Preventing surgical-site infections: Measures other than antibiotics

Abstract

Surgical-site infections (SSIs) due to intra-operative contamination are chiefly ascribable to airborne particles carrying microorganisms, mainly Staphylococcus aureus, which settle on the surgeon's hands and instruments. SSI prevention therefore rests on minimisation of airborne contaminated particle counts, although these have not been demonstrated to correlate significantly with SSI rates. Maintaining clear air in the operating room classically involves the use of ultra clean ventilation systems combining laminar airflow and high-efficiency particulate air filters to create a physical barrier around the surgical table; in addition to a stringent patient preparation protocol, appropriate equipment, and strict operating room discipline on the part of the surgeon and other staff members. SSI rates in clean surgery, although influenced by the type of procedure and by patient-related factors, are consistently very low, of about 1% to 2%. These low rates, together with the effectiveness of prophylactic antibiotic therapy and the multiplicity of parameters influencing the SSI risk, are major obstacles to the demonstration that a specific measure is effective in decreasing SSIs. As a result, controversy surrounds the usefulness of many measures, including laminar airflow, body exhaust suits, patient preparation techniques, and specific surgical instruments. Impeccable surgical technique and operating room behaviour, in contrast, are clearly essential.

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

“…Although a statistically significant reduction in CFU/m 3 was not observed, these results are encouraging and a larger sample size is required to further investigate these preliminary findings and reduce the likelihood of a type II error. Furthermore, studies have found significant correlations between particle counts and airborne bacteria . Hansen et al found that both ultra‐fine particles and particles larger 5 μm were good surrogates for airborne bacteria and viruses as bacteria are 0.2–5 μm in size and often adhere to larger particles larger than 5 μm to form aggregates.…”

“…The particle counter sampled the air for 1 min and rested for 9 min until the subsequent sample collection. It recorded particles in the size range of 0.5–10 μm, which corresponds to the size range of bacteria and bacteria‐laden particles . TPC included both viable (e.g., bacteria or skin cells) and non‐viable (e.g., dust) particles.…”

“…Another study on wound contamination in TJA found that 98% of bacterial contaminants came directly or indirectly from the air . It follows that this principal source of infection has been targeted through several preventative measures …”

Factors contributing to airborne particle dispersal in the operating room

“…Although surgical-site bacterial counts correlate with airborne bacteria and particle counts [3–5], they have not been demonstrated to correlate directly with the rate of SSIs [4]. The actual relationship among the amount of particles, the incidence of bacterial contamination, and the rate of SSIs was not addressed in this study.…”

“…However, airborne particles can act as vectors for transmission of bacteria after coming in contact with unsterile areas (e.g. skin, walls, or floor) [4]. Particles settled on an unsterile floor can be easily dispersed by air eddies generated from opening doors and foot traffic.…”