneous estimation of the microbial counts present in the OR.

Time-dependent bacterial air contamination of sterile fields in a controlled operating room environment: an experimental intervention study

BACKGROUND

Surgical site infections are a global patient safety concern. Due to lack of evidence on contamination, pre-set surgical goods are sometimes disposed of or re-sterilized, thus increasing costs, resource use, and environmental effects.

AIM

To investigate time-dependent bacterial air contamination of covered and uncovered sterile goods in the operating room.

METHODS

Blood agar plates (N = 1584) were used to detect bacterial air contamination of sterile fields on 48 occasions. Each time, three aerobe and three anaerobe plates were used as baseline to model the preparation time, and 60 (30 aerobe, 30 anaerobe) were used to model the time pending before operation; half of these were covered with sterile drapes and half remained uncovered. Plates were collected after 4, 8, 12, 16, and 24 h.

FINDINGS

Mean time before contamination was 2.8 h (95% confidence interval: 2.1-3.4) in the uncovered group and 3.8 h (3.2-4.4) in the covered group (P = 0.005). The uncovered group had 98 colony-forming units (cfu) versus 20 in the covered group (P = 0.0001). Sixteen different micro-organisms were isolated, the most common being Cutibacterium acnes followed by Micrococcus luteus. Of 32 Staphylococcus cfu, 14 were antibiotic resistant, including one multidrug-resistant Staphylococcus epidermidis.

CONCLUSION

Protecting sterile fields from bacterial air contamination with sterile covers enhances the durability of sterile goods up to 24 h. Prolonged durability of sterile goods might benefit patient safety, since surgical sterile material could be prepared in advance for acute surgery, thereby enhancing quality of care and reducing both climate impact and costs.

Intraoperative Bacterial Contamination and Activity of Different Antimicrobial Prophylaxis Regimens in Primary Knee and Hip Replacement

Surgical antimicrobial prophylaxis (SAP) is important for the prevention of prosthetic joint infections (PJIs) and must be effective against the microorganisms most likely to contaminate the surgical site. Our aim was to compare different SAP regimens (cefazolin, cefuroxime, or vancomycin, alone or combined with gentamicin) in patients undergoing total knee (TKA) and hip (THA) arthroplasty. In this preclinical exploratory analysis, we analyzed the results of intraoperative sample cultures, the ratio of plasma antibiotic levels to the minimum inhibitory concentrations (MICs) for bacteria isolated at the surgical wound and ATCC strains, and serum bactericidal titers (SBT) against the same microorganisms. A total of 132 surgical procedures (68 TKA, 64 THA) in 128 patients were included. Cultures were positive in 57 (43.2%) procedures (mostly for coagulase-negative staphylococci and Cutibacterium spp.); the rate was lower in the group of patients receiving combination SAP (adjusted OR 0.475, CI95% 0.229-0.987). The SAP regimens evaluated achieved plasma levels above the MICs in almost all of intraoperative isolates (93/94, 98.9%) and showed bactericidal activity against all of them (SBT range 1:8-1:1024), although SBTs were higher in patients receiving cefazolin and gentamicin-containing regimens. The potential clinical relevance of these findings in the prevention of PJIs remains to be determined.

Surgical site infections in a tertiary hospital over 10 years. The effect of hospital accreditation strategy implementation

Objectives:

To analyze the rate of surgical site infections (SSIs), the type, and the frequency of the commonly-associated microorganisms.

Methods:

A retrospective study was conducted in King Fahd Hospital of the University, Al Khobar, Saudi Arabia between December 2018 and June 2019 comprising data from August 2008 to August 2018 from patients with culture-confirmed surgical site infection at a tertiary hospital.

Results:

Out of 2716 wound infection cases during the study period, a total of 289 patients were diagnosed with SSI. The rate of SSI in the tertiary hospital decreased from 20 per 1000 operations in 2009 to 3.5 per 1000 operations in 2018. A significant decrease in the rate of SSIs was observed in 2014 and 2015 when self-assessment strategies in preparation for the accreditation of the hospital were implemented. A significant shift in the SSI rate from type I and II wounds to type IV wounds was observed coinciding with implementation of accreditation procedures. Escherichia coli was the most common pathogen. Antibiotic susceptibility patterns showed reduced resistance to ceftazidime and tazocin, while Acinetobacter baumannii was resistant to most of the antibiotics over 10 years.

Conclusion:

This study describes, for the first time, the status of SSI over the past 10 years in Saudi Arabia. The study also demonstrated the effect of hospital accreditation on healthcare organization performance regarding infection control and antibiogram pattern.

Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining

A projected increased use of total joint arthroplasties will naturally result in a related increase in the number of prosthetic joint infections (PJIs). Suppression of the local peri-implant immune response counters efforts to eradicate bacteria, allowing the formation of biofilms and compromising preventive measures taken in the operating room. For these reasons, the prevention of PJI should focus concurrently on the following targets: (i) identifying at-risk patients; (ii) reducing “bacterial load” perioperatively; (iii) creating an antibacterial/antibiofilm environment at the site of surgery; and (iv) stimulating the local immune response. Despite considerable recent progress made in experimental and clinical research, a large discrepancy persists between proposed and clinically implemented preventative strategies. The ultimate anti-infective strategy lies in an optimal combination of all preventative approaches into a single “clinical pack”, applied rigorously in all settings involving prosthetic joint implantation. In addition, “anti-infective” implants might be a choice in patients who have an increased risk for PJI. However, further progress in the prevention of PJI is not imaginable without a close commitment to using quality improvement tools in combination with continual data mining, reflecting the efficacy of the preventative strategy in a particular clinical setting.

Particle control reduces fine and ultrafine particles greater than HEPA filtration in live operating rooms and kills biologic warfare surrogate

BACKGROUND

Controlling indoor air quality and the airborne transmission of infectious agents in hospitals is critical. The most hazardous particles and pathogens are not easily eliminated by traditionally passive air cleansing.

METHODS

We studied the effect of a novel particle control technology on airborne particulate matter in 2 live real-world operating room settings and on pathogen survival in a microbiology laboratory.

RESULTS

Particle control technology reduced operating room particle and pathogen loads by 94.4% in a community hospital operating room, and by 95% in an academic medical center operating room. The addition of particle control technology to a collector loaded with a biologic warfare surrogate resulted in a 95% kill rate of an anthrax surrogate (Bacillus subtilis) within 3 hours.

DISCUSSION

Deployment of this emerging technology could significantly reduce indoor air contamination and associated infections in operating rooms, hospital isolation rooms, and intensive care settings, as well as reduce inflammatory responses to airborne particles.

CONCLUSIONS

The particle control technology studied may protect patients from hospital-acquired infections, reduce inflammatory pulmonary disease, and mitigate exposure to biologic weapons.

What every orthopaedic surgeon should know about COVID-19: A review of the current literature

The coronavirus (COVID-19) pandemic has severely affected the medical community and stopped the world in its tracks. This review aims to provide the basic information necessary for us, orthopaedic surgeons to prepare ourselves to face this pandemic together. Herein, we cover the background of COVID-19, presentation, investigations, transmission, infection control and touch upon emerging treatments. It is of paramount importance that we should stay vigilant for our patients, our families and ourselves. Adequate infection control measures are necessary during day-to-day clinical work.

An in-depth survey of the microbial landscape of the walls of a neonatal operating room

Bacteria found in operating rooms (ORs) might be clinically relevant since they could pose a threat to patients. In addition, C-sections operations are performed in ORs that provide the first environment and bacterial exposure to the sterile newborns that are extracted directly from the uterus to the OR air. Considering that at least one third of neonates in the US are born via C-section delivery (and more than 50% of all deliveries in some countries), understanding the distribution of bacterial diversity in ORs is critical to better understanding the contribution of the OR microbiota to C-section- associated inflammatory diseases. Here, we mapped the bacteria contained in an OR after a procedure was performed; we sampled grids of 60x60 cm across walls and wall-adjacent floors and sequenced the V4 region of 16S rRNA gene from 260 samples. The results indicate that bacterial communities changed significantly (ANOSIM, p-value < 0.001) with wall height, with an associated reduction of alpha diversity (t-test, p-value <0.05). OR walls contained high proportions of Proteobacteria, Firmicutes, and Actinobacteria, with Proteobacteria and Bacteroidetes being the highest in floors and lowest in the highest wall sites. Members of Firmicutes, Deinococcus-thermus, and Actinobacteria increased with wall height. Source-track analysis estimate that human skin is the major source contributing to bacterial composition in the OR walls, with an increase of bacteria related to human feces in the lowest walls and airborne bacteria in the highest wall sites. The results show that bacterial exposure in ORs varies spatially, and evidence exposure of C-section born neonates to human bacteria that remain on the floors and walls, possibly accumulated from patients, health, and cleaning staff.

In-Room Ultraviolet Air Filtration Units Reduce Airborne Particles During Total Joint Arthroplasty

Reducing airborne bioburden in total joint arthroplasty (TJA) is of critical importance. The efficacy of crystalline ultraviolet-C (C-UVC) filtration in reducing bioburden in a dynamic operating room (OR) environment has not been evaluated. We assessed whether C-UVC filtration reduced (i) total particle counts (TPC); (ii) viable particle counts (VPC); and (iii) colony-forming units (CFUs). Fifty primary TJA cases were performed in a positive-pressure OR; 25 cases with the C-UVC unit and 25 cases without. The air was sampled by a particle counter and an impact air sampler to measure particle counts and CFUs, respectively. To compare TPC, VPC, and CFU/m³ between groups, independent t tests and multivariate regression, adjusted for number of OR staff and door openings, were performed. The C-UVC group had significantly lower TPC (2.6 × 10⁶ vs. 4.7 × 10⁶ particles, p = 0.001) and VPC (18,605 vs. 27,516 particles, p = 0.001). There were fewer CFUs in the C-UVC group (10.9 CFU/m³ vs. 13.7 CFU/m³ , p = 0.163). Multivariate analysis identified C-UVC filtration as a significant predictor of decreased TPC (β = -0.44, p = 0.002) and VPC (β = -0.47, p = 0.001) after accounting for door openings and number of OR staff. The reduction in CFUs was not significant on multivariate analysis. In this prospective pilot study, a C-UVC air disinfection and recirculation unit led to a significant reduction in both TPC and VPC and a non-significant reduction in CFU. Statement of clinical significance: Further studies are needed to investigate the effects of C-UVC filtration units on surgical-site infection rates. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:431-437, 2020.

Re-examining causes of surgical site infections following elective surgery in the era of asepsis

The currently accepted assumption that most surgical site infections (SSIs) occurring after elective surgery under standard methods of antisepsis are due to an intraoperative contamination event, remains unproven. We examined the available evidence in which microbial cultures of surgical wounds were taken at the conclusion of an operation and determined that such studies provide more evidence to refute that an SSI is due to intraoperative contamination than support it. We propose that alternative mechanisms of SSI development should be considered, such as when a sterile postoperative wound becomes infected by a pathogen originating from a site remote from the operative wound-eg, from the gums or intestinal tract (ie, the Trojan Horse mechanism). We offer a path forward to reduce SSI rates after elective surgery that includes undertaking genomic-based microbial tracking from the built environment (ie, the operating room and hospital bed), to the patient's own microbiome, and then to the surgical site. Finally, we posit that only by generating this dynamic microbial map can the true pathogenesis of SSIs be understood enough to inform novel preventive strategies against infection following elective surgery in the current era of asepsis.

Guideline Implementation: Sterile Technique

Establishing and maintaining a sterile field to help prevent surgical site infections requires specific knowledge and skills and is among the most important responsibilities of the perioperative RN. Perioperative RNs should remain vigilant in monitoring the sterile field, communicate when a break in sterile technique occurs, and collaborate with other surgical team members to correct the break in technique. The AORN "Guideline for sterile technique" provides guidance to perioperative personnel on the principles and processes of sterile technique. This article elaborates on key takeaways from the guideline, including using sterile technique when donning sterile gowns and gloves, delivering sterile items to the sterile field, using drapes to establish a sterile field, and maintaining the sterile field. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.

Influence of a visible-light continuous environmental disinfection system on microbial contamination and surgical site infections in an orthopedic operating room

BACKGROUND

A growing body of research has demonstrated that manual cleaning and disinfection of the operating room (OR) is suboptimal. Residual environmental contamination may pose an infection risk to the surgical wound. This study evaluates the impact of a visible-light continuous environmental disinfection (CED) system on microbial surface contamination and surgical site infections (SSI) in an OR.

METHODS

Samples from 25 surfaces within 2 contiguous ORs sharing an air supply were obtained after manual cleaning on multiple days before and after a visible-light CED system installation in 1 of the ORs. Samples were incubated and enumerated as total colony-forming units. SSIs in both ORs, and a distant OR, were tracked for 1 year prior to and 1 year after the visible-light CED system installation.

RESULTS

There was an 81% (P = .017) and 49% (P = .015) reduction in total colony-forming units after the visible-light CED system installation in the OR in which the system was installed, and in the contiguous OR, respectively. In the OR with the visible-light CED system, SSIs decreased from 1.4% in the year prior to installation to 0.4% following installation (P = .029).

CONCLUSIONS

A visible-light CED system, used in conjunction with manual cleaning, resulted in significant reductions in both microbial surface contamination and SSIs in the OR.

Perioperative Contamination of Orthopaedic Polyethylene Implants, Targeting Devices and Arthroscopes. Experts' Decision Tree and Literature Review

Introduction Sterility errors during orthopaedic procedures can be stressful for the surgeon or scrub nurse and lead to devastating infectious complications and liability issues. This paper aims to review orthopaedic surgeon practices and propose possible attitudes to adopt.

Methods Out of 1023 questionnaires sent, 170 orthopaedic surgeons answered a Volunteer Feedback Template (multiple-choice test) by SurveyMonkey® (San Mateo, CA, USA) anonymously. The survey questioned surgeon's response to a sterility mistake during a standard total knee joint replacement, trauma surgery and arthroscopic procedure. Those “sterility mistake” situations occurred when there was contamination of 1) a sterile polyethylene (PE) 2) a sterile targeting device, and 3) an arthroscope.

Results When the definitive PE is contaminated, and if a new definitive PE will only be available 2 hours later, 52% of surgeons would wait for the new definitive PE (p<0.001). In the same situation, if a new PE will only be available in 4 hours, the results showed a significant difference favoring two other options: ”putting a definitive PE one size smaller or bigger with balance adjustment” (31%); and “leaving the provisional PE in the joint, closing the wound and re-operating the patient in the coming days when the definitive PE arrives” (29%) (p<0.001). When the new PE is only available 24 hours later results were 34% and 31%, respectively (p<0.001). In the case of a surgical procedure for a classic intertrochanteric fracture, if the carbon fiber targeting device is contaminated, most surgeons (50%) chose to put the nail without the targeting device and finish the surgery (p<0.001). When the arthroscope is desterilized, 39% of participants would wait until the arthroscope has been sterilized again (approximately 2 hours), while 24% would use another procedure (p<0.001). Sixty-two percent of surgeons would adapt their strategy. No clear trend could be identified in terms of antibiotic treatment following a sterility error.

Conclusions There are no established guidelines on how to deal with sterility breaches during surgery and on the antibiotic strategy following the prolonged surgical time resulting from the delay for a new implant. The most common course of action chosen by participating surgeons is detailed in our expert decision tree - if another sterile component is not available within 2 hours - : insertion of another PE size, rescheduling the operation, adapting the surgical technique (for trauma procedures), or soaking the arthroscope in disinfectant solution. As instances of contamination cannot be avoided, it is recommended to have a minimum of two copies of sterile PE implants, arthroscopes or targeting devices readily available before surgery begins-.

The Impact of Supplemental Intraoperative Air Decontamination on the Outcome of Total Joint Arthroplasty: A Pilot Analysis

BACKGROUND

During the early era of arthroplasty, the concept of ultraclean operating room (OR) was introduced based on the principle that the number of airborne particles in the OR directly influences incidence of device-related infections. The hypothesis of this pilot study was that use of an innovative UV-C air decontamination technology would lead to a reduction in the incidence of periprosthetic joint infection (PJI) following total joint arthroplasty.

METHODS

A retrospective, observational, surveillance study was conducted with a consecutive series of patients who underwent total joint arthroplasty (n = 496) between January 2016 and August 2017. All perioperative and postoperative care protocols were identical for both groups, only study variable was that in 231 arthroplasty patients (OR B), an innovative supplemental UV-C air decontamination technology was used, whereas in the remaining 265 patients, arthroplasty was performed with standard turbulent HVAC (OR A).

RESULTS

There was no significant difference between patient groups regarding age, body mass index, diabetes diagnosis, smoking status, length of surgery, or revision status. The rate of PJI was documented to be 1.9% in the turbulent air group, and no infections were documented in the cohorts operated under UV-C air decontamination, which was statistically significant (P < .044).

CONCLUSION

While PJI is multifactorial in nature, the present retrospective pilot study suggests that use of an intraoperative supplemental air decontamination significantly reduced the overall risk of PJI. The findings of this study are encouraging and should be examined in a larger-scale, prospective, multicenter study.

Stevioside Prevents Wear Particle-Induced Osteolysis by Inhibiting Osteoclastogenesis and Inflammatory Response via the Suppression of TAK1 Activation

Aseptic loosening and periprosthetic osteolysis are the leading causes of total joint arthroplasty failure, which occurs as a result of chronic inflammatory response and enhanced osteoclast activity. Here we showed that stevioside, a natural compound isolated from Stevia rebaudiana, exhibited preventative effects on titanium particle-induced osteolysis in a mouse calvarial model. Further histological assessment and real-time PCR analysis indicated that stevioside prevented titanium particle-induced osteolysis by inhibiting osteoclast formation and inflammatory cytokine expression in vivo. In vitro, we found that stevioside could suppress RANKL-induced osteoclastogenesis and titanium particle-induced inflammatory response in a dose-dependent manner. Mechanistically, stevioside achieved these effects by disrupting the phosphorylation of TAK1 and subsequent activation of NF-κB/MAPKs signaling pathways. Collectively, our data suggest that stevioside effectively suppresses osteoclastogenesis and inflammatory response both in vitro and in vivo, and it might be a potential therapy for particle-induced osteolysis and other osteolytic diseases.

A Clinical Test to Measure Airborne Microbial Contamination on the Sterile Field During Total Joint Replacement: Method, Reference Values, and Pilot Study

Background

Airborne microbe-carrying particles in the operating-room environment during total joint replacement are a risk factor for periprosthetic joint infection. The present study focuses on a simple environmental test, based on practices used in aseptic cleanrooms, to quantify the deposition of microbe-carrying particles onto the sterile field.

Methods

Settle plates are exposed Petri dishes. A settle plate test system and sampling plan were developed from current practices used in aseptic manufacturing. A pilot study evaluated this system in an orthopaedic operating room during 22 total knee and hip arthroplasties. The microbial deposition total (MDT), expressed in colonies/m², is proposed as an outcome variable to report airborne sterile-field contamination as measured with settle plates. Two reference MDT levels were developed: (1) an upper limit of 450, corresponding with the ultraclean air definition of 10 colonies/m³, and (2) a target level of 100, corresponding with 1 colony/m³. These levels also correspond with widely used limits in aseptic cleanrooms and controlled environments.

Results

High MDT standard deviations were noted. Ninety-one percent (95% confidence interval, 71.0% to 98.7%) of wound zone MDT levels were within the upper limit. Twenty-seven percent (95% confidence interval, 12.9% to 48.4%) of wound zone levels were within the target level.

Conclusions

Settle plates are a feasible technique to test environmental levels of microbe-carrying particles on sterile fields during total joint replacement for scientific and environmental quality studies.

Clinical Relevance

This settle plate operating-room environmental test can be used in future research to validate the presence of actual ultraclean-air conditions during periprosthetic joint infection outcome studies. Surgeons also can use this test to measure intraoperative airborne microbe-carrying-particle sterile-field contamination and compare it with ultraclean-air reference levels for environmental quality-control programs.

Implementation of a Wisconsin Division of Public Health Surgical Site Infection Prevention Champion Initiative

Approximately 900 surgical site infections (SSIs) were reported to the Wisconsin Division of Public Health annually from 2013 to 2015, representing the most prevalent reported health care-associated infection in the state. Personnel at the Wisconsin Division of Public Health launched an SSI prevention initiative in May 2015 using a surgical care champion to provide surgical team peer-to-peer guidance through voluntary, nonregulatory, fee-exempt onsite visits that included presentations regarding the evidence-based surgical care bundle, tours of the OR and central processing areas, and one-on-one discussions with surgeons. The surgical care champion visited 10 facilities from August to December 2015, and at those facilities, SSIs decreased from 83 in 2015 to 47 in 2016 and the overall SSI standardized infection ratio decreased by 45% from 1.61 to 0.88 (P = .002), suggesting a statewide SSI prevention champion model can help lead to improved patient outcomes.