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Ibáñez-Prada ED, Bustos IG, Gamboa-Silva E, Josa DF, Mendez L, Fuentes YV, Serrano-Mayorga CC, Baron O, Ruiz-Cuartas A, Silva E, Judd LM, Harshegyi T, Africano HF, Urrego-Reyes J, Beltran CC, Medina S, Leal R, Stewardson AJ, Wyres KL, Hawkey J, Reyes LF. Molecular characterization and descriptive analysis of carbapenemase-producing Gram-negative rod infections in Bogota, Colombia. Microbiol Spectr 2024; 12:e0171423. [PMID: 38629835 DOI: 10.1128/spectrum.01714-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 03/13/2024] [Indexed: 06/06/2024] Open
Abstract
In this study, the genetic differences and clinical impact of the carbapenemase-encoding genes among the community and healthcare-acquired infections were assessed. This retrospective, multicenter cohort study was conducted in Colombia and included patients infected with carbapenem-resistant Gram-negative rods between 2017 and 2021. Carbapenem resistance was identified by Vitek, and carbapenemase-encoding genes were identified by whole-genome sequencing (WGS) to classify the alleles and sequence types (STs). Descriptive statistics were used to determine the association of any pathogen or gene with clinical outcomes. A total of 248 patients were included, of which only 0.8% (2/248) had community-acquired infections. Regarding the identified bacteria, the most prevalent pathogens were Pseudomonas aeruginosa and Klebsiella pneumoniae. In the WGS analysis, 228 isolates passed all the quality criteria and were analyzed. The principal carbapenemase-encoding gene was blaKPC, specifically blaKPC-2 [38.6% (88/228)] and blaKPC-3 [36.4% (83/228)]. These were frequently detected in co-concurrence with blaVIM-2 and blaNDM-1 in healthcare-acquired infections. Notably, the only identified allele among community-acquired infections was blaKPC-3 [50.0% (1/2)]. In reference to the STs, 78 were identified, of which Pseudomonas aeruginosa ST111 was mainly related to blaKPC-3. Klebsiella pneumoniae ST512, ST258, ST14, and ST1082 were exclusively associated with blaKPC-3. Finally, no particular carbapenemase-encoding gene was associated with worse clinical outcomes. The most identified genes in carbapenemase-producing Gram-negative rods were blaKPC-2 and blaKPC-3, both related to gene co-occurrence and diverse STs in the healthcare environment. Patients had several systemic complications and poor clinical outcomes that were not associated with a particular gene.IMPORTANCEAntimicrobial resistance is a pandemic and a worldwide public health problem, especially carbapenem resistance in low- and middle-income countries. Limited data regarding the molecular characteristics and clinical outcomes of patients infected with these bacteria are available. Thus, our study described the carbapenemase-encoding genes among community- and healthcare-acquired infections. Notably, the co-occurrence of carbapenemase-encoding genes was frequently identified. We also found 78 distinct sequence types, of which two were novel Pseudomonas aeruginosa, which could represent challenges in treating these infections. Our study shows that in low and middle-income countries, such as Colombia, the burden of carbapenem resistance in Gram-negative rods is a concern for public health, and regardless of the allele, these infections are associated with poor clinical outcomes. Thus, studies assessing local epidemiology, prevention strategies (including trials), and underpinning genetic mechanisms are urgently needed, especially in low and middle-income countries.
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Affiliation(s)
- Elsa D Ibáñez-Prada
- Unisabana Center for Translational Science, School of Medicine, Universidad de la Sabana, Chía, Colombia
- Critical Care Department, Clínica Universidad de La Sabana, Chía, Colombia
| | - Ingrid G Bustos
- Unisabana Center for Translational Science, School of Medicine, Universidad de la Sabana, Chía, Colombia
- Critical Care Department, Clínica Universidad de La Sabana, Chía, Colombia
| | - Enrique Gamboa-Silva
- Unisabana Center for Translational Science, School of Medicine, Universidad de la Sabana, Chía, Colombia
| | - Diego F Josa
- Unisabana Center for Translational Science, School of Medicine, Universidad de la Sabana, Chía, Colombia
- Microbiology Department, Fundación Clínica Shaio, Bogota, Colombia
| | - Lina Mendez
- Critical Care Department, Clínica Universidad de La Sabana, Chía, Colombia
| | - Yuli V Fuentes
- Unisabana Center for Translational Science, School of Medicine, Universidad de la Sabana, Chía, Colombia
| | | | - Oscar Baron
- Unisabana Center for Translational Science, School of Medicine, Universidad de la Sabana, Chía, Colombia
| | - Alejandra Ruiz-Cuartas
- Unisabana Center for Translational Science, School of Medicine, Universidad de la Sabana, Chía, Colombia
| | - Edwin Silva
- Unisabana Center for Translational Science, School of Medicine, Universidad de la Sabana, Chía, Colombia
- Microbiology Department, Fundación Clínica Shaio, Bogota, Colombia
| | - Louise M Judd
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Taylor Harshegyi
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Hector F Africano
- Critical Care Department, Clínica Universidad de La Sabana, Chía, Colombia
| | | | | | - Sebastian Medina
- Global Medical Scientific Affairs, MSD Colombia, Bogota, Colombia
| | - Rafael Leal
- Microbiology Department, Fundación Clínica Shaio, Bogota, Colombia
| | - Andrew J Stewardson
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Kelly L Wyres
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jane Hawkey
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Luis Felipe Reyes
- Unisabana Center for Translational Science, School of Medicine, Universidad de la Sabana, Chía, Colombia
- Critical Care Department, Clínica Universidad de La Sabana, Chía, Colombia
- Pandemic Sciences Institute, University of Oxford, Oxford, United Kingdom
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Dexter F, Walker KM, Brindeiro CT, Loftus CP, Banguid CCL, Loftus RW. A threshold of 100 or more colony-forming units on the anesthesia machine predicts bacterial pathogen detection: a retrospective laboratory-based analysis. Can J Anaesth 2024; 71:600-610. [PMID: 38413516 DOI: 10.1007/s12630-024-02707-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 02/29/2024] Open
Abstract
PURPOSE Preventing the spread of pathogens in the anesthesia work area reduces surgical site infections. Improved cleaning reduces the percentage of anesthesia machine samples with ≥ 100 colony-forming units (CFU) per surface area sampled. Targeting a threshold of < 100 CFU when cleaning anesthesia machines may be associated with a lower prevalence of bacterial pathogens. We hypothesized that anesthesia work area reservoir samples returning < 100 CFU would have a low (< 5%) prevalence of pathogens. METHODS In this retrospective cohort study of bacterial count data from nine hospitals, obtained between 2017 and 2022, anesthesia attending and assistants' hands, patient skin sites (nares, axilla, and groin), and anesthesia machine (adjustable pressure-limiting valve and agent dials) reservoirs were sampled at case start and at case end. The patient intravenous stopcock set was sampled at case end. The isolation of ≥ 1 CFU of Staphylococcus aureus, methicillin-resistant Staphylococcus aureus, Enterococcus, vancomycin-resistant Enterococcus, gram-negative (i.e., Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter spp.) or coagulase-negative Staphylococcus was compared for reservoir samples returning ≥ 100 CFU vs those returning < 100 CFU. RESULTS Bacterial pathogens were isolated from 24% (7,601/31,783) of reservoir samples, 93% (98/105) of operating rooms, and 83% (2,170/2,616) of cases. The ratio of total pathogen isolates to total CFU was < 0.0003%. Anesthesia machine reservoirs returned ≥ 100 CFU for 44% (2,262/5,150) of cases. Twenty-three percent of samples returning ≥ 100 CFU were positive for ≥ 1 bacterial pathogen (521/2,262; 99% lower confidence limit, 22%) vs 3% of samples returning < 100 CFU (96/2,888; 99% upper limit, 4%). CONCLUSIONS Anesthesia machine reservoir samples returning < 100 CFU were associated with negligible pathogen detection. This threshold can be used for assessment of terminal, routine, and between-case cleaning of the anesthesia machine and equipment. Such feedback may be useful because the 44% prevalence of ≥ 100 CFU was comparable to the 46% (25/54) reported earlier from an unrelated hospital.
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Affiliation(s)
- Franklin Dexter
- University of Iowa, Iowa City, IA, USA.
- Division of Management Consulting, Department of Anesthesia, University of Iowa, 200 Hawkins Drive, 6-JCP, Iowa City, IA, 52242, USA.
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Gibbons S, Dexter F, Loftus RW, Brown JR, Wanta BT, Charnin JE. The relative efficacy of multiple syringe tip disinfection techniques against virulent staphylococcus contamination. J Hosp Infect 2024; 145:142-147. [PMID: 38272124 DOI: 10.1016/j.jhin.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/19/2023] [Accepted: 01/11/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND A recent study confirmed significant contamination of syringe tips following routine anaesthesia practice of at least 6 h in duration. AIM We assessed the relative efficacy of clinically relevant syringe tip disinfection techniques following contamination with the hyper transmissible and more pathogenic Staphylococcus aureus sequence type 5 (S. aureus ST5) strain characteristic associated with increased strength of biofilm formation and greater desiccation tolerance. METHODS Syringe tips (N=40) contaminated with S. aureus ST5 were randomized to 70% isopropyl pads with 10 or 60 s of drying time, scrubbing alcohol disinfection caps with 10 or 60 s of dwell time, or to non-scrubbing alcohol disinfection caps with 60 s of dwell time. The primary outcome was residual 24-h colony forming units (cfu) >10. RESULTS Scrubbing disinfection caps were more effective than alcohol pads (25% (12/48) <10 cfu for scrubbing caps (10- or 60-s dwell times) vs 0% (0/48) <10 cfu for alcohol pads (10 or 60 s of drying time), Holm-Sidak adjusted P=0.0016). Scrubbing disinfection caps were more effective than non-scrubbing alcohol disinfection caps (25% (12/48) <10 cfu for scrubbing alcohol caps (10- or 60-s dwell times) vs 2% (1/48) for non-scrubbing alcohol caps (60-s dwell time), adjusted P=0.0087). CONCLUSIONS Scrubbing alcohol caps are more effective than alcohol pads or non-scrubbing disinfecting caps for microbial reduction of syringe tips contaminated with the more pathogenic S. aureus ST5.
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Affiliation(s)
- S Gibbons
- Department of Anesthesia, University of Iowa, Iowa City, IA, USA
| | - F Dexter
- Department of Anesthesia, University of Iowa, Iowa City, IA, USA
| | - R W Loftus
- Department of Anesthesia, University of Iowa, Iowa City, IA, USA; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - J R Brown
- Dartmouth Center for Implementation Science, Departments of Epidemiology Biomedical Data Science, Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - B T Wanta
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - J E Charnin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
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Dexter F, Loftus RW. Estimation of the contribution to intraoperative pathogen transmission from bacterial contamination of patient nose, patient groin and axilla, anesthesia practitioners' hands, anesthesia machine, and intravenous lumen. J Clin Anesth 2024; 92:111303. [PMID: 37875062 DOI: 10.1016/j.jclinane.2023.111303] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/30/2023] [Accepted: 10/18/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Earlier studies showed net cost saving from anesthesia practitioners' use of a bundle of infection prevention products, with feedback on monitored Staphylococcus aureus intraoperative transmission. ESKAPE pathogens also include Enterococcus and gram-negative pathogens: Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter. We evaluated whether bacterial contamination of patient nose, patient groin and axilla, anesthesia practitioners' hands, anesthesia machine, and intravenous lumen all contribute meaningfully to ESKAPE pathogen transmission within anesthesia work areas. METHODS The retrospective cohort study used bacterial count data from nine hospitals, 43 months, and 448 ESKAPE pathogen transmission events within anesthesia areas of 86 operating rooms. Transmission was measured within and between pairs of successive surgical cases performed in the same operating room on the same day. RESULTS There were 203 transmission events with S. aureus, 72 with Enterococcus, and 173 with gram negatives. ESKAPE pathogens in the nose contributed to transmission for 50% (99% confidence limit ≥45%) of case pairs, on the groin or axilla for 54% (≥49%), on the hands for 53% (≥47%), on the anesthesia machine for 21% (≥17%), and in the intravenous lumen for 24% (≥20%). ESKAPE pathogens in the nose started a transmission pathway for 27% (≥22%) of case pairs, on the groin or axilla for 24% (≥19%), on the hands for 38% (≥33%), on the anesthesia machine for 11% (≥7.6%), and in the intravenous lumen for 8.0% (≥5.3%). All P ≤ 0.0022 compared with 5%. CONCLUSIONS To prevent intraoperative ESKAPE pathogen transmission, anesthesia practitioners would need to address all five categories of infection control approaches: nasal antisepsis (e.g., povidone-iodine applied the morning of surgery), skin antisepsis (e.g., chlorhexidine wipes), hand antisepsis with dispensers next to the patient, decontamination of the anesthesia machine before and during anesthetics, and disinfecting caps for needleless connectors, disinfecting port protectors, and disinfecting caps for open female Luer type connectors.
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Affiliation(s)
- Franklin Dexter
- University of Iowa, Iowa City, IA, United States of America.
| | - Randy W Loftus
- University of Iowa, Iowa City, IA, United States of America.
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Fernandez PG, Dexter F, Brown J, Whitney G, Koff MD, Cao S, Loftus RW. Epidemiology of Enterococcus , Staphylococcus aureus , Klebsiella , Acinetobacter , Pseudomonas , and Enterobacter Species Transmission in the Pediatric Anesthesia Work Area Environment With and Without Practitioner Use of a Personalized Body-Worn Alcohol Dispenser. Anesth Analg 2024; 138:152-160. [PMID: 36623234 PMCID: PMC10918764 DOI: 10.1213/ane.0000000000006326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Personalized body-worn alcohol dispensers may serve as an important tool for perioperative infection control, but the impact of these devices on the epidemiology of transmission of high-risk Enterococcus , Staphylococcus aureus , Klebsiella, Acinetobacter , Pseudomonas , and Enterobacter (ESKAPE) pathogens is unknown. We aimed to characterize the epidemiology of ESKAPE transmission in the pediatric anesthesia work area environment with and without a personalized body-worn alcohol dispenser. METHODS This controlled before and after study included 40 pediatric patients enrolled over a 1-year study period. Two groups of operating room cases were compared: (1) operating room cases caring for patients with usual care (December 17, 2019, to August 25, 2020), and (2) operating room cases caring for patients with usual care plus the addition of a personalized, body-worn alcohol hand rub dispenser (September 30, 2020, to December 16, 2020). Operating rooms were randomly selected for observation of ESKAPE transmission in both groups. Device use was tracked via wireless technology and recorded in hourly hand decontamination events. RESULTS Anesthesia providers used the alcohol dispenser 3.3 ± 2.1 times per hour. A total of 57 ESKAPE transmission events (29 treatment and 28 control) were identified. The personalized body-worn alcohol dispenser impacted ESKAPE transmission by increasing the contribution of provider hand contamination at case start (21/29 device versus 10/28 usual care; relative risk, [RR] 2.03; 99.17% confidence interval [CI], 1.025-5.27; P = .0066) and decreasing the contribution of environmental contamination at case end (3/29 device versus 12/28 usual care; RR, 0.24; 99.17% CI, 0.022-0.947; P = .0059). ESKAPE pathogen contamination involved 20% (8/40) of patient intravascular devices. There were 85% (34/40) of preoperative patient skin surfaces contaminated with ≥1 (1.78 ± 0.19 [standard deviation {SD}]) ESKAPE pathogens. CONCLUSIONS A personalized body-worn alcohol dispenser can impact the epidemiology of ESKAPE transmission in the pediatric anesthesia work area environment. Improved preoperative patient decolonization and vascular care are indicated to address ESKAPE pathogens among pediatric anesthesia work area reservoirs.
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Affiliation(s)
- Patrick G Fernandez
- From the Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Colorado, Aurora, Colorado
| | - Franklin Dexter
- Department of Anesthesia, University of Iowa, Iowa City, Iowa
| | - Jeremiah Brown
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Gina Whitney
- From the Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Colorado, Aurora, Colorado
| | - Matthew D Koff
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Scott Cao
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Randy W Loftus
- Department of Anesthesia, University of Iowa, Iowa City, Iowa
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Loftus RW, Brindeiro CT, Loftus CP, Brown JR, Charnin JE, Dexter F. Characterizing the molecular epidemiology of anaesthesia work area transmission of Staphylococcus aureus sequence type 5. J Hosp Infect 2024; 143:186-194. [PMID: 37451409 DOI: 10.1016/j.jhin.2023.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/23/2023] [Accepted: 07/02/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Staphylococcus aureus sequence type 5 (ST5) is an emerging global threat. AIM To characterize the epidemiology of ST5 transmission in the anaesthesia work area. METHODS The retrospective cohort study analysed transmitted, prophylactic antibiotic-resistant Staphylococcus aureus isolates involving anaesthesia work area reservoirs. Using whole-genome analysis, the epidemiology of ST5 transmission was characterized by reservoir(s) of origin, transmission location(s), portal of entry, and mode(s) of transmission. All patients were followed for at least 30 days for surgical site infection (SSI) development. FINDINGS Forty-one percent (18/44; 95% confidence interval: 28-56%) of isolates were ST5. Provider hands were the reservoir of origin for 28% (5/18) of transmitted ST5 vs 4% (1/26) for other STs. Provider hands were the transmission location for 28% (5/18) of ST5 vs 7% (2/26) of other STs. Stopcock contamination occurred for 8% (1/13) of ST5 isolates vs 12% (3/25) of other STs. Sixty-three percent of transmission events occurring between cases on separate operative dates involved ST5. ST5 was more likely to harbour resistance traits (ST5 median (interquartile range) 3 (2-3) vs 2 (1-2) other STs; P < 0.001) and had greater resistance to cefazolin, piperacillin-tazobactam, and/or ciprofloxacin (ST5: 3 (2-3) vs 2 (1-3) other STs; P = 0.02). ST5 was associated with three of six SSIs. CONCLUSION ST5 is prevalent among transmitted, prophylactic antibiotic-resistant isolates in the anaesthesia work area. Transmission involves provider hands and one patient to another on future date(s). ST5 is associated with a greater number of resistance traits and reduced in-vitro susceptibility vs other intraoperative meticillin-resistant S. aureus.
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Affiliation(s)
- R W Loftus
- Department of Anaesthesia, University of Iowa, Iowa City, IA, USA.
| | - C T Brindeiro
- RDB Bioinformatics, University of Iowa, Medical Laboratories Building, Iowa City, IA, USA
| | - C P Loftus
- RDB Bioinformatics, University of Iowa, Medical Laboratories Building, Iowa City, IA, USA
| | - J R Brown
- The Dartmouth Institute, Dartmouth Geisel School of Medicine, NH, USA
| | | | - F Dexter
- Department of Anaesthesia, University of Iowa, Iowa City, IA, USA
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Epstein RH, Dexter F, Loftus RW. Most hospital patients at risk for bacterial infection undergo an anesthetic: implications for infection control practices related to the anesthesia workspace. Can J Anaesth 2023; 70:1330-1339. [PMID: 37308738 DOI: 10.1007/s12630-023-02515-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 12/03/2022] [Accepted: 12/21/2022] [Indexed: 06/14/2023] Open
Abstract
PURPOSE Even with nearly 100% compliance with prophylactic antibiotic protocols, many surgical patients (> 5%) develop surgical site infections, some caused by pathogens transmitted from the anesthesia workspace (e.g., anesthesia machine), including multidrug-resistant Staphylococcus aureus. Reducing contamination of the anesthesia workspace substantively reduces the risk of surgical site infections. We estimated the percentage of hospital patients at risk for health care-associated infections who may benefit from the application of basic preventive measures under the control of anesthesia practitioners (e.g., their hand hygiene). METHODS We conducted a retrospective cohort study which included every patient admitted to the University of Miami Health System from April 2021 through March 2022 for hospitalization, surgery, emergency department visits, or outpatient visits. Lists were created for the start date and times of every parenteral antibiotic administered and every anesthetic. RESULTS Among 28,213 patient encounters including parenteral antibiotic(s), more than half (64.3%) also included an anesthetic (99% confidence interval, 62.2 to 66.6). The hypothesis that most antibiotics were administered during encounters when a patient underwent an anesthetic was accepted (P < 0.001). This observation may seem counterintuitive because parenteral antibiotics were administered for fewer than half of the 53,235 anesthetics (34.2%). The result was a consequence of most anesthetics (63.5%) at the health system being conducted in nonoperating room locations, and only 7.2% of such patients received a parenteral antibiotic. CONCLUSIONS Because approximately two-thirds of patients who receive an intravenous antibiotic also undergo an anesthetic, greater use of effective infection control measures in the anesthesia operating room workspace has the potential to substantively reduce overall rates of hospital infections.
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Affiliation(s)
- Richard H Epstein
- Department of Anesthesiology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Franklin Dexter
- Division of Management Consulting, Department of Anesthesia, University of Iowa, 200 Hawkins Drive, 6-JCP, Iowa City, IA, 52242, USA.
| | - Randy W Loftus
- Department of Anesthesia, University of Iowa, Iowa City, IA, USA
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Loftus RW, Dexter F, Brown J. The importance of targeting intraoperative transmission of bacteria with antibiotic resistance and strain characteristics. Am J Infect Control 2023; 51:612-618. [PMID: 35926685 PMCID: PMC10918765 DOI: 10.1016/j.ajic.2022.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/20/2022] [Accepted: 07/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Evidence-based intraoperative infection control measures can reduce Staphylococcus aureus transmission and infections. We aimed to determine whether transmitted S. aureus isolates were associated with increased risk of multidrug resistance and associated traits. METHODS S. aureus isolates obtained from intraoperative environmental, patient skin, and provider hand reservoirs among 274 operating room case pairs (1st and 2nd case of the day) across 3 major academic medical centers from March 2009 to February 2010 underwent systematic-phenotypic-genomic analysis to identify clonal transmission events. The association of clonal S. aureus transmission with multidrug resistance and resistance traits was investigated. Transmission dynamics were characterized. RESULTS Transmitted isolates (N=58) were associated with increased risk of multi-drug antibiotic resistance [33% (19/58) transmitted vs. 10% (12/115) other isolates, risk ratio 3.14, 99% CI 1.34-7.38, P=0.0006]. Transmission was associated with a significant increase in resistance traits including mecA [40% transmitted isolates vs. 17% other isolates, risk ratio 2.28, P=0.0026] and ant (6)-Ia [26% transmitted isolates vs. 9% other isolates, risk ratio 2.97, P=0.0050]. Provider hands were a frequent reservoir of origin, between-case a common mode of transmission, and patient skin and provider hands frequent transmission locations for multidrug resistant pathogens. CONCLUSIONS Intraoperative S. aureus transmission was associated with multidrug resistance and resistance traits. Proven infection control measures should be leveraged to target intraoperative transmission of multidrug resistant pathogens.
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Dexter F, Brown JR, Wall RT, Loftus RW. The efficacy of multifaceted versus single anesthesia work area infection control measures and the importance of surgical site infection follow-up duration. J Clin Anesth 2023; 85:111043. [PMID: 36566648 PMCID: PMC9892236 DOI: 10.1016/j.jclinane.2022.111043] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/28/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Earlier a randomized trial showed efficacy of a multifaceted intervention approach for reducing surgical site infection: hand hygiene, vascular care, environmental cleaning, patient decolonization (nasal povidone iodine, chlorhexidine wipes), with feedback on pathogen transmission. The follow-up prospective observational study showed effectiveness when applied to all operating rooms of an inpatient surgical suite. In practice, many organizations will at baseline not be using conditions equivalent to the control groups but instead functionally have had ongoing a single intervention for infection control (e.g., encouraging better hand hygiene). Organizations also differ in how well and long they survey every surgical patient for postoperative surgical site infection. Thus, estimation of the expected net cost savings from implementing multifaceted intervention depends on the relative efficacy of multifaceted approach versus single intervention approaches and on the incidence of surgical site infection, the latter depending itself on the monitoring period for infection development. METHODS The retrospective cohort analysis included 4865 patients from two single intervention and two multifaceted studies, each of the four studies with matched control groups. We used Poisson regression with robust variance to estimate the relative risk reduction in surgical site infections for the multifaceted approach versus single interventions and, with 30-day follow-up versus ≥60-day follow-up for infection. RESULTS The multifaceted approach was associated with an estimated 68% reduction in postoperative surgical site infections relative to single interventions (risk ratio 0.32, 97.5% confidence interval 0.15-0.70, P = 0.001). There were approximately 2.61-fold more surgical site infections detected with follow-up for at least 60 days of medical records relative to 30 days of records reviewed (97.5% CI 1.62 to 4.21, P < 0.001). CONCLUSIONS An evidence-based, multifaceted approach to anesthesia work area infection control can generate substantial reductions in surgical site infections. A follow-up period of at least 60-days is indicated for infection detection.
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Affiliation(s)
- Franklin Dexter
- University of Iowa, 200 Hawkins Drive, Iowa City, IA 52240, United States.
| | - Jeremiah R Brown
- Dartmouth-Hitchcock Medical Center, WTRB 6, Lebanon, NH 03756, United States.
| | - Russell T Wall
- MedStar Georgetown University Hospital, 3800 Reservoir Road, NW, CCC Building, Lower Level, Washington, DC 20007, United States.
| | - Randy W Loftus
- University of Iowa, 200 Hawkins Drive, Iowa City, IA 52240, United States.
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Loftus RW, Dexter F, Brown JR. Transmission of Staphylococcus aureus in the anaesthesia work area has greater risk of association with development of surgical site infection when resistant to the prophylactic antibiotic administered for surgery. J Hosp Infect 2023; 134:121-128. [PMID: 36693592 PMCID: PMC10066826 DOI: 10.1016/j.jhin.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/24/2022] [Accepted: 01/12/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND The extent to which the transmission of prophylactic-antibiotic-resistant bacteria from the anaesthesia work area increases the risk of surgical site infection (SSI) is unknown. It was hypothesized that the risk of SSI would increase progressively from no transmission to transmission of prophylactic-antibiotic-resistant isolates. METHODS This was a retrospective analysis of archival samples collected in two previously published studies with similar inclusion criteria and sample collection methodology (observational study 2009-2010 and randomized trial 2018-2019). Archival isolates were linked by barcode to all patient demographic and procedural information, including the prophylactic antibiotic administered, transmission and development of SSI. For this study, all archival isolates underwent prophylactic antibiotic susceptibility testing, and the ordered association of transmission of Staphylococcus aureus (no transmission, transmission of prophylactic-antibiotic-susceptible isolates and transmission of prophylactic-antibiotic-resistant isolates) with SSI was assessed. RESULTS The risk of development of SSI was 2% (8/406) without S. aureus transmission, 11% (9/84) with transmission of S. aureus isolates that were susceptible to the prophylactic antibiotic used, and 18% (4/22) with transmission of prophylactic-antibiotic-resistant S. aureus isolates. The Cochrane-Armitage two-sided test for ordered association was P<0.0001. Treating these three groups as 0, 1 and 2, by exact logistic regression, the odds of SSI increased by 3.59 with each unit increase (95% confidence interval 1.92-6.64; P<0.0001). CONCLUSIONS Transmission of S. aureus in the anaesthesia work area reliably increases the risk of SSI, especially when the isolates are resistant to the prophylactic antibiotic administered.
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Affiliation(s)
| | - F Dexter
- University of Iowa, Iowa City, IA, USA
| | - J R Brown
- Dartmouth Geisel School of Medicine, Hanover, NH, USA
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11
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Frödin M, Rogmark C, Nellgård B, Gillespie BM, Wikström E, Andersson AE. Interactive Interventions Can Improve Hand Hygiene and Aseptic Techniques During Perioperative Care-Experience From the "Safe Hands" Project. J Perianesth Nurs 2023; 38:284-290. [PMID: 36319520 DOI: 10.1016/j.jopan.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 06/27/2022] [Accepted: 07/13/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE This paper evaluates a theory-driven, interactive hand hygiene (HH) intervention, the Safe Hands project, based on theories of organizational learning and culture including leadership support, dialogue and co-creation. DESIGN This prospective quasi-experimental study used unobtrusive overt observations to evaluate adherence to HH recommendations after implementing an infection-prevention intervention. METHODS The primary outcome was differences in HH practices "Before aseptic/clean procedure" (WHO moment 2), "After body fluid exposure risk" (WHO moment 3) and performance of aseptic techniques. One operating room (OR) department served as the study hospital and the other as the control hospital, both at Swedish university hospitals. Adherence to HH guidelines was measured 4 times during 2015 to 2017. FINDINGS The intervention site displayed a significant improvement in adherence to HH guidelines and aseptic techniques. WHO 2; from 23.8% to 36.2%, (P = .014), WHO 3; from 22.2% to 42.3%, (P = .002), and aseptic techniques; from 17.5% to 31.6%, (P = .003). No changes in adherence were identified at the control site. The use of contaminated gloves decreased post intervention at the study operating department. CONCLUSIONS This study shows that implementing tailored interventions that are underpinned by theories from organizational learning and culture can improve adherence to hand hygiene in a complex setting as the OR up to 6 months post-intervention. The interprofessional co-creation of standards operating procedures addressing specific care procedures and emphasizing the importance of aseptic techniques can be an acceptable and feasible way to reduce the risks of contaminating medical devices and patients during perioperative care.
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Affiliation(s)
- Maria Frödin
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Västra Götalandregionen, Sweden; Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Västra Götalandregionen, Sweden.
| | - Cecilia Rogmark
- Department of Orthopedics Malmö, Lund University, Skane University Hospital, Lund, Skane, Sweden; The Swedish Hip Arthroplasty Register, Registercentrum VGR, Gothenburg, Västra Götalandregionen, Sweden
| | - Bengt Nellgård
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Västra Götalandregionen, Sweden
| | - Brigid M Gillespie
- NMHRC Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute, Griffith University, Griffith, Queensland, Australia; Health Service, Gold Coast University Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Ewa Wikström
- School of Business, Economics and Law, Department of Business Administration, University of Gothenburg, Gothenburg, Västra Götalandregionen, Sweden
| | - Annette E Andersson
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Västra Götalandregionen, Sweden
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12
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Dexter F, Epstein RH, Loftus RW. Quantifying and Interpreting Inequality in Surgical Site Infections per Quarter Among Anesthetizing Locations and Specialties. Cureus 2023; 15:e36878. [PMID: 37123760 PMCID: PMC10147407 DOI: 10.7759/cureus.36878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 03/31/2023] Open
Abstract
Background Earlier studies have shown that prevention of surgical site infection can achieve net cost savings when targeted to operating rooms with the most surgical site infections. Methodology This retrospective cohort study included all 231,057 anesthetics between May 2017 and June 2022 at a large teaching hospital. The anesthetics were administered in operating rooms, procedure rooms, radiology, and other sites. The 8,941 postoperative infections were identified from International Classification of Diseases diagnosis codes relevant to surgical site infections documented during all follow-up encounters over 90 days postoperatively. To quantify the inequality in the counts of infections among anesthetizing locations, the Gini index was used, with the Gini index being proportional to the sum of the absolute pairwise differences among anesthetizing locations in the counts of infections. Results The Gini index for infections among the 112 anesthetizing locations at the hospital was 0.64 (99% confidence interval = 0.56 to 0.71). The value of 0.64 is so large that, for comparison, it exceeds nearly all countries' Gini index for income inequality. The 50% of locations with the fewest infections accounted for 5% of infections. The 10% of locations with the most infections accounted for 40% of infections and 15% of anesthetics. Among the 57 operating room locations, there was no association between counts of cases and infections (Spearman correlation coefficient r = 0.01). Among the non-operating room locations (e.g., interventional radiology), there was a significant association (Spearman r = 0.79). Conclusions Targeting specific anesthetizing locations is important for the multiple interventions to reduce surgical site infections that represent fixed costs irrespective of the number of patients (e.g., specialized ventilatory systems and nightly ultraviolet-C disinfection).
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13
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Ming Q, Huang X, Guo L, Liu D, Qin L, He Y, Tang Y, Liu Y, Liu J, Li P. Diversity of endophytic fungi in Coptis chinensis Franch. and their activity against methicillin-resistant Staphylococcus aureus. Folia Microbiol (Praha) 2022; 67:965-974. [PMID: 35907122 DOI: 10.1007/s12223-022-00994-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/21/2022] [Indexed: 11/04/2022]
Abstract
This study aimed at investigating the diversity of endophytic fungi from Coptis chinensis and their activity against methicillin-resistant Staphylococcus aureus (MRSA). Seventy-nine fungal isolates obtained from C. chinensis were identified to belong to 27 species based on morphological features and internal transcript spacer (ITS) gene sequencing analysis. Comparing relative frequency values, the most frequent genera were Colletotrichum and Fusarium, while most frequent species were C. gloeosporioides and F. avenaceum. Analysis of diversity indices indicated that C. chinensis harbored abundant fungal resources. Methanol extracts of fungal endophyte cultures were evaluated for antibacterial activity against S. aureus ATCC 25923 and two other MRSA clinical strains. Nine of 27 endophytic fungi exhibited inhibitory activities against S. aureus ATCC 25923. Among them, Paraboeremia litseae HL-17, Fusarium sp. HL-23, and Fusarium sp. HL-27 exhibited obvious inhibition against the three S. aureus strains. Our findings suggest that the endophytic fungi in C. chinensis have a high diversity and an obvious tissue specificity, and could be of potential interest in screening anti-MRSA agents. To the best of our knowledge, this is the first report on the diversity and anti-MRSA activity of fungal endophytes from C. chinensis.
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Affiliation(s)
- Qianliang Ming
- Department of Pharmacognosy, College of Pharmacy, Army Medical University, 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Xiuning Huang
- Department of Pharmacognosy, College of Pharmacy, Army Medical University, 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Linming Guo
- Department of Pharmacognosy, College of Pharmacy, Army Medical University, 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Dong Liu
- Department of Pharmacognosy, College of Pharmacy, Army Medical University, 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Lingyue Qin
- Department of Pharmacognosy, College of Pharmacy, Army Medical University, 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Yimo He
- Department of Pharmacognosy, College of Pharmacy, Army Medical University, 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Yu Tang
- Department of Pharmacognosy, College of Pharmacy, Army Medical University, 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Yanxia Liu
- Department of Pharmacognosy, College of Pharmacy, Army Medical University, 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Junkang Liu
- Department of Pharmacognosy, College of Pharmacy, Army Medical University, 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Peng Li
- Department of Pharmacognosy, College of Pharmacy, Army Medical University, 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China.
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Laceb ZM, Diene SM, Lalaoui R, Kihal M, Chergui FH, Rolain JM, Hadjadj L. Genetic Diversity and Virulence Profile of Methicillin and Inducible Clindamycin-Resistant Staphylococcus aureus Isolates in Western Algeria. Antibiotics (Basel) 2022; 11:antibiotics11070971. [PMID: 35884225 PMCID: PMC9312111 DOI: 10.3390/antibiotics11070971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/07/2022] [Accepted: 07/13/2022] [Indexed: 02/04/2023] Open
Abstract
Staphylococcusaureus causes a wide range of life-threatening infections. In this study, we determined its prevalence in the hospital environment and investigated nasal carriage among healthcare workers and patients admitted to a hospital in western Algeria. A total of 550 specimens were collected. An antibiogram was performed and the genes encoding resistance to methicillin, inducible clindamycin and toxins were sought among the 92 S. aureus isolates. The spread of clones with a methicillin- and/or clindamycin-resistance phenotype between these ecosystems was studied using genomic analysis. A prevalence of 27%, 30% and 13% of S. aureus (including 2.7%, 5% and 1.25% of MRSA) in patients, healthcare workers and the hospital environment were observed, respectively. The presence of the mecA, erm, pvl and tsst-1 genes was detected in 10.9%, 17.4%, 7.6% and 18.5% of samples, respectively. Sequencing allowed us to identify seven sequence types, including three MRSA-IV-ST6, two MRSA-IV-ST80-PVL+, two MRSA-IV-ST22-TSST-1, two MRSA-V-ST5, and one MRSA-IV-ST398, as well as many virulence genes. Here, we reported that both the hospital environment and nasal carriage may be reservoirs contributing to the spread of the same pathogenic clone persisting over time. The circulation of different pathogenic clones of MRSA, MSSA, and iMLSB, as well as the emergence of at-risk ST398 clones should be monitored.
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Affiliation(s)
- Zahoua Mentfakh Laceb
- Laboratoire de Biotechnologies, Environnement et Santé, Faculté des Sciences de la Nature et de la Vie, Université de Blida 01, BP270 Route Soumaa, Blida 09000, Algeria; (Z.M.L.); (F.H.C.)
- Faculté de Médecine et de Pharmacie, IRD, APHM, MEPHI, Aix Marseille University, 19-21 Boulevard Jean Moulin, CEDEX 05, 13385 Marseille, France; (S.M.D.); (R.L.); (J.-M.R.)
- IHU Méditerranée Infection, 13005 Marseille, France
| | - Seydina M. Diene
- Faculté de Médecine et de Pharmacie, IRD, APHM, MEPHI, Aix Marseille University, 19-21 Boulevard Jean Moulin, CEDEX 05, 13385 Marseille, France; (S.M.D.); (R.L.); (J.-M.R.)
- IHU Méditerranée Infection, 13005 Marseille, France
| | - Rym Lalaoui
- Faculté de Médecine et de Pharmacie, IRD, APHM, MEPHI, Aix Marseille University, 19-21 Boulevard Jean Moulin, CEDEX 05, 13385 Marseille, France; (S.M.D.); (R.L.); (J.-M.R.)
- IHU Méditerranée Infection, 13005 Marseille, France
| | - Mabrouk Kihal
- Laboratoire de Microbiologie Appliquée, Université Ahmed Ben Bella Oran1, BP1524 El M’naouer, Oran 31000, Algeria;
| | - Fella Hamaidi Chergui
- Laboratoire de Biotechnologies, Environnement et Santé, Faculté des Sciences de la Nature et de la Vie, Université de Blida 01, BP270 Route Soumaa, Blida 09000, Algeria; (Z.M.L.); (F.H.C.)
| | - Jean-Marc Rolain
- Faculté de Médecine et de Pharmacie, IRD, APHM, MEPHI, Aix Marseille University, 19-21 Boulevard Jean Moulin, CEDEX 05, 13385 Marseille, France; (S.M.D.); (R.L.); (J.-M.R.)
- IHU Méditerranée Infection, 13005 Marseille, France
| | - Linda Hadjadj
- Faculté de Médecine et de Pharmacie, IRD, APHM, MEPHI, Aix Marseille University, 19-21 Boulevard Jean Moulin, CEDEX 05, 13385 Marseille, France; (S.M.D.); (R.L.); (J.-M.R.)
- IHU Méditerranée Infection, 13005 Marseille, France
- Correspondence: ; Tel.: +33-4-8613-6930
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15
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Wall RT, Datta S, Dexter F, Ghyasi N, Robinson ADM, Persons D, Boling KA, McCloud CA, Krisanda EK, Gordon BM, Koff MD, Yeager MP, Brown J, Wong CA, Loftus RW. Effectiveness and feasibility of an evidence-based intraoperative infection control program targeting improved basic measures: a post-implementation prospective case-cohort study. J Clin Anesth 2022; 77:110632. [PMID: 34929497 DOI: 10.1016/j.jclinane.2021.110632] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/04/2021] [Accepted: 12/09/2021] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE A randomized controlled study demonstrated that an optimized intraoperative infection control program targeting basic preventive measures can reduce Staphylococcus aureus transmission and surgical site infections. In this study we address potential limitations of operating room heterogeneity of infections and compliance with behavioral interventions following adoption into clinical practice. DESIGN A post-implementation prospective case-cohort study. SETTING Twenty-three operating rooms at a large teaching hospital. PATIENTS A total of 801 surgical patients [425 (53%) women; 350 (44%) ASA > 2, age 54.6 ± 15.9 years] were analyzed for the primary and 804 for the secondary outcomes. INTERVENTIONS A multifaceted, evidence-based intraoperative infection control program involving hand hygiene, vascular care, and environmental cleaning improvements was implemented for 23 operating room environments. Bacterial transmission monitoring was used to provide monthly feedback for intervention optimization. MEASUREMENTS S. aureus transmission (primary) and surgical site infection (secondary). MATERIALS AND METHODS The incidence of S. aureus transmission and surgical site infection before (3.5 months) and after (4.5 months) infection control optimization was assessed. Optimization was defined by a sustained reduction in anesthesia work area bacterial reservoir isolate counts. Poisson regression with robust error variances was used to estimate the incidence risk ratio (IRR) of intraoperative S. aureus transmission and surgical site infection for the independent variable of optimization. MAIN RESULTS Optimization was associated with decreased S. aureus transmission [24% before (85/357) to 9% after (42/444), IRR 0.39, 95% CI 0.28 to 0.56, P < .001] and surgical site infections [8% before (29/360) and 3% after (15/444) (IRR 0.42, 95% CI 0.23 to 0.77, P = .005; adjusted for American Society of Anesthesiologists' physical status, aIRR 0.45, 95% CI 0.25 to 0.82, P = .009]. CONCLUSION An optimized intraoperative infection control program targeting improvements in basic preventive measures is an effective and feasible approach for reducing S. aureus transmission and surgical site infection development.
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Affiliation(s)
- Russell T Wall
- Department of Anesthesia, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Subhradeep Datta
- Medical Student Class of 2022, Georgetown University, Washington, DC, United States
| | - Franklin Dexter
- Department of Anesthesia, University of Iowa, Iowa City, IA, United States
| | - Niloofar Ghyasi
- Medical Student Class of 2022, Georgetown University, Washington, DC, United States
| | - Alysha D M Robinson
- Medical Laboratory Scientist, RDB Bioinformatics, Iowa City, IA, United States
| | - Deanna Persons
- Laboratory Assistant, RDB Bioinformatics, Iowa City, IA, United States
| | - Kate A Boling
- Research Assistant, Georgetown University, Washington, DC, United States
| | | | - Emily K Krisanda
- Medical Student Class of 2022, Georgetown University, Washington, DC, United States
| | - Brandon M Gordon
- Information Technologist, RDB Bioinformatics, Iowa City, IA, United States
| | - Matthew D Koff
- Department of Anesthesia, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
| | - Mark P Yeager
- Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
| | - Jeremiah Brown
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, NH, United States
| | - Cynthia A Wong
- Department of Anesthesia, University of Iowa, Iowa City, IA, United States
| | - Randy W Loftus
- Department of Anesthesia, University of Iowa, Iowa City, IA, United States.
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16
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Dexter F, Epstein RH, Loftus RW. Quantifying and interpreting inequality of surgical site infections among operating rooms. Can J Anaesth 2021; 68:812-824. [PMID: 33547628 DOI: 10.1007/s12630-021-01931-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 01/27/2023] Open
Abstract
PURPOSE The incidence of surgical site infection differs among operating rooms (ORs). However, cost effectiveness of interventions targeting ORs depends on infection counts. The purpose of this study was to quantify the inequality of infection counts among ORs. METHODS We performed a single-centre historical cohort study of elective surgical cases spanning a 160-week period from May 2017 to May 2020, identifying cases of infection within 90 days using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes. We used the Gini index to measure inequality of infections among ORs. As a reference, the Gini index for inequality of household disposable income in the US in 2017 was 0.39, and 0.31 for Canada. RESULTS There were 3,148 (3.67%) infections among the 85,744 cases studied. The 20% of 57 ORs with the most and least infections accounted for 44% (99% confidence interval [CI], 36 to 52) and 5% (99% CI, 2 to 8), respectively. The Gini index was 0.40 (99% CI, 0.31 to 0.50), which is comparable to income inequality in the US. There were more infections in ORs with more minutes of cases (Spearman correlation ρ = 0.68; P < 0.001), but generally not in ORs with more total cases (ρ = 0.11; P = 0.43). Moderately long (3.3 to 4.8 hr) cases had a large effect, having greater incidences of infection, while not being so long as to have just one case per day per OR. There was substantially greater inequality in infection counts among the 557 observed combinations of OR specialty (Gini index 0.85; 99% CI, 0.81 to 0.88). CONCLUSIONS Inequality of infections among ORs is substantial and caused by both inequality in the incidence of infections and inequality in the total minutes of cases. Inequality in infections among OR and specialty combinations is due principally to inequality in total minutes of cases.
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Affiliation(s)
- Franklin Dexter
- Division of Management Consulting, Department of Anesthesia, University of Iowa, 200 Hawkins Drive, 6-JCP, Iowa City, IA, 52242, USA.
| | | | - Randy W Loftus
- Department of Anesthesia, University of Iowa, Iowa City, IA, USA
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17
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Greene ES. Challenges in reducing the risk of infection when accessing vascular catheters. J Hosp Infect 2021; 113:130-144. [PMID: 33713758 DOI: 10.1016/j.jhin.2021.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/04/2021] [Accepted: 03/04/2021] [Indexed: 10/21/2022]
Abstract
Injection safety is essential to reduce the risk of healthcare-associated infections (HAIs) when accessing vascular catheters. This general review evaluates the contamination of vascular catheter access ports and associated HAIs in acute care settings, focusing on open lumen stopcocks (OLSs) and disinfectable needleless closed connectors (DNCCs). PubMed was searched from January 2000 to February 2021. OLS intraluminal surfaces are frequently contaminated during patient care, increasing the risk of HAIs, and neither an isopropyl alcohol (IPA) pad nor a port-scrub device can reduce contamination effectively. In contrast, DNCCs can be disinfected, with most studies indicating less intraluminal contamination than OLSs and some studies showing decreased HAIs. While the optimal DNCC design to reduce HAIs needs to be determined, DNCCs alone or stopcocks with a DNCC bonded to the injection port should replace routine use of OLSs, with OLSs restricted to use in sterile fields. Compliance with disinfection is essential immediately before use of a DNCC as use of a non-disinfected DNCC can have equivalent or greater risk of HAIs compared with use of an OLS. The recommendations for access port disinfection in selected national and international guidelines vary. When comparing in-vitro studies, clinical studies and published guidelines, consensus is lacking; therefore, additional studies are needed, including large randomized controlled trials. IPA caps disinfect DNCCs passively, eliminate scrubbing and provide a contamination barrier; however, their use in neonates has been questioned. Further study is needed to determine whether IPA caps are more efficacious than scrubbing with disinfectant to decrease HAIs related to use of central venous, peripheral venous and arterial catheters.
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Affiliation(s)
- E S Greene
- Department of Anesthesiology, Albany Medical College, Albany, NY, USA.
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18
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Ochoa SA, Cruz-Córdova A, Mancilla-Rojano J, Escalona-Venegas G, Esteban-Kenel V, Franco-Hernández I, Parra-Ortega I, Arellano-Galindo J, Hernández-Castro R, Perez-López CF, De la Rosa-Zamboni D, Xicohtencatl-Cortes J. Control of Methicillin-Resistant Staphylococcus aureus Strains Associated With a Hospital Outbreak Involving Contamination From Anesthesia Equipment Using UV-C. Front Microbiol 2020; 11:600093. [PMID: 33381094 PMCID: PMC7767929 DOI: 10.3389/fmicb.2020.600093] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 11/25/2020] [Indexed: 12/23/2022] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) is considered an opportunistic pathogen in humans and is mainly associated with healthcare-associated infections (HCAIs). This bacterium colonizes the skin and mucous membranes of healthy people and causes frequent hospital outbreaks. The aim of this study was to perform molecular typing of the staphylococcal cassette chromosome mec (SCCmec) and agr loci as wells as to establish the pulsotypes and clonal complexes (CCs) for MRSA and methicillin-sensitive S. aureus (MSSA) outbreaks associated with the operating room (OR) at a pediatric hospital. Twenty-five clinical strains of S. aureus (19 MRSA and 6 MSSA strains) were recovered from the outbreak (patients, anesthesia equipment, and nasopharyngeal exudates from external service anesthesia technicians). These clinical S. aureus strains were mainly resistant to benzylpenicillin (100%) and erythromycin (84%) and were susceptible to vancomycin and nitrofurantoin. The SCCmec type II was amplified in 84% of the S. aureus strains, and the most frequent type of the agr locus was agrII, which was amplified in 72% of the strains; however, the agrI and agrIII genes were mainly detected in MSSA strains. A pulsed-field gel electrophoresis (PFGE) analysis grouped the 25 strains into 16 pulsotypes (P), the most frequent of which was P1, including 10 MRSA strains related to the anesthesia equipment, external service anesthesia technicians, and hospitalized patients. Multilocus sequence typing (MLST) identified 15 sequence types (STs) distributed in nine CCs. The most prevalent ST was ST1011, belonging to CC5, which was associated with the SCCmec type II and agrII type. We postulate that the external service anesthesia technicians were MRSA carriers and that these strains were indirectly transmitted from the contaminated anesthesia equipment that was inappropriately disinfected. Finally, the MRSA outbreak was controlled when the anesthesia equipment disinfection was improved and hand hygiene was reinforced.
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Affiliation(s)
- Sara A Ochoa
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico Gómez, Ciudad de México, Mexico
| | - Ariadnna Cruz-Córdova
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico Gómez, Ciudad de México, Mexico
| | - Jetsi Mancilla-Rojano
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico Gómez, Ciudad de México, Mexico.,Facultad de Medicina, Posgrado de Ciencias Biológicas, Universidad Nacional Autónoma de México, Ciudad de México, Mexico
| | - Gerardo Escalona-Venegas
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico Gómez, Ciudad de México, Mexico
| | - Veronica Esteban-Kenel
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico Gómez, Ciudad de México, Mexico
| | - Isabel Franco-Hernández
- Laboratorio Central de Bacteriología, Hospital Infantil de México Federico Gómez, Ciudad de México, Mexico
| | - Israel Parra-Ortega
- Laboratorio Central de Bacteriología, Hospital Infantil de México Federico Gómez, Ciudad de México, Mexico
| | - José Arellano-Galindo
- Departamento de Infectología, Hospital Infantil de México Federico Gómez, Ciudad de México, Mexico
| | - Rigoberto Hernández-Castro
- Departamento de Ecología de Agentes Patógenos, Hospital General Dr. Manuel Gea González, Ciudad de México, Mexico
| | - Citlalli F Perez-López
- Departamento de Epidemiología Hospitalaria, Hospital Infantil de México Federico Gómez, Ciudad de México, Mexico
| | - Daniela De la Rosa-Zamboni
- Departamento de Epidemiología Hospitalaria, Hospital Infantil de México Federico Gómez, Ciudad de México, Mexico
| | - Juan Xicohtencatl-Cortes
- Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico Gómez, Ciudad de México, Mexico
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Datta S, Dexter F, Ledolter J, Wall RT, Loftus RW. Sample times for surveillance of S. aureus transmission to monitor effectiveness and provide feedback on intraoperative infection control. ACTA ACUST UNITED AC 2020; 21:100137. [PMID: 33072894 PMCID: PMC7547614 DOI: 10.1016/j.pcorm.2020.100137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/04/2020] [Accepted: 10/08/2020] [Indexed: 01/17/2023]
Abstract
Background Reductions in perioperative surgical site infections are obtained by a multifaceted approach including patient decolonization, vascular care, hand hygiene, and environmental cleaning. Associated surveillance of S. aureus transmission quantifies the effectiveness of these basic measures to prevent transmission of pathogenic bacteria and viruses to patients and clinicians, including Coronavirus Disease 2019 (COVID-19). To measure transmission, the observational units are pairs of successive surgical cases in the same operating room on the same day. In this prospective cohort study, we measured sampling times for inexperienced and experienced personnel. Methods OR PathTrac kits included 6 samples collected before the start of surgery and 7 after surgery. The time for consent also was recorded. We obtained 1677 measurements of time among 132 cases. Results Sampling times were not significantly affected by technician's experience, type of anesthetic, or patient's American Society of Anesthesiologists’ Physical Status. Sampling times before the start of surgery averaged less than 5 min (3.39 min [SE 0.23], P < 0.0001). Sampling times after surgery took approximately 5 min (4.39 [SE 0.25], P = 0.015). Total sampling times averaged less than 10 min without consent (7.79 [SE 0.50], P < 0.0001), and approximately 10 min with consent (10.22 [0.56], P = 0.70). Conclusions For routine use of monitoring S. aureus transmission, when done by personnel already present in the operating rooms of the cases, the personnel time budget can be 10 min per case.
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Affiliation(s)
- Subhradeep Datta
- Medical student 2022 class, Georgetown University, United States
| | - Franklin Dexter
- Division of Management Consulting, Department of Anesthesia, University of Iowa, 200 Hawkins Drive, 6-JCP, Iowa City, IA, 52242, United States
| | | | | | - Randy W Loftus
- Division of Management Consulting, Department of Anesthesia, University of Iowa, 200 Hawkins Drive, 6-JCP, Iowa City, IA, 52242, United States
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Affiliation(s)
- Duncan Maguire
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada,
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Dexter F, Elhakim M, Loftus RW, Seering MS, Epstein RH. Strategies for daily operating room management of ambulatory surgery centers following resolution of the acute phase of the COVID-19 pandemic. J Clin Anesth 2020; 64:109854. [PMID: 32371331 PMCID: PMC7188624 DOI: 10.1016/j.jclinane.2020.109854] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/19/2020] [Accepted: 04/23/2020] [Indexed: 12/15/2022]
Abstract
We performed a narrative review to explore the economics of daily operating room management decisions for ambulatory surgery centers following resolution of the acute phase of the Coronavirus Disease 2019 (COVID-19) pandemic. It is anticipated that there will be a substantive fraction of patients who will be contagious, but asymptomatic at the time of surgery. Use multimodal perioperative infection control practices (e.g., including patient decontamination) and monitor performance (e.g., S. aureus transmission from patient to the environment). The consequence of COVID-19 is that such processes are more important than ever to follow because infection affects not only patients but the surgery center staff and surgeons. Dedicate most operating rooms to procedures that are not airway aerosol producing and can be performed without general anesthesia. Increase throughput by performing nerve blocks before patients enter the operating rooms. Bypass the phase I post-anesthesia care unit whenever possible by appropriate choices of anesthetic approach and drugs. Plan long-duration workdays (e.g., 12-h). For cases where the surgical procedure does not cause aerosol production, but general anesthesia will be used, have initial (phase I) post-anesthesia recovery in the operating room where the surgery was done. Use anesthetic practices that achieve fast initial recovery of the brief ambulatory cases. When the surgical procedure causes aerosol production (e.g., bronchoscopy), conduct phase I recovery in the operating room and use multimodal environmental decontamination after each case. Use statistical methods to plan for the resulting long turnover times. Whenever possible, have the anesthesia and nursing teams stagger cases in more than one room so that they are doing one surgical case while the other room is being cleaned. In conclusion, this review shows that while COVID-19 is prevalent, it will markedly affect daily ambulatory workflow for patients undergoing general anesthesia, with potentially substantial economic impact for some surgical specialties.
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Affiliation(s)
| | - Mohamed Elhakim
- Department of Anesthesia and Critical Care Medicine, Royal Hobart Hospital, Hobart, Tasmania, Australia
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Sharma A, Fernandez PG, Rowlands JP, Koff MD, Loftus RW. Perioperative Infection Transmission: the Role of the Anesthesia Provider in Infection Control and Healthcare-Associated Infections. CURRENT ANESTHESIOLOGY REPORTS 2020; 10:233-241. [PMID: 32837343 PMCID: PMC7366489 DOI: 10.1007/s40140-020-00403-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Abstract
PURPOSE OF REVIEW This review aims to highlight key factors in the perioperative environment that contribute to transmission of infectious pathogens, leading to healthcare-associated infection. This knowledge will provide anesthesia providers the tools to optimize preventive measures, with the goal of improved patient and provider safety. RECENT FINDINGS Over the past decade, much has been learned about the epidemiology of perioperative pathogen transmission. Patients, providers, and the environment serve as reservoirs of origin that contribute to infection development. Ongoing surveillance of pathogen transmission among these reservoirs is essential to ensure effective perioperative infection prevention. SUMMARY Recent work has proven the efficacy of a strategic approach for perioperative optimization of hand hygiene, environmental cleaning, patient decolonization, and intravascular catheter design and handling improvement protocols. This work, proven to generate substantial reductions in surgical site infections, can also be applied to aide prevention of SARS-CoV-2 spread in the COVID-19 era.
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Affiliation(s)
- Archit Sharma
- Department of Anesthesia, University of Iowa, 200 Hawkins Drive, 6512 JCP, Iowa City, IA 52242 USA
| | - Patrick G. Fernandez
- Department of Anesthesia, University of Colorado School of Medicine, Children’s Hospital Colorado, 13123 E. 16th Ave, Aurora, CO 80045 USA
| | - John P. Rowlands
- Delaware Orthopaedic Specialists, Pain Management, 3401 Brandywine Parkway, Wilmington, DE 19803 USA
| | - Matthew D. Koff
- Department of Anesthesia and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, 1 Medical Center Drive, Lebanon, NH 03756 USA
| | - Randy W. Loftus
- Department of Anesthesia, University of Iowa, 200 Hawkins Drive, 6512 JCP, Iowa City, IA 52242 USA
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Loftus RW, Dexter F, Parra MC. In Response: 'Perioperative COVID-19 Defense: An Evidence-Based Approach for Optimization of Infection Control and Operating Room Management'. Anesth Analg 2020; 131:e27-e28. [PMID: 32250978 PMCID: PMC7173083 DOI: 10.1213/ane.0000000000004854] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Affiliation(s)
- Randy W. Loftus
- Department of Anesthesia, University of Iowa, Iowa City, Iowa,
| | - Franklin Dexter
- Department of Anesthesia, University of Iowa, Iowa City, Iowa,
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Dexter F, Parra MC, Brown JR, Loftus RW. Perioperative COVID-19 Defense: An Evidence-Based Approach for Optimization of Infection Control and Operating Room Management. Anesth Analg 2020; 131:37-42. [PMID: 32217947 PMCID: PMC7172574 DOI: 10.1213/ane.0000000000004829] [Citation(s) in RCA: 171] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We describe an evidence-based approach for optimization of infection control and operating room management during the Coronavirus Disease 2019 (COVID-19) pandemic. Confirmed modes of viral transmission are primarily, but not exclusively, contact with contaminated environmental surfaces and aerosolization. Evidence-based improvement strategies for attenuation of residual environmental contamination involve a combination of deep cleaning with surface disinfectants and ultraviolet light (UV-C). (1) Place alcohol-based hand rubs on the intravenous (IV) pole to the left of the provider. Double glove during induction. (2) Place a wire basket lined with a zip closure plastic bag on the IV pole to the right of the provider. Place all contaminated instruments in the bag (eg, laryngoscope blades and handles) and close. Designate and maintain clean and dirty areas. After induction of anesthesia, wipe down all equipment and surfaces with disinfection wipes that contain a quaternary ammonium compound and alcohol. Use a top-down cleaning sequence adequate to reduce bioburden. Treat operating rooms using UV-C. (3) Decolonize patients using preprocedural chlorhexidine wipes, 2 doses of nasal povidone-iodine within 1 hour of incision, and chlorhexidine mouth rinse. (4) Create a closed lumen IV system and use hub disinfection. (5) Provide data feedback by surveillance of Enterococcus, Staphylococcusaureus, Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter spp. (ESKAPE)transmission. (6) To reduce the use of surgical masks and to reduce potential COVID-19 exposure, use relatively long (eg, 12hours) staff shifts. If there are 8 essential cases to be done (each lasting 1–2 hours), the ideal solution is to have 2 teams complete the 8 cases, not 8 first case starts. (7) Do 1 case in each operating room daily, with terminal cleaning after each case including UV-C or equivalent. (8) Do not have patients go into a large, pooled phase I postanesthesia care unit because of the risk of contaminating facility at large along with many staff. Instead, have most patients recover in the room where they had surgery as is done routinely in Japan. These 8 programmatic recommendations stand on a substantial body of empirical evidence characterizing the epidemiology of perioperative transmission and infection development made possible by support from the Anesthesia Patient Safety Foundation (APSF).
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Affiliation(s)
- Franklin Dexter
- From the Department of Anesthesia, University of Iowa, Iowa City, Iowa
| | - Michelle C Parra
- From the Department of Anesthesia, University of Iowa, Iowa City, Iowa
| | - Jeremiah R Brown
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Randy W Loftus
- From the Department of Anesthesia, University of Iowa, Iowa City, Iowa
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26
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Schmidt E, Dexter F, Herrmann J, Godding JD, Hadder B, Loftus RW. Assessment of anesthesia machine redesign on cleaning of the anesthesia machine using surface disinfection wipes. Am J Infect Control 2020; 48:675-681. [PMID: 31733809 DOI: 10.1016/j.ajic.2019.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 09/19/2019] [Accepted: 09/20/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The use of surface disinfection wipes after induction of anesthesia improves anesthesia machine cleaning. We assessed whether anesthesia machine surface redesign improves disinfection wipe cleaning by anesthesia residents. METHODS Sixteen anesthesia residents were assigned to 2 cases in series. The first case was randomly assigned to regional knee or hip surgery, a brief or detailed checklist, and the Perseus A500 (redesigned) or GE Aespire 7900 (conventional) machine. The second case was assigned to the opposite for each condition. Setup checklists included cleaning instructions. Eight machine sites representing redesign were contaminated with fluorescent gel prior to setup and reassessed after setup to assess cleaning efficacy. Cleaning was compared by fluorescence quantification of before and after setup images. Our primary hypothesis was that, overall, more sites would be cleaned on the Perseus machine. Our secondary hypothesis was that redesign would affect some sites. RESULTS Overall, the number of sites cleaned did not differ between machines (median 0.74 more sites out of 8 for the Perseus A500; 25th and 75th percentiles, -0.34 and 1.04; P = .093). However, greater cleaning was observed for the work surface and manual bag arm/hose of the Perseus machine (0.58 more sites out of 2; 25th and 75th percentiles, 0.35 and 1.05; P = .0004). CONCLUSIONS The number of sites cleaned overall did not differ between the conventional and redesigned Perseus A500 machines. However, the redesigned work surface and smooth manual bag arm features improved resident cleaning with surface disinfection wipes.
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Dexter F, Epstein RH, Gostine AL, Penning DH, Loftus RW. Benefit of systematic selection of pairs of cases matched by surgical specialty for surveillance of bacterial transmission in operating rooms. Am J Infect Control 2020; 48:682-687. [PMID: 31679749 DOI: 10.1016/j.ajic.2019.09.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 09/25/2019] [Accepted: 09/26/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Bacterial transmission within and between successive surgical cases occurs in operating rooms (ORs), often includes anesthesia equipment as a reservoir, and can be monitored by collecting samples and identifying bacteria by genetic testing. We evaluated how to choose cases for active surveillance to quantify the effectiveness of interventions in 2 groups of ORs (eg, rooms with germicidal lighting vs those without). METHODS Data were from a 7 OR single-specialty gastrointestinal endoscopy suite and from a typical 8 OR multispecialty surgical suite. RESULTS At the multispecialty hospital, 40.3% (SE 1.2%) of the total number of cases could be used for surveillance (ie, followed by another case of the same specialty and matched with a corresponding pair of cases from the other OR group). Random selection obtained fewer matched pairs than deliberate selection: mean ratio of random/deliberate = 0.64 (0.01) for the single-specialty and 0.51 (0.02) for the multispecialty suite (P <.001). CONCLUSIONS The efficiency of sampling to obtain pairs of successive surgical cases of the same specialty is impaired markedly by randomly selecting pairs of cases (or using convenience sampling) as compared to choosing pairs deliberately. This is important because the number of cases that can be suitably used for surveillance of bacterial transmission will typically be less than one-half the total case number.
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Dexter F, Ledolter J, Wall RT, Datta S, Loftus RW. Sample sizes for surveillance of S. aureus transmission to monitor effectiveness and provide feedback on intraoperative infection control including for COVID-19. ACTA ACUST UNITED AC 2020; 20:100115. [PMID: 32501426 PMCID: PMC7240254 DOI: 10.1016/j.pcorm.2020.100115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/12/2020] [Accepted: 05/17/2020] [Indexed: 12/19/2022]
Abstract
Reductions in perioperative surgical site infections are obtained by a multifaceted approach including patient decolonization, hand hygiene, and hub disinfection, and environmental cleaning. Associated surveillance of S. aureus transmission quantifies the effectiveness of the basic measures to prevent the transmission to patients and clinicians of pathogenic bacteria and viruses, including Coronavirus Disease 2019 (COVID-19). To measure transmission, the observational units are pairs of successive surgical cases in the same operating room on the same day. We evaluated appropriate sample sizes and strategies for measuring transmission. There was absence of serial correlation among observed counts of transmitted isolates within each of several periods (all P ≥.18). Similarly, observing transmission within or between cases of a pair did not increase the probability that the next sampled pair of cases also had observed transmission (all P ≥.23). Most pairs of cases had no detected transmitted isolates. Also, although transmission (yes/no) was associated with surgical site infection (P =.004), among cases with transmission, there was no detected dose response between counts of transmitted isolates and probability of infection (P =.25). The first of a fixed series of tests is to use the binomial test to compare the proportion of pairs of cases with S. aureus transmission to an acceptable threshold. An appropriate sample size for this screening is N =25 pairs. If significant, more samples are obtained while additional measures are implemented to reduce transmission and infections. Subsequent sampling is done to evaluate effectiveness. The two independent binomial proportions are compared using Boschloo's exact test. The total sample size for the 1st and 2nd stage is N =100 pairs. Because S. aureus transmission is invisible without testing, when choosing what population(s) to screen for surveillance, another endpoint needs to be used (e.g., infections). Only 10/298 combinations of specialty and operating room were relatively common (≥1.0% of cases) and had expected incidence ≥0.20 infections per 8 hours of sampled cases. The 10 combinations encompassed ≅17% of cases, showing the value of targeting surveillance of transmission to a few combinations of specialties and rooms. In conclusion, we created a sampling protocol and appropriate sample sizes for using S. aureus transmission within and between pairs of successive cases in the same operating room, the purpose being to monitor the quality of prevention of intraoperative spread of pathogenic bacteria and viruses.
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Loftus RW, Dexter F, Goodheart MJ, McDonald M, Keech J, Noiseux N, Pugely A, Sharp W, Sharafuddin M, Lawrence WT, Fisher M, McGonagill P, Shanklin J, Skeete D, Tracy C, Erickson B, Granchi T, Evans L, Schmidt E, Godding J, Brenneke R, Persons D, Herber A, Yeager M, Hadder B, Brown JR. The Effect of Improving Basic Preventive Measures in the Perioperative Arena on Staphylococcus aureus Transmission and Surgical Site Infections: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e201934. [PMID: 32219407 PMCID: PMC11071519 DOI: 10.1001/jamanetworkopen.2020.1934] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Importance Surgical site infections increase patient morbidity and health care costs. The Centers for Disease Control and Prevention emphasize improved basic preventive measures to reduce bacterial transmission and infections among patients undergoing surgery. Objective To assess whether improved basic preventive measures can reduce perioperative Staphylococcus aureus transmission and surgical site infections. Design, Setting, and Participants This randomized clinical trial was conducted from September 20, 2018, to September 20, 2019, among 19 surgeons and their 236 associated patients at a major academic medical center with a 60-day follow-up period. Participants were a random sample of adult patients undergoing orthopedic total joint, orthopedic spine, oncologic gynecological, thoracic, general, colorectal, open vascular, plastic, or open urological surgery requiring general or regional anesthesia. Surgeons and their associated patients were randomized 1:1 via a random number generator to treatment group or to usual care. Observers were masked to patient groupings during assessment of outcome measures. Interventions Sustained improvements in perioperative hand hygiene, vascular care, environmental cleaning, and patient decolonization efforts. Main Outcomes and Measures Perioperative S aureus transmission assessed by the number of isolates transmitted and the incidence of transmission among patient care units (primary) and the incidence of surgical site infections (secondary). Results Of 236 patients (156 [66.1%] women; mean [SD] age, 57 [15] years), 106 (44.9%) and 130 (55.1%) were allocated to the treatment and control groups, respectively, received the intended treatment, and were analyzed for the primary outcome. Compared with the control group, the treatment group had a reduced mean (SD) number of transmitted perioperative S aureus isolates (1.25 [2.11] vs 0.47 [1.13]; P = .002). Treatment reduced the incidence of S aureus transmission (incidence risk ratio; 0.56; 95% CI, 0.37-0.86; P = .008; with robust variance clustering by surgeon: 95% CI, 0.42-0.76; P < .001). Overall, 11 patients (4.7%) experienced surgical site infections, 10 (7.7%) in the control group and 1 (0.9%) in the treatment group. Transmission was associated with an increased risk of surgical site infection (8 of 73 patients [11.0%] with transmission vs 3 of 163 [1.8%] without; risk ratio, 5.95; 95% CI, 1.62-21.86; P = .007). Treatment reduced the risk of surgical site infection (hazard ratio, 0.12; 95% CI, 0.02-0.92; P = .04; with clustering by surgeon: 95% CI, 0.03-0.51; P = .004). Conclusions and Relevance Improved basic preventive measures in the perioperative arena can reduce S aureus transmission and surgical site infections. Trial Registration ClinicalTrials.gov Identifier: NCT03638947.
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Affiliation(s)
| | | | | | | | - John Keech
- Department of Anesthesia, University of Iowa, Iowa City
| | | | - Andrew Pugely
- Department of Anesthesia, University of Iowa, Iowa City
| | - William Sharp
- Department of Anesthesia, University of Iowa, Iowa City
| | | | | | - Mark Fisher
- Department of Anesthesia, University of Iowa, Iowa City
| | | | - Jennifer Shanklin
- Department of Anesthesia, University of Iowa, Iowa City
- now with Allina Health Surgical Specialists, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Dionne Skeete
- Department of Anesthesia, University of Iowa, Iowa City
| | - Chad Tracy
- Department of Anesthesia, University of Iowa, Iowa City
| | | | | | - Lance Evans
- Department of Anesthesia, University of Iowa, Iowa City
| | - Eli Schmidt
- Department of Anesthesia, University of Iowa, Iowa City
| | | | | | | | - Alexia Herber
- Department of Anesthesia, University of Iowa, Iowa City
| | - Mark Yeager
- Department of Anesthesia, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Brent Hadder
- Department of Anesthesia, University of Iowa, Iowa City
| | - Jeremiah R Brown
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Kwanten LE. Anaesthetists and syringe hygiene: getting to the pointy end – a summary of recommendations. Br J Anaesth 2019; 123:e475-e479. [DOI: 10.1016/j.bja.2019.05.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 05/03/2019] [Accepted: 05/22/2019] [Indexed: 11/26/2022] Open
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Robinson AD, Dexter F, Renkor V, Reddy S, Loftus RW. Operating room PathTrac analysis of current intraoperative Staphylococcus aureus transmission dynamics. Am J Infect Control 2019; 47:1240-1247. [PMID: 31036398 DOI: 10.1016/j.ajic.2019.03.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/20/2019] [Accepted: 03/20/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Operating room (OR) reservoir Staphylococcus aureus isolates have been linked to 50% of surgical site infections. We aimed to assess S aureus transmission dynamics in today's ORs to further guide health care-associated infection prevention. METHODS Forty OR case-pairs were randomly selected for observation in a 5-month prospective cohort study. Case-pair S aureus transmission dynamics were mapped using OR PathTrac. RESULTS S aureus pathogens were isolated from ≥1 OR reservoirs in 45.7% (37 of 81) of surgical cases, and epidemiologically related transmission events were confirmed in 22.5% (9 of 40) of case-pairs. Patient skin sites and provider hands provided comparable risk of OR S aureus exposure (19 of 481 patient vs 35 of 1,173 provider hands, relative risk [RR], 1.32; 95% confidence interval [CI], 0.77-2.29; P = .32). Environmental contamination at case 2 start was higher than at case 1 start (case 2 start 32 of 152 sites with >20 colony-forming units vs case 1 start 7 of 163 sites with >20 colony-forming units; RR, 4.90; 95% CI, 2.23-10.77; P < .0001). The stopcock contamination rate was not significantly different than our prior study in 2008 (19 of 164 2008 vs 8 of 77 2018; RR, 1.12; 95% CI, 0.51-2.43; P = .78). All epidemiologically related transmission events involved the between-case mode of transmission and phenotype H. CONCLUSIONS Current OR S aureus exposure threats reliably include patient skin sites and provider hands. Perioperative S aureus preventive measures should extend from patient decolonization to include improved hand decontamination efforts.
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32
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Loftus RW, Campos JH. The anaesthetists' role in perioperative infection control: what is the action plan? Br J Anaesth 2019; 123:531-534. [PMID: 31451191 DOI: 10.1016/j.bja.2019.07.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 06/27/2019] [Accepted: 07/26/2019] [Indexed: 12/28/2022] Open
Affiliation(s)
- Randy W Loftus
- Department of Anesthesia, University of Iowa, Iowa City, IA, USA.
| | - Javier H Campos
- Department of Anesthesia, University of Iowa, Iowa City, IA, USA
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33
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Merry AF, Gargiulo DA, Bissett I, Cumin D, English K, Frampton C, Hamblin R, Hannam J, Moore M, Reid P, Roberts S, Taylor E, Mitchell SJ. The effect of implementing an aseptic practice bundle for anaesthetists to reduce postoperative infections, the Anaesthetists Be Cleaner (ABC) study: protocol for a stepped wedge, cluster randomised, multi-site trial. Trials 2019; 20:342. [PMID: 31182142 PMCID: PMC6558820 DOI: 10.1186/s13063-019-3402-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 05/06/2019] [Indexed: 11/12/2022] Open
Abstract
Background Postoperative infection is a serious problem in New Zealand and internationally with considerable human and financial costs. Also, in New Zealand, certain factors that contribute to postoperative infection are more common in Māori and Pacific populations. To date, most efforts to reduce postoperative infection have focussed on surgical aspects of care and on antibiotic prophylaxis, but recent research shows that anaesthesia providers may also have an impact on infection transmission. These providers sometimes exhibit imperfect hand hygiene and frequently transfer the blood or saliva of their patients to their work environment. In addition, intravenous medications may become contaminated whilst being drawn up and administered to patients. Working with relevant practitioners and other experts, we have developed an evidence-informed bundle to improve key aseptic practices by anaesthetists with the aim of reducing postoperative infection. The key elements of the bundle are the filtering of compatible drugs, context-relevant hand hygiene practices and enhanced maintenance of clean work surfaces. Methods We will seek support for implementation of the bundle from senior anaesthesia and hospital leadership and departmental “champions”. Anaesthetic teams and recovery room staff will be educated about the bundle and its potential benefits through presentations, written material and illustrative videos. We will implement the bundle in operating rooms where hip or knee arthroplasty or cardiac surgery procedures are undertaken in a five-site, stepped wedge, cluster randomised, quality improvement design. We will compare outcomes between approximately 5000 cases before and 5000 cases after implementation of our bundle. Outcome data will be collected from existing national and hospital databases. Our primary outcome will be days alive and out of hospital to 90 days, which is expected to reflect all serious postoperative infections. Our secondary outcome will be the rate of surgical site infection. Aseptic practice will be observed in sampled cases in each cluster before and after implementation of the bundle. Discussion If effective, our bundle may offer a practical clinical intervention to reduce postoperative infection and its associated substantial human and financial costs. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12618000407291. Registered on 21 March 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3402-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alan F Merry
- Department of Anaesthesiology, School of Medicine, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand. .,Department of Anaesthesia, Auckland City Hospital, PO Box 92024, Auckland, 1142, New Zealand.
| | - Derryn A Gargiulo
- Department of Anaesthesiology, School of Medicine, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - Ian Bissett
- Department of Surgery, School of Medicine, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.,Department of Surgery, Auckland City Hospital, Private Bag 92019, Auckland, 1142, New Zealand
| | - David Cumin
- Department of Anaesthesiology, School of Medicine, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - Kerry English
- Department of Anaesthesia, Auckland City Hospital, PO Box 92024, Auckland, 1142, New Zealand
| | - Christopher Frampton
- Department of Psychological Medicine, University of Otago, PO Box 4345, Christchurch, 8140, New Zealand
| | - Richard Hamblin
- Health Quality & Safety Commission, PO Box 25496, Wellington, 6146, New Zealand
| | - Jacqueline Hannam
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - Matthew Moore
- Department of Anaesthesiology, School of Medicine, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - Papaarangi Reid
- Te Kupenga Hauora Māori, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - Sally Roberts
- LabPLUS, Auckland City Hospital, PO Box 110031, Auckland, 1070, New Zealand
| | - Elsa Taylor
- Starship Children's Health, Auckland District Health Board, PO Box 9389, Auckland, 1149, New Zealand
| | - Simon J Mitchell
- Department of Anaesthesiology, School of Medicine, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.,Department of Anaesthesia, Auckland City Hospital, PO Box 92024, Auckland, 1142, New Zealand
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