The anaesthetists' role in perioperative infection control: what is the action plan?
2019; Elsevier BV; Volume: 123; Issue: 5 Linguagem: Inglês
10.1016/j.bja.2019.07.013
ISSN1471-6771
AutoresRandy W. Loftus, Javier H. Campos,
Tópico(s)Antimicrobial Resistance in Staphylococcus
ResumoHospitalised patients who suffer from healthcare-associated infections (HAIs) experience increased morbidity, mortality, and healthcare costs.1Magill S.S. O'Leary E. Janelle S.J. et al.Emerging infections program hospital prevalence survey team. Changes in prevalence of health care-associated infections in U.S. Hospitals.N Engl J Med. 2018; 379: 1732-1744Crossref PubMed Scopus (481) Google Scholar, 2Koff M.D. Brown J.R. Marshall E.J. et al.Frequency of hand decontamination of intraoperative providers and reduction of postoperative healthcare-associated infections: a randomized clinical trial of a novel hand hygiene system.Infect Control Hosp Epidemiol. 2016; 37: 888-895Crossref PubMed Scopus (29) Google Scholar Enterococcus, Staphylococcus aureus, Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter spp. (ESKAPE) are leading causative organisms of infection.3Boucher H.W. Talbot G.H. Bradley J.S. et al.Bad bugs, no drugs: no ESKAPE! an update from the Infectious Diseases Society of America.Clin Infect Dis. 2009; 48: 1-12Crossref PubMed Scopus (3718) Google Scholar Postoperative HAIs affect at least 7% of patients undergoing surgery, as proven by rigorous investigation2Koff M.D. Brown J.R. Marshall E.J. et al.Frequency of hand decontamination of intraoperative providers and reduction of postoperative healthcare-associated infections: a randomized clinical trial of a novel hand hygiene system.Infect Control Hosp Epidemiol. 2016; 37: 888-895Crossref PubMed Scopus (29) Google Scholar and falling within the 1.9–8.8% range reported by national stakeholders.4World Health Organization Antimicrobial resistance: global report on surveillance. WHO, 2014Google Scholar, 5Centers for Disease Control and PreventionUpdated guidelines for evaluating public health surveillance systems: recommendations from the Guidelines Working Group.MMWR. 2001; 50: 1-35PubMed Google Scholar, 6FACT SHEET: Obama Administration Takes Actions to Combat Antibiotic-Resistant Bacteria. The White House, Office of the Press Secretary. http://www.whitehouse.gov/the-press-office/2014/09/18/fact-sheet-obama-administration-takes-actions-combat-antibiotic-resistan (accessed 1 September 2018).Google Scholar Treatment of HAIs has fuelled resistance, making infections more difficult to treat when they develop.3Boucher H.W. Talbot G.H. Bradley J.S. et al.Bad bugs, no drugs: no ESKAPE! an update from the Infectious Diseases Society of America.Clin Infect Dis. 2009; 48: 1-12Crossref PubMed Scopus (3718) Google Scholar Given that improved basic preventive measures can significantly reduce postoperative HAIs7Schweizer M.L. Chiang H.Y. Septimus E. et al.Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery.JAMA. 2015; 313: 2162-2171Crossref PubMed Scopus (192) Google Scholar, 8Loftus R.W. Patel H.M. Huysman B.C. et al.Prevention of intravenous bacterial injection from health care provider hands: the importance of catheter design and handling.Anesth Analg. 2012; 115: 1109-1119Crossref PubMed Scopus (39) Google Scholar, 9Koff M.D. Loftus R.W. Burchman C.C. et al.Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a novel device.Anesthesiology. 2009; 110: 978-985Crossref PubMed Scopus (103) Google Scholar, 10Loftus R.W. Brindeiro B.S. Kispert D.P. et al.Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a passive catheter care system.Anesth Analg. 2012; 115: 1315-1323Crossref PubMed Google Scholar, 11Bode L.G. Kluytmans J.A. Wertheim H.F. et al.Preventing surgical-site infections in nasal carriers of Staphylococcus aureus.N Engl J Med. 2010; 362: 9-17Crossref PubMed Scopus (893) Google Scholar, 12Phillips M. Rosenberg A. Shopsin B. et al.Preventing surgical site infections: a randomized, open-label trial of nasal mupirocin ointment and nasal povidone iodine solution.Infect Control Hosp Epidemiol. 2014; 35: 826-832Crossref PubMed Scopus (90) Google Scholar, 13Huang S.S. Singh R. McKinnell J.A. et al.Decolonization to reduce postdischarge infection risk among MRSA carriers.N Engl J Med. 2019; 380: 638-650Crossref PubMed Scopus (64) Google Scholar and thereby decrease the need for antibiotic use, national organisations have encouraged healthcare systems to focus on three key initiatives: (1) prevention of postoperative infections, (2) prevention of patient-to-patient bacterial transmission, and (3) improved antibiotic stewardship.4World Health Organization Antimicrobial resistance: global report on surveillance. WHO, 2014Google Scholar, 5Centers for Disease Control and PreventionUpdated guidelines for evaluating public health surveillance systems: recommendations from the Guidelines Working Group.MMWR. 2001; 50: 1-35PubMed Google Scholar, 6FACT SHEET: Obama Administration Takes Actions to Combat Antibiotic-Resistant Bacteria. The White House, Office of the Press Secretary. http://www.whitehouse.gov/the-press-office/2014/09/18/fact-sheet-obama-administration-takes-actions-combat-antibiotic-resistan (accessed 1 September 2018).Google Scholar Anaesthetists are well positioned to embrace these initiatives given our historical and current leadership in patient safety.14Agarwala A.V. McCarty L.K. Pian-Smith M.C.M. Anesthesia quality and safety: advancing on a legacy of leadership.Anesthesiology. 2014; 120: 253-256Crossref PubMed Scopus (10) Google Scholar Kwanten15Kwanten L. Anesthetists and syringe hygiene: getting to the pointy end.Br J Anaesth. 2019 Jun 24; (pii: S0007-0912 (19)30440-4)Google Scholar has summarised broad categories of recommendations to guide our next steps, emphasising bloodstream and surgical site infection prevention and the early work by Pronovost and colleagues.16Pronovost P. Needham D. Berenholtz S. et al.An intervention to decrease catheter-related bloodstream infections in the ICU.N Engl J Med. 2006; 355: 2725-2732Crossref PubMed Scopus (3163) Google Scholar Given the breadth of recommendations discussed, there remains a lack of clarity regarding what specifically our next steps should be. Our next steps for perioperative infection control should be borne out of careful synthesis of the literature pertaining to perioperative bacterial transmission and infection. Evidence gleaned from comprehensive and rigorous evaluation of the epidemiology of perioperative transmission17Loftus R.W. Brown J.R. Koff M.D. et al.Multiple reservoirs contribute to intraoperative bacterial transmission.Anesth Analg. 2012; 114: 1236-1248Crossref PubMed Scopus (98) Google Scholar, 18Loftus R.W. Patel H.M. Huysman B.C. et al.Prevention of intravenous bacterial injection from health care provider hands: the importance of catheter design and handling.Anesth Analg. 2012; 115: 1109-1119Crossref PubMed Scopus (29) Google Scholar, 19Rowlands J. Yeager M.P. Beach M. Patel H.M. Huysman B.C. Loftus R.W. Video observation to map hand contact and bacterial transmission in operating rooms.Am J Infect Control. 2014; 42: 698-701Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 20von Eiff C. Becker K. Machka K. Stammer H. Peters G. Nasal carriage as a source of Staphylococcus aureus bacteremia.N Engl J Med. 2001; 344: 11-16Crossref PubMed Scopus (1506) Google Scholar, 21Loftus R.W. Dexter F. Robinson A.D.M. High-risk Staphylococcus aureus transmission in the operating room: a call for widespread improvements in perioperative hand hygiene and patient decolonization practices.Am J Infect Control. 2018; 46: 1134-1141Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 22Clark C. Taenzer A. Charette K. Whitty M. Decreasing contamination of the anesthesia environment.Am J Infect Control. 2014; 42: 1223-1225Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 23Loftus R.W. Koff M.D. Burchman C.C. et al.Transmission of pathogenic bacterial organisms in the anesthesia work area.Anesthesiology. 2008; 109: 399-407Crossref PubMed Scopus (137) Google Scholar, 24Robinson A.D.M. Dexter F. Renkor V. Reddy S. Loftus R.W. Operating room PathTrac analysis of current intraoperative Staphylococcus aureus transmission dynamics.Am J Infect Control. April 27 2019; (pii: S0196-6553 (19)30211-1. [Epub ahead of print])https://doi.org/10.1016/j.ajic.2019.03.028Abstract Full Text Full Text PDF Scopus (11) Google Scholar has led to the development of evidence-based, clinical interventions that can address perioperative infection control barriers, attenuate proven bacterial reservoirs, and reduce HAIs.7Schweizer M.L. Chiang H.Y. Septimus E. et al.Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery.JAMA. 2015; 313: 2162-2171Crossref PubMed Scopus (192) Google Scholar, 8Loftus R.W. Patel H.M. Huysman B.C. et al.Prevention of intravenous bacterial injection from health care provider hands: the importance of catheter design and handling.Anesth Analg. 2012; 115: 1109-1119Crossref PubMed Scopus (39) Google Scholar, 9Koff M.D. Loftus R.W. Burchman C.C. et al.Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a novel device.Anesthesiology. 2009; 110: 978-985Crossref PubMed Scopus (103) Google Scholar, 10Loftus R.W. Brindeiro B.S. Kispert D.P. et al.Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a passive catheter care system.Anesth Analg. 2012; 115: 1315-1323Crossref PubMed Google Scholar, 11Bode L.G. Kluytmans J.A. Wertheim H.F. et al.Preventing surgical-site infections in nasal carriers of Staphylococcus aureus.N Engl J Med. 2010; 362: 9-17Crossref PubMed Scopus (893) Google Scholar, 12Phillips M. Rosenberg A. Shopsin B. et al.Preventing surgical site infections: a randomized, open-label trial of nasal mupirocin ointment and nasal povidone iodine solution.Infect Control Hosp Epidemiol. 2014; 35: 826-832Crossref PubMed Scopus (90) Google Scholar, 13Huang S.S. Singh R. McKinnell J.A. et al.Decolonization to reduce postdischarge infection risk among MRSA carriers.N Engl J Med. 2019; 380: 638-650Crossref PubMed Scopus (64) Google Scholar Intraoperative bacterial contamination is of significant magnitude and occurs rapidly, and high-risk bacterial transmission is associated with intravascular catheters.23Loftus R.W. Koff M.D. Burchman C.C. et al.Transmission of pathogenic bacterial organisms in the anesthesia work area.Anesthesiology. 2008; 109: 399-407Crossref PubMed Scopus (137) Google Scholar Intravascular contamination has been repeatedly associated with increased patient mortality.17Loftus R.W. Brown J.R. Koff M.D. et al.Multiple reservoirs contribute to intraoperative bacterial transmission.Anesth Analg. 2012; 114: 1236-1248Crossref PubMed Scopus (98) Google Scholar, 23Loftus R.W. Koff M.D. Burchman C.C. et al.Transmission of pathogenic bacterial organisms in the anesthesia work area.Anesthesiology. 2008; 109: 399-407Crossref PubMed Scopus (137) Google Scholar When disinfected before injection, disinfectable, needleless, closed catheter (DNCC) devices have been shown to reduce both the incidence of bacterial injection during routine anaesthesia practice and postoperative infections.8Loftus R.W. Patel H.M. Huysman B.C. et al.Prevention of intravenous bacterial injection from health care provider hands: the importance of catheter design and handling.Anesth Analg. 2012; 115: 1109-1119Crossref PubMed Scopus (39) Google Scholar, 10Loftus R.W. Brindeiro B.S. Kispert D.P. et al.Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a passive catheter care system.Anesth Analg. 2012; 115: 1315-1323Crossref PubMed Google Scholar However, failure to disinfect these devices before injection may increase the risk of bacterial injection in the operating room,8Loftus R.W. Patel H.M. Huysman B.C. et al.Prevention of intravenous bacterial injection from health care provider hands: the importance of catheter design and handling.Anesth Analg. 2012; 115: 1109-1119Crossref PubMed Scopus (39) Google Scholar consistent with the ICU environment where implementation of DNCCs without proper hub disinfection has been associated with increased risk of bloodstream infections.25Rupp M.E. Sholtz L.A. Jourdan D.R. et al.Outbreak of bloodstream infection temporally associated with the use of an intravascular needleless valve.Clin Infect Dis. 2007; 44: 1408-1414Crossref PubMed Scopus (90) Google Scholar This evidence strongly supports the current emphasis on proper selection and maintenance of intravascular devices to assist in prevention of bloodstream infections.26Tand B. O'Grady N. Prevention of central line-associated bloodstream infections.Infect Dis Clin North Am. 2017; 31: 551-559Google Scholar As highlighted by Kwanten,15Kwanten L. Anesthetists and syringe hygiene: getting to the pointy end.Br J Anaesth. 2019 Jun 24; (pii: S0007-0912 (19)30440-4)Google Scholar important parallel considerations include maintenance of syringe tip sterility and medical vial disinfection before use. A catheter care system has been developed that can address injection ports and syringe tips simultaneously along with controlling syringe exposure to the contaminated environment.10Loftus R.W. Brindeiro B.S. Kispert D.P. et al.Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a passive catheter care system.Anesth Analg. 2012; 115: 1315-1323Crossref PubMed Google Scholar This system was shown in a randomised, single-blinded study involving 572 patients to reduce stopcock contamination, postoperative HAIs, and phlebitis.10Loftus R.W. Brindeiro B.S. Kispert D.P. et al.Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a passive catheter care system.Anesth Analg. 2012; 115: 1315-1323Crossref PubMed Google Scholar The finding that stopcock contamination rates are no different today than a decade ago24Robinson A.D.M. Dexter F. Renkor V. Reddy S. Loftus R.W. Operating room PathTrac analysis of current intraoperative Staphylococcus aureus transmission dynamics.Am J Infect Control. April 27 2019; (pii: S0196-6553 (19)30211-1. [Epub ahead of print])https://doi.org/10.1016/j.ajic.2019.03.028Abstract Full Text Full Text PDF Scopus (11) Google Scholar is an alarming finding that strongly supports expert guidance for improved monitoring of hub disinfection practices.27Munoz-Price L.S. Bowdle A. Johnston B.L. et al.Infection prevention in the operating room anesthesia work area.Infect Control Hosp Epidemiol. 2019; 40: 1-17Crossref PubMed Scopus (57) Google Scholar Next steps include transition from open to closed lumens and assurance of proper disinfection of injection ports, syringe tips, and medication vials before use. Intraoperative provider hands have been directly linked by advanced molecular techniques to stopcock contamination and postoperative infection.17Loftus R.W. Brown J.R. Koff M.D. et al.Multiple reservoirs contribute to intraoperative bacterial transmission.Anesth Analg. 2012; 114: 1236-1248Crossref PubMed Scopus (98) Google Scholar, 18Loftus R.W. Patel H.M. Huysman B.C. et al.Prevention of intravenous bacterial injection from health care provider hands: the importance of catheter design and handling.Anesth Analg. 2012; 115: 1109-1119Crossref PubMed Scopus (29) Google Scholar, 21Loftus R.W. Dexter F. Robinson A.D.M. High-risk Staphylococcus aureus transmission in the operating room: a call for widespread improvements in perioperative hand hygiene and patient decolonization practices.Am J Infect Control. 2018; 46: 1134-1141Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 24Robinson A.D.M. Dexter F. Renkor V. Reddy S. Loftus R.W. Operating room PathTrac analysis of current intraoperative Staphylococcus aureus transmission dynamics.Am J Infect Control. April 27 2019; (pii: S0196-6553 (19)30211-1. [Epub ahead of print])https://doi.org/10.1016/j.ajic.2019.03.028Abstract Full Text Full Text PDF Scopus (11) Google Scholar The need for improved hand hygiene compliance applies to all perioperative providers (e.g. anaesthesia supervisors, resident physicians, nurse anaesthetists, circulating nurses, scrub technologists, and surgeons/proceduralists).24Robinson A.D.M. Dexter F. Renkor V. Reddy S. Loftus R.W. Operating room PathTrac analysis of current intraoperative Staphylococcus aureus transmission dynamics.Am J Infect Control. April 27 2019; (pii: S0196-6553 (19)30211-1. [Epub ahead of print])https://doi.org/10.1016/j.ajic.2019.03.028Abstract Full Text Full Text PDF Scopus (11) Google Scholar Proximity of alcohol-based dispensers to these providers is an important consideration given high operating room task density.9Koff M.D. Loftus R.W. Burchman C.C. et al.Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a novel device.Anesthesiology. 2009; 110: 978-985Crossref PubMed Scopus (103) Google Scholar Koff and colleagues9Koff M.D. Loftus R.W. Burchman C.C. et al.Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a novel device.Anesthesiology. 2009; 110: 978-985Crossref PubMed Scopus (103) Google Scholar used a personalised, body worn alcohol dispenser to increase hand hygiene hourly events and to reduce both stopcock and environmental contamination and 30-day postoperative infections. The next steps are to leverage proximity of alcohol-based dispensers to improve perioperative hand hygiene compliance. Isolation of 100 colony forming units per surface area sampled (CPSS) from the anaesthesia work area (AWA) is associated with increased probability of high-risk stopcock contamination events that are in turn associated with increased mortality.17Loftus R.W. Brown J.R. Koff M.D. et al.Multiple reservoirs contribute to intraoperative bacterial transmission.Anesth Analg. 2012; 114: 1236-1248Crossref PubMed Scopus (98) Google Scholar, 23Loftus R.W. Koff M.D. Burchman C.C. et al.Transmission of pathogenic bacterial organisms in the anesthesia work area.Anesthesiology. 2008; 109: 399-407Crossref PubMed Scopus (137) Google Scholar AWA contamination accounted for the majority of stopcock contamination in a multicentre study evaluating the relative contribution of proven intraoperative reservoirs.17Loftus R.W. Brown J.R. Koff M.D. et al.Multiple reservoirs contribute to intraoperative bacterial transmission.Anesth Analg. 2012; 114: 1236-1248Crossref PubMed Scopus (98) Google Scholar AWA contamination exceeding 100 CPSS occurs only during induction and emergence of anaesthesia, time points that correlate with nadirs in hand hygiene compliance.19Rowlands J. Yeager M.P. Beach M. Patel H.M. Huysman B.C. Loftus R.W. Video observation to map hand contact and bacterial transmission in operating rooms.Am J Infect Control. 2014; 42: 698-701Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar Thus, there is a need for both improved quality and increased frequency of AWA cleaning. Clark and coleagues22Clark C. Taenzer A. Charette K. Whitty M. Decreasing contamination of the anesthesia environment.Am J Infect Control. 2014; 42: 1223-1225Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar utilised this foundation of evidence to devise an improvement strategy incorporating improved quality and frequency of cleaning (use of a surface disinfection wipe in addition to conventional, routine cleaning after induction of anaesthesia and patient stabilisation) with improved organisation (designation of clean and dirty areas). This approach was shown to reduce the number of contaminated sites reaching ≥100 CPSS from 46% to 12% during routine anaesthesia care.22Clark C. Taenzer A. Charette K. Whitty M. Decreasing contamination of the anesthesia environment.Am J Infect Control. 2014; 42: 1223-1225Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Additional work examining the clinical efficacy of double gloving in reducing environmental contamination should be executed before inclusion in national recommendations such as those provided by the Society for Healthcare Epidemiology of America (SHEA).27Munoz-Price L.S. Bowdle A. Johnston B.L. et al.Infection prevention in the operating room anesthesia work area.Infect Control Hosp Epidemiol. 2019; 40: 1-17Crossref PubMed Scopus (57) Google Scholar, 28Birnbach D.J. Rosen L.F. Fitzpatrick M. Carling P. Arheart K.L. Munoz-Price L.S. A new approach to pathogen containment in the operating room: sheathing the laryngoscope after intubation.Anesth Analg. 2015; 121: 120Google Scholar, 29Birnbach D.J. Rosen L.F. Fitzpatrick M. Carling P. Arheart K.L. MunozPrice L.S. Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room.Anesth Analg. 2015; 120: 848-852Crossref PubMed Scopus (48) Google Scholar While two clinical trials were referenced in the expert guidance document in support of consideration of double gloving,28Birnbach D.J. Rosen L.F. Fitzpatrick M. Carling P. Arheart K.L. Munoz-Price L.S. A new approach to pathogen containment in the operating room: sheathing the laryngoscope after intubation.Anesth Analg. 2015; 121: 120Google Scholar, 29Birnbach D.J. Rosen L.F. Fitzpatrick M. Carling P. Arheart K.L. MunozPrice L.S. Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room.Anesth Analg. 2015; 120: 848-852Crossref PubMed Scopus (48) Google Scholar both study designs evaluated movement of DAZO fluorescent marking gel (Ecolab, St. Paul, MN) during a simulated exercise involving a convenience sample of resident anaesthesia physicians participating in induction of anaesthesia.28Birnbach D.J. Rosen L.F. Fitzpatrick M. Carling P. Arheart K.L. Munoz-Price L.S. A new approach to pathogen containment in the operating room: sheathing the laryngoscope after intubation.Anesth Analg. 2015; 121: 120Google Scholar, 29Birnbach D.J. Rosen L.F. Fitzpatrick M. Carling P. Arheart K.L. MunozPrice L.S. Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room.Anesth Analg. 2015; 120: 848-852Crossref PubMed Scopus (48) Google Scholar These simulated studies represent important first steps that should be followed by more rigorous investigations involving clinically relevant outcomes. Guidance provided regarding consideration for use of anaesthesia machine covers27Munoz-Price L.S. Bowdle A. Johnston B.L. et al.Infection prevention in the operating room anesthesia work area.Infect Control Hosp Epidemiol. 2019; 40: 1-17Crossref PubMed Scopus (57) Google Scholar, 30Biddle C.J. George-Gay B. Prasanna P. Hill E.M. Davis T.C. Verhulst B. Assessing a novel method to reduce anesthesia machine contamination: a prospective, observational trial.Can J Infect Dis Med Microbiol. 2018; : 1905360Google Scholar is similarly premature given study limitations such as the small sample size (n=22 anaesthesia machines) and the lack of assessment of clinically relevant outcomes such as transmission or infection. The impact of widespread use of such disposables on overall environmental health and cost-effectiveness should also be considered .31Eckelman M.J. Sherman J. Environmental impacts of the U.S. health care system and effects on public health.PLoS One. 2016; 11e0157014Crossref PubMed Scopus (337) Google Scholar Environmental sites currently excluded from routine and terminal cleaning procedures, such as the circulating nurse desk, are proven vectors for transmission of major bacterial pathogens such as S. aureus.24Robinson A.D.M. Dexter F. Renkor V. Reddy S. Loftus R.W. Operating room PathTrac analysis of current intraoperative Staphylococcus aureus transmission dynamics.Am J Infect Control. April 27 2019; (pii: S0196-6553 (19)30211-1. [Epub ahead of print])https://doi.org/10.1016/j.ajic.2019.03.028Abstract Full Text Full Text PDF Scopus (11) Google Scholar The relationship between frequently touched sites in the AWA and clinically relevant levels of contamination remains unclear.17Loftus R.W. Brown J.R. Koff M.D. et al.Multiple reservoirs contribute to intraoperative bacterial transmission.Anesth Analg. 2012; 114: 1236-1248Crossref PubMed Scopus (98) Google Scholar, 19Rowlands J. Yeager M.P. Beach M. Patel H.M. Huysman B.C. Loftus R.W. Video observation to map hand contact and bacterial transmission in operating rooms.Am J Infect Control. 2014; 42: 698-701Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 23Loftus R.W. Koff M.D. Burchman C.C. et al.Transmission of pathogenic bacterial organisms in the anesthesia work area.Anesthesiology. 2008; 109: 399-407Crossref PubMed Scopus (137) Google Scholar Together, these findings argue for proactive, perioperative environmental mapping and surveillance of major bacterial pathogens and their associated strain characteristics across several environmental sites in order that the fidelity of environmental cleaning approaches can be ascertained and fatigue effectively mitigated.24Robinson A.D.M. Dexter F. Renkor V. Reddy S. Loftus R.W. Operating room PathTrac analysis of current intraoperative Staphylococcus aureus transmission dynamics.Am J Infect Control. April 27 2019; (pii: S0196-6553 (19)30211-1. [Epub ahead of print])https://doi.org/10.1016/j.ajic.2019.03.028Abstract Full Text Full Text PDF Scopus (11) Google Scholar This recommendation is consistent with expert guidance for improved monitoring.27Munoz-Price L.S. Bowdle A. Johnston B.L. et al.Infection prevention in the operating room anesthesia work area.Infect Control Hosp Epidemiol. 2019; 40: 1-17Crossref PubMed Scopus (57) Google Scholar Recent recommendations for assigning priority of cleaning to frequently touched sites27Munoz-Price L.S. Bowdle A. Johnston B.L. et al.Infection prevention in the operating room anesthesia work area.Infect Control Hosp Epidemiol. 2019; 40: 1-17Crossref PubMed Scopus (57) Google Scholar32SHEA issues infection control guidance for OR anesthesia care. Available from: Anesthesiologynews.com (accessed May 25, 2019).Google Scholar should be interpreted with caution given that frequency of touch has not been precisely associated with clinically relevant levels of contamination.17Loftus R.W. Brown J.R. Koff M.D. et al.Multiple reservoirs contribute to intraoperative bacterial transmission.Anesth Analg. 2012; 114: 1236-1248Crossref PubMed Scopus (98) Google Scholar, 19Rowlands J. Yeager M.P. Beach M. Patel H.M. Huysman B.C. Loftus R.W. Video observation to map hand contact and bacterial transmission in operating rooms.Am J Infect Control. 2014; 42: 698-701Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 23Loftus R.W. Koff M.D. Burchman C.C. et al.Transmission of pathogenic bacterial organisms in the anesthesia work area.Anesthesiology. 2008; 109: 399-407Crossref PubMed Scopus (137) Google Scholar The next steps include increased frequency and quality of environmental cleaning via use of a surface disinfection wipe after induction of anaesthesia, organisation of the environment according to clean and dirty areas, and improved monitoring of environmental cleaning fidelity. In a multicentre study, Bode and colleagues11Bode L.G. Kluytmans J.A. Wertheim H.F. et al.Preventing surgical-site infections in nasal carriers of Staphylococcus aureus.N Engl J Med. 2010; 362: 9-17Crossref PubMed Scopus (893) Google Scholar randomised S. aureus-positive patients with planned admissions of at least 4 days to internal medicine, cardiothoracic surgery, vascular surgery, orthopaedics, gastrointestinal surgery, or general surgery departments to a preoperative decolonisation strategy involving nasal mupirocin and 4% chlorhexidine gluconate shampoo vs placebo.11Bode L.G. Kluytmans J.A. Wertheim H.F. et al.Preventing surgical-site infections in nasal carriers of Staphylococcus aureus.N Engl J Med. 2010; 362: 9-17Crossref PubMed Scopus (893) Google Scholar Patients were screened on or within the week before admission with a primary outcome of the cumulative incidence of hospital-associated S. aureus infections. Of those patients identified as positive for S. aureus and meeting inclusion criteria, 917 were enrolled in an intention-to-treat analysis, of whom 808 (88.1%) underwent a surgical procedure. Decolonisation reduced the risk of hospital-associated S. aureus infections from 7.7% to 3.4%, a relative risk of infection of 0.42, with the effect most pronounced for deep surgical site infections.11Bode L.G. Kluytmans J.A. Wertheim H.F. et al.Preventing surgical-site infections in nasal carriers of Staphylococcus aureus.N Engl J Med. 2010; 362: 9-17Crossref PubMed Scopus (893) Google Scholar In a subsequent multicentre, quasi-experimental study,7Schweizer M.L. Chiang H.Y. Septimus E. et al.Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery.JAMA. 2015; 313: 2162-2171Crossref PubMed Scopus (192) Google Scholar a similar decolonisation strategy along with glycopeptide use in addition to a beta lactam for patients colonised with methicillin-resistant S. aureus (MRSA) reduced the incidence of complex surgical site infections for hip and knee arthroplasty and cardiothoracic surgery. Nasal povidone iodine has been identified as an effective alternative to nasal mupirocin for patients undergoing arthroplasty or spine fusion.12Phillips M. Rosenberg A. Shopsin B. et al.Preventing surgical site infections: a randomized, open-label trial of nasal mupirocin ointment and nasal povidone iodine solution.Infect Control Hosp Epidemiol. 2014; 35: 826-832Crossref PubMed Scopus (90) Google Scholar A meta-analysis showed that preoperative decolonisation of patients undergoing cardiac, orthopaedic, general, gynaecological, neurological, or Mohs micrographic surgery was associated with a reduction in S. aureus HAIs (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.32–0.71), with 37 (20–49) fewer infections per 1000 patients treated.33WHO Surgical Site Infection Prevention Guidelines. Web Appendix 3. Summary of a systematic review on decolonization with mupirocin ointment with or without chlorhexidine gluconate body wash for the prevention of Staphylococcus aureus infection in nasal carriers undergoing surgery. https://www.who.int/gpsc/appendix3.pdf (accessed June 27, 2019).Google Scholar A meta-regression analysis showed no differential treatment effect by procedure.33WHO Surgical Site Infection Prevention Guidelines. Web Appendix 3. Summary of a systematic review on decolonization with mupirocin ointment with or without chlorhexidine gluconate body wash for the prevention of Staphylococcus aureus infection in nasal carriers undergoing surgery. https://www.who.int/gpsc/appendix3.pdf (accessed June 27, 2019).Google Scholar Finally, postoperative decolonisation of patients with recent hospital exposure using nasal mupirocin and chlorhexidine has been shown to reduce the incidence of MRSA infections by 30%.13Huang S.S. Singh R. McKinnell J.A. et al.Decolonization to reduce postdischarge infection risk among MRSA carriers.N Engl J Med. 2019; 380: 638-650Crossref PubMed Scopus (64) Google Scholar The next steps include implementing evidence-based, perioperative (pre- and post-hospital exposure) patient decolonisation strategies involving nasal mupirocin and chlorhexidine for patients undergoing cardiothoracic, vascular, orthopaedic, gastrointestinal, gynaecological, neurological, Mohs micrographic surgery, and/or general surgery where hospital admission is planned. Nasal povidone may be a reasonable alternative for those with allergies/sensitivities to mupirocin. Implementation of host optimisation strategies such as glycaemic control, normothermia, or both without substantial effort to prevent perioperative transmission of major bacterial pathogens within and between patients ignores the complex pathophysiology of surgical site infection development and national recommendations.4World Health Organization Antimicrobial resistance: global report on surveillance. WHO, 2014Google Scholar, 6FACT SHEET: Obama Administration Takes Actions to Combat Antibiotic-Resistant Bacteria. The White House, Office of the Press Secretary. http://www.whitehouse.gov/the-press-office/2014/09/18/fact-sheet-obama-administration-takes-actions-combat-antibiotic-resistan (accessed 1 September 2018).Google Scholar, 34Awad S.S. Adherence to surgical care improvement project measures and postoperative surgical site infections.Surg Infect (Larchmt). 2012; 13: 234-237Crossref PubMed Scopus (162) Google Scholar Increased antibiotic use is not appropriate in the post-antibiotic era where antibiotics are no longer as effective because of increased acquisition of resistance and virulence traits.3Boucher H.W. Talbot G.H. Bradley J.S. et al.Bad bugs, no drugs: no ESKAPE! an update from the Infectious Diseases Society of America.Clin Infect Dis. 2009; 48: 1-12Crossref PubMed Scopus (3718) Google Scholar In conclusion, anaesthetists are well positioned as leaders in patient safety to reduce perioperative bacterial contamination below clinically relevant thresholds. Our success will undoubtedly reduce HAIs and associated antibiotic use, and thwart the evolution of bacterial pathogens towards increasing acquisition of resistance and virulence traits. Our first steps should be to utilise the evidence-based tools and guidelines outlined above to generate sustained, perioperative improvements in intravascular catheter design and handling, improved hand hygiene compliance, improved environmental cleaning, and perioperative patient decolonisation. Writing and revising manuscript: RWL, JHC. RWL has received research funding from Dräger, Kenall Manufacturing, B. Braun, and the Anesthesia Patient Safety Foundation. RWL has presented at educational meetings sponsored by Kenall Manufacturing (AORN) and B.Braun (APIC). He is a shareholder in RDB Bioinformatics, LLC, a company that provides PathTrac services to track bacterial transmission in operating rooms. JHC reports no conflicts of interest. Anaesthetists and syringe hygiene: getting to the pointy end – a summary of recommendationsBritish Journal of AnaesthesiaVol. 123Issue 4PreviewEditor—Bloodstream infection (BSI) and surgical site infection (SSI) are major causes of morbidity and mortality, causing more deaths annually than influenza and pneumonia combined.1 Despite being potentially preventable, nosocomial BSI increases hospital length of stay by more than 1 week while also increasing the estimated annual economic burden by £1 billion in the UK and $30 billion in the USA.2,3 Anaesthetists' roles in these adverse outcomes are not benign, with evidence that the environment and manner in which medications are prepared and administered increases the risk of syringe and stopcock contamination, which are associated with postoperative morbidity and mortality. Full-Text PDF Open Archive
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