ABSTRACT, fino. be wearing of masks influenced th peng units (CFU of bacterin the viiny of 14 operations on the thyroid glad were ined in pods during which personal were rom aloe fo vent or molto wear masks, The watt eat one ih and One witbout mats during each operation as ssapled 20 cm fo the wound ting » Sctosus an= Fier sampits, There were no sicicant dfler ieiveen the groups in either auubers of CFU or eso! stbouenie bacteria fn. ord: face mas, airborne bacteria cost reduction allents une patio thootdienne este divist en plusieurs periods de 30 cs Pedant Hesquelles yn rage au so didnt fe el porat ou ton un masque chiar, Pou cha tien, acu au moins une pésiode ee mesave fans masque. Les pelevements de Paton ic efectos Je dnp en lsat ua apparel Med membrane J couturier. Aucune airene sigaifeaive nm dans le nombre ou te ype de bactssy entre le vce masge ete roupe sans masque, INTRODUCTION wearing of masks iy routine in most operating 6s, and the taf is often required to put one on ‘entering. Masks are nowadays also worn dur other procedures, such as wound dressing, cathe- ation, and angiography. In spite of the cost and venience this practice has become generally ac- without any studies being carried ox proving it protects patients against infections. One re- not randomised and’ using historical controls, Even suggested an adverse impact of masks (2) Ia study of airborte bacteria in the operating theatre vas a 33fold increase in the number of colony units (CFU) when an empty theatre was en- by ‘ive people, but it made no difference wheth- ¥ wore masks or not (10) Eur J Surg 158: 263-266, 1992 INFLUENCE OF WEARING MASKS ON THE DENSITY OF AIRBORNE BACTERIA IN THE VICINITY OF THE SURGICAL WOUND ‘T, Goran Tunevall and Hans Jorbeck ram the Department of Srgry and Deparment af Inction Cont, Karinska Institue, er Se Pe Hal bce ee (Submitta far publication November 19,1990. Accepted ate revision March 18,1992) In. randomised study of 3088 general surgical ‘operations at this hospital the rate of postoperative ‘wound infection did not difersignticantly whether ‘or not masks were worn (11) In that study operations for insertion of prostheses were excluded. The result my either be due to that the wound is resistant to Small variations inthe number of bacteria deposited init, or that the bacterial challenge was unaffected by the use of masks, ‘The aim of the present study was to compare the counts of airborne bacteria inthe veinty ofthe op- eration wound during operations when masks were ‘worn by the team and omitted, respectively. PATIENTS AND METHODS ‘The stay was carved out during 22 general surgical oper ations. ph operalons formed it study for evalation ‘of mstneds for counting itsorae bates an for seetion ‘of sunita procedures that Were suited forthe sady, Tout ‘een operations on te hid glad the formed the ah study. Preoperative protocol All patients had atleast ne whole body shower onthe day before dperaton and-ane shower on the day 0 operation witha detegeat solution containing 4% corhexine (1h biserubeTcH- During the plot study hae tm the aren being ‘operated on was shortened mh sessrs or removed with ‘plato ream (mae This was never neceary Qarng "he operations on be tyro sland. Tho operations was fisinfected with ehlohexadine ia 709% acco Oveating hares “Thnee dierem operating testes were sed doting the stds. According fo eset tecnica! Chest he Semon ‘yams yielded 17 to 20 air chang, nos Ihe "commanded ir exchange rat genta sug ope ions in Sweden (3 Air sain ond verobiologicalrechmaues ‘8 Savtovius air sampler (M2) with gelatin filers ype SM 12653 (ore size im ana dameter 80-mm) ws wet Ths sampler hasan ar suction device, Ikea vacua cleaner Which ams aconsant amount ofa ad able up 103200 ‘out, troup a tabe wth a connecting device for fiter holder.at the other end, Senile geatine ites, parse Bae sung 158264 T. G. Tunevall and. Jrbeck “Table I. Air counts of bacteria (CFU) inthe wound area during 14 operations om the thyroid and prety lands 7 ach operation included lst ne 30min peiod when personne Wore mask, and one Sutin which they cid a ‘With masks (17 periods) Withow masks 28 periods) ==> Mean Range of Mean Rasen of Crum Guim CEU? CEU ‘Staph, epidermidis ‘ 3 5 ous Connetecerim spp, ne t os Propionbact spp 5 (60 5 0-50 ‘atlnemolstie step, ° o i os ‘Gtner scene a 6 I oto siebut not bactsa, re mounted i ster filter holders aod fan be changed during tbe operation “At the end ofeach operation the ides containing the ‘ers were brougst immediately to the mjrebology labors ory where he ites were removed om he helders ahd ‘ive two halves under sen sonditioas One bale ‘eas used foraerabic and the the for snacrobiceultere on 9 ‘2m blood agar plats. During the iat st 14cm diameter Blood agasetle lates were also used. Al plates were incor ated at 47°C for 48 hours and colonies Colony forming Unis, CFU) were counted. All cts olted mere sent fed by standard ashngues(D, Plot study. During eaht clean, clive surgical proce dirs lace mas wee aed tn furan ome i foe) both of countine he numbers CEU neu the operation ‘wound were evaluated. The seit plates were placed onthe Instrument table and exposed Tor prods of 20 ot 30 min st {he sme time asthe Sutoriv sampler was being wed Main sud). Asa esl oF te pie ay On) the Sarto us sampler as used im he maim study: Pourees operations ‘on the thyroid gland that were planned fle longer than ‘Ste hour mere ehosen to obtain at east two 30 min ait ‘tanlingpvs, Nk were nyo waxy nem: sof the opereing team, including the anesthesilots During each operation thee wa alwys Test One 30 mit period with and one witht, masks. When it was obvious {hat there would be thee or mare peiod we made seta (9 have at lens #0 periods without face masks ia order 1 Inereae the possiblity of nding bacteria fom the ep "ory tat, To sold any iuence of illercnces in number lt dome bacteria between te art a0 end oF te oper ton, the operating team started with Mats 1-9} othe ut inks (ne 3 according tga atm list total of 17 Sake an 2 "unmasted prods were rere Jor Ingthe 18 operations "The Sarton Semper wa sett filler 20001 of ious, “The tube wit ts connecting device and fier older as stelise, which made posse oplce the er verily ‘Within 20 cm Hom the supe wound. The fers were hanged every 20 in Surin thes Five operations in th Plt sty, and every 0 min during the resto the sul ‘he interval as inreted both inorder {o ese feed ‘ursance duting the operations 30 ocruse fre were 00 robles to count the CYUs ip site of tht ineensed ensty'on the filters. he fina epistraton paiog daring fm operation listed 10-30 mi the valve was ted afer ‘ovrection Tor the shorter time ad expressed p30 mia Gloor ms ofan ‘The colnies ere counted ab ented snd the mum bots of enone onthe sorbic and the anerobic haves oF Bur surg 18 the fier were add together. This men thet sony bacteria growing on oly one half fT: shoe tes ‘bles to get the right somber of CFU/wuine of er bevod. This has, however, not Been done Decne st {he bactertaprew bate on one half thas on he ose sl ‘would be confusing f we etitous values se wells a led, Because al commpareona wee tad (om nosey ‘biaind in the same way they are vais. To coming Drocedore should he bore im mind in Gitano aft {Gal number of CFU volume Eshis The study vas approved by the ethics commie oie Karolinsea Insite RESULTS Pilot study ‘The counts of CFU/m? air differed widely amoee iffeent types of surgical procedures, mainly deere ing on the number of staff involved and how much they moved sbost. Operations on the salllade: spleen, ond arteries (without grafts) all yielded hah: counts of CFU? ai than eperations on the thy tid land, which showed less differences both amorg ep erations and among different periods of the same ‘operation, There were no systematic silences io bctoral air counts during the frst and the flowing Periods of she operations. The counts of CFU on settle plates were low (0-5), and these were terio® ‘omitted from the main study The main sty Fourteen operations on the thyroid gland were sls ed for further study because they yielded lw int and innes-operatian variations in bacterial ar tut® land thus were the most standardized procedures this point of view. ‘Similar ir counts of aerobic and anaerobic bac were recorded whether or no masks were worn it ‘operating room (see Table I), The aerobic skin jam Staphylococcus epidermidis was the most ‘mon cxgatism found during 13 of the 1é oprsio™12 CFU/m?. The highest counts is creanism were registered after masked periods 4 cases and after unmasked periods in 5 cases. In vation no CFU were obtained and in another ‘vere counted during both the masked and the sk! period. The difference between masked fj unmisked periods is clearly not significant, No roataining Staphylococcus aureus was found Perio. Between one and 3 CFU eontain- tehoomoliesteptococe! were found during 7 of 28 wnmasked periods, but newer during the 17 yed periods. The anaerobie skin organism Pro- bacterium aenes was found during seven oper- ons, hc highest count being 60 CFU/m (Table D, highs counts of other bacteria were also equally ibuicd between masked and unmasked periods rnebsclesium spp, Acinetobacter spp. and a few rob.) INo pos‘operative wound infections were encoun- fed ducing the study. DISCUSSION found almost identical air counts of aerobic and bic skin bacteria whether or net masks were by ine operating staff. The greatest differences fumbers were found among different operations ing te pilot study and depended on the kind of ation, the number of people in the theatre, and amount of activity i the theatre during the opera- ‘We mace no attempts to measure the bacterial eon- ation in the operative wounds, but estimations the airborne contamination can be made because ‘numbers of CFUs close to the wound are known. ircular operation wound with a diameter oP 1 em be caleulated to receive the CFU from 1/3 Mou:. (Sedimentation speed for CFUs is 0.3 in oc 18 mhour multiplied by the area of the id= 0.075 m*, according to Noble (9). This at during the operation with the highest plvlococens epidermidis air counts the Wound as laminated with 10 CFU/h from the air. (The Ont ofthis bacterium was similar om the halves of te fiters incubated aerobically and anacrobiclly) SHaemotyic streptococci, normal inhabitants of ‘oropharyngeal tract, were found only after une ! operation periods and. are ‘not normally to be wound pathogens after general surgery B contrst to Pshacmolytic streptococci). The few a embolic streptococet that occured in the ar when bs were noe worn cannot be regarded as risks for and infetion unless a prosthesis is being implant- (5,8) Our results thus confirm those of a similar study en masked and unmasked staff produce identical Masks and airborne bacteria 265 air counts of bacteria in the operating theatre (10), ‘They also support the results of our previous clinical study (11) in which no difference in infection rates was found between operations performed by masked and unmasked staf. The bacterial contgaination of ‘the air in the operating cheatre is determined by sev- ral factors (6): The nurmber of air changesshout, the {ype of ventilation system used, the number of peo- ple, their physical activity and cling are all exam- ples of factors that determine the degree of airborne bacterial contamination. Thus, the type of procedure performed is of major importance. Therefore, the total numbers of CFU are not directly comparable with the results of other investigations. Blomgren et. al. (2) and Carlsson etal (3) used a zonal ventilation system and the Sartorius sampler and repistered a mean of 49 CFU/m? and 48 CFUtm?, respectively. ‘They wore conventional clothing, as we did. Using & Reuter centrifugal air sampler, Casewell etl. (4) registered a mean of 640 CFUfm’, but they ques tioned the manufacturer's declared rate of 40 Lait? ‘min. The low counts we registered were probably ‘mainly due to the type of procedure studied. Other factors influencing the results could be the age and condition ofthe gelatine ites aswell asthe time to transport the sémples to the microbiology laboratory. It therefore seems advsible to compare the results obtained with one sampler and one meth ‘od of culturing withthe same transport time to mini- ‘mise the influence of these factors. In the present study the operations were their own controls and no ‘comparisons have been made between different oper= ations. We conclude that the use of masks during oper: tions does not influence the number of potentially pathoyenie bacteria inthe air close to the operation: wound. This observation again raises eh question of the value of masks as an infectinn control measure ‘uring surgical procedures. However, te importance ‘of masks on surpeal staff memibers with respiratory ‘ract infections remains to be studied. It should also be stressed that masks may be Used by the surgeon and the assistants for protection of the mouth and nose from drops of blood that may carry HIV of hepatitis B virus, The present data indicates that stat not in contact with the wound do not need (o Wear ‘masks, saving themselves the inconvenience. In addi- tion, such a regimen might reduce the gost of masks by perhaps half. REFERENCES Bergey D. H. Bergey's Maneaf of SjtemtieRacerioo f- London: Wilsams & Wilkins, 198 2 Blomgren G, Hambraeus A, Mainborg A'S. The inte: ence Of the ital body exhaust suit on ale and wound Barb 188266 1. G. Tunevall and H, Jérbeck contamination in elestive hip operations. J Hosp Int toy, 4257-208 3. Carlson AS, Nilson B, Walder MH, Oxerber K. UE feavoletradtton andar contamination during tll hip eplaemeat J Hosp If 1986.7 176184 4. Catewell MW, Desi N, Leas FY, The use of We Reuter entefgal ai sampler or the estinationofacterial at unt miferent Hospital oct. sp int 1986, 5250-26 5. Exsmon CSF. Miroorgniss of concern to the sar fon To: Pollock. A, ed. Sura infections. Edward ‘Amoid, 1987-11 6, Fry DE. The patogen, I: Polk HC, ed. Infection and the Srpeal patient Edinburgh: Churchill Livingstone, 19 Bard 18 Hambraeas A. Aerobie inthe oping to fevien J Hosp in 1988, 1, Suppl Ae Noble WC, Ldwell OM, Kingstone D. Tsing bution of sibore panicles carrying mice sae ‘GUN Isa mas _ iE NW, ea mat neces in he etn tg ‘An Col Surg Eng 1981-63. 80-3b5. EM Biter MA, Eien H, Poach MON ar 81 dingo envonsen! ahead tyres Shep ae mat Cin Orthop 195, Lt ecg urea TG: Posner woud inet an fal ace mass. A controll sady, Wall anes Escher seein