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Surgical site infections (SSIs) are second to third most common site of health care associated infections. These complications of surgical procedures cause considerable morbidity, and mortality. If these occur deep at the site of the procedure, can carry mortality as high as 77 % [ !. There is considerable evidence available to indicate that the surgical site infections are a significant health risk to hospital patients. Sources of infection may be either endogenous (from the patient himself) or e ogenous from the theatre environment. ! large body of information is available "hich indicates that prevention of post operative infection is dependent on several factors including effective theatre design, sterili#ation and disinfection procedures, good surgical techni$ue, bacterial contamination of theatre air, discipline "hich includes restricting the movement of staff ["!. %any of debates are e tended over on this topic including the fre$uency of microbiological surveillance for operation theatres. ←
Key words: Air sampling, three bucket system, slit sampler,
colony forming units ← ← #$TROD%CT#O$ & S#T%AT#O$ A$A'(S#S ← &ven today most of the surgeons are "orrying about the 'T associated infections "ith anaerobes like clostridium tetani in most of the instances. Infections "ith (l. tetani are associated "ith very bad surgical procedures "hich includes the over )ealous manipulations of the tissues of surgical site and leaving the dead tissue in the surgical site at the end of the procedure and also heavy dust in the operation theatre environment. Surveillance for clostridial spores is an age old concept of 'T surveillance and lost its importance "ith the available and applicable 'T sterili#ation and disinfection a"areness *rogramme and practices. Today "e rarely encounter a infection "ith (.tetani
+outine testing for clostridial spores is not mandatory e cept during certain situations like ne" constructions or structural alterations are made to the theatre. ,ut pyogenic infections mostly "ith S.aureus and S.epidermidis are possible even "ith technically $ualitative surgical procedures [)!. -ealthy carriers have been found to shed staphylococci "hich is responsible for inevitable airborne contamination. .hile there is evidence to indicate that most outbreaks are caused by heavy dispersers [*! + every attempt should be made to minimi#e airborne transmission "ithin operating theatres. Studies in a number of operating theatres have suggested that there is a general relationship bet"een total air count and risk of infection. (ounts in the range of 7//012//3m 4 "ere related to significant risk of infection and "hen they "ere under 12/3m 4 the risk "as slight [,!. ← So prevention of airborne microbial contamination "ill prevent the surgical site infections. To achieve this basic strategy "e should follo" the certain guidelines. .hich "ould include, proper and continuing education to staff to prevent shedding of microbes and restrict the unnecessary movements of 'T staff "ithin and outside the 'T environment. ← ← M-AS%R-S TO R-D%C- M#CROB#A' 'OAD #$ OT: ←
5umigation or other ne"er methods of sterili#ation of 'peration Theater alone cannot sterili#e or make the 'T environment safe. 5ailure to provide ade$uate operation theatre ventilation is associated "ith risk of postoperative infections. Theatre ventilation has been found to be a critical factor in prosthetic and )oint surgery [,!. .hile maintaining the proper ventilation, "e have to be careful about the microbial load in the 'T environment .5iltration of 'T air by fitting the -&*! filters are mandatory to fulfill the above criteria. Since the operation theater environments are the dynamic, good e$uipment and arrangements are only not safe since it becomes unsafe because of human activities. (ulture s"abs from unnecessary surfaces of 'T environment (roof, upper parts of "all) may causes confusion during the interpretation of the results [*!. 6ust should be removed "ith cloth "etted "ith clean "ater (hemical and disinfectants should not be used as habit. (hemical agents or disinfectants or detergents should be used "hen 'T floor and surfaces are contaminated "ith blood and body fluids. S"abbing the surfaces "ith suitable commercially available disinfectant Bacillocid .%i ture of dihydro y formaldehyde, glutaraldehyde and be#alkonium chloride/ by using the three 0uc1et s2stem "ill remove the ma)ority of the microbes. ← 1st ,ucket "ith "ater7 6irty mop is rinsed ← 8nd ,ucket "ith fresh "ater for rinsing7 %op rinsed again in this "ater ← 4rd,ucket "ith suitable disinfectant7 %op is immersed in the solution and floor ← Should be mopped liberally. .ash the used mop "ith disinfectant after use and dry. ← ← STA$DARD 3%#D-'#$-S A$D 4'A$$#$3 5OR A#R SAM4'#$3: ←
There are no 9niversally agreed standards for any country or place regarding "hen to undertake microbiological sampling in the operating theatre and on the interpretation of sampling results [6!. -o"ever, there is sufficient evidence to support the undertaking of microbiological air sampling in the operation theatre as part of the vigilance : safety of an operating theatre, after any ma)or structural replacements (not including -igh &fficiency *articulate (-&*!) filter changes and as deemed necessary by the hospital infection control committee. -ealth care "orkers should follo" certain guidelines before air sampling. *rior to air sampling, obtain the suitable air sampling e$uipment from a laboratory, establish laboratory time0lines for sample collection, processing and provision of results and should not ignore to consult the hospital microbiologist or infection control unit. ← ← ← 7O8 TO DO T7- A#R SAM4'#$39
,acterial counts in operation theaters are influenced by the number of individuals present, ventilation and air flo" methods. !ir sampling should be done after the all ne" or replacement "ork has completed. The ventilation system should run continuously for 8; hours before sampling and the theatre surfaces and fi ed e$uipment, ducting and air diffuser plates have to be cleaned. ← Settle plate method by using blood agar, It is being practiced in basic hospitals to detect pathogenic bacteria ma)or isolate being Staphylococcus aureus bacteria in hospital air. Settle plate method "ith blood agar "here the plates have to be kept at 8 < feet height on the four corners of room and results are obtained based on the mean colony number on the all culture plates after a prescribed time. ,ecause of recent advances in certain surgical procedures and bacterial counts settle plate method is replaced "ith Slit sampler and Air centri:uge equipment through "hich "e can calculate the safe levels of colony counts. There are several different types of air samplers available and the manufacturer=s instructions for use must be follo"ed. If affordable, the preferred method is to use a sampler "ith timer and remote control.
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R-COMM-$D-D M-T7OD 5OR A#R SAM4'#$3
! single sample should be collected from each operating theatre. 4
The air sampler should be checked for cleanliness before use by follo"ing the manufacturer=s instructions. ← The theatre being sampled should have been left vacant for a minimum of 1> minutes, preferably one hour. To avoid false0positive results the theatre doors must be kept closed prior to and during the sampling period. ← Staff should "ear theatre attire and a surgical mask, "ith proper hands "ash and surgical gloves. ← *lace the agar strips or plate into the sampler under aseptic precautions and set up the e$uipment. ← The air sampler should be placed in the middle of the theatre table at the height of 8.> feet and to be secured on a trolley. ← The air sampler should then be s"itched on either by remote control or manually, before leaving the room. ← The sampling e$uipment "ill determine the volume of air sampled. Sampling volume needs to be more than /.8> m4 (8>/ ?) and optimally around 1m4 (1/// ?). ← 'nce sampling is completed, remove the test strips3agar plate aseptically and label it clearly and send it the processing environment. ←
R-S%'TS A$D #$T-R4R-TAT#O$:
(ulture plates should be incubated under optimum conditions in the microbiology laboratory. &arly culture reports hardly available until after 8; hours of incubation. !erobic cultures on non0selective medium (preferably ,lood agar) should not e ceed 4> colony @ forming units of bacteria and fungi per cubic meter of air for a conventional theatre and 1cfu for an ultra clean theatre to perform )oint replacement and cardiac surgeries [ !. These counts are not rigid standards and are intended as a guideline only. &ven though the s"abs are taken for 'T surveillance to isolate and identify the clostridial spores, air sampling is must to measure the safer load of microbes. In some of the hospitals 'T sampling is done by s"abbing and plating on the blood agar and results are being announced after 8;0;2 hours of aerobic incubation. ,y the above mentioned method $uantitative estimation of the microbial load is not possible. ?iterature "hich is supporting for this kind of practice is not available from various sources. %oreover, this type of cultures on non0 selective medium "ill create unnecessary confusion "hile detecting 'T sterili#ation status and "hich should be abandoned. 5
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R-5-R-$C-S: 1. 6avis A., (urry !, Bambhir !C, *anigrahi -, .alker (+, .ilkins &B, .orsley %! and Cay *+ Intraoperative bacterial contamination in operations for )oint replacement. J Bone Joint Surg Br 1999; 1!B: "9. ← 8.(ol$uun D, *artridge ?. (omputational 5luid 6ynamics !pplications in -ospital Eentilation 6esign. #he Australian $ospital %ngineer &''(; &" )1* (+!,'. ← 4. Buidelines to standards for operating rooms. ?ocated at. http733""".health."a.gov. ← ;. Beeta %ehta. %icrobiological surveillance of operation theatre @ 8//>. http733""".orthoteers.org. ← >. 6haran S, *ittet 6. &nvironmental controls in operating theatres. J $osp infect &''&; +1)&* -9! ,. ← F. 6epartment of -ealth, .estern !ustralia. *rivate -ospital Buidelines, 4rd edition. 1GG2. http733""".health."a.gov. ← ←
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