Abstract
Background:
Intraoperative transmission of major bacterial pathogens has been characterized for adult surgical patients. Little is known about these events in the pediatric surgical population. Personalized body worn alcohol dispensers may serve as an important tool for perioperative infection control, but the impact of these devices on the epidemiology of pathogens is unclear. Our primary aim was to characterize the epidemiology of bacterial transmission for the pediatric surgical population. Secondarily, we aimed to evaluate the impact of this transmission while utilizing a personalized body worn alcohol dispenser.
Methods:
The prospective cohort study included 40 pediatric patients for whom pathogen transmission was evaluated. These operative cases were assigned randomly to two groups: (a) usual care or (b) the addition of a body worn alcohol dispenser to usual care. Transmission of S aureus (methicillin-sensitive and methicillin-resistant), Enterococcus, Pseudomonas, and other gram-negative pathogens was assessed. The study was performed over a one-year period, December 2019 to December 2020.
Results:
A total of 57 bacterial transmission events (29 treatment, 28 control) were identified. Fifty-five percent (22/40) of intravascular stopcocks became contaminated with >100 colony forming units, 20% (8/40) with major bacterial pathogens. Eighty-five percent (34/40) of patients were colonized preoperatively with ≥ 1 (1.78 ± 0.19 [SD]) major bacterial pathogen. Patients were the primary reservoir for S. aureus and Pseudomonas. Regarding secondary aim, anesthesia providers used the alcohol dispenser 3.3 ± 2.1 times per hour. Their hands were the primary reservoir for other gram-negative and Enterococcal pathogens. The device changed bacterial transmission, increasing the contribution of provider hand contamination at the start of cases (relative risk [RR] 2.03, 99.17% CI 1.025–5.27, P =.0066) and decreasing the contribution of environmental contamination by end of cases (3/29 device vs. 12/28 usual care, RR 0.24, 99.17% CI 0.022–0.947, P =.006).
Conclusions:
This study highlights that targets to improve infection control in pediatric operating room environments should include preoperative patient decolonization and vascular care improvement. A personalized body worn alcohol dispenser can augment environmental cleaning, but World Health Organization guidelines for hand hygiene, including before patient care, should be followed.
Introduction
Intraoperative transmission of major bacterial pathogens has been repeatedly associated with increased patient mortality and directly linked to surgical site infections (SSI) for adult patients undergoing a variety of surgical procedures.1,2 Attenuation of bacterial transmission with an evidence-based, multifaceted approach involving optimization of basic preventive measures is an efficacious and feasible strategy for reducing pathogen transmission3,4 Analyses of pediatric surgical outcomes using American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data has shown healthcare associated infections (HAI) to be the most common complication; including SSIs, sepsis, pneumonia and urinary tract infection.5 Among all patients, the rate of pediatric SSIs as reported by ACS NSQIP is 1.8% while the rate is 3% among neonates undergoing surgery.2 HAI rates among pediatric cardiac surgeries have been reported to be as high as 6% with SSI rates ranging from 1.4 to 6.3%.7,8
Details about the pathogens responsible these SSIs are limited. Lake and colleagues found S. aureus to be the most common pathogen responsible for pediatric SSIs from the National Healthcare Safety Network.9 Similarly, Watanabe and collaborators recently reported that methicillin-resistant staphylococci most commonly lead to SSIs that develop following pediatric spine surgery.10 Although information with respect to the pathogens responsible for pediatric SSI is beginning to emerge, more detail is needed to improve patient care. Specifically, the epidemiology of major bacterial pathogen transmission in pediatric operating rooms has not yet been characterized. As a result, potential targets for improvement on pathogen transmission are currently unknown.5–8 To establish effective perioperative infection prevention measures for the pediatric surgical population knowledge about the epidemiology pathogen transmission is needed.
One implementation feature of a multifaceted approach used in the perioperative care of adult patients leverages provider proximity to hand sanitizer to augment hand hygiene compliance.3,4,11 Nadirs in hand hygiene compliance were correlated with peaks in environmental contamination and periods of increased task density such as induction and emergence of anesthesia.12 This has led to an increased risk of stopcock contamination meeting or exceeding 100 colony forming units (CFU) per surface area sampled,1,2 increasing the risk of the development of infection.1–4,13 The efficacy of a personalized dispenser on reducing contamination of the healthcare environment and HAIs has been mixed.11,14 Further, while the impact of the device on overall environmental contamination has been assessed, the role of the device in addressing the transmission of major bacterial pathogens has also not yet been evaluated. Thus, the role of the device in reducing perioperative infection remains unclear.
In this study, we aimed to characterize the epidemiology of major bacterial transmission in the pediatric surgical population in order to identify improvement targets for pediatric perioperative infection control. Secondarily, we evaluated the impact of a personalized, body worn alcohol dispenser in reducing the intraoperative spread of major bacterial pathogens in a younger patient population.
Methods
General Description
This study was conducted at a large teaching pediatric hospital over a 1-year period (December 2019 – December 2020). Twenty operating room case pairs (40 total surgical cases) were assigned to each of two groups, (a) usual practice or (b) the addition of a personalized, body worn alcohol dispenser to usual practice (SafeHaven, Georgia-Pacific Consumer Products, Atlanta, GA). The original intent was to assess two consecutive cases occurring in the same operating room, this did not necessarily include first case of the day. However, due to unforeseen case reassignments after patient enrollment, seventeen pairs were assessed in the same operating room and three pairs were assessed having been done in different operating rooms. Operating rooms were chosen using a random number generator to achieve balance between the groups. The epidemiology of major bacterial transmission was assessed for each group (OR PathTrac, RDB Bioinformatics, Omaha, NE 68154). Institutional review board approval (COMIRB# 19–0759) was obtained with requirement for informed written consent by the parent (or legal guardian) for all patients and in addition, assent for patients age 13–17. The trial protocol was registered at clinicaltrials.gov (NCT03992209) prior to enrollment of the first patient. Our study is being reported with adherence to guidelines specified in the STrengthening the Reporting of Observational studies in Epidemiology (STROBE) standards.
Standard operating room infection control practices at the time of study included routine between-case and terminal environmental cleaning with quaternary ammonium compounds by hospital environmental services (floor mopping and removal of trash) and anesthesia technologists (anesthesia machine and medication Omnicell cleaning). Anesthesia providers had access to alcohol-based hand sanitizer (62% isopropyl) located in wall-mounted and cart-based dispensers in the operating room. Closed lumen IV sets with 3 stopcocks in combination with disinfection/protection caps impregnated with 70% isopropyl alcohol (DualCap System, Merit Medical Systems, Jordan, Utah) were used on all intravenous lines.
One SafeHaven® device was given to each anesthesia provider prior to their preparation for the first case enrolled in their OR. The device was warn on the providers’ waist for both cases of a pair and retrieved once the end of case hand sample was collected after the second case. The device dispensed 0.8–1.2mL of an alcohol-based hand rub depending on the force used. Use was recorded by the device as average hand hygiene events per hour of clinical time and total hand hygiene events performed. Multiple dispenses within a 20 sec window were counted as a single hand hygiene event.
Pediatric patients (age < 18 years) considered eligible for enrollment were undergoing otolaryngology, general surgery, urologic, orthopedic, ophthalmologic, or thoracic surgery requiring general anesthesia with the placement of at least one peripheral IV catheter. Exclusion criteria included patients > 18 years old, a surgical procedure outside of the above classification, lack of requirement for an IV catheter, and lack of informed written consent from the patient or family. All intraoperative anesthesia providers were considered eligible to participate but were not required to provide consent.
Information pertaining to the operating room number, sex, American Society of Anesthesiologists (ASA) health classification status, age, surgical specialty (otolaryngology, general surgery, urologic, orthopedic, ophthalmologic, or thoracic surgery), anesthesia duration, and dirty or infected surgical classification was collected for each patient of a pair.
Primary aim:
Characterization of the epidemiology of transmission of major bacterial pathogens for the pediatric operating room environment.
Secondary aim:
To assess the impact of the hand hygiene device on the epidemiology of pathogen transmission.
Reservoir sampling and analysis
We used systematic phenotypic analysis and temporal association to analyze the epidemiology of S. aureus (methicillin-sensitive and methicillin-resistant), Enterococcus, Pseudomonas, and other gram-negative spp. using the methodology detailed below. 3,4,15,16 A bacterial transmission event was defined as an isolate present at case end that was not present at case start or ≥ 2 epidemiologically related isolates (by class of pathogen and temporal association) obtained from two distinct reservoirs.3,4 For Staphylococcus aureus isolates, antibiotic susceptibility testing involving ampicillin, cefazolin, cefepime, ceftazidime, cefuroxime, ciprofloxacin, clindamycin, gentamicin, linezolid, meropenem, penicillin, trimethoprim/sulfamethoxazole, and tetracycline was used to confirm epidemiological-relatedness. Given this definition of bacterial transmission event and the sampling of multiple reservoirs we anticipated the possibility of observing multiple transmission events within a single case and between a case pair.
One collection tube and swab (ESwab, Copan Diagnostics Inc., Murrieta, CA) was used to sample each location by the same research assistant except for provider hands as described.1–4
Provider hands:
Provider hands were sampled before patient care and at end of surgical case using a glove juice technique to assess hand hygiene, where recovery of <100 colony forming units from measured samples indicated compliance with hand hygiene.1–4
Patient skin sites:
Patient nasopharyngeal, axillary, and inguinal skin sites were sampled at case beginning and case end to assess preoperative patient decolonization, where recovery of <100 colony forming units from measured samples indicated compliance with patient decolonization.1–4
Environmental sites:
Proven representatives of the anesthesia environment, the adjustable pressure-limiting valve and agent dial, were sampled prior to case start and at case end by swabbing the entire surface area.1–4 These reservoirs were used to assess routine, terminal, and post-induction environmental cleaning by anesthesia and operating room personnel where recovery of <100 colony forming units from measured samples indicated compliance with environmental cleaning.1–4
Peripheral intravenous tubing injection ports:
A positive stopcock set at case end was defined as ≥1 colony forming unit per culture plate. This reservoir was used to assess syringe tip and intravascular catheter injection port cleaning where recovery of <100 colony forming units from measured samples indicated compliance with vascular care.1–4
Microbial culture conditions and Bacterial identification
Blood agar plates were incubated at 35°C for 48 h, and microorganisms were quantified according to colony forming units and identified according to standard laboratory methods as described below.1–4 Bacterial isolates were presumptively identified by colony morphology, Gram stain, and simple rapid tests. Organism identification was based on modified conventional and chromogenic tests using pH changes, substrate utilization, and growth in the presence of antimicrobial agents after 16–44 h of incubation at 35 °C.1–4
Statistical analysis
For our primary aim, epidemiology of pathogen transmission, the study was designed to detect bacterial (Enterococcus, S. aureus (methicillin-sensitive and methicillin-resistant, Pseudomonas, and other gram-negative spp.) transmission to characterize the epidemiology of bacterial transmission in the patient cohort. The chosen sample size of 20 pairs was based on an evidence-based approach for transmission monitoring requiring 15 to 25 case-pairs.17 Simple descriptive statistics were used to report results.
For our secondary outcome, there were 6 comparisons between usual care and alcohol dispensing groups, one comparison for each of the 6 times/locations (e.g., hands before case started and environment after case ended). The corresponding 99.17% exact confidence intervals for ratios of proportions were calculated by inverting two-sided tests (StatXact-12.0, Cytel, Cambridge, MA), where 99.17% = 1–0.05/6. The matching P-values are exact. We performed a secondary, unplanned analysis of mean hourly hand hygiene events. For that we similarly used a 99.17% two-sided confidence interval, for simplicity and to be conservative, calculated based on Student t-distribution.
Results
Forty-one patients were screened, and 40 patients enrolled; one patient declined consent. There were seventeen complete pair observations; three other pairs were enrolled having been done in different operating rooms due to unplanned schedule changes. There were 20 operating room observations with and without the hand hygiene device that involved 10 of 15 unique operating room environments. A total of 21 unique anesthesia providers participated in the study, none of the providers opted out of participation. Basic patient demographics are shown in Table 1.
Table 1:
Patient Demographics Stratified by Bacterial Transmission
| Bacterial Transmission | No Transmission | P-Value | |
|---|---|---|---|
| Procedure | 0.65 | ||
| Orthopedics N (%) | 5 (83) | 1 (17) | |
| General abdominal | 7 (100) | 0 | |
| Thoracic | 2 (100) | 0 | |
| Urological | 5 (100) | 0 | |
| Case 1 ASA | 0.61 | ||
| 1 | 8 | 2 | |
| 2 | 10 | 0 | |
| 3 | 3 | 0 | |
| Case 1 Sex | 1 | ||
| Male | 17 | 2 | |
| Female | 4 | 0 | |
| Case 1 Dirty or Infected | 3 | 0 | 1 |
| Case 1 Age Years mean (SD) | 8 (5.97) | 7 (2.83) | 0.91 |
| Case 1 Duration Minutes mean (SD) | 78.9 (36.33) | 128 (111.73) | 0.85 |
| Case 2 ASA | 0.53 | ||
| 1 | 4 | 1 | |
| 2 | 8 | 0 | |
| 3 | 4 | 0 | |
| Case 2 Sex | 0.56 | ||
| Male | 8 | 1 | |
| Female | 7 | 0 | |
| Case 2 Dirty or Infected | 2 | 0 | 0.85 |
| Case 2 Age years mean (SD) | 6 (3.65) | 8 (0) | 0.82 |
| Case 2 Duration Minutes mean (SD) | 99.3 (54.37) | 67 (0) | 0.59 |
ASA = American Society of Anesthesiologists health classification status
Primary Aim:
Epidemiology of perioperative pathogen transmission
A total of 57 bacterial transmission events were identified (28 control, 29 hand hygiene device) (Table 2). Most measured reservoirs exceeded 100 CFU (Fig.1.) including the anesthesia machine adjustable pressure-limiting valve and agent dial (a process measure for effective environmental cleaning), provider hands before care (a process measure for hand hygiene prior to patient care), patient nares, axilla, and groin after induction and stabilization (a process measure for preoperative patient decolonization), provider hands during care (a process measure for adequacy of hand hygiene during patient care), patient skin sites (nares, axilla, and inguinal) at case end (a process measure for intraoperative skin asepsis), and environmental sites (adjustable pressure-limiting valve and agent dial) at case end (a process measure for postinduction cleaning and routine, between-case cleaning). There were 30% (12/40) of cases with documented S. aureus transmission, with all events characterized by the detection of S. aureus after the end of patient care.
Table 2:
The epidemiology of transmission with and without the hand hygiene device stratified by class of pathogen.
| Hand Before | Hands After Care | Patient Before | Patient After | Environment Before | Environment After | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Pathogen Events Control (Device) | Device | Usual | Device | Usual | Device | Usual | Device | Usual | Device | Usual | Device | Usual |
| S. aureus 5 (7) | 3 | 0 | 3 | 1 | 7 | 3 | 7 | 5 | 1 | 1 | 1 | 3 |
| Other Gram-Negative 9 (8) | 8 | 5 | 7 | 4 | 5 | 7 | 3 | 6 | 1 | 2 | 1 | 3 |
| Enterococcus 6 (9) | 5 | 3 | 4 | 4 | 3 | 5 | 4 | 4 | 1 | 3 | 1 | 2 |
| Pseudomonas 6 (5) | 5 | 2 | 5 | 4 | 4 | 4 | 3 | 2 | 0 | 2 | 0 | 2 |
| Methicillin-Resistant S. aureus 2 (0) | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 2 | 0 | 2 | 0 | 2 |
| Total 28 (29) | 21 | 10 | 19 | 13 | 19 | 20 | 17 | 19 | 3 | 10 | 3 | 12 |
Figure 1:
Reservoirs with >100 colony forming units (CFU) increase the probability of high-risk transmission events, to stopcock sets, which is in turn repeatedly associated with increased mortality and directly linked to infection (whole cell genome analysis).1 Fifty percent of S. aureus surgical site infections (SSIs) can be traced back to transmission/reservoir contamination occurring while the patient was in the operating room.13 Black, > 100 CFU, indicates room for improvement. Left: Case 1. Right: Case 2, a case-pair. Case 1 Reservoirs: VDO1= anesthesia machine adjustable pressure-limiting valve and agent dial at the start of the day, mapping to terminal environmental cleaning. AA01= the anesthesia assistant hands at baseline, prior to patient care. AHO1= the anesthesia attending hands at baseline, prior to patient care, mapping to hand hygiene before care. PA1= the patient axilla after induction and stabilization, PG1= the patient groin after induction and stabilization, PN1= the patient anterior nares after induction and stabilization, mapping to patient decolonization preoperatively. PAE, PGE, and PNE are those same patient skin sites at the end of surgery, mapping to maintenance of skin asepsis during surgery. AAOE, AHOE are those same provider hands at the end of surgery, mapping to hand hygiene during care. VDOE= the same environmental sites of the anesthesia machine at the end of surgery, mapping to maintenance of a clean workspace achieved in part by post induction wiping and environmental organization,3,4 and LE= the primary injection port used during the procedure, mapping to vascular care. Case 2 reservoirs: VD01= the same sites on the anesthesia machine sampled after routine cleaning, mapping to routine between case cleaning. The other sites mirror those of case 2 and serve to monitor for transmission occurring between cases occurring sequentially in the same operating room environment (case-pair).
Sixty percent (24/40) of stopcocks were contaminated with at least 1 CFU, 55% (22/40) with >100 CFU, and 20% (8/40) with major bacterial pathogens (3 S. aureus, 4 Enterococcus, and 1 other gram-negative) at case conclusion.
The primary reservoirs of origin for transmission stories summarized by class of pathogen are shown in Table 3. The most frequently observed reservoirs of origin for S. aureus and Pseudomonas were the patients. There were 85% (34/40) of patients colonized with ≥ 1 (1.78 ± 0.19) major bacterial pathogens at case start (Table 4). The most frequently observed reservoirs observed for gram-negative pathogens and Enterococcus were providers’ hands. The provider hands were most frequently contaminated at case start (Fig.2.).
Table 3:
Primary Reservoir of Origin by Class of Pathogen
| Pathogen (N Events) | Patient N (%) | Environment N (%) | Provider Hand N (%) |
|---|---|---|---|
| S. aureus (12) | 8 (67) | 1 (8) | 3 (25) |
| Other Gram Negative (17) | 2 (12) | 2 (12) | 13 (76) |
| Enterococcus (15) | 4 (27) | 4 (27) | 7 (47) |
| Pseudomonas (11) | 5 (45) | 1 (9) | 4 (36) |
| Methicillin-Resistant S. aureus (2) | 1 (50) | 1 (50) | 0 (0) |
Table 4:
Proportion of Patients Colonized at ≥ 1 Skin Site Preoperatively Stratified by Class of Pathogen
| S. aureus N (%) | 22 (55) |
| Other Gram-Negative N (%) | 20 (50) |
| Enterococcus N (%) | 16 (40) |
| Pseudomonas N (%) | 10 (25) |
| Methicillin-Resistant S. aureus N (%) | 3 (8) |
Figure 2:
Reservoir contamination dynamics from case 1 to case 2. Cultured reservoirs are listed vertically on the left. Degree of contamination is represented by intensity of red color (light pink = less contamination, dark red = more contamination).
A total of 97 S. aureus isolates were obtained with 90% (87/97) implicated in possible transmission. Of possibly transmitted isolates, 83% (72/87) were confirmed by antibiotic susceptibility testing. Patients remained the most frequent reservoir of origin.
Secondary Outcome:
Impact of hand hygiene device on perioperative pathogen transmission
The epidemiology of transmission with and without the hand hygiene device stratified by class of pathogen is shown in Table 2. Use of the hand hygiene device was associated with more frequent provider hand contamination at baseline (21/29 with device vs. 10/28 usual care, RR 2.03, 99.17% CI 1.025–5.27, P=0.0066). There were fewer transmission events including environmental contamination at case end (3/29 with device vs. 12/28 usual care, RR 0.24, 99.17% CI 0.022–0.947, P =.006). The hourly rates of hand hygiene among providers are shown in Table 5. Providers performed hand hygiene 3.3 ± 2.1 [SD] times per hour, 99.17% CI for mean 2.0 to 4.6.
Table 5:
Hourly Provider Hand Decontamination Events (HHDE)
| Providerτ | Goal HHDE* | Average HHDE | HHDE Standard Deviation | Total HHDE |
|---|---|---|---|---|
| Anesthetist | 8 | 2.7 | 4.4 | 55 |
| Attending | 8 | 3.8 | 4.7 | 165 |
| Fellow | 8 | 4.0 | 1.8# | 39 |
| Resident | 8 | 2.7 | 1.5# | 36 |
Anesthetist = Certified-Registered Nurse Anesthetist or Certified Anesthesiologist Assistant
Koff MD, Loftus RW, Burchman CC, Schwartzman JD, Read ME, Henry ES, Beach ML. Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a novel device. Anesthesiology 2009;110:978–85.
Significant increase above average use of wall-mounted dispensers at 5.7 per hour (Koff et.al. Anesthesiology 2009; 110: 978–85.
Discussion:
The novel feature of our paper is the characterization of transmission of major bacterial pathogens in the pediatric operating room. We also explored the impact of pediatric anesthesia providers’ utilizing a personalized, body worn hand hygiene device on intraoperative transmission events.
Our study identifies several improvement targets for the pediatric operating room environment that align with those seen adults. Vascular access care represents a major opportunity for improvement with 55% of intravascular devices contaminated with >100 CFU and 20% contaminated with major bacterial pathogens at case conclusion. Previous studies have shown that these findings are associated with increased patient mortality and directly linked to HAI infection in the adult patient population.1–4 The impact of stopcock contamination for adults is clear, and when attenuated, there are fewer infections.13 This level of contamination for pediatric patients is twice that reported by Loftus et al in their original study, a rate that occurred despite implementation of the perioperative use of disinfecting caps.2 Thus, evidence-based and established monitoring practices must be implemented to improve patient safety.3,4
Suboptimal environmental cleaning was also evident. There was frequent failure of terminal and routine between-case cleaning efforts. There should be augmentation with evidence-based postinduction surface disinfection cleaning and UV-C measures. 3,4,13,15
Many patients were colonized with at least one major bacterial pathogen at case start, and patients were a common reservoir of origin for all groups of major bacterial pathogens tested in this study. Thus, these results indicate a need for more widespread preoperative patient decolonization efforts with utilization of an agent with broad spectrum activity (i.e., povidone iodine).3,4,19 Nasal mupirocin would not suffice due to a narrow efficacy range. Further, S. aureus was detected for 30% of patients after care. Healthcare exposure to S. aureus is associated with increased long-term risk of invasive infection, and active decolonization can reduce that risk.20 Pathogen surveillance and monitoring is indicated in order that healthcare systems can act to prevent high risk patient discharge.3,4,15
Overall, this novel study in a pediatric patient population mirrored the epidemiology of bacterial transmission in adult patients shown by Loftus et al over the last 12 years of study.1–4,21–24 Patients were the most frequent reservoir of origin for S. aureus,1,15,16,21 anesthesia providers’ hands were the most frequent reservoir of origin for gram-negative pathogens apart from Pseudomonas spp., and hands were also the most frequent reservoir of origin for Enterococcus.22–23 The joint involvement of patients, the environment, and providers’ hands to transmitted pathogens supports, again like adults, the need for a multifaceted intervention.1–4,24
Rowlands et.al. identified induction and emergence of anesthesia as periods correlating with nadirs in hand hygiene and in turn, peaks in environmental contamination exceeding the 100 CFU threshold associated with high-risk bacterial transmission events.12 Koff et.al. leveraged provider proximity to potentially combat these periods of high task density and reduced environmental and stopcock contamination along with 30-day postoperative infections.11 Use of the device was associated with a 20-fold increase in hourly hand hygiene events at a recommended target of 8 hourly events from a baseline of 0.38.9 These findings were not reproduced in a large multicenter trial of anesthesia providers caring for adult patients.14 One potential explanation for that discordance was that the target hourly hand hygiene events were not achieved in the follow-up study; only 4 hourly hand hygiene events were achieved.11,14 Our observed rates of hand hygiene were comparable (Table 5). However, our microbiological results show that this rate was insufficient (Tables 2, 3). There were high rates of stopcock contamination and significant contribution of provider hand contamination at the start of the case leading to perioperative bacterial transmission. Based on our study results, optimal performance of hand hygiene via use of this device would ensure that; 1) the devices are disinfected prior to use, 2) the device is used to perform the WHO 5 moments of hand hygiene, which includes before patient care, and 3) at least 8 hourly hand hygiene events are achieved in the fast paced, task-dense, and complex intraoperative environment.9, 27, 28
Single interventions are prone to failure as shown by Rupp et. al. regarding hand hygiene alone in the intensive care unit and by Konvalinka et al. regarding preoperative nasal decolonization alone for patients undergoing cardiothoracic surgery.25,26 In the operating room, a solid foundation of published evidence clarifies that a complex interplay of intraoperative reservoirs demands a multimodal approach. 1–4, 15,16 Our study results support this foundation of evidence; the hand hygiene device alone without a multimodal approach is unlikely to reduce major bacterial transmission sufficiently to prevent infection.1–4,11,13 However, we confirmed the utility of the device in attenuating the impact of the intraoperative environment, a potent transmission vehicle. That finding reinforces both the interplay of reservoirs and the important role of hand hygiene as part of a multifaceted approach. 1–4,11, 27, 28
Our study was limited by the inability to assess the impact of the personalized body worn dispenser on overall transmission. Designing such a study was not feasible given that there were no previous studies of bacterial transmission among pediatric patients. The study scope and design were appropriate to initially investigate and appropriately powered to assess the primary study aim. For S. aureus, we demonstrated a > 80% positive predictive value for the reported methodology of transmission detection using class of pathogen and temporal association as compared to the addition of antibiotic susceptibility testing, and on change in reservoir of origin. These results validate cost-effective use of temporal association and class of pathogen to monitor S. aureus transmission to identify improvement targets. 1–3, 16,17, 21,30
In conclusion, our results provide the impetus for implementation of an evidence-based, multifaceted approach for improved infection control1–4 in the pediatric intraoperative arena. This study represents a potential major safety concern in this patient population that must be further addressed. A personalized body worn alcohol dispenser attenuates major bacterial pathogen transmission from the contaminated environment, but hand disinfection prior to patient care should be encouraged and enforced.
Key Points:
Question:
What is the epidemiology of pathogen transmission in pediatric surgical patients?
Findings:
Perioperative pathogen transmission is common in pediatric patients with multiple pathogen reservoirs contributing.
Meaning:
Targets for multifaceted intervention to improve pathogen transmission in pediatric operative patients have been identified.
Funding:
Support was provided solely from departmental sources.
Randy W. Loftus reported research funding from Georgia-Pacific Consumer Products, Sage Medical Inc., B. Braun, Draeger, and Kenall, has one or more patents pending, and is a partner of RDB Bioinformatics, LLC, and 1055 N 115th St #301, Omaha, NE 68154, a company that owns OR PathTrac, and has spoken at educational meetings sponsored by Kenall (AORN) and B. Braun (APIC).
Glossary of Terms:
- SSI
Surgical site infection
- ACS NSQIP
American College of Surgeons National Surgical Quality Improvement Program
- HAI
Healthcare Associated Infection
- CFU
Colony forming unit
Footnotes
Conflicts of Interest: All other authors report no conflicts of interest.
Clinical Trial Registry: clinicaltrials.gov, Registration Number: NCT03992209, Principal Investigator: Patrick G. Fernandez, Date of Registration: June 20, 2019
Contributor Information
Patrick G. Fernandez, Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Colorado.
Franklin Dexter, Department of Anesthesia, University of Iowa.
Jeremiah Brown, Department of Epidemiology, Geisel School of Medicine.
Gina Whitney, Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Colorado.
Matthew D. Koff, Department of Anesthesiology, Dartmouth-Hitchcock Medical Center.
Randy W. Loftus, Department of Anesthesia, University of Iowa.
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