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Hoch C, Allen JR, Morningstar J, Materon SR, Scott DJ, Gross CE. Identification and Analysis of the Ankle Microbiome Using Next-Generation DNA Sequencing: An Observational Analysis. J Am Acad Orthop Surg 2024; 32:786-792. [PMID: 37976386 DOI: 10.5435/jaaos-d-23-00387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Indexed: 11/19/2023] Open
Abstract
INTRODUCTION Next-generation DNA sequencing (NGS) technologies have increased the sensitivity for detecting the bacterial presence and have been used in other areas of orthopaedics to better understand the native microbiome of various joints. This study uses NGS to determine whether (1) a unique microbiome exists in human ankle tissues, (2) if components of the ankle microbiome affect patient outcomes, and (3) whether microbes found on the skin are a normal part of the ankle microbiome. METHODS A prospective study recruited 32 patients undergoing total ankle arthroplasty (n = 23) or ankle arthrodesis (n = 9) via direct anterior approach between November 2020 and October 2021. During surgery, five layers of the ankle were swabbed: skin (n = 32), retinaculum (n = 31), tibialis anterior tendon (n = 31), joint capsule (n = 31), and distal tibia (n = 32). These swabs (N = 157) were sent to MicroGen Diagnostics (Lubbock) for NGS. Demographics, medical comorbidities, surgical indication, postoperative complications, readmission, and revision surgery rates were collected from patient records. RESULTS The mean age was 60.7 (range, 19 to 85) years, and the mean follow-up duration was 10.2 (range, 4.8 to 20.6) months. Of 157 swabs sent for NGS, 19 (12.1%) indicated that bacteria were present (positive), whereas the remaining 138 (87.9%) had no bacteria present (negative). The most common organisms were Cutibacterium acnes in eight ankles (25.0%) and Staphylococcus epidermidis in two ankles (6.25%). Most bacteria were found in the retinaculum (29.6%). Complications, nonunions, infections, 90-day readmission, and revision surgery rates did not differ by NGS profile. DISCUSSION This study found that C acnes and S epidermidis were the most common bacteria in the ankle microbiome, with C acnes being present in 25% of ankles. Complication rates did not differ between patients with or without positive bacterial DNA remnants. Thus, we concluded that a unique ankle microbiome is present in some patients, which is unique from that of the skin of the ankle. LEVEL OF EVIDENCE Level II, Prospective cohort study.
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Affiliation(s)
- Caroline Hoch
- From the Department of Orthopaedics and Physical, Medical University of South Carolina, Charleston, SC (Allen, Morningstar, Materon, Scott, and Gross), and the University of North Carolina, Gillings School of Global Public Health, Chapel Hill, NC (Hoch)
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Fann LY, Cheng CC, Chien YC, Hsu CW, Chien WC, Huang YC, Chung RJ, Huang SH, Jiang YH, Yin SH, Cheng KW, Wu YP, Hsiao SH, Hsu SY, Huang YC, Chu CM. Effect of far-infrared radiation on inhibition of colonies on packaging during storage of sterilised surgical instruments. Sci Rep 2023; 13:8490. [PMID: 37231027 DOI: 10.1038/s41598-023-35352-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 05/16/2023] [Indexed: 05/27/2023] Open
Abstract
The sterilisation of surgical instruments is a major factor in infection control in the operating room (OR). All items used in the OR must be sterile for patient safety. Therefore, the present study evaluated the effect of far-infrared radiation (FIR) on the inhibition of colonies on packaging surface during the long-term storage of sterilised surgical instruments. From September 2021 to July 2022, 68.2% of 85 packages without FIR treatment showed microbial growth after incubation at 35 °C for 30 days and at room temperature for 5 days. A total of 34 bacterial species were identified, with the number of colonies increasing over time. In total, 130 colony-forming units were observed. The main microorganisms detected were Staphylococcus spp. (35%) and Bacillus spp. (21%) , Kocuria marina and Lactobacillus spp. (14%), and mould (5%). No colonies were found in 72 packages treated with FIR in the OR. Even after sterilisation, microbial growth can occur due to movement of the packages by staff, sweeping of floors, lack of high-efficiency particulate air filtration, high humidity, and inadequate hand hygiene. Thus, safe and simple far-infrared devices that allow continuous disinfection for storage spaces, as well as temperature and humidity control, help to reduce microorganisms in the OR.
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Affiliation(s)
- Li-Yun Fann
- Department of Nursing, Taipei City Hospital, Taipei, 10684, Taiwan
- Department of Nurse-Midwifery and Women Health, National Taipei University of Nursing and Health Sciences, Taipei, 11220, Taiwan
- School of Public Health, National Defense Medical Center, Taipei, 11490, Taiwan
| | - Chih-Chien Cheng
- Univeraity of Taipei, Taipei, 10048, Taiwan
- Department of Obstetrics/Gynecology, Taipei City Hospital, Taipei, 10341, Taiwan
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, 242062, Taiwan
| | - Yung-Chen Chien
- Department of Inspection, Taipei City Hospital, Ren-Ai Branch, Taipei, 10629, Taiwan
| | - Cheng-Wei Hsu
- Department of Nursing, Taipei City Hospital, Taipei, 10684, Taiwan
| | - Wu-Chien Chien
- School of Public Health, National Defense Medical Center, Taipei, 11490, Taiwan
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, 11490, Taiwan
- Department of Medical Research, Tri-Service General Hospital, Taipei, 11490, Taiwan
| | - Yao-Ching Huang
- School of Public Health, National Defense Medical Center, Taipei, 11490, Taiwan
- Department of Medical Research, Tri-Service General Hospital, Taipei, 11490, Taiwan
- Department of Chemical Engineering and Biotechnology, National Taipei University of Technology (Taipei Tech), Taipei, 10608, Taiwan
| | - Ren-Jei Chung
- Department of Chemical Engineering and Biotechnology, National Taipei University of Technology (Taipei Tech), Taipei, 10608, Taiwan
| | - Shi-Hao Huang
- Department of Chemical Engineering and Biotechnology, National Taipei University of Technology (Taipei Tech), Taipei, 10608, Taiwan
| | - Ying-Hua Jiang
- Department of Nursing, Taipei City Hospital, Taipei, 10684, Taiwan
| | - Shih-Han Yin
- Department of Nursing, Taipei City Hospital, Taipei, 10684, Taiwan
| | - Kai-Wen Cheng
- Department of Nursing, Taipei City Hospital, Taipei, 10684, Taiwan
| | - Yi-Ping Wu
- Department of Nursing, Taipei City Hospital, Taipei, 10684, Taiwan
| | - Sheng-Huang Hsiao
- Department of Neurosurgery, Taipei City Hospital, Ren-Ai Branch, Taipei, 10629, Taiwan.
| | - Shao-Yuan Hsu
- Department of Neurosurgery, Taipei City Hospital, Ren-Ai Branch, Taipei, 10629, Taiwan.
| | - Ying-Che Huang
- Department of Anesthesia and Critical Care Medicine, Taipei City Hospital, Ren-Ai Branch, Taipei, 10629, Taiwan.
| | - Chi-Ming Chu
- School of Public Health, National Defense Medical Center, Taipei, 11490, Taiwan.
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, 11490, Taiwan.
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Abstract
IMPORTANCE Approximately 0.5% to 3% of patients undergoing surgery will experience infection at or adjacent to the surgical incision site. Compared with patients undergoing surgery who do not have a surgical site infection, those with a surgical site infection are hospitalized approximately 7 to 11 days longer. OBSERVATIONS Most surgical site infections can be prevented if appropriate strategies are implemented. These infections are typically caused when bacteria from the patient's endogenous flora are inoculated into the surgical site at the time of surgery. Development of an infection depends on various factors such as the health of the patient's immune system, presence of foreign material, degree of bacterial wound contamination, and use of antibiotic prophylaxis. Although numerous strategies are recommended by international organizations to decrease surgical site infection, only 6 general strategies are supported by randomized trials. Interventions that are associated with lower rates of infection include avoiding razors for hair removal (4.4% with razors vs 2.5% with clippers); decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures (0.8% with decolonization vs 2% without); use of chlorhexidine gluconate and alcohol-based skin preparation (4.0% with chlorhexidine gluconate plus alcohol vs 6.5% with povidone iodine plus alcohol); maintaining normothermia with active warming such as warmed intravenous fluids, skin warming, and warm forced air to keep the body temperature warmer than 36 °C (4.7% with active warming vs 13% without); perioperative glycemic control (9.4% with glucose <150 mg/dL vs 16% with glucose >150 mg/dL); and use of negative pressure wound therapy (9.7% with vs 15% without). Guidelines recommend appropriate dosing, timing, and choice of preoperative parenteral antimicrobial prophylaxis. CONCLUSIONS AND RELEVANCE Surgical site infections affect approximately 0.5% to 3% of patients undergoing surgery and are associated with longer hospital stays than patients with no surgical site infections. Avoiding razors for hair removal, maintaining normothermia, use of chlorhexidine gluconate plus alcohol-based skin preparation agents, decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures, controlling for perioperative glucose concentrations, and using negative pressure wound therapy can reduce the rate of surgical site infections.
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Affiliation(s)
- Jessica L Seidelman
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina
| | - Christopher R Mantyh
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Deverick J Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina
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Birgand G, Ahmad R, Bulabula ANH, Singh S, Bearman G, Sánchez EC, Holmes A. Innovation for infection prevention and control-revisiting Pasteur's vision. Lancet 2022; 400:2250-2260. [PMID: 36528378 PMCID: PMC9754656 DOI: 10.1016/s0140-6736(22)02459-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022]
Abstract
Louis Pasteur has long been heralded as one of the fathers of microbiology and immunology. Less known is Pasteur's vision on infection prevention and control (IPC) that drove current infection control, public health, and much of modern medicine and surgery. In this Review, we revisited Pasteur's pioneering works to assess progress and challenges in the process and technological innovation of IPC. We focused on Pasteur's far-sighted conceptualisation of the hospital as a reservoir of microorganisms and amplifier of transmission, aseptic technique in surgery, public health education, interdisciplinary working, and the protection of health services and patients. Examples from across the globe help inform future thinking for IPC innovation, adoption, scale up and sustained use.
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Affiliation(s)
- Gabriel Birgand
- Centre d'appui pour la Prévention des Infections Associées aux Soins, Nantes, France; National Institute for Health and Care Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London, London, UK
| | - Raheelah Ahmad
- National Institute for Health and Care Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London, London, UK; School of Health and Psychological Sciences, City University of London, London, UK; Institute of Business and Health Management, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Sanjeev Singh
- Department of Medicine, Amrita Institute of Medical Sciences, Amrita University, Kerala, India
| | - Gonzalo Bearman
- Division of Infectious Diseases, Department of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Enrique Castro Sánchez
- National Institute for Health and Care Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London, London, UK; College of Nursing, Midwifery and Healthcare, Richard Wells Centre, University of West London, London, UK
| | - Alison Holmes
- National Institute for Health and Care Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London, London, UK; Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK.
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Wistrand C, Söderquist B, Sundqvist AS. Time-dependent bacterial air contamination of sterile fields in a controlled operating room environment: an experimental intervention study. J Hosp Infect 2021; 110:97-102. [PMID: 33516797 DOI: 10.1016/j.jhin.2021.01.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/14/2021] [Accepted: 01/24/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Surgical site infections are a global patient safety concern. Due to lack of evidence on contamination, pre-set surgical goods are sometimes disposed of or re-sterilized, thus increasing costs, resource use, and environmental effects. AIM To investigate time-dependent bacterial air contamination of covered and uncovered sterile goods in the operating room. METHODS Blood agar plates (N = 1584) were used to detect bacterial air contamination of sterile fields on 48 occasions. Each time, three aerobe and three anaerobe plates were used as baseline to model the preparation time, and 60 (30 aerobe, 30 anaerobe) were used to model the time pending before operation; half of these were covered with sterile drapes and half remained uncovered. Plates were collected after 4, 8, 12, 16, and 24 h. FINDINGS Mean time before contamination was 2.8 h (95% confidence interval: 2.1-3.4) in the uncovered group and 3.8 h (3.2-4.4) in the covered group (P = 0.005). The uncovered group had 98 colony-forming units (cfu) versus 20 in the covered group (P = 0.0001). Sixteen different micro-organisms were isolated, the most common being Cutibacterium acnes followed by Micrococcus luteus. Of 32 Staphylococcus cfu, 14 were antibiotic resistant, including one multidrug-resistant Staphylococcus epidermidis. CONCLUSION Protecting sterile fields from bacterial air contamination with sterile covers enhances the durability of sterile goods up to 24 h. Prolonged durability of sterile goods might benefit patient safety, since surgical sterile material could be prepared in advance for acute surgery, thereby enhancing quality of care and reducing both climate impact and costs.
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Affiliation(s)
- C Wistrand
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Sweden; Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Sweden.
| | - B Söderquist
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Sweden; Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital, Sweden
| | - A-S Sundqvist
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Sweden; Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Sweden
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Motion-capture system to assess intraoperative staff movements and door openings: Impact on surrogates of the infectious risk in surgery. Infect Control Hosp Epidemiol 2019; 40:566-573. [PMID: 30857569 DOI: 10.1017/ice.2019.35] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES We longitudinally observed and assessed the impact of the operating room (OR) staff movements and door openings on surrogates of the exogenous infectious risk using a new technology system. DESIGN AND SETTING This multicenter observational study included 13 ORs from 10 hospitals, performing planned cardiac and orthopedic surgery (total hip or knee replacement). Door openings during the surgical procedure were obtained from data collected by inertial sensors fixed on the doors. Intraoperative staff movements were captured by a network of 8 infrared cameras. For each surgical procedure, 3 microbiological air counts, longitudinal particles counts, and 1 bacteriological sample of the wound before skin closure were performed. Statistics were performed using a linear mixed model for longitudinal data. RESULTS We included 34 orthopedic and 25 cardiac procedures. The median frequency of door openings from incision to closure was independently associated with an increased log10 0.3 µm particle (ß, 0.03; standard deviation [SD], 0.01; P = .01) and air microbial count (ß, 0.07; SD, 0.03; P = .03) but was not significantly correlated with the wound contamination before closure (r = 0.13; P = .32). The number of persons (ß, -0.08; SD, 0.03; P < .01), and the cumulated movements by the surgical team (ß, 0.0004; SD, 0.0005; P < .01) were associated with log10 0.3 µm particle counts. CONCLUSIONS This study has demonstrated a previously missing association between intraoperative staff movements and surrogates of the exogenous risk of surgical site infection. Restriction of staff movements and door openings should be considered for the control of the intraoperative exogenous infectious risk.
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Surgical site infections and the microbiome: An updated perspective. Infect Control Hosp Epidemiol 2019; 40:590-596. [PMID: 30786943 DOI: 10.1017/ice.2018.363] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To address 3 questions: What are the origins of bacteria causing surgical site infections (SSIs)? Is there evidence that the offending bacteria are present at the incision site when surgery begins? What are the estimates of the proportion of SSIs that can be prevented with perioperative control of the microbiome? DESIGN Review of the literature, examining recognized sources of bacteria causing surgical site infections. METHODS Specifically, I examined the impact of improved control of the microbiome of the skin and nares on reducing SSIs. The initial effort was to examine the reduction of SSIs linked solely to preoperative skin preparation regimens and to either topical nasal antibiotics or pre- and postoperative nasal antiseptic regimens. To corroborate the concept of the importance of the microbiome, a review of studies showing the relationship of SSIs and marker organisms (eg, Propionobacterium acnes) present at the incision sites was performed. The relationships of SSIs to the microbiome of the skin and nares were summarized. RESULTS Depending on key assumptions, ∼70%-95% of all SSIs arise from the microbiome of the patients' skin or nares. Data from the studies of marker organisms suggest that the infecting bacteria are present at the incision site at the time of surgery. CONCLUSIONS Almost all SSIs arise from the patient's microbiome. The occurrence of SSIs can be viewed as a perioperative failure to control the microbiome.
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Abouljoud MM, Alvand A, Boscainos P, Chen AF, Garcia GA, Gehrke T, Granger J, Kheir M, Kinov P, Malo M, Manrique J, Meek D, Meheux C, Middleton R, Montilla F, Reed M, Reisener MJ, van der Rijt A, Rossmann M, Spangehl M, Stocks G, Young P, Young S, Zahar A, Zhang X. Hip and Knee Section, Prevention, Operating Room Environment: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S293-S300. [PMID: 30343970 DOI: 10.1016/j.arth.2018.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Bartek M, Verdial F, Patchen Dellinger E. Reply to Hambraeus and Lytsy. Clin Infect Dis 2018; 67:159-160. [PMID: 29370343 PMCID: PMC6005022 DOI: 10.1093/cid/ciy061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Matthew Bartek
- Department of Surgery, University of Washington, Seattle
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Baumann M, Cater JE. The Effect of Heated CO 2 Insufflation in Minimising Surgical Wound Contamination During Open Surgery. Ann Biomed Eng 2018; 46:1101-1111. [PMID: 29704185 DOI: 10.1007/s10439-018-2034-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 04/19/2018] [Indexed: 10/17/2022]
Abstract
The primary source of infections in open surgeries has been found to be bacteria and viruses carried into the surgical wound on the surfaces of skin particles shed by patients and surgical staff. In open cardiac surgeries, insufflation of the wound with carbon dioxide is used to limit the quantity of air able to enter into the heart, avoiding air embolisms when the heart is restarted. This surgical technique has been evaluated as a method of limiting the number of skin particles able to enter into the wound, using computational fluid dynamics (CFD) simulations and experimental testing. Spherical particles of 5.0 and 13.5 μm in diameter were used to simulate skin particles falling above a wound, travelling in air ventilation velocities of either 0.2 or 0.4 m/s, and with or without CO2 insufflation. The CFD simulations with CO2 included a diffuser placed in the wound and supplied with CO2 at a rate of 10 L/min. Experimental testing was completed under similar conditions. The results of CFD simulations and experimental testing showed CO2 insufflation can significantly limit the number of particles able to enter into the wound.
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Affiliation(s)
- Monika Baumann
- Fisher & Paykel Healthcare Ltd, 15 Maurice Paykel Pl, East Tamaki, Auckland, 2013, New Zealand
| | - John E Cater
- Department of Engineering Science, The University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.
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Stauning MT, Bediako-Bowan A, Andersen LP, Opintan JA, Labi AK, Kurtzhals JAL, Bjerrum S. Traffic flow and microbial air contamination in operating rooms at a major teaching hospital in Ghana. J Hosp Infect 2017; 99:263-270. [PMID: 29253624 DOI: 10.1016/j.jhin.2017.12.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 12/11/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Current literature examining the relationship between door-opening rate, number of people present, and microbial air contamination in the operating room is limited. Studies are especially needed from low- and middle-income countries, where the risk of surgical site infections is high. AIM To assess microbial air contamination in operating rooms at a Ghanaian teaching hospital and the association with door-openings and number of people present. Moreover, we aimed to document reasons for door-opening. METHODS We conducted active air-sampling using an MAS 100® portable impactor during 124 clean or clean-contaminated elective surgical procedures. The number of people present, door-opening rate and the reasons for each door-opening were recorded by direct observation using pretested structured observation forms. FINDINGS During surgery, the mean number of colony-forming units (cfu) was 328 cfu/m3 air, and 429 (84%) of 510 samples exceeded a recommended level of 180 cfu/m3. Of 6717 door-openings recorded, 77% were considered unnecessary. Levels of cfu/m3 were strongly correlated with the number of people present (P = 0.001) and with the number of door-openings/h (P = 0.02). In empty operating rooms, the mean cfu count was 39 cfu/m3 after 1 h of uninterrupted ventilation and 52 (51%) of 102 samples exceeded a recommended level of 35 cfu/m3. CONCLUSION The study revealed high values of intraoperative airborne cfu exceeding recommended levels. Minimizing the number of door-openings and people present during surgery could be an effective strategy to reduce microbial air contamination in low- and middle-income settings.
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Affiliation(s)
- M T Stauning
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - A Bediako-Bowan
- Department of Surgery, School of Medicine and Dentistry, University of Ghana, Accra, Ghana; Department of Surgery, Korle-Bu Teaching Hospital, Accra, Ghana
| | - L P Andersen
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - J A Opintan
- Department of Medical Microbiology, School of Biomedical and Allied Health Sciences, University of Ghana, Accra, Ghana
| | - A-K Labi
- Department of Microbiology, Korle-Bu Teaching Hospital, Accra, Ghana
| | - J A L Kurtzhals
- Centre for Medical Parasitology, Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark.
| | - S Bjerrum
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Global Health Section, Department of Public Health, University of Copenhagen, Denmark
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Cracking the case: should orthopaedic case carts be subjected to more stringent regulations? CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Compliance with clothing regulations and traffic flow in the operating room: a multi-centre study of staff discipline during surgical procedures. J Hosp Infect 2017; 96:281-285. [DOI: 10.1016/j.jhin.2017.03.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 03/23/2017] [Indexed: 11/23/2022]
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Antimicrobial efficacy of preoperative skin antisepsis and clonal relationship to postantiseptic skin-and-wound flora in patients undergoing clean orthopedic surgery. Eur J Clin Microbiol Infect Dis 2015; 34:2265-73. [PMID: 26337434 DOI: 10.1007/s10096-015-2478-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 08/20/2015] [Indexed: 10/23/2022]
Abstract
Nosocomial surgical site infections (SSI) are still important complications in surgery. The underlying mechanisms are not fully understood. The aim of this study was to elucidate the possible role of skin flora surviving preoperative antisepsis as a possible cause of SSI. We conducted a two-phase prospective clinical trial in patients undergoing clean orthopedic surgery at a university trauma center in northern Germany. Quantitative swab samples were taken from pre- and postantiseptic skin and, additionally, from the wound base, wound margin, and the suture of 137 patients. Seventy-four patients during phase I and 63 during phase II were investigated. Microbial growth, species spectrum, and antibiotic susceptibility were analyzed. In phase two, the clonal relationship of strains was additionally analyzed. 18.0 % of the swab samples were positive for bacterial growth in the wound base, 24.5 % in the margin, and 27.3 % in the suture. Only 65.5 % of patients showed a 100 % reduction of the skin flora after antisepsis. The microbial spectrum in all postantiseptic samples was dominated by coagulase-negative staphylococci (CoNS). Clonally related staphylococci were detected in ten patients [nine CoNS, one methicillin-susceptible Staphylococcus aureus (MSSA)]. Six of ten patients were suspected of having transmitted identical clones from skin flora into the wound. Ethanol-based antisepsis results in unexpected high levels of skin flora, which can be transmitted into the wound during surgery causing yet unexplained SSI. Keeping with the concept of zero tolerance, further studies are needed in order to understand the origin of this flora to allow further reduction of SSI.
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Birgand G, Toupet G, Rukly S, Antoniotti G, Deschamps MN, Lepelletier D, Pornet C, Stern JB, Vandamme YM, van der Mee-Marquet N, Timsit JF, Lucet JC. Air contamination for predicting wound contamination in clean surgery: A large multicenter study. Am J Infect Control 2015; 43:516-21. [PMID: 25752955 DOI: 10.1016/j.ajic.2015.01.026] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 01/22/2015] [Accepted: 01/22/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The best method to quantify air contamination in the operating room (OR) is debated, and studies in the field are controversial. We assessed the correlation between 2 types of air sampling and wound contaminations before closing and the factors affecting air contamination. METHODS This multicenter observational study included 13 ORs of cardiac and orthopedic surgery in 10 health care facilities. For each surgical procedure, 3 microbiologic air counts, 3 particles counts of 0.3, 0.5, and 5 μm particles, and 1 bacteriologic sample of the wound before skin closure were performed. We collected data on surgical procedures and environmental characteristics. RESULTS Of 180 particle counts during 60 procedures, the median log10 of 0.3, 0.5, and 5 μm particles was 7 (interquartile range [IQR], 6.2-7.9), 6.1 (IQR, 5.4-7), and 4.6 (IQR, 0-5.2), respectively. Of 180 air samples, 50 (28%) were sterile, 90 (50%) had 1-10 colony forming units (CFU)/m(3) and 40 (22%) >10 CFU/m(3). In orthopedic and cardiac surgery, wound cultures at closure were sterile for 24 and 9 patients, 10 and 11 had 1-10 CFU/100 cm(2), and 0 and 6 had >10 CFU/100 cm(2), respectively (P < .01). Particle sizes and a turbulent ventilation system were associated with an increased number of air microbial counts (P < .001), but they were not associated with wound contamination (P = .22). CONCLUSIONS This study suggests that particle counting is a good surrogate of airborne microbiologic contamination in the OR.
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Influence of Staff Behavior on Infectious Risk in Operating Rooms: What Is the Evidence? Infect Control Hosp Epidemiol 2015; 36:93-106. [DOI: 10.1017/ice.2014.9] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
SUMMARYA systematic literature review was performed to assess the impact of surgical-staff behaviors on the risk of surgical site infections. Published data are limited, heterogeneous, and weakened by several methodological flaws, underlying the need for more studies with accurate tools.OBJECTIVETo assess the current literature regarding the impact of surgical-staff behaviors on the risk of surgical-site infection (SSI).DESIGNSystematic literature review.METHODSWe searched the Medline, EMBASE, Ovid, Web of Science, and Cochrane databases for original articles about the impact of intraoperative behaviors on the risk of SSI published in English before September 2013.RESULTSWe retrieved 27 original articles reporting data on number of people in the operating room (n=14), door openings (n=14; number [n=6], frequency [n=7], reasons [n=4], or duration [n=3]), surgical-team discipline (evidence of distraction; n=4), compliance with traffic measures (n=6), or simulated behaviors (n=3). Most (59%) articles were published in 2009–2013. End points were the 30-day SSI rate (n=8), air-particle count (n=2), or microbiological air counts (n=6); 11 studies were only descriptive. Number of people in the operating room and SSI rate or airborne contaminants (particle/bacteria) were correlated in 2 studies. Door openings and airborne bacteria counts were correlated in 2 observational studies and 1 experimental study. Two cohort studies showed a significant association between surgeon interruptions/distraction or noise and SSI rate. The level of evidence was low in all studies.CONCLUSIONSPublished data about the impact of operating-room behaviors on the risk of infection are limited and heterogeneous. All studies exhibit major methodological flaws. More studies with accurate tools should be performed to address the influence of operating room behaviors on the infectious risk.Infect Control Hosp Epidemiol 2015;36(1): 93–106
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Birgand G, Azevedo C, Toupet G, Pissard-Gibollet R, Grandbastien B, Fleury E, Lucet JC. Attitudes, risk of infection and behaviours in the operating room (the ARIBO Project): a prospective, cross-sectional study. BMJ Open 2014; 4:e004274. [PMID: 24384903 PMCID: PMC3902656 DOI: 10.1136/bmjopen-2013-004274] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Inappropriate staff behaviours can lead to environmental contamination in the operating room (OR) and subsequent surgical site infection (SSI). This study will focus on the continued assessment of OR staff behaviours using a motion tracking system and their impact on the SSI risk during surgical procedures. METHODS AND ANALYSIS This multicentre prospective cross-sectional study will include 10 ORs of cardiac and orthopaedic surgery in 12 healthcare facilities (HCFs). The staff behaviour will be assessed by an objective, continued and prolonged quantification of movements within the OR. A motion tracking system including eight optical cameras (VICON-Bonita) will record the movements of reflective markers placed on the surgical caps/hoods of each person entering the room. Different configurations of markers positioning will be used to distinguish between the staff category. Doors opening will be observed by means of wireless inertial sensors fixed on the doors and synchronised with the motion tracking system. We will collect information on the OR staff, surgical procedures and surgical environment characteristics. The behavioural data obtained will be compared (1) to the 'best behaviour rules' in the OR, pre-established using a Delphi method and (2) to surrogates of the infectious risk represented by microbiological air counts, particle counts, and a bacteriological sample of the wound at closing. Statistics will be performed using univariate and multivariate analysis to adjust on the aerolic and architectural characteristics of the OR. A multilevel model will allow including surgical specialty and HCFs effects. Through this study, we will develop an original approach using high technology tools associated to data processing techniques to evaluate 'automatically' the behavioural dynamics of the OR staff and their impact on the SSI risk. ETHICS AND DISSEMINATION Approbation of the Institutional Review Board of Paris North Hospitals, Paris 7 University, AP-HP (no 11-113, 6 April 2012). The findings will be disseminated through peer-reviewed journals, and national and international conference presentations.
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Affiliation(s)
- Gabriel Birgand
- IAME, UMR 1137, Univ Paris Diderot, Sorbonne Paris Cité, Paris, France
- IAME, UMR 1137, INSERM, Paris, France
- Infection Control Unit, AP-HP, Hôpital Bichat, Paris, France
| | - Christine Azevedo
- Laboratoire d'Informatique de Robotique et de Microélectronique de Montpellier (LIRMM), CNRS: UMR5506—Université Montpellier II—Sciences et techniquesNRIA Sophia Antipolis-LIRMM, Montpellier, France
- Institut National de Recherche en Informatique et en Automatique, Montbonnot, France
| | - Gaelle Toupet
- Infection Control Unit, AP-HP, Hôpital Bichat, Paris, France
| | | | | | - Eric Fleury
- Institut National de Recherche en Informatique et en Automatique, Montbonnot, France
- Laboratoire de l'Informatique du Parallélisme (LIP), PRES Université de Lyon—CNRS: UMR5668—Ecole Normale Supérieure—Lyon, Université Claude Bernard, Lyon I, France
| | - Jean-Christophe Lucet
- IAME, UMR 1137, Univ Paris Diderot, Sorbonne Paris Cité, Paris, France
- IAME, UMR 1137, INSERM, Paris, France
- Infection Control Unit, AP-HP, Hôpital Bichat, Paris, France
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Andersson AE, Bergh I, Karlsson J, Eriksson BI, Nilsson K. Traffic flow in the operating room: an explorative and descriptive study on air quality during orthopedic trauma implant surgery. Am J Infect Control 2012; 40:750-5. [PMID: 22285652 DOI: 10.1016/j.ajic.2011.09.015] [Citation(s) in RCA: 163] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Revised: 09/13/2011] [Accepted: 09/13/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Understanding the protective potential of operating room (OR) ventilation under different conditions is crucial to optimizing the surgical environment. This study investigated the air quality, expressed as colony-forming units (CFU)/m(3), during orthopedic trauma surgery in a displacement-ventilated OR; explored how traffic flow and the number of persons present in the OR affects the air contamination rate in the vicinity of surgical wounds; and identified reasons for door openings in the OR. METHODS Data collection, consisting of active air sampling and observations, was performed during 30 orthopedic procedures. RESULTS In 52 of the 91 air samples collected (57%), the CFU/m(3) values exceeded the recommended level of <10 CFU/m(3). In addition, the data showed a strongly positive correlation between the total CFU/m(3) per operation and total traffic flow per operation (r = 0.74; P = .001; n = 24), after controlling for duration of surgery. A weaker, yet still positive correlation between CFU/m(3) and the number of persons present in the OR (r = 0.22; P = .04; n = 82) was also found. Traffic flow, number of persons present, and duration of surgery explained 68% of the variance in total CFU/m(3) (P = .001). CONCLUSIONS Traffic flow has a strong negative impact on the OR environment. The results of this study support interventions aimed at preventing surgical site infections by reducing traffic flow in the OR.
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Affiliation(s)
- Annette Erichsen Andersson
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Braswell ML, Spruce L. Implementing AORN Recommended Practices for Surgical Attire. AORN J 2012; 95:122-37; quiz 138-40. [DOI: 10.1016/j.aorn.2011.10.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 10/19/2011] [Indexed: 10/14/2022]
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Wiener-Well Y, Galuty M, Rudensky B, Schlesinger Y, Attias D, Yinnon AM. Nursing and physician attire as possible source of nosocomial infections. Am J Infect Control 2011; 39:555-9. [PMID: 21864762 DOI: 10.1016/j.ajic.2010.12.016] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 12/12/2010] [Accepted: 12/14/2010] [Indexed: 12/27/2022]
Abstract
BACKGROUND Uniforms worn by medical and nursing staff are not usually considered important in the transmission of microorganisms. We investigated the rate of potentially pathogenic bacteria present on uniforms worn by hospital staff, as well as the bacterial load of these microorganisms. METHODS Cultures were obtained from uniforms of nurses and physicians by pressing standard blood agar plates at the abdominal zone, sleeve ends, and pockets. Each participant completed a questionnaire. RESULTS A total of 238 samples were collected from 135 personnel, including 75 nurses (55%) and 60 physicians (45%). Of these, 79 (58%) claimed to change their uniform every day, and 104 (77%) defined the level of hygiene of their attire as fair to excellent. Potentially pathogenic bacteria were isolated from at least one site of the uniforms of 85 participants (63%) and were isolated from 119 samples (50%); 21 (14%) of the samples from nurses' gowns and 6 (6%) of the samples from physicians' gowns (P = NS) included of antibiotic-resistant bacteria. CONCLUSION Up to 60% of hospital staff's uniforms are colonized with potentially pathogenic bacteria, including drug-resistant organisms. It remains to be determined whether these bacteria can be transferred to patients and cause clinically relevant infection.
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Graf K, Ott E, Vonberg RP, Kuehn C, Schilling T, Haverich A, Chaberny IF. Surgical site infections--economic consequences for the health care system. Langenbecks Arch Surg 2011; 396:453-9. [PMID: 21404004 DOI: 10.1007/s00423-011-0772-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 02/24/2011] [Indexed: 11/28/2022]
Abstract
PURPOSES Unfortunately, surgical site infections (SSIs) are a quite common complication and represent one of the major causes of postoperative morbidity and mortality, and may furthermore lead to enormous additional costs for hospitals and health care systems. METHODS In order to determine the estimated costs due to SSIs, a MEDLINE search was performed to identify articles that provide data on economic aspects of SSIs and compared to findings from a matched case-control study on costs of SSIs after coronary bypass grafting (CABG) in a German tertiary care university hospital. RESULTS A total of 14 studies on costs were found. The additional costs of SSI vary between $3,859 (mean) and $40,559 (median). Median costs of a single CABG case in the recently published study were $49,449 (€36,261) vs. $18,218 (€13,356) in controls lacking infection (p < 0.0001). The median reimbursement from health care insurance companies was $36,962 (€27,107) leading to a financial loss of $12,482 (€9,154) each. CONCLUSION Costs of SSIs may almost triple the individual overall health care costs and those additional charges may not be sufficiently covered. Appropriate measures to reduce SSI rates must be taken to improve the patient's safety. This should also diminish costs for health care systems which benefits the entire community.
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Affiliation(s)
- Karolin Graf
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover, D-30625, Germany.
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Tanner J, Khan D. Surgical site infection, preoperative body washing and hair removal. J Perioper Pract 2008; 18:232, 237-43. [PMID: 18616201 DOI: 10.1177/175045890801800602] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Estimates suggest one in 20 patients develop an infection following surgery, costing the NHS around pounds 1bn each year (SSHAIP 2004). This article discusses surgical site infections and the commonest bacteria which cause them. It then explores two practices, preoperative body washing and preoperative hairremoval, and their effect on bacterial reduction and surgical site infection.
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Affiliation(s)
- Judith Tanner
- Montfort University, University Hospitals Leicester, Charles Frears Campus, Leicester, UK.
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Francois P, Hochmann A, Huyghe A, Bonetti EJ, Renzi G, Harbarth S, Klingenberg C, Pittet D, Schrenzel J. Rapid and high-throughput genotyping of Staphylococcus epidermidis isolates by automated multilocus variable-number of tandem repeats: A tool for real-time epidemiology. J Microbiol Methods 2008; 72:296-305. [DOI: 10.1016/j.mimet.2007.12.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Revised: 11/23/2007] [Accepted: 12/07/2007] [Indexed: 11/25/2022]
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Hurst EA, Grekin RC, Yu SS, Neuhaus IM. Infectious Complications and Antibiotic Use in Dermatologic Surgery. ACTA ACUST UNITED AC 2007; 26:47-53. [PMID: 17349563 DOI: 10.1016/j.sder.2006.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Infection rates in dermatologic surgery are low, ranging on average from 1 to 3%. Studies have shown that many practitioners likely overuse antibiotics, both for prevention of wound infection and in endocarditis prophylaxis. This article discusses patient and environmental risk factors in would infection. Data on wound infection prophylaxis are reviewed, and specific guidelines set forth with regards to appropriate antibiotic usage, drug selection, dosage, and timing. In addition, recommendations surrounding endocarditis and prosthetic joint infection prophylaxis are presented as they apply to dermatologic surgery.
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Affiliation(s)
- Eva A Hurst
- UCSF Dermatologic Surgery and Laser Center, San Francisco, CA 94115, USA
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Hakalehto E. Semmelweis' present day follow-up: Updating bacterial sampling and enrichment in clinical hygiene. ACTA ACUST UNITED AC 2006; 13:257-67. [PMID: 17010578 DOI: 10.1016/j.pathophys.2006.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2005] [Revised: 07/31/2006] [Accepted: 08/02/2006] [Indexed: 11/23/2022]
Abstract
Potentially dangerous antibiotic resistant contaminants have permanently penetrated at least well-off western populations. The danger is so evident that some hospitals have started to refuse accepting patients who carry such bacteria. Sampling and enrichment measures in hygiene monitoring must be updated as they are corner stones in handling the problems and safeguarding the health care units. Their patients, when exposed to microorganisms are strenuous to treat. Sometimes even this fails, if the infections are spreading in weakened patients. The present review summarizes currently used technologies and the abilities of bacteria to avoid detection. Improved protocols on environmental monitoring in healthcare units are required. They should be comparable with contamination control in industries. Actually these measures in health care should be even stricter because human lives are directly endangered as the resistance of especially elderly patients is low.
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Affiliation(s)
- Elias Hakalehto
- Department of Chemistry, University of Kuopio, P.O. Box 1627, FIN-70211 Kuopio, Finland
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Swenne CL, Lindholm C, Borowiec J, Carlsson M. Surgical-site infections within 60 days of coronary artery by-pass graft surgery. J Hosp Infect 2006; 57:14-24. [PMID: 15142711 DOI: 10.1016/j.jhin.2004.02.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2003] [Accepted: 01/30/2004] [Indexed: 11/29/2022]
Abstract
Surgical wound infections (SWIs) after coronary artery by-pass graft (CABG) within 30 and 60 days of operation were registered. Already known risk factors and possible risk factors for wound infection were studied. SWIs of sternal and/or leg wounds have been reported to occur in 2-20% of patients after CABG. Deep sternal infection, mediastinitis, occurs after 0.5-5% of CABG procedures. The duration and methods of follow-up, as well as definitions of SWI, vary in different studies. Previously known and possible new risk factors were registered for 374 patients. Patients were contacted by telephone 30 and 60 days after surgery and interviewed in accordance with a questionnaire about symptoms and signs of wound infections. Our definition of SWI was based on the Centers for Disease Control and Prevention (CDC) definition. SWIs were diagnosed in 114 of 374 (30.5%) of the patients. In total SWI were diagnosed in 120 surgical-site incisions. Almost all SWIs of the sternum (93.3%) were diagnosed within 30 days of surgery. Most of the SWIs of the leg (73%) were diagnosed within 30 days of surgery and 27% were diagnosed within 31 to 60 days of surgery. Being female was the most important risk factor for SWI of the leg. Low preoperative haemoglobin concentrations were the most important risk factor for superficial SWI on the sternum. Patients with mediastinitis had higher BMI and had more often received erythrocyte transfusions on postoperative day two or later than those without infections.
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Affiliation(s)
- C L Swenne
- FoUU-board, Karolinska University Hospital, H4:06, Stockholm, Sweden.
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Swenne CL, Lindholm C, Borowiec J, Schnell AE, Carlsson M. Peri-operative glucose control and development of surgical wound infections in patients undergoing coronary artery bypass graft. J Hosp Infect 2005; 61:201-12. [PMID: 16039014 DOI: 10.1016/j.jhin.2005.02.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2004] [Accepted: 02/21/2005] [Indexed: 01/08/2023]
Abstract
Elevated blood glucose following coronary artery bypass graft (CABG) is associated with an increased risk of surgical wound infection (SWI). It is unclear whether hyperglycaemia, the diabetic state, the longstanding vascular effects of diabetes, or the systematic inflammatory response confers the increased vulnerability to SWI. This study was designed to examine the significance of postoperative blood glucose control as a risk factor for SWI after vein graft harvesting on the leg and sternotomy. Patients with and without diabetes had a CABG within 60 days to be eligible. The present study was part of a larger protocol investigating SWI following CABG in a total of 374 patients. Potential risk factors, duration of diabetes, pre-operative glycated haemoglobin (HbA(1c)) and presence of long-term complications were recorded. All patient records were reviewed retrospectively to record 10% glucose infusions during the operation, and blood glucose concentrations and insulin therapy on postoperative days 0, 1 and 2. Patients were contacted by telephone 30 and 60 days after surgery and interviewed in accordance with a questionnaire about symptoms and signs of wound infection. In the present study, it was not possible to separate the effect of diabetes as a risk factor for SWI from that of hyperglycaemia. However, in the subgroup of patients without a pre-operative diagnosis of diabetes, increased blood glucose concentrations during postoperative days 0, 1 and 2 was associated with an increased risk of mediastinitis.
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Affiliation(s)
- C L Swenne
- Department of Cardiothoracic Surgery, Uppsala University Hospital, OTM divisionen ing 40, 4tr, SE-751 85 Uppsala, Sweden.
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Tegnell A, Saeedi B, Isaksson B, Granfeldt H, Ohman L. A clone of coagulase-negative staphylococci among patients with post-cardiac surgery infections. J Hosp Infect 2002; 52:37-42. [PMID: 12372324 DOI: 10.1053/jhin.2002.1267] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Coagulase-negative staphylococci (CoNS) are important causes of hospital-acquired infections such as infections after cardiac surgery. Efforts to reduce these infections are hampered by the lack of knowledge concerning the epidemiology of CoNS in this setting. Forty strains of CoNS collected during the surgical revision of 27 patients operated on between 1997 and 2000 were analysed. Strains were also collected from the ambient air in the operating suite. Their pulsed-field gel electrophoresis (PFGE) characteristics and antibiotic resistance were analysed. Using PFGE 19 of 40 strains from 15 of 27 patients were shown to belong to one clone, and strains from this clone were also isolated from the ambient air. This clone had caused infections throughout the period. Antibiotic resistance did not correlate with PFGE patterns. Using PFGE one clone could be identified that caused 56% of the CoNS infections during this period. A strain from this clone was also found in the air of the operating suite suggesting the origin of the CoNS causing infections was the hospital environment.
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Affiliation(s)
- A Tegnell
- Division of Infectious Diseases, Department of Health and Environment, Linköping University, Sweden.
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Tammelin A, Hambraeus A, Ståhle E. Mediastinitis after cardiac surgery: improvement of bacteriological diagnosis by use of multiple tissue samples and strain typing. J Clin Microbiol 2002; 40:2936-41. [PMID: 12149355 PMCID: PMC120659 DOI: 10.1128/jcm.40.8.2936-2941.2002] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The diagnosis of postsurgical mediastinitis (PSM) among patients with sternal wound complication (SWC) after cardiac surgery is sometimes difficult, as fever, elevated C-reactive protein levels, and chest pain can be caused by a general inflammatory reaction to the operative trauma and/or sternal dehiscence without infection. The definitions of PSM usually used emphasize clinical signs and symptoms easily observed by the surgeon. The aim of the study was to investigate whether the use of standardized multiple tissue sampling, optimal culturing methods, and strain typing, together with a microbiological criterion for infection, could identify more infected patients than clinical assessment alone. Patients reexplored due to SWC after cardiac artery bypass grafting (CABG) or heart valve replacement (HVR) with or without CABG performed at the Department for Cardio-Thoracic Surgery at the Uppsala University Hospital between 10 March 1998 and 9 September 2000 were investigated prospectively. Tissue samples were taken from the sternum or adjacent mediastinal tissue, preferably before the administration of antibiotics. Culturing was performed both directly (on agar plates) and using enrichment broth. Species identification was performed by standard methods, and strain typing was performed by pulsed-field gel electrophoresis. A total of 41 cases with at least five tissue samples each were included in the study group. Of these patients, 32 were infected according to the microbiological criterion (i.e., the same strain was found in >/=50% of the samples). Staphylococcus epidermidis was the primary pathogen in 38% of the cases (12/32), S. aureus was the primary pathogen in 31% (10/32), P. acnes was the primary pathogen in 25% (8/32), and S. simulans and S. haemolyticus were the primary pathogens in 3% (1/32) each. All cases of S. aureus infection and 86% (12/14) of coagulase-negative staphylococcus (CoNS) infections were identified from primary cultures. All cases fulfilling the microbiological criterion for S. aureus infection were clinically diagnosed as cases of infection, but among the 14 cases fulfilling the criterion for microbiological diagnosis of CoNS infection, only 10 appeared to qualify clinically as cases of infection. Among the patients with sternal dehiscence in whom a microbiological diagnosis was established, 67% (12/18) had a CoNS infection, compared to 14% (2/14) of those without sternal dehiscence. The difference was statistically significant. PSM caused by S. aureus is readily identified by the surgeon, whereas 30% of cases with CoNS infections may be misinterpreted as noninfected. Multiple sampling before administration of antibiotics, primary culturing on agar plates, species identification, strain typing, and susceptibility testing should be used to ensure a fast and microbiologically correct diagnosis which identifies the primary pathogen and infected patients among those with minor infective symptoms. The role of P. acnes as a possible cause of PSM needs further investigation. PSM caused by CoNS is significantly related to sternal dehiscence.
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Affiliation(s)
- Ann Tammelin
- Department of Clinical Bacteriology, University of Uppsala, Sweden.
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Abstract
PURPOSE OF THE REVIEW The present review covers the literature on prevention of surgical site infections published during 2001. Only papers that offer new insights or question current recommendations are included. RECENT FINDINGS The most interesting advances have been made in the preoperative preparation of the patient. In particular, the effects of preoperative warming of the patient, either generally or locally at the incision site, on the rate of surgical site infections are impressive and warrant further investigation. Also, the effects of strict control of perioperative blood glucose levels and of preoperative eradication of nasal carriage of Staphylococcus aureus should be studied in greater detail. SUMMARY The protective effect of local and systemic warming before surgical procedures has been described in two well designed studies. Although a final judgement regarding effectiveness can only be made after more extensive investigations have been conducted, there appear to be few arguments against application of this cheap and safe measure. Thus, implementation of preoperative warming can be justified in settings associated with high rates of surgical site infections.
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Affiliation(s)
- Jan Kluytmans
- Department of Microbiology and Infection Control, Amphia Hospital Breda, Breda, The Netherlands.
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Eklund AM, Ojajärvi J, Laitinen K, Valtonen M, Werkkala KA. Glove punctures and postoperative skin flora of hands in cardiac surgery. Ann Thorac Surg 2002; 74:149-53. [PMID: 12118748 DOI: 10.1016/s0003-4975(02)03690-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Surgical gloves are frequently perforated during operations, including heart operations. This infection risk factor is inadequately studied. METHODS After preoperative hand disinfection and at the end of 116 heart operations, bacterial samples from hands of surgeons, altogether 800 samples, were taken. Glove punctures were examined with water test. RESULTS Surgeons changed 70 gloves because of breakage during operations. Additionally, 154 of 400 (39%) gloves had holes in postoperative testing. The breakage rate of gloves increased from 30% in operations shorter than 3 hours to 65% when operations were longer than 5 hours. High bacterial counts of the hands were also more common after prolonged operations. CONCLUSIONS Glove puncture rates and bacterial counts of hands increase with increasing operation time. We recommend changing of both gloves when a puncture is detected. Before donning new gloves, hands should be disinfected.
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Affiliation(s)
- Anne M Eklund
- Department of Cardiothoracic Surgery, Helsinki University Central Hospital, Finland.
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