Chauveau X 2015
Chauveau X 2015
Chauveau X 2015
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Review article
a r t i c l e i n f o a b s t r a c t
Article history: Surgical-site infections (SSIs) due to intra-operative contamination are chiefly ascribable to airborne par-
Accepted 2 July 2014 ticles 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,
Keywords: although these have not been demonstrated to correlate significantly with SSI rates. Maintaining clear air
Clean air in the operating room classically involves the use of ultra clean ventilation systems combining laminar
Airborne contamination airflow and high-efficiency particulate air filters to create a physical barrier around the surgical table; in
Laminar airflow
addition to a stringent patient preparation protocol, appropriate equipment, and strict operating room
Turbulent airflow
discipline on the part of the surgeon and other staff members. SSI rates in clean surgery, although influ-
enced 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, includ-
ing laminar airflow, body exhaust suits, patient preparation techniques, and specific surgical instruments.
Impeccable surgical technique and operating room behaviour, in contrast, are clearly essential.
© 2015 Published by Elsevier Masson SAS.
The prevention of surgical-site infections (SSIs) is an integral replacement procedures. In contrast, SSIs may develop in up to
component of nosocomial infection control and a major priority 15% of high-risk patients undergoing contaminated procedures, a
in orthopaedic surgery. Surgical wound contamination must be situation encountered chiefly in emergency trauma surgery [1–3].
prevented to avoid patient colonisation by microorganisms dur-
ing surgery. In addition to prophylactic antibiotic therapy, SSI 2. Contaminants
prevention involves maintaining an aseptic operating room (OR)
environment and impeccable OR discipline on the part of all staff 2.1. Source of surgical-site infections (SSIs)
members. The effectiveness of preventive measures is influenced
by the quality of the patient’s immune defences and type of surgical The contaminating microorganisms may be endogenous or
procedure. exogenous. The skin is a source of endogenous microorganisms,
and optimal preoperative skin preparation is therefore essential.
Exogenous microorganisms are vectored by airborne particles, the
1. Epidemiology of surgical-site infections (SSIs)
staff (hands, other areas of the skin, and mucous membranes) or,
more rarely, inanimate objects (instruments, material, furnishing,
The incidence of SSIs in orthopaedic and trauma surgery varies
or irrigation solutions) [4]. The patient’s skin is the direct source
with the level of risk associated with each type of procedure, as
of contamination in only 2% of cases, leaving 98% of cases related
assessed using the Altemeier classification (Table 1); general health
to airborne particles [5]. Surgical-site contamination by airborne
of the patient (ASA class) (Table 2); and National Nosocomial Infec-
particles is ascribable in 30% of cases to direct settling of the
tions Surveillance (NNIS) risk index based on the contamination
particles on the wound and in 70% of cases to settling on the instru-
class, ASA class, and operative time (Table 3). SSIs occur in less
ments and surgeon’s hands followed by transfer to the wound [6].
than 1% of low-risk patients, who account for most scheduled joint
Thus, surgical-site contamination is chiefly attributable to airborne
particles, some of which may carry microorganisms. Given this pre-
dominant role for airborne contamination, air quality in the OR
E-mail address: [email protected] deserves close attention.
http://dx.doi.org/10.1016/j.otsr.2014.07.028
1877-0568/© 2015 Published by Elsevier Masson SAS.
S78 D. Chauveaux / Orthopaedics & Traumatology: Surgery & Research 101 (2015) S77–S83
Table 1 diameter. Despite their large size, squames circulate via the con-
Contamination classes according to Altemeier et al.
vection currents created by the temperature gradient between the
Contamination classes Classification body and the environment [7]. Other sources of airborne parti-
Class I, clean surgery (SSI The surgical procedure involves a cles include dust and condensation droplets measuring less than
risk < 1%) normally sterile area of the body. The 5 in diameter and representing the remnants of larger droplets
skin is initially intact. If drainage is produced during coughing, talking, and suction systems.
required, a closed system must be used Particle size influences the tendency to settle on surfaces. Parti-
The surgical procedure does not
cles smaller than 5 remain suspended in the air, those larger than
involve opening of the
gastro-intestinal, respiratory, 100 settle rapidly, and those of intermediate size (5–100 ) may
genito-urinary, or oro-pharyngeal tract settle on potentially contaminated surfaces then migrate to another
Class II, clean-contaminated The procedure involves opening the sites. Particles may carry variable bacterial loads, depending on
surgery (SSI risk 2–5%) gastro-intestinal, respiratory, or
their source.
genito-urinary or oro-pharyngeal tract
under tightly controlled technical Particle production and mobilisation vary according to the
conditions and in the absence of number of individuals in the OR. Another factor is whether the
abnormal contamination (i.e., urine or surgical attire constitutes an effective barrier against the shed-
bile is sterile) ding of squames into the OR air: thus, squames may migrate from
Class III, contaminated surgery Massive surgical-site soiling by
sites of uncovered skin (e.g., neck and forearms) or through gaps
(SSI risk 5–10%) gastro-intestinal lumen contents,
opening of the genito-urinary or biliary in the material used to make surgical garments (e.g., 80 for
tract in a patient with urinary or biliary woven cotton) [8]. Any movement in the OR can mobilise particles.
tract infection. Recent open traumatic Airborne particle counts are highest at the beginning of the opera-
wounds
tion because patient installation requires displacements and other
Class IV, dirty or infected Surgical procedure involving a body
surgery (SSI risk > 10%) site that contains pus, foreign bodies,
movements of the personnel [9]. The many other sources of parti-
or faeces. Traumatic wounds created cles include the use of a cautery, which produces fine and ultrafine
more than 4 hours earlier particles, and the use of saws or drills [10].
This definition suggests the presence of Controlling airborne particle circulation requires careful atten-
microorganisms responsible for SSI in
tion to OR discipline, surgical technique, and operative time. Air can
the surgical-site the before the
operation act not only as a reservoir, but also as a vector for the transmission
of bacteria via particles (e.g., dust and squames) or condensation
Altemeier WA, Burke JF, Puitt BA, Sandusky WR. Manual on control of infection in surgical
patients. JB Lippincott 2nd Ed, Philadelphia, 1984, p 29. droplets smaller than 5 .
Contamination by airborne microorganisms plays a central role
in the pathogenesis of SSIs. Prevention of contamination by air-
Table 2
American Society of Anesthesiologists (ASA) preoperative assessment classification. borne microorganisms requires knowledge of the most commonly
encountered microorganisms and of their dissemination character-
ASA classification Preoperative assessement
istics. In addition, familiarity with air quality parameters, air quality
I No health condition other than that requiring surgery measurement tools, and air treatment methods is crucial.
II Mild abnormality in a major function
III Severe abnormality in a major function
IV Disease that is a constant threat to life 3. Air quality control
V Moribund patient
3.1. Nature of contaminants
2.2. Characteristics of airborne particles
The microorganisms most often responsible for SSIs are Staphy-
lococcus aureus, with 40% to 70% of cases [1,11], followed by
Airborne particles come from multiple sources, of which the
coagulase-negative staphylococci and Gram-negative bacteria.
most relevant is the shedding of squames or skin scales. On
These bacteria exhibit considerable resistance to exogenous insults
average, an individual having a moderate level of physical activ-
(which allows them to survive while airborne) and are con-
ity sheds about 10 min−1 particles measuring at least 0.5 mm in
sequently associated with a high-risk of transmission (AFNOR
classification of the pathogenic potential of microorganisms, from
Table 3
1 to 4).
National Nosocomial Infections Surveillance risk index (NNIS).
Bacteria measure 0.2 to 5 · They can adhere to particles,
Variables Codification preferably those of greater size, to form larger aggregates known
Contamination class 0, clean or clean-contaminated as colony-forming units (CFUs, measured per m2 ). Hansen et al.
1, contaminated or dirty reported a statistically significant correlation between counts of
ASA class 0, patient in normal health or with particles larger than 5 and counts of bacterial colonies. Thus, all
mild systemic disease
particles measuring 5 to 10 can be considered potentially infected
1, patient with severe or incapacitating
systemic disease or moribund patient [10].
Operative time 0, time shorter than the T point Measures that decrease airborne particle counts are central to
1, time equal to or longer than the T diminishing the risk of contamination by airborne microorganisms.
point
The T point is the time that represents
the 75th percentile of similar 3.2. Air quality parameters
procedures in the NNIS database
The NNIS risk index is computed as the
Several parameters are used to assess OR air quality:
sum of the codes for the three variables
and can therefore range from 0 to 3
The NNIS risk index is based on three variables (contamination class, ASA class, and
• the airborne particle count at rest is used to classify ORs according
NISS value) scored as described below. Garner JS. CDC guideline for prevention of to an ISO standard. Orthopaedic ORs must meet the ISO 5 crite-
surgical wound infections. Revised. Infect Control 1985;7:193–200, 1986. rion, namely, < 3500 particles/m3 (Table 4). A limitation to this
D. Chauveaux / Orthopaedics & Traumatology: Surgery & Research 101 (2015) S77–S83 S79
Table 4
ISO classification of air particle concentration.
4.1. Limitations
4.3. Patient preparation
Mean SSI rates are very low after clean surgery: 0.9% (range,
Preparation of the surgical-site in the OR makes a crucial contri-
0.7–2.6% depending on the NNIS index) in total hip arthroplasty
bution to SSI prevention. This well-standardised measures cannot
(THA) and 0.6% (range, 0.4–2.3%) in total knee arthroplasty (TKA)
be separated from the overall preparation of the patient.
[13]. These very low rates constitute a major obstacle to the demon-
At a 2004 consensus conference held by the French Society for
stration of a statistically significant effect of preventive measures.
Hospital Hygiene, a number of recommendations were issued.
In practice, a major issue is whether the contaminated parti-
Preparation of the patient should include at least showering
cle count and, therefore, the number of bacteria that settle on the
(with an antiseptic detergent solution) on the day before and morn-
surgical-site dictate the SSI rate or not. A simple and direct relation-
ing of the operation, without hair removal, provided this measure
ship linking the surgical-site bacterial count (which depends on the
does not interfere with surgical requirements.
number of airborne bacteria carried by particles) to the SSI rate may
In the OR, the patient’s skin should be cleansed with an antisep-
seem to make intuitive sense. Such a relationship would mean that
tic detergent solution, rinsed with sterile water, dried, and liberally
a high particle count indicates a high-risk of SSI. However, although
painted with antiseptic, preferably two coats of an alcoholic solu-
surgical-site bacterial counts correlate with airborne bacteria and
tion.
particle counts, they have not been demonstrated to correlate with
Given the absence of proof that showering with an antisep-
the SSI risk.
tic solution and application of a detergent decreased the SSI risk,
This fact is related to the multiplicity of factors that influence the
patient preparation measures were reappraised in 2013. Neverthe-
SSI risk, including the nature and virulence of the bacteria, quality
less, the beneficial effects of skin preparation before entering the
of the patient’s immune defences, and type of surgical procedure,
OR have been convincingly demonstrated [20]. Thus, in patients
which can modify local conditions, most notably by promoting
undergoing emergency THA after a hip fracture, skin microorgan-
the development of a local inflammatory response. Furthermore,
ism counts before detergent skin cleansing in the OR were 3 times
prophylactic antibiotic therapy is routinely administered and sig-
higher than in patients undergoing scheduled hip arthroplasty with
nificantly decreases the SSI risk. Our current surgical methods
skin preparation on the day before surgery [21].
combine numerous preventive measures derived from recommen-
The current tendency is to simplify the skin preparation proto-
dations and everyday practice. As a result, evaluating the specific
col. No recommendations can be made about the following points:
effect attributable to a given measure in isolation is extremely dif-
ficult, particularly as conflicting data have been published.
• number of preoperative showers, type of cleansing agent (anti-
4.2. Laminar flow septic or non-antiseptic), or usefulness of a shampoo; however,
at least one preoperative shower is advisable, provided it is per-
Since Charnley, who did not use prophylactic antibiotic therapy, formed very shortly before surgery;
the use of a laminar airflow system has long been considered cru- • nail polish removal when the fingers or hand (or the toes and
cial to the prevention of SSIs. Lidwell reported that a unidirectional foot) are not included in the surgical field;
vertical airflow decreased the SSI rate by 50% after THA or TKA. • use of topical chemical depilatory agents: hair removal is not
Vichard confirmed this beneficial effect, with a number of caveats among the preventive measures for SSIs and should not be per-
[14]. The French Society for Hospital Hygiene (Société Française formed routinely; in addition, shaving with a mechanical razor
d’Hygiène Hospitalière, SF2H) and French-Speaking Society for should be banned;
Infectious Diseases (Société de Pathologie Infectieuse de Langue • application of a detergent before the antiseptic agents when the
Française, SPILF) reached a strong consensus in 2004 and 2009, skin is not soiled;
D. Chauveaux / Orthopaedics & Traumatology: Surgery & Research 101 (2015) S77–S83 S81
• selection of the antiseptic agent (chlorhexidine or povidone- exhaust suits incorporating a self-contained ventilation system
iodine) or the usefulness of successively applying two antiseptics were not more effective than conventional surgical masks [22,26].
belonging to different classes. Nevertheless, preference should be Furthermore, Shaw et al. suggested that the increased tempera-
given to alcohol-based antiseptic agents. Small studies suggest ture around the face might promote bacterial growth and that the
that chlorhexidine alcohol may be more effective than iodinated increased pressure within the suit might increase the dissemina-
agents with or without alcohol in diminishing skin microorgan- tion of bacteria if the seal between the helmet and gown was not
ism counts [22]. fully effective [27]. Thus, body exhaust suits with incorporated air
ventilation systems do not seem mandatory, even for prosthetic
Nasal carriage of S. aureus is often cited among factors likely to surgery. In addition, consideration should be given to surgeon dis-
increase the risk of air contamination during clean orthopaedic comfort related to the suit.
surgery. However, routine screening and decolonisation are not
currently recommended, except in the following two situations: 4.4.3. Gloves
Double gloving is mandatory but does not dispense from full
• when the rate of SSIs due to S. aureus is abnormally high (greater compliance with hand washing technique. Perforation of the glove
than 2% despite the usual SSI prevention measures); in direct contact with the skin occurs in 15% of cases with single
• when scheduled surgery is to be performed in a patient previ- gloving compared to only 5% with double gloving [28]. Further-
ously hospitalised in an intensive care unit or intermediate- or more, perforation of the outermost glove has been noted in 3.7%
extended-care facility or in a patient with chronic skin lesions. of primary prosthetic surgery procedures and 8.3% of revision pro-
cedures; unrecognised perforations of the innermost glove were
4.4. Surgical staff preparation and patient installation found in 19% of cases. In orthopaedic surgery, glove perforation
occurs consistently, after a mean of 90 minutes [22]. The relative
4.4.1. Hand hygiene discomfort related to wearing two pairs of gloves is considered
Substantial changes in hand hygiene practices have occurred acceptable by 92.2% of orthopaedic surgeons [28]. The gloves should
over the last decade, most notably with the introduction of alcohol- be changed at least every 90 minutes, although a shorter interval is
based hand rubs. Classic hand hygiene products include povidone- undoubtedly preferable [29].
iodine, alcohol-based solutions, and chlorhexidine gluconate. The gloves should be changed before performing the incision, as
Alcohol-based solutions produce the largest decreases in hand 12% of gloves are contaminated after draping and 24% once patient
bacteria counts, with sustained results after 3 hours. Nevertheless, installation is complete.
the presence of glycerol in the formulation may result in the shed- A glove change is also required before touching the implants
ding of small sticky agglomerates produced by a reaction between and after cementation, since the gloves may become permeable
the skin cells and glycerol in the moist environment within the after contacting cement [12].
gloves [23]. Strict compliance with instructions for using these Triple gloving, with a resistant liner between two pairs of gloves,
products, particularly regarding brushing and the duration and impairs dexterity to an unacceptable degree.
extent of rubbing, is mandatory. The optimal duration of antiseptic
product application seems to be at least 2 minutes, after washing 4.4.4. Draping
with soap for at least 2 minutes, with a separation between hand Impermeable, disposable, non-woven drapes deserve prefer-
washing and antiseptic product application. ence. The use of plastic film impermeable to bacteria is intended
to prevent microorganism migration after draping but it is not
4.4.2. Operating room (OR) attire the focus of any of the current recommendations. Neither are
Many studies have sought to define the optimal OR attire. The recommendations available regarding the usefulness of antiseptic-
results are mixed and at times controversial, and they should be impregnated drapes or films compared to those without antiseptics
interpreted according to the type of surgical procedure, i.e., con- [20,22].
taminated emergency surgery or joint replacement surgery. Here,
we will focus on clean (Class I) surgical procedures. 4.5. Conduct of the surgical procedure
A number of points are well established:
4.5.1. Discipline
• special garments should be worn in the OR. However, the useful- Many factors require attention, most notably those capable of
ness of surgical masks, hoods covering the hair (a major location distracting the surgical team. Antoniadis et al. found a mean of
for staphylococci), and shoe covers during conventional surgical nearly 10 interruptions or distractions per hour during 65 proce-
procedures has been challenged [24]. OR garments should opti- dures in a range of surgical specialities, with 25% of these events
mally be sealed by elastics at the waist, ankles, neck, and wrists being related to personnel entering or exiting the OR and 25% to
to avoid the shedding of skin squames; calls from cell phones or beepers [30]. The introduction of com-
• the surgical staff should wear disposable impermeable garments puters, tablets, radios and, above all, cell phones into the OR is a
made of non-woven fabric, which should be tightened depending potential source of contamination. Among these devices, 44% to 98%
on the material used (polypropylene or Gore-Tex) [25]. carry resistant microorganisms (Gram-negative rods and S. aureus).
Therefore, the introduction of portable electronic devices into the
Laminar airflow produces air eddies that mandate the use of OR is best avoided, and when their use is mandatory, they should be
fairly loose masks and hoods. Tight masks and hoods rub against thoroughly cleansed using an alcohol-related solution before they
the skin, thereby increasing the shedding of contaminated particles. are taken into the OR [22].
Their use in combination with laminar airflow may result in 3- to
5-fold increases in CFU/m3 values and in a nearly 60-fold increase 4.5.2. Foot traffic in the operating room (OR)
in the number of settled bacteria [24]. When combined with lami- Airborne particle counts increase with the number of people
nar airflow, a total body suit was not superior over a conventional in the OR and, above all, with their movements and the number
disposable non-woven gown [25] in decreasing air contamination of door openings, which affect the direction of air circulation [8].
[6]. The only benefit from the suit was improved protection of the Door opening rates of 13 to 40 per hour have been reported during
staff from splashes of blood or other body fluids. Similarly, filtered prosthesis implantation procedures. In a study by Andersson et al.
S82 D. Chauveaux / Orthopaedics & Traumatology: Surgery & Research 101 (2015) S77–S83
[8], 7% of door openings were related to unexpected events pertain- protocol between patients [22]. Nevertheless, contaminated proce-
ing to the surgical procedure; 26% to a need for material, indicating dures are best performed at the end of the OR schedule, and surgical
suboptimal preoperative planning and preparation; and 27% to the staff must comply with individual decontamination procedures to
entry of people who had no role in the surgical procedure. There is prevent staff-to-patient transmission of microorganisms.
strong agreement that the number of people in the OR should be
kept at 5 or 6 at the most to ensure that the airborne bacterial count
5. Conclusion
does not exceed 10 CFU/m3 [31].
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