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INTERNATIONAL JOURNAL
OF CURRENT RESEARCH
International Journal of Current Research
Vol. 7, Issue, 03, pp.13977-13980, March, 2015

ISSN: 0975-833X RESEARCH ARTICLE

ENVIRONMENTAL MICROBIOLOGICAL SURVEILLANCE OF OPERATION THEATRES IN A
TERTIARY CARE HOSPITAL
1, *Anjali, K., 2Anamika, V., 3Mrithunjay, K., 4Dalal, A. S. and 5Amritesh Kumar
Department of Microbiology, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India

ARTICLE INFO ABSTRACT

Article History: Microbial contamination of air/surfaces/articles in operation theatre (OT) is a major cause of surgical
th
Received 09 December, 2014 site and nosocomial infections. Approximately 10% of nosocomial infections have serious outcomes
Received in revised form leading to longer duration of hospital stay and cost burden.
burden. Currently there is no uniform consensus
06th January, 2015 on either the standards for surveillance, methodology for monitoring or the levels of acceptable
Accepted 28th February, 2015 contamination and the risk of nosocomial infections borne by OT. The present study was conducted
Published online 31st March, 2015 with an aim to isolate and identify the microbial contamination of the air, surfaces and equipments of
the OT of a tertiary care post graduate teaching hospital. Air quality surveillance of OT’s was done by
Key words: settle plate method and note of bacterial CFU/ m3 count was mad made. For surface sampling, wet swabs
were taken from different sites and equipments. Bacterial species were isolated and identified by
Operating Theaters, conventional methods. In the settle plate technique, mean CFU/m3 was recorded for 8 different OT’s.
Microbial Contamination,
Ophthalmology OT recorded
recorded least bacterial CFU rate of air(114 CFU/m3) followed by EN ENT OT(166
Nosocomial Infections.
CFU/m3) and in Gynaecology and Obstretics OT(255CFU/m3), highest bacterial CFU rate was noted.
Out of total 68 surface and articles sampled from different OTs, only 9(13.2%) showed grow growth of
bacteria. The most common isolate was Coagulase negative Staphylococcus species (5.8%) followed
by Bacillus and Klebsiella species (4.4%) each.

Copyright © 2015 Anjali et al. This is an open access article distributed under the Creative Commons Attribution
Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.

INTRODUCTION
microbial counts and micro-flora
flora (Baird, 1996). It helps in
Microbial contamination of air/surfaces/articles in OTs is a monitoring the capability of the air filters used in the OT’s and
major cause of surgical site and nosocomial infections. also helps in assessing quality and making timely changes in
Approximately 10% of the nosocomial infections have serious measures that need to be adopted in order to maintain air
outcomes leading to longer duration of hospital stay and cost quality in these areas. Though at present, there is no
burden. Air bioload present in the form of aerosols may international consenses on the methods, types of samples
contain bacteria, viruses, yeasts, moulds and fungal spores. (settle plate versus volumetric air sampling), frequencies of
The most important source for generating aerosol is infected sampling and tolerable limits of bioburden in OTs. It is
patient, activities of medical staff and visitors load. Once recommended that for conventional operating theatres, the bio
aerosolized, subsequent loss of water helps the pathogen to load should not exceed 35 CFU/m3 in an empty theatre or 180
remain suspended and carried to considerable distance. CFU/m3 during an operation. It is also suggested that for ultra
ultra-
Microbiological contamination of air in the OTs is a major risk clean operating theatres the bioload should be less than 1.0
factor for surgical site infection (SSI) (Fleischer et al., 2006). CFU/m3 in the centre of an empty theatre and less than 10
SSI delays wound healing, prolongs hospitalization, increases CFU/m3 during an operation and should not exceed 20
morbidity and the overall costs. The environment in the CFU/m3 at the periphery (Baird,
Baird, 1996)
1996).
operation theatre is dynamic and subject to continuous change.
Invasive procedures,
ures, high antibiotic usage and transmission of MATERIALS AND METHODS
bacteria between patients due to inadequate infection control The study was carried out at the Department of Microbiology,
measures explain why OTs are “hot zones” for the spread of Geetanjali
etanjali Medical College and Hospital, Udaipur Rajasthan,
antibiotic resistant organisms. Environmental monitoring for a period of three months during the year 2014.
means the microbiological testing ing of air, surface and
equipment in order to detect changing trends of Sample Collection and Transport
*Corresponding author: Anjali, K. Air and surface samples were taken randomly without prior
Department of Microbiology, Geetanjali Medical college and discussion with the cleaning staff and adequate care wa
was taken
Hospital, Udaipur, Rajasthan, India. to ensure that there was no trafficking in these areas while the
13978 Anjali et al. Environmental microbiological surveillance of operation theatres in a tertiary care Hospital

sampling procedures were completed. Standard operating Table 2. Various Bacterial Isolates From Ot’s In Air Sampling
procedures (SOP) were followed at the operation theatres to
monitor the bacterial load by the settle plate method (Charnley Name of OT Organism isolated
Orthopedics No Bacterial growth
and Efthekhar, 1969). Air sampling was done by settle plate Neuro surgery No Bacterial growth
method. Blood Agar and Sabourd’s Dextrose Agar plates were Cardio-thoracic vascular surgery No Bacterial growth
taken to the operation theaters in sealed plastic bags. The General surgery Coagulase negative Staphylococcus species
and Bacillus species
plates were labeled with sample number, site within theatre, Urology Coagulase negative Staphylococcus species
time and date of sample collection. One plate each was kept at Ophthalmology Coagulase negative Staphylococcus species
the center of operation theatre and the four corners of the ENT Coagulase negative Staphylococcus species
and Bacillus species
operation theatre at about 1 meter above the ground, 1 meter Gynaecology and Obstretics Coagulase negative Staphylococcus species
from the wall and exposed for 1 hour (Baird, 1996). Surface
sampling was done by soaking a swab in nutrient broth which Table 3. Various bacterial isolates from ots in surface sampling
was rolled over to the surfaces of equipments, instruments
trolley, operation tables at the head end, Over head lamp, Bacterial isolates Number (%) n/68
monitor, an aesthesia table, IV infusion pumps, crash cart, door Coagulase Negative Staphylococcus species 4 (5.8 %)
handles. A total of 68 surface samples were labeled properly Klebsiella species 3 (4.4 %)
and transported immediately to the microbiology laboratory for Bacillus species 3 (4.4 %)
Total 10 (14.6%)
processing.
Table 3. Various Bacterial Isolates From OT’s in Surface
Processing Of Samples Sampling

Air sampling – Exposed plates were sent to laboratory in Name of OT Organism isolated
sealed plastic bags. Blood agar plates were incubated at 37°C Orthopedics No Bacterial growth
for 24 hours and SDA plates were incubated at 25°C for 7 Neuro surgery No Bacterial growth
Cardio-thoracic vascular surgery No Bacterial growth
days. After incubation, the colonies were counted and isolates General surgery Coagulase negative
were identified by using conventional methods. The resultant Staphylococcus species
colonies were counted and converted into colony forming unit Urology No Bacterial growth
Ophthalmology No Bacterial growth
per cubic meter of air (CFU/m3) using Omeliansky formula ENT Coagulase negative
(Abdel Hameed, 2013). Staphylococcus species
Gynaecology and Klebsiella species, Coagulase negative
Obstretics Staphylococcus species and Bacillus species
N=5a x 104 (bt)-1
N=colony forming unit per cubic meter of air (CFU/m3)
a=number of colonies per petridish DISCUSSION
b=surface area of petridish in cm2
t=time exposure (minutes) The clinical implication of microbial contamination in OT is a
hot topic for patients safety, clinicians and hospital
Surface sampling - Swabs collected from various surfaces administrators as post operative infections can cause burden in
were inoculated by streaking on Blood Agar and MacConkey terms of extra cost of medication, prolonged hospitalization,
Agar plates. These culture plates were incubated at 370C for re-operations, etc. Prevention measures that need to be
24 hours under aerobic condition. After incubation, the isolates practiced to avoid such critical situations rest not only with the
were identified by conventional methods. All isolates were operating personnel but also with the entire infection control
divided in to three broad categories: (Fleischer et al., 2006) team. The role of the clinical microbiologist becomes crucial,
Normal flora e.g. Coagulase Negative Staphylococcus (CoNS) as they help in identifying and give suggestion for controlling
(Sandle, 2006) Contaminant e.g. Bacillus species (Baird, 1996) some of the microbial contamination. In this context,
Pathogen e.g. Staphylococcus aureus, Klebsiella species, and monitoring and microbiological surveillance can serve as
Pseudomonas aeruginosa (Desai et al., 2012). warning systems for change in the type and count of microbial
flora.
RESULTS Counting microbes in the air is not a easy task, but through air
Table 1. Bacterial Count Of Air From Various Ot’s : (Air and surface sampling it is possible to evaluate bacterial
Sampling) contamination of environment (Davis et al., 1999). Many
different methods are in use which can be divided into four
Name of OT CFU/m3 groups: counts of colony forming units per cubic meter of air
Orthopedics 00 (CFU/m3); counts of CFU on settle plates; counts under a
Neuro surgery 00 microscope; and measurement of a chemical component of the
Cardio-thoracic vascular surgery [CTVS] 00
General surgery 204
microbial cells per cubic meter of air. At the moment, the only
Urology 218 effective means of quantifying airborne microbes is limited to
Ophthalmology 114 the count of CFU. The CFU count is the most important
ENT 166 parameter, as it measures the live micro-organisms which can
Gynaecology and Obstretics 255
multiply. Air samples can be collected in two ways: by active
air samplers or by passive air sampling (the settle plates). Both
methods are widely used (Pasquarella et al., 2004). From table
 13979 International Journal of Current Research, Vol. 7, Issue, 03, pp.13977-13980, March, 2015

I of our study, the bacterial CFU counts of air from all OTs interpretation of results and are not in direct contact with
ranged from 114 CFU/m3 (Ophthalmology OT) to 255 patients, hence they do not contribute in the prevention of SSI
CFU/m3 (Gynaecology and Obstretics OT). From table II of infection (Stockley et al., 2006). Bacterial surface sampling of
our study, Coagulase Negative Staphylococci (CoNS) was OT’s were observed to be colonized with CoNS, which was
isolated from air samples from all operation theatres except the most predominant organism isolated from various surfaces
Orthopedics, Neurosurgery and Cardio-thoracic vascular and articles. The reason might be due to the shedding of CoNS
surgery OT. Bacillus species were present in the air of ENT from skin of health care workers and patients and easy cross
and General surgery operation theatres. No fungus were transmission in between the patient and the health care worker
isolated from any OTs. or vice versa. This was followed by Bacillus species, which are
considered to be the contaminant.
Microorganisms that cause infections in OT include bacteria,
fungi and viruses (Qudiesat et al., 2009). It has been observed Limitation of Our Present Study
that counts in the range of 700-1800/m3 were related to
significant risk of infection and the risk was slight when they In our study settle plate method for air sampling was used,
were below 180/m3 (Parker, 1978). A 13-fold reduction in though it may be regarded as a crude measure of airborne
airborne bacteria in the OTs would reduce wound contamination. In places without other facilities it can still
contamination by around 50% (Genet et al., 2011). In our provide a simple and cost effective way of enumerating the air
study, bacterial count of air is in a range of 114-255 CFU/m3. contamination rate at multiple points. With limited sources in
Microbiological surveillance study in OTs of a tertiary care our hospital, settle method and environmental sampling has
hospital at Lahore (Javed et al., 2008) and Mysore (Deepa et given a valuable report. Settle plates are inexpensive and easy
al., 2014) have reported a significantly higher bacterial air to use and require no special equipment. They are useful for
count in the range of 6500-15730CFU/m3 and 628- qualitative analysis of airborne microorganisms and the data
1571CFU/m3 respectively. This is in contradiction with the they produce may detect underlying trends in airborne
study conducted by Desai et al. 2012, in which a low bacterial contamination and provide early warning of problems.
air count in the range of 20-75 CFU/m3 was reported. The
reason for such variations many be attributed to the method Conclusion
employed for surveillance (active air sampling or passive air Harboring of potential pathogens in OTs of hospital can pose a
sampling), time of sampling, disinfectant used and mechanical great risk to patients. Monitoring the bioload of air helps in
ventilation of OTs. assessing the capability of air filters used in the OT’s and also
Air sampling of all OTs showed that they were free from helps in assessing quality and making timely changes in
pathogens. CoNS were isolated from the air sample of all OTs measures that need to be adopted. Our study was conducted to
except, orthopedics, CTVS, and Neurosurgical OT. Highest gain knowledge regarding the air quality and the quantity of
prevalence of CoNS was in Gynaecology and Obstretic OT airborne pathogens in OT. In our study, bacterial air sampling
(40%), General surgery OT (30%) and lowest prevalence was in all OTs showed a much less colony count ranging from 114-
from ophthalmology (5.5%). These findings are concurrent 255CFU/m3. This data can be used to set regional standards for
with various studies conducted by Javed et al. 2008 and Desai levels of acceptable microbial population and can also be used
et al. 2012. to suggest suitable guidelines in order to decrease the
microbial rates in indoor air. Strengthening surveillance and
From table III of our study, a total of 68 swabs were collected laboratory capacity will surely enhance infection prevention
from various surfaces and articles from different operation and control. Routine sampling is strongly recommended so
theatres. Out of which 9 [13.2%] samples showed growth on that we can become more aware and alert to identify and
the culture media at 370C after 24 hours of incubation and control all possible sources and types of infections. Hence in
remaining 45 samples showed no growth. Nine swab samples future, more and more studies should be undertaken to find out
yielded 10 isolates. Of these 10 isolates obtained from various prevalence of type of bacterial isolates and also comparative
OTs, 4(5.8%) were Coagulase Negative Staphylococcus studies on the types of routine sampling for detection of
species, 3 (4.4%) were Klebsiella species and the remaining 3 microbiological quality of air of OT along with infection
were Bacillus species. control measures which will be very helpful in controlling SSI.

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