An overview of the studies on microbial air contamination in operating theatres and related issues over time: a useful tool for a multidisciplinary approach

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Roberto Albertini
Alessia Coluccia
Maria Eugenia Colucci
Roberta Zoni
Paola Affanni
Licia Veronesi
Cesira Pasquarella

Keywords

Microbial air contamination, operating theatres, air sampling, ventilation, behaviour, airflow

Abstract

Background and aim


Surgical site infection (SSI) is a major complication following surgery associated with increased morbidity and mortality, as well as increased health and not health costs. A variety of factors affect airborne contamination in operating theatres (OT). Following the Medical Research Council study showing a correlation between microbial air contamination and SSI incidence in prosthetic joint surgery ultraclean OTs have been recommended for this type of surgery, while OTs supplied by turbulent airflow plants are recommended for other types of surgery. The aim of this study was to illustrate the studies on this topic.


Methods


Scopus was considered for articles published until January 2023 on OTs and air contamination in article title or abstract or keywords. Many issues were deepened: “microbial”, “bacterial”, “fungi”, “viruses”, “surgical site/wound infection”, “monitoring/sampling”, “air changes”, “behaviour”, “door openings”, “particles”, turbulent flow”, “unidirectional flow”.


Results


Total papers published were 907 and 249 papers faced monitoring/sampling. A total of 313 papers investigated airborne bacterial contamination and 63 papers investigated fungal air contamination. There were 218 papers that have evaluated particle contamination in OTs. Many other issues were deepened.


Conclusions


This study shows a picture of the studies on biological air contamination in OTs and related issues over time. We think that the results of our study will provide a useful tool to increase awareness towards a better sharing of aims, approaches, and results, above all in the interest of the patients, but also of the health services of the different countries. (www.actabiomedica.it)

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References

1. Meara JG, Leather AJ, Hagander L et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Int J Obstet Anesth. 2016 Feb;25:75-8. doi: 10.1016/j.ijoa.2015.09.006.2.
2. Badia JM, Casey AL, Petrosillo N, Hudson PM, Mitchell SA, Crosby C. Impact of surgical site infection on healthcare costs and patient outcomes: a systematic review in six European countries. J Hosp Infect. 2017 May;96(1):1-15. doi: 10.1016/j.jhin.2017.03.004.
3. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999 Apr;27(2):97-132. PMID: 10196487
4. Kapadia BH, McElroy MJ, Issa K, Johnson AJ, Bozic KJ, Mont MA. The economic impact of periprosthetic infections fol-lowing total knee arthroplasty at a specialized tertiary-care center. J Arthroplasty. 2014 May;29(5):929-32. doi: 10.1016/j.arth.2013.09.017.
5. Charnley J. Postoperative infection after total hip replacement with special reference to air contamination in the operating room. Clin Orthop Relat Res. 1972;87:167-87. doi: 10.1097/00003086-197209000-00020.
6. Dharan S, Pittet D. Environmental controls in operating theatre. J Hosp Infect 2002;51:79e84.22
7. Whyte W. (2015) The effect of mechanical ventilation and clothing on airborne microbes and wound sepsis in hospital oper-ating rooms, Part 1. Clean Air and Containment Review, 22, pp. 4-11.
8. Evans RP. Current concepts for clean air and total joint arthroplasty: laminar airflow and ultraviolet radiation: a systematic review. Clin Orthop Relat Res. 2011 Apr;469(4):945-53. doi: 10.1007/s11999-010-1688-7.
9. Centers for Disease Control and Prevention (CDC). Guidelines for environmental infection control in health-care facilities. Atlanta, GA: U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC); 2003.
10. Berríos-Torres SI, Umscheid CA, Bratzler DW et al. for the Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection. JAMA Surg. 2017;152(8):784-791. doi:10.1001/jamasurg.2017.0904 7.
11. Global guidelines for the prevention of surgical site infection World Health Organization – 2016.
12. Uçkay I, Harbarth S, Peter R, Lew D, Hoffmeyer P, Pittet D. Preventing surgical site infections. Expert Rev Anti Infect Ther. 2010 Jun;8(6):657-70. doi: 10.1586/eri.10.41.
13. Parvizi J, Barnes S, Shohat N, Edmiston CE. Environment of care: Is it time to reassess microbial contamination of the oper-ating room air as a risk factor for surgical site infection in total joint arthroplasty? Am J Infect Control 2017;45(11):1267-1272. doi.org/10.1016/j.ajic.2017.06.027.
14. Reichman DE, Greenberg JA. Reducing surgical site infections: a review. Rev Obstet Gynecol. 2009 Fall;2(4):212-21.
15. Barimani B, Ahangar P, Nandra R, Porter K. The WHO surgical safety checklist: a review of outcomes and implementation strategies. Perioper Care Oper Room Manag 2020;21, 100117. doi: 10.1016/j.pcorm.2020.100117
16. Whyte W, Hodgson R, Tinkler J. The importance of airborne bacterial contamination of wounds. J Hosp Infect. 1982 Jun;3(2):123-35. doi: 10.1016/0195-6701(82)90004-4.
17. Fard RF, Aali R. Airborne antibiotic resistant bacteria: hospital indoor air pollution and the challenge of nosocomial infec-tion. J Environ Health Sustain Dev. 2019;4:859-861. doi: 10.18502/jehsd.v4i4.2017
18. Shahroudi P, Aarabi A. Quality improvement through lean A3 method for foot traffic in operating room. Perioper Care and Oper Room Manag 2021;23, 100155. doi: 10.1016/j.pcorm.2021.100155
19. Cao G, Pedersen C, Zhang Y, et al. Can clothing systems and human activity in operating rooms with mixed flow ventilation systems help achieve the ultraclean air requirement (≤10 CFU/m3) during orthopaedic surgeries? J Hosp Infect. 2022 Feb;120:110-116. doi: 10.1016/j.jhin.2021.11.005.
20. Pasquarella C, Balocco C, Colucci ME et al. The Influence of Surgical Staff Behavior on Air Quality in a Conventionally Ventilated Operating Theatre during a Simulated Arthroplasty: A Case Study at the University Hospital of Parma. Int J Environ Res Public Health. 2020 Jan 10;17(2):452. doi: 10.3390/ijerph17020452.
21. Spagnolo AM, Ottria G, Amicizia D, Perdelli F, Cristina ML. Operating theatre quality and prevention of surgical site in-fections. J Prev Med Hyg 2013;54:131-137. PMID: 24783890
22. Bhattacharya A, Ghahramani A, Mousavi E. The effect of door opening on air-mixing in a positively pressurized room: Im-plications for operating room air management during the COVID outbreak. J Build. Eng. 2021;44:102900. doi:10.1016/j.jobe.2021.102900
23. Lidwell OM, Lowbury EJ, Whyte W, Blowers R, Stanley SJ, Lowe D. Effect of ultraclean air in operating rooms on deep sepsis in the joint after total hip or knee replacement: a randomised study. Br Med J (Clin Res Ed). 1982 Jul 3;285(6334):10-4. doi: 10.1136/bmj.285.6334.10.
24. DIN 1946-4:2008 Ventilation and Air Conditioning - Part 4: Ventilation in Buildings and Rooms of Health Care. Berlin: Beuth Verlag, 2008..
25. Aganovic A, Cao G, Fecer T, et al. Ventilation design conditions associated with airborne bacteria levels within the wound area during surgical procedures: a systematic review. J Hosp Infect. 2021 Jul;113:85-95. doi: 10.1016/j.jhin.2021.04.022.
26. Knudsen RJ, Knudsen SMN, Nymark T, et al. Laminar airflow decreases microbial air contamination compared with turbu-lent ventilated operating theatres during live total joint arthroplasty: a nationwide survey. J Hosp Infect. 2021 Jul;113:65-70. doi: 10.1016/j.jhin.2021.04.019.
27. Whyte W, Lytsy B. Ultraclean air systems and the claim that laminar airflow systems fail to prevent deep infections after to-tal joint arthroplasty. J Hosp Infect. 2019 Sep;103(1):e9-e15. doi: 10.1016/j.jhin.2019.04.021.
28. Pasquarella C, Barchitta M, D’Alessandro D. et al. Heating, ventilation and air conditioning (HVAC) system, microbial air contamination and surgical site infection in hip and knee arthroplasties: the GISIO-SItI Ischia study. Ann Ig. 2018 Sep-Oct;30(5 Supple 2):22-35. doi: 10.7416/ai.2018.2248.
29. Agodi A, Auxilia F, Barchitta M. et al. Italian Study Group of Hospital Hygiene. Operating theatre ventilation systems and microbial air contamination in total joint replacement surgery: results of the GISIO-ISChIA study. J Hosp Infect. 2015 Jul;90(3):213-9. doi: 10.1016/j.jhin.2015.02.014.
30. Pasquarella, C., Agodi, A., Auxilia, F. et al. Air quality in the operating theatre: a perspective. Aerobiologia 2020; 36: 113–117 (2020). doi: 10.1007/s10453-019-09584-018.
31. Aganovic A. Airflow distribution for minimizing human exposure to airborne contaminants in healthcare facilities Trond-heim. Norwegian University of Science and Technology; 2019. Available at: https://ntnuopen.ntnu.no/ntnu-xmlui/handle/11250/2584954 [last access 29 August 2023]
32. Hb+ Die Spitäler der Schweiz. Klassifizierung und technisce Anfordungen an Spitälraume. Bern; 2007.
33. NHS Estates. Health technical memorandum 2025. Ventilation in healthcare premises. Part 3. Validation and verification. London: National Health Service; 1994.
34. Health Technical Memorandum 03-01. Specialised ventilation for healthcare premises. Norwich: TSU; 2007.
35. Health Technical Memorandum 03-01 Specialised ventilation for healthcare buildings. 2021.
36. ISPESL. Linee guida per la definizione degli standard di sicurezza e di igiene ambientale dei reparti operatori. Rome: ISPESL; 1999.
37. ISPESL. Linee Guida sugli Standard di Sicurezza e di Igiene del Lavoro nel Reparto Operatorio. Rome: ISPESL; 2009.
38. Hoffman PN, Williams J, Stacey A, et al. Microbiological commissioning and monitoring of operating theatre suites. J Hosp Infect 2002;52:1e28. doi: 10.1053/jhin.2002.1237
39. Societé Française d’hygiène hospitalière. La qualité´ de l’air au bloc opératoire. Recommandations d’experts. GR-AIR; 2004
40. NFS 90-351 Établissement de Santé - Salles Propres et Environnements Maîtrisés Apparentés - Exigences Relatives pour la Maîtrise de la Contamination Aéroportée 2013.
41. SF2H. Risque infectieux fongique et travaux en établissement de santé. Available at: https://www.cpias.fr/nosobase/recommandations/sfhh/2011_RIinfectieuxfongique_travaux_SF2H.pdf [Last access 29 August 2023].
42. SF2H. Qualité de l’air au bloc opératoire et autres secteurs interventionnels. Available at: https://www.sf2h.net/k-stock/data/uploads/2015/05/SF2H_recommandations_qualite-de-l-air-au-bloc-operatoire-et-autres-secteurs-interventionnels-2015.pdf [last access 29 August 2023].
43. UNI EN 17141:2021 – Camere bianche ed ambienti controllati associati; Controllo della biocontaminazione. Rome: Ente Unificatore Italiano; 2021.
44. Surveillance microbiologique de l’environnement dans les établissements de santé. Guide de bonnes pratiques – CCLIN Sud-Ouest – 2016.
45. Carroll GT, Kirschman DL. Discrete room pressure drops predict door openings and contamination levels in the operating room setting. Perioperative Care and Operating Room Management 2022; 29, 100291. doi: 10.1016/j.pcorm.2022.100291
46. D’Orazio A, D’Alessandro D. Air bio-contamination control in hospital environment by UV-C rays and HEPA filters in HVAC systems. Ann Ig. 2020 Sep-Oct;32(5):449-461. doi: 10.7416/ai.2020.2369
47. Barnewall RE, Bischoff WE. Removal of SARS-CoV-2 bioaerosols using ultraviolet air filtration. Infect Control Hosp Epi-demiol. 2021 Aug;42(8):1014-1015. doi: 10.1017
/ice.2021.103
48. Popovic M, Beathe JC, Gbaje E, Sharp M, Memtsoudis SG. Effect of portable negative pressure units on expelled aerosols in the operating room environment. Reg Anesth Pain Med. 2022;47:426–429. doi: 10.1136
/rapm-2022-103489.
49. Carroll GT, Kirschman DL. A portable negative pressure unit reduces bone cement fumes in a simulated operating room. Sci Rep. 2022;12:1–6. doi: 10.1038
/s41598-022-16227-x, 11890.
50. Colella Y, Valente AS, Rossano L, Trunfio TA, Fiorillo A, Improta G. A fuzzy interference system for the assessment of in-door air quality in an operating room to prevent surgical site infection. Int J Environ Res Public Health. 2022;19:3533.40. doi: 10.3390/ijerph19063533
51. Madeo M. The role of air ventilation and air sampling in reducing the incidence of surgical wound infection rates. Br J Theatre Nurs 1996;6:29e32. PMID: 9052043
52. Pasquarella C. Microbial control of the environment in the operating theatre. Ann Ig 2009;21(Suppl. 1):9e16.
53. Pasquarella C, Albertini R, Dall’Aglio P, et al. Air microbial sampling: the state of the art. Ig San Pubb 2008;64:79e120. PMID: 18379608.
54. Birgand G, Saliou P, Lucet JC. Influence of staff behavior on infectious risk in operating rooms: what is the evidence? Infect Control Hosp Epidemiol. 2015 Jan;36(1):93-106. doi: 10.1017/ice.2014.9.
55. Eickhoff TC. Microbiological sampling. Hospitals 1970;44:86e87.24. Eickhoff TC. Airborne nosocomial infection; a con-temporary perspective. Infect Control Hosp Epidemiol 1994;15:663e672. doi: 10.1086/646830
56. Faure O, Fricker-Hidalgo H, Lebeau B, Mallaret MR, Ambroise-Thomas P, Grillot R. Eight-year surveillance of environ-mental fungal contamination in hospital operating rooms and haematological units. J Hosp Infect 2002;50:155e160. doi: 10.1053/jhin.2001.1148
57. Fox C, Whyte A. Theatre air sampling e ignorance is bliss. J Hosp Infect 1995;30:80e82. doi: 10.1016/0195-6701(95)90256-2
58. Fox C, Whyte A. Theatre air sampling e once a year is not enough. J Hosp Infect 1996;32:319e320.
59. French MLV, Eitzen HE, Ritter MA, Leland DS. Environmental control of microbial contamination in the operating room. In:Hunt TK, editor. Wound healing and wound infection. New York:Appleton-Century-Crofts; 1980.
p. 254e261.
60. Friberg B, Friberg S, Burman LG. Inconsistent correlation between aerobic bacterial surface and air counts in operating rooms with ultraclean laminar air flows: proposal of a new bacteriological standard for surface contamination. J Hosp Infect 1999;42:287e293. doi: 10.1053/jhin.1998.0598
61. Groschel DH. Air sampling in hospitals. Ann N Y Acad Sci 1980;353:230e239. doi: 10.1111/j.1749-6632.1980.tb18926.x
62. Humphreys H, Taylor EW. Hospital Infection Society Working Party on Infection Control and Operating Theatres. Oper-ating theatre ventilation standards and the risk of postoperative infection. J Hosp Infect 2002;50:85e90. doi: 10.1053/jhin.2001.1126
63. Jowitt D, Morris AJ. The questionable value of microbiological sampling when commissioning new operating theatres. J Hosp Infect 2005;59:267e268. doi: 10.1016/j.jhin.2004.09.019
64. Pitzurra M, Savino A, Pasquarella C. Microbiological environment monitoring (MEM)]. Ann Ig. 1997 Nov-Dec;9(6):439-54. PMID: 9528153
65. Pasquarella C, Pitzurra O, Savino A. The index of microbial air contamination. J Hosp Infect. 2000 Dec;46(4):241-56. doi: 10.1053/jhin.2000.0820.
66. Pasquarella C, Vitali P, Saccani E. et al. Microbial air monitoring in operating theatres: experience at the University Hospital of Parma. J Hosp Infect. 2012 May;81(1):50-7. doi: 10.1016/j.jhin.2012.01.007
67. Albertini R, Veronesi L, Colucci ME, Pasquarella C. The scenario of the studies on ragweed (Ambrosia Sp.) and related is-sues from its beginning to today: a useful tool for future goals in a one health approach. Acta Biomed. 2022 Oct 26;93(5):e2022324. doi: 10.23750/abm.v93i5.13771
68. Falagas ME, Pitsouni EI, Malietzis GA, Pappas G. Comparison of PubMed, Scopus, Web of Science, and Google Scholar: strengths and weaknesses. FASEB J. 2008 Feb;22(2):338-42. doi: 10.1096/fj.07-9492LSF.
69. D’Amico A, Fara GM. The need to develop a multidisciplinary expertise for the microbiolo-gical safety of operating theatres Ann Ig 2016; 28: 379-380 doi:10.7416/ai.2016.2119