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Standard manual cleaning and disinfection practices are often inadequate. Persistent contamination in the environment poses an infection risk that may be mitigated by no-touch disinfection systems. This study evaluates the efficacy of dry hydrogen peroxide (DHP) on microbial air and surface contamination as an adjunct to routine cleaning and disinfection in a large urban hospital.Surface samples were collected in five different hospital units, two pediatric and three adult, after manual cleaning on multiple days before and after DHP implementation. Air samples were also collected in each unit pre- and post-DHP use. Data outcomes were reported as colony forming units (CFU) with species identification.The overall mean surface microbial burden was reduced by 96.5 percent for all units post-DHP compared to baseline (P0.001), with the greatest reductions achieved on privacy curtains (99.5 %). Mean microbial air sample counts were also reduced post-DHP compared to pre-DHP.This study demonstrates that DHP was effective in reducing both air and surface microbial contamination in a variety of settings within a large, tertiary care hospital.

Background Colorectal surgical procedures place substantial burden on health care systems because of the high complication risk, of surgical site infections in particular. The risk of surgical site infection after colorectal surgery is one of the highest of any surgical specialty. Objective The purpose of this study was to determine the incidence, cost of infections after colorectal surgery, and potential economic benefit of using antimicrobial wound closure to improve patient outcomes. Design Retrospective observational cohort analysis and probabilistic cost analysis were performed. Settings The analysis utilized a database for colorectal patients in the United States between 2014 and 2018. Patients A total of 107,665 patients who underwent colorectal surgery were included in the analysis. Main outcome measures Rate of infection was together with identified between 3 and 180 days postoperatively, infection risk factors, infection costs over 24 months postoperatively by payer type (commercial payers and Medicare), and potential costs avoided per patient by using an evidence-based innovative wound closure technology. Results Surgical site infections were diagnosed postoperatively in 23.9% of patients (4.0% superficial incisional and 19.9% deep incisional/organ space). Risk factors significantly increased risk of deep incisional/organ-space infection and included several patient comorbidities, age, payer type, and admission type. After 12 months, adjusted increased costs associated with infections ranged from $36,429 to $144,809 for commercial payers and $17,551 to $102,280 for Medicare, depending on surgical site infection type. Adjusted incremental costs continued to increase over a 24-month study period for both payers. Use of antimicrobial wound closure for colorectal surgery is projected to significantly reduce median payer costs by $809 to $1170 per patient compared with traditional wound closure. Limitations The inherent biases associated with retrospective databases limited this study. Conclusions Surgical site infection cost burden was found to be higher than previously reported, with payer costs escalating over a 24-month postoperative period. Cost analysis results for adopting antimicrobial wound closure aligns with previous evidence-based studies, suggesting a fiscal benefit for its use as a component of a comprehensive evidence-based surgical care bundle for reducing the risk of infection. See Video Abstract at http://links.lww.com/DCR/B358. EVALUACION DEL RIESGO Y LA CARGA ECONOMICA DE LA INFECCION DEL SITIO QUIRURGICO DESPUES DE UNA CIRUGIA COLORRECTAL UTILIZANDO UNA BASE DE DATOS LONGITUDINAL DE EE.UU.: ?EXISTE UN PAPEL PARA LA TECNOLOGIA INNOVADORA DE CIERRE DE HERIDAS ANTIMICROBIANAS PARA REDUCIR EL RIESGO DE INFECCION?: Los procedimientos quirurgicos colorrectales suponen una carga considerable para los sistemas de salud debido al alto riesgo de complicaciones, particularmente las infecciones del sitio quirurgico. El riesgo de infeccion posoperatoria del sitio quirurgico colorrectal es uno de los mas altos de cualquier especialidad quirurgica.El proposito de este estudio fue determinar la incidencia, el costo de las infecciones despues de la cirugia colorrectal y el beneficio economico potencial del uso del cierre de la herida con antimicrobianos para mejorar los resultados de los pacientes.Analisis retrospectivo de cohorte observacional y analisis de costo probabilistico.El analisis utilizo la base de datos para pacientes colorrectales en los Estados Unidos entre 2014 y 2018.Un total de 107,665 pacientes sometidos a cirugia colorrectal.Se identifico una tasa de infeccion entre 3 y 180 dias despues de la operacion, los factores de riesgo de infeccion, los costos de infeccion durante 24 meses posteriores a la operacion por tipo de pagador (pagadores comerciales y Medicare), y los costos potenciales evitados por paciente utilizando una tecnologia innovadora de cierre de heridas basada en evidencias.Infecciones del sitio quirurgico, diagnosticadas postoperatoriamente en el 23,9% de los pacientes (4,0% incisional superficial y 19,9% incisional profunda / espacio organico). Los factores de riesgo aumentaron significativamente el riesgo de infeccion profunda por incision / espacio organico e incluyeron comorbilidades selectivas del paciente, edad, tipo de pagador y tipo de admision. Despues de 12 meses, el aumento de los costos asociados con las infecciones vario de $ 36,429 a $ 144,809 para los pagadores comerciales y de $ 17,551 a $ 102,280 para Medicare, segun el tipo de infeccion del sitio quirurgico. Los costos incrementales ajustados continuaron aumentando durante un periodo de estudio de 24 meses para ambos pagadores. Se preve que el uso del cierre antimicrobiano de la herida para la cirugia colorrectal reducira significativamente los costos medios del pagador en $ 809- $ 1,170 por paciente en comparacion con el cierre tradicional de la herida.Los sesgos inherentes asociados a las bases de datos retrospectivas limitaron este estudio.Se encontro que la carga del costo de la infeccion del sitio quirurgico es mayor que la reportada previamente, y los costos del pagador aumentaron durante un periodo postoperatorio de 24 meses. Los resultados del analisis de costos para la adopcion del cierre de heridas antimicrobianas se alinean con estudios previos basados en evidencia, lo que sugiere un beneficio fiscal para su uso como componente de un paquete integral de atencion quirurgica basada en evidencia para reducir el riesgo de infeccion. Consulte Video Resumen en http://links.lww.com/DCR/B358.

Fifty years of evolution in infection prevention and control programs have involved significant accomplishments related to clinical practices, methodologies, and technology. However, regulatory mandates, and resource and research limitations, coupled with emerging infection threats such as the COVID-19 pandemic, present considerable challenges for infection preventionists. This article provides guidance and recommendations in 14 key areas. These interventions should be considered for implementation by United States health care facilities in the near future.

Background Surgical site infection is a major postoperative complication after surgical procedures. The effectiveness of postoperative antimicrobial dressings in reducing surgical site infections is unclear and limited information is available on the efficacy of chlorhexidine gluconate (CHG)-impregnated postoperative dressings. Methods A pilot study was conducted to examine the efficacy of an innovative CHG-impregnated postoperative dressing in reducing the burden of methicillin-resistant Staphylococcus aureus (MRSA) in an in vivo porcine, incisional-wound model. Sutured incisional wounds were contaminated with MRSA and then covered with a CHG wound dressing, a placebo control, or a nonantimicrobial gauze. The surviving MRSA population was quantitatively cultured 3 days postprocedure. Results MRSA was not recovered from any of the 8 wounds that were treated with the CHG dressing (limit of detection, approximately 1.7 log10 colony-forming units [cfu]/g tissue). In contrast, the average microbial recovery from wounds treated with the placebo dressing was 4.2 log10 cfu/g and the average microbial recovery from wounds treated with the gauze dressing was 3.2 log10 cfu/g. Conclusions An innovative CHG dressing provided significant antimicrobial activity against MRSA contaminating a surgical wound in a porcine, incisional-wound model. Future clinical studies are needed to assess the efficacy of the CHG dressing to reduce the bacterial burden in postoperative wounds of surgical patients.

Accurate and rapid antimicrobial susceptibility testing with pathogen identification in bloodstream infections is critical to life results for early sepsis intervention. Advancements in rapid diagnostics have shortened the time to results from days to hours and have had positive effects on clinical outcomes and on efforts to combat antimicrobial resistance when paired with robust antimicrobial stewardship programs. This article provides infection preventionists with a working knowledge of available rapid diagnostics for bloodstream infections.

The global push to combat the problem of antimicrobial resistance has led to the development of antimicrobial stewardship programs (ASPs), which were recently mandated by The Joint Commission and the Centers for Medicare and Medicaid Services. However, the use of topical antibiotics in the open surgical wound is often not monitored by these programs nor is it subject to any evidence-based standardization of care. Survey results indicate that the practice of using topical antibiotics intraoperatively, in both irrigation fluids and powders, is widespread. Given the risks inherent in their use and the lack of evidence supporting it, the practice should be monitored as a core part of ASPs, and alternative agents, such as antiseptics, should be considered.

Showering preoperatively with chlorhexidine gluconate is an issue that continues to promote debate; however, many studies demonstrate evidence of surgical site infection risk reduction. Methodological issues have been present in many of the studies used to compile guidelines and there has been a lack of standardisation of processes for application of the active agents in papers pre-2009. This review and commentary paper highlights the potential for enhancing compliance with this low-risk and low-cost intervention and provides some guidance for enhancing implementation of preoperative showering with both chlorhexidine in solution and impregnated wipes.

Background Despite several randomized trials, systematic reviews and meta-analyses that have demonstrated the effectiveness of antimicrobial (triclosan-coated or -impregnated) sutures (TCS), the clinical and economic impact of using these sutures compared with conventional non-antimicrobial-coated absorbable sutures (NCS) remains poorly documented. Methods An independent systematic review and meta-analysis of all published evidence from January 2005 to September 2016 comparing TCS with NCS was conducted. Surgical-site infection (SSI) was the primary outcome. The results of the meta-analysis were used in a decision-tree deterministic and stochastic cost model, using the National Health Service (NHS England)-based cost of inpatient admissions for infections and differential costs of TCSversus NCS. Results Thirty-four studies were included in the final assessment from an initial 163 identified citations; 20 of 34 studies were randomized, and 17 of 34 reported blinding of physicians and assessors. Using a random-effects model, the odds ratio for SSI in the TCS compared with NCS control groups was statistically significant (odds ratio 0·61, 95 per cent c.i. 0·52 to 0·73; P < 0·001). There was significant heterogeneity (I2 = 49 per cent). Using random-effects event estimates of SSI for TCS and NCS for each individual wound type, the mean savings per surgical procedure from using antimicrobial sutures were significant: £91·25 (90 per cent c.i. 49·62 to 142·76) (€105·09 (57·15 to 164·41); exchange rate 15 November 2016) across all wound types. Conclusion The reviewed literature suggested that antimicrobial sutures may result in significant savings across various surgical wound types.

Objective: The global impact of surgical site infections (SSIs) on health-care systems is considerable: many are related to the formation of a microbial biofilm. Biofilm plays a significant role in the pathogenesis of implantable device-related infections and are also important in persistent postoperative skin and soft tissue wound infections. Method: PubMed and OVID databases were searched for relevant articles regarding biofilm-associated infection in surgery, including epidemiology, diagnosis, treatment and management. Results: Biofilm-associated infections increase the use of health-care resources, prolong length of stay, increase cost of antibiotic therapy, result in additional surgical revisions and extend rehabilitation after discharge from health care. Staphylococcus aureus and Staphylococcus epidermidis are the most common isolates recovered from device-related infections. Early infection occurs within two weeks of implantation and is associated with intraoperative wound contamination; late-onset infections are often occult prolonging recognition by weeks, months and in some cases, years. Biofilm is a physical barrier against antibodies and granulocytic cell populations which may also impede the penetration of antibiotics. The ideal strategy for preventing biofilm-associated SSI is to prevent intraoperative contamination through compliance with effective surgical care bundles. Management of postoperative biofilm-associated infections involves surgical debridement followed by irrigation with antimicrobial agents and removal of infected devices, followed by insertion of antimicrobial adjuncts such as antimicrobial spacers, beads or sutures together with selective therapeutic agents that penetrate the mature biofilm. Conclusion: Biofilm-associated infections are a significant source of postoperative morbidity and mortality. Appropriate interventional strategies are warranted to reduce the risk of intraoperative contamination. Declaration of interest: The authors have no conflicts.

Infection is the likeliest single cause of delayed healing in healing of chronic open wounds by secondary intention. If neglected it can progress from contamination to colonization and local infection through to systemic infection, sepsis and multiple organ dysfunction syndrome, and it can be life-threatening. Infection in chronic wounds is not as easy to define as in acute wounds, and is complicated by the presence of biofilms. There is, as yet, no diagnostic for biofilm presence, but it contributes to excessive inflammation - through excessive and prolonged stimulation of nitric oxide, inflammatory cytokines and free radicals - and activation of immune complexes and complement, leading to a delay in healing. Control of biofilm is a key part of chronic wound management. Maintenance debridement and use of topical antimicrobials (antiseptics) are more effective than antibiotics, which should be reserved for treating spreading local and systemic infection. The continuing rise of antimicrobial resistance to antibiotics should lead us to reserve their use for these indications, as no new effective antibiotics are in the research pipeline. Antiseptics are effective through many mechanisms of action, unlike antibiotics, which makes the development of resistance to them unlikely. There is little evidence to support the theoretical risk that antiseptics select resistant pathogens. However, the use of antiseptic dressings for preventing and managing biofilm and infection progression needs further research involving well-designed, randomized controlled trials.

Summary Healthcare workers (HCWs) wear uniforms, such as scrubs and lab coats, for several reasons: (1) to identify themselves as hospital personnel to their patients and employers; (2) to display professionalism; and (3) to provide barrier protection for street clothes from unexpected exposures during the work shift. A growing body of evidence suggests that HCWs' apparel is often contaminated with micro-organisms or pathogens that can cause infections or illnesses. While the majority of scrubs and lab coats are still made of the same traditional textiles used to make street clothes, new evidence suggests that current innovative textiles function as an engineering control, minimizing the acquisition, retention and transmission of infectious pathogens by reducing the levels of bioburden and microbial sustainability. This paper summarizes recent literature on the role of apparel worn in healthcare settings in the acquisition and transmission of healthcare-associated pathogens. It proposes solutions or technological interventions that can reduce the risk of transmission of micro-organisms that are associated with the healthcare environment. Healthcare apparel is the emerging frontier in epidemiologically important environmental surfaces.

In the modern operating room (OR), traditional surgical mask, frequent air exchanges, and architectural barriers are viewed as effective in reducing airborne microbial populations. Intraoperative sampling of airborne particulates is rarely performed in the OR because of technical difficulties associated with sampling methodologies and a common belief that airborne contamination is infrequently associated with surgical site infections (SSIs). Recent studies suggest that viable airborne particulates are readily disseminated throughout the OR, placing patients at risk for postoperative SSI. In 2017, virtually all surgical disciplines are engaged in the implantation of selective biomedical devices, and these implants have been documented to be at high risk for intraoperative contamination. Approximately 1.2 million arthroplasties are performed annually in the United States, and that number is expected to increase to 3.8 million by the year 2030. The incidence of periprosthetic joint infection is perceived to be low (

ObjectiveThe Surgical Care Improvement Project (SCIP) is a national initiative to reduce surgical complications, including postoperative surgical site infection (SSI), through protocol-driven antibiotic usage. This study aimed to determine the effect SCIP guidelines have had on in-hospital SSIs after open vascular procedures.MethodsThe Nationwide Inpatient Sample (NIS) was retrospectively analyzed using International Classification of Diseases, Ninth Revision, diagnosis codes to capture SSIs in hospital patients who underwent elective carotid endarterectomy, elective open repair of an abdominal aortic aneurysm (AAA), and peripheral bypass. The pre-SCIP era was defined as 2000 to 2005 and post-SCIP was defined as 2007 to 2010. The year 2006 was excluded because this was the transition year in which the SCIP guidelines were implemented. Analysis of variance and χ2 testing were used for statistical analysis.ResultsThe rate of SSI in the pre-SCIP era was 2.2% compared with 2.3% for carotid endarterectomy (P = .06). For peripheral bypass, both in the pre- and post-SCIP era, infection rates were 0.1% (P = .22). For open, elective AAA, the rate of infection in the post-SCIP era increased significantly to 1.4% from 1.0% in the pre-SCIP era (P < .001). Demographics and in-hospital mortality did not differ significantly between the groups.ConclusionsImplementation of SCIP guidelines has made no significant effect on the incidence of in-hospital SSIs in open vascular operations; rather, an increase in SSI rates in open AAA repairs was observed. Patient-centered, bundled approaches to care, rather than current SCIP practices, may further decrease SSI rates in vascular patients undergoing open procedures.

Pathogens are inherently present in thesurgical setting, and several significant health careeassociated pathogens can be transferred from pa-tient to patient, from health care worker to patientor vice versa, and from surfaces to patients orhealth care workers and cause surgical site in-fections (SSIs). These pathogens (eg, methicillin-resistant Staphylococcus aureus [MRSA], S aureus,vancomycin-resistant enterococci, Acinetobacterspecies) may survive on environmental surfaces forweeks or months.

The inappropriate use and overuse of antibiotics, together with the demographic changes of an ageing population, chronic diseases such as diabetes mellitus, increased patient contact with healthcare facilities, high bed occupancy rates and the increase in surgical procedures, have all contributed to the rise in prevalence of Healthcare Associated Infections. These are attributable to selection and emergence of multi-resistant organisms. Additionally, there is evidence that this surveillance programme considerably underestimates true rates of SSI. Strategies for prevention of SSIs are still in development and both MSSA and MRSA surveillance/suppression are likely to be considered as a plausible strategy for identifying at-risk patient prior to surgery, but a pertinent question remains: which surgical patients are likely to benefit most from this intervention?

Background It has been estimated that 750,000 to 1 million surgical-site infections (SSIs) occur in the United States each year, causing substantial morbidity and mortality. Triclosan-coated sutures were developed as an adjunctive strategy for SSI risk reduction, but a recently published systematic literature review and meta-analysis suggested that no clinical benefit is associated with this technology. However, that study was hampered by poor selection of available randomized controlled trials (RCTs) and low patient numbers. The current systematic review involves 13 randomized, international RCTs, totaling 3,568 surgical patients. Methods A systematic literature search was performed on PubMed, Embase/Medline, Cochrane database group (Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Health Economic Evaluations Database/Database of Health Technology Assessments), and www.clinicaltrials.gov to identify RCTs of triclosan-coated sutures compared with conventional sutures and assessing the clinical effectiveness of antimicrobial sutures to decrease the risk for SSIs. A fixed- and random-effects model was developed, and pooled estimates reported as risk ratio (RR) with a corresponding 95% confidence interval (CI). Publication bias was assessed by analyzing a funnel plot of individual studies and testing the Egger regression intercept. Results The meta-analysis (13 RCTs, 3,568 patients) found that use of triclosan antimicrobial-coated sutures was associated with a decrease in SSIs in selected patient populations (fixed effect: RR = 0.734; 95% CI: 0.590–0.913; P = .005; random-effect: RR = 0.693; 95% CI: 0.533–0.920; P = .011). No publication bias was detected (Egger intercept test: P = .145). Conclusion Decreasing the risk for SSIs requires a multifaceted “care bundle” approach, and this meta-analysis of current, pooled, peer-reviewed, randomized controlled trials suggests a clinical effectiveness of antimicrobial-coated sutures (triclosan) in the prevention of SSIs, representing Center for Evidence-Based Medicine level 1a evidence.

Chlorhexidine gluconate (CHG) has been available as a topical antiseptic for over 50 years, having broad clinical application throughout the health care environment. Evidence-based clinical studies have shown chlorhexidine gluconate to be a safe and effective perioperative skin-prepping agent. Renewed interest has emerged for use of the antiseptic bath/shower to reduce the microbial skin burden prior to hospital admission. Recent clinical studies have documented that multiple applications of 2% or 4% CHG using a standardized protocol results in high skin surface concentrations sufficient to inhibit/kill skin colonizing flora, including methicillin-resistant Staphylococcus aureus. A new focus for the use of CHG in surgical patients involves irrigation of the wound prior to closure with 0.05% CHG followed by saline rinse. Recent laboratory studies suggest that, following a 1-minute exposure, 0.05% CHG produces a >5-log reduction against selective health care-associated pathogens and reduces microbial adherence to the surface of implantable biomedical devices. General, orthopedic, cardiothoracic, and obstetrical surgical studies have documented the safety of selective CHG formulations in elective surgical procedures. The following discussion will address both the evidence-based literature and preliminary findings suggesting that CHG has a broad and safe range of applications when used as an adjunctive interventional strategy for reducing the risk of postoperative surgical site infections (SSI).

Clostridium difficile infections are the leading cause of health care-associated infectious diarrhea, posing a significant risk for both medical and surgical patients. Because of the significant morbidity and mortality associated with C difficile infections, knowledge of the epidemiology of C difficile in combination with a high index of suspicion and susceptible patient populations (including surgical, postcolectomy, and inflammatory bowel disease patients) is warranted. C difficile infections present with a wide spectrum of disease, ranging from mild diarrhea to fulminant colitis or small bowel enteritis and recurrent C difficile infections. Early implementation of medical and operative treatment strategies for C difficile infections is imperative for optimal patient outcomes. National and international guidelines recommend early operative consultation and total abdominal colectomy with end ileostomy and preservation of rectum. Diverting loop ileostomy and colonic lavage followed by intravenous metronidazole and intracolonic vancomycin administered via the efferent limb of the ileostomy should be considered as an alternative to total colectomy in selected patients. New and emerging strategies for C difficile infection treatment include monoclonal antibodies, vaccines, probiotics, biotherapeutics, and new antibiotics. A successful C difficile prevention and eradication program requires a multidisciplinary approach that includes early disease recognition, implementation of guidelines for monitoring adherence to environmental control, judicious hand hygiene, evidence-based treatment and management strategies, and a focused antibiotic stewardship program. Surgeons are an important part of the clinical team in the management of C difficile infection prevention and treatment.

Percutaneous injuries associated with cutting instruments, needles, and other sharps (eg, metallic meshes, bone fragments, etc) occur commonly during surgical procedures, exposing members of surgical teams to the risk for contamination by blood-borne pathogens. This study evaluated the efficacy of an innovative integrated antimicrobial glove to reduce transmission of the human immunodeficiency virus (HIV) following a simulated surgical-glove puncture injury.A pneumatically activated puncturing apparatus was used in a surgical-glove perforation model to evaluate the passage of live HIV-1 virus transferred via a contaminated blood-laden needle, using a reference (standard double-layer glove) and an antimicrobial benzalkonium chloride (BKC) surgical glove. The study used 2 experimental designs. In method A, 10 replicates were used in 2 cycles to compare the mean viral load following passage through standard and antimicrobial gloves. In method B, 10 replicates were pooled into 3 aliquots and were used to assess viral passage though standard and antimicrobial test gloves. In both methods, viral viability was assessed by observing the cytopathic effects in human lymphocytic C8166 T-cell tissue culture. Concurrent viral and cell culture viability controls were run in parallel with the experiment's studies.All controls involving tissue culture and viral viability were performed according to study design. Mean HIV viral loads (log(10)TCID(50)) were significantly reduced (P.01) following passage through the BKC surgical glove compared to passage through the nonantimicrobial glove. The reduction (log reduction and percent viral reduction) of the HIV virus ranged from 1.96 to 2.4 and from 98.9% to 99.6%, respectively, following simulated surgical-glove perforation.Sharps injuries in the operating room pose a significant occupational risk for surgical practitioners. The findings of this study suggest that an innovative antimicrobial glove was effective at significantly (P.01) reducing the risk for blood-borne virus transfer in a model of simulated glove perforation.

Surgical gloves provide a protective barrier for patients and members of the surgical team. Although glove integrity is important in an era of blood-borne pathogens, little data exist on bacterial passage after glove perforation. This study evaluated the impact of antimicrobial surgical gloves in reducing microbial passage after glove puncture in a model of wound contamination.Staphylococcus aureus (ATCC 6538) and Brevundimonas diminuta (DSM 1639) were used to prepare a standardized suspension for testing bacterial passage after glove puncture in volunteers wearing single-layer gloves (group A), double-layer gloves (group B), or antimicrobial trilayer gloves (group C). After exposure periods of 5, 10, 30 and 45 minutes, the outer test gloves were removed and microbial passage was measured on the inner surface of the base gloves. Multiple repetitions (5 or 6) were performed at each sampling time.Microbial passage at 5-, 10-, 30-, and 45-minute exposures were analyzed both separately and combined (5 and 10 minutes and 30 and 45 minutes). No difference was observed in microbial passage between group A and group B at the 10-, 30-, and 45-minute exposures for S aureus, whereas a significant reduction in microbial passage was observed in group C compared with group A (P ≤ .05 to.005) at the 5-, 30-, and 45-minute exposures for both S aureus and B diminuta. When timed groups were combined (5 and 10 minutes and 30 and 45 minutes), a significant reduction (P ≤ .01 to ≤ .005) in microbial passage of S aureus and B diminuta was observed in group C compared with both group A and group B.These findings represent the first evidence that microbial passage across surgical gloves can be reduced significantly using an innovative antimicrobial glove technology.

OBJECTIVES To review clinical and surgical factors in patients who have undergone staged sacral nerve stimulator implantation and to determine whether there are any identifiable risk factors for infection. METHODS A retrospective chart review was performed on 76 consecutive patients undergoing staged implantation for sacral nerve stimulation for voiding dysfunction. Patients with postprocedural wound infections (after Stage 1 or Stage 2) were compared with those without infections with regard to demographic factors and surgical characteristics, such as operative time and duration of exposed lead wire. Organisms cultured were also documented. RESULTS Lead infection occurred in 9 of 76 patients (12%). All cultures grew Staphylococcus aureus. Of 9 patients with lead infection, 6 had organisms sensitive to their perioperative antibiotic. Forty-five patients had an implantable pulse generator implanted, and 5 infections occurred (11%). Four cultures grew S. aureus (all sensitive to the perioperative antibiotic given), whereas one grew Pseudomonas. The only significant difference in clinical/surgical characteristics between infected and noninfected patients was a longer operative time for Stage 2 in infected patients. In addition, 3 patients with infection had one or more known risk factors for wound infection (steroid use, severe psoriasis, recurrent skin abscess). CONCLUSIONS Apart from known risk factors for surgical wound infections, the only variable we could identify that might increase the risk for infection is a longer operative time for Stage 2. S. aureus was the organism most commonly cultured. Often it was sensitive to the perioperative antibiotic prophylaxis.

Surgical site infections are associated with severe morbidity and mortality. The role of surgical sutures in the etiology of surgical site infection has been the objective of discussion for decades. This study used a standardized in vitro microbiologic model to assess bacterial adherence and the antibacterial activity of a triclosan-coated polyglactin 910 (braided) suture against selected Gram-positive and Gram-negative clinical isolates that may infect surgical wounds.Standardized cultures (2.0 log(10) colony forming units/mL and 5.0 log(10) colony forming units/mL of three clinical strains, Staphyllococcus aureus (methicillin-resistant S aureus [MRSA]), S epidermidis (biofilm-positive) and Escherichia coli (extended-spectrum beta-lactamase [ESBL]-producer) were inoculated to triclosan-coated and noncoated polyglactin 910 sutures to evaluate comparative adherence of bacterial isolates to the antibacterial coated and noncoated surgical sutures; to assess the impact of serum proteins (bovine serum albumin) on antibacterial activity of triclosan-coated suture; and to document the duration of antibacterial activity of the triclosan-coated material. Selected suture samples were prepared for scanning electron microscopy to demonstrate bacterial adherence.Substantial (p0.01) reductions in both Gram-positive and Gram-negative bacterial adherence were observed on triclosan-coated sutures compared with noncoated material. Pretreatment of surgical sutures with 20% BSA did not diminish antibacterial activity of the triclosan-coated braided device compared with noncoated suture (p0.01), and antibacterial activity was documented to persist for at least 96 hours compared with controls (p0.01).The in vitro model demonstrated a considerable reduction (p0.01) in Gram-positive and Gram-negative bacterial adherence to a triclosan-coated braided suture, which was associated with decreased microbial viability (p0.001). Because bacterial contamination of suture material within a surgical wound may increase the virulence of a surgical site infection, treating the suture with triclosan provides an effective strategy for reducing perioperative surgical morbidity.

Infection of intravascular or implanted biomedical devices often involves biofilm-forming staphylococci that are recalcitrant to antimicrobial therapy. The present study investigated the activity of 6 antimicrobial agents against biofilm-forming and non-biofilm-forming strains of staphylococci adherent to the surface of selected biomedical devices.Five clinical staphylococcal strains were selected for study in (1) antibiotic-lock model (ALM) and (b) vascular graft model (Dacron and expanded polytetrafluoroethylene [ePFTE]) devices. Test strains were inoculated for 30 minutes to stabilize microbial adherence and then exposed to antibiotic; the impact on bacterial adherence was assessed at 1, 2, 4, 7, and 10 days.Regarding ALM, daptomycin and rifampin were effective at eradicating staphylococcal adherence by day 4 (P.01); linezolid and gentamicin by day 7 (P.01); vancomycin by day 7; and ceftriaxone failed to eradicate staphylococcal adherence in 4 of 5 strains by day 10. Regarding ePTFE, daptomycin and linezolid eradicated staphylococcal adherence by day 2 (P.01); rifampin by day 4 (P.01); vancomycin and gentamicin by day 7 (P.01); and ceftriaxone failed to eliminate staphylococcal adherence in 3 of 5 strains by day 10. Regarding Dacron, daptomycin and rifampin eradicated adherent strains by day 4 (P.01); linezolid by day 7 (P.01), and vancomycin, gentamicin, and ceftriaxone decreased staphylococcal adherence by 90%, 95%, and 78%, respectively, by day 10.Daptomycin, rifampin, and linezolid demonstrated greater efficacy and speed in eradicating microbial adherence of staphylococcal isolates from selected devices compared with vancomycin, gentamicin, or ceftriaxone (P.01). Further studies are warranted, however, to validate the clinical efficacy of daptomycin and linezolid in the treatment of biomedical device-associated infections.

Interferon-gamma modulates host defense in a number of infectious diseases. Previous studies have shown that systemic administration of interferon-gamma (IFN-gamma) can enhance survival in experimental invasive aspergillosis (IA).Using a novel model of murine IA that is characterized by primary pulmonary infection, we investigated the role of IFN-gamma in the phagocytosis and killing of Aspergillus fumigatus by murine neutrophils and pulmonary alveolar macrophages in vitro and the impact of systemic and regional administration of IFN-gamma on the course of IA in glucocorticoid-treated mice.In vitro, IFN-gamma significantly enhanced phagocytosis and killing function of both neutrophils and alveolar macrophages from normal animals, but not cortisone-treated animals. In vivo, intravenous administration of IFN-gamma did not improve phagocyte recruitment, in vivo killing, or mortality from IA. Regional (intranasal) administration of IFN-gamma to the lungs enhanced recruitment of phagocytic cells to the lungs and improved in vivo killing, but did not alter (and actually worsened) mortality from IA.The in vitro and in vivo effects of IFN-gamma in IA are contingent on many variables, including the route of administration and the specific pathogenesis of infection.

Background. Modern operating rooms are considered to be aseptic environments. The use of surgical mask, frequent air exchanges, and architectural barriers are used to reduce airborne microbial populations. Breaks in surgical technique, host contamination, or hematogenous seeding are suggested as causal factors in these infections. This study implicates contamination of the operating room air as an additional etiology of infection. Methods. To investigate the potential sources of perioperative contamination, an innovative in situ airsampling analysis was conducted during an 18-month period involving 70 separate vascular surgical procedures. Air-sample cultures were obtained from multiple points within the operating room, ranging from 0.5 to 4 m from the surgical wound. Selected microbial clonality was determined by pulse-field gel electrophoresis. In a separate series of studies microbial nasopharyngeal shedding was evaluated under controlled environmental conditions in the presence and absence of a surgical mask. Results. Coagulase-negative staphylococci were recovered from 86% of air samples, 51% from within 0.5 m of the surgical wound, whereas Staphylococcus aureus was recovered from 64% of air samples, 39% within 0.5 m from the wound. Anterior nares swabs were obtained from 11 members of the vascular team, clonality was observed between 8 strains of S epidermidis, and 2 strains of S aureus were recovered from selected team members and air-samples collected throughout the operating room environment. Miscellaneous Gram-negative isolates were recovered less frequently (

Cochlear implantation in patients with chronic suppurative otitis media is managed with perioperative antibiotics; however, fungal overgrowth can occur. We present a child who received oral cefdinir and topical ofloxacin (Floxin). After 6 weeks, a fungal (Candida) biofilm was demonstrated on the implant surface. In this clinical setting, an antimicrobial strategy using an oral antifungal to prevent fungal overgrowth is a possibility.

Anaerobic infections occur in surgical patients in part because of structural or functional defects in the host that (1) cause a breech in the normal mucosal barriers, (2) create localized vascular insufficiencies, or (3) produce an obstruction. Any or all of these events may compromise the oxidation-reduction potential within the tissues, encouraging rapid anaerobic growth. Although diverse anaerobic populations are spread throughout the gastrointestinal tract, a relatively limited number of organisms are responsible for clinical infection in the surgical patient. Many of these offending organisms express overt virulence factors that enhance microbial adherence, tissue destruction, and, in the case of Bacteroides fragilis, facilitate abscess formation. The selection of an appropriate perioperative or therapeutic agent requires a fundamental knowledge of the microbial ecology of this microbial population. The failure to consider the anaerobic flora as a component in the etiology of mixed surgical infections is associated with a high rate of perioperative and therapeutic failures.

Objective: Antibiotically coated or impregnated catheters are effective in eliminating gram-positive bacteria from their surfaces. However, their activity against gram-negative bacteria is not well known. The aim of this study was to evaluate and compare the adherence, persistence and colonization of Klebsiella pneumoniae on catheter surfaces and also to assess bacteriostatic and bactericidal levels. Design: Randomized, controlled, laboratory study. Setting: University surgical microbiology laboratory. Subjective: Silver sulfadiazine-chlorhexidine impregnated (SSC), minocycline and rifampin bonded (M+R), silver, platinum and carbon incorporated (SP+C) and non-antiseptic central venous catheter segments. Interventions: Catheter segments were immersed in 1 ml of phosphate buffered saline (0.01 mol/l) with 0.25% dextrose (PBSD) and incubated at 37°C. The PBSD was replaced daily. Effluents were frozen at –70°C for subsequent determination of bacteriostatic and bactericidal activity. On days 1,3,7,14 and 21 after initial immersion, 1 ml standardized inoculum of Klebsiella pneumoniae was added to 90 tubes for a period of 30 min. The inoculum was then replaced with PBSD. One third of the samples were immediately sonicated and plated for the determination of bacterial adherence. The remaining segments were incubated for 4 and 24 h, followed by the same procedure to determine bacterial persistence and colonization with time. All plates were read after 24 h of incubation. Measurements and results: There was a significant reduction in initial bacterial adherence for SP+C catheters on all days (p

Infection remains the leading complication that is associated with intravascular access devices. Despite continuous research efforts and advances in technology, the rate of central venous catheter infections has remained relatively constant over the past decade. This article focuses on four pertinent aspects of central venous access infection: microbial etiology and pathogenesis, diagnosis, prevention, and treatment. An update of the scientific literature in this area will aid clinicians in their patient care practices and serve to identify unanswered questions.

The utility of lysine-based aldehyde-ruthenium red fixatives for the preservation and/or staining of the fibrous staphylococcal glycocalyx was improved by substitution of alternative forms of lysine for the free amino form. Paraformaldehyde-glutaraldehyde fixatives containing alternative lysines, with or without ruthenium red, were compared at short 20-minute prefixation times and at extended overnight fixation times. Although inclusion of paraformaldehyde made longer fixation times possible, the length of time for "safe" fixation varied per sample and could not be predicted. All alternative lysine forms permitted fixation of at least 24 hours without sample loss. The L-lysine monohydrochloride or L-lysine acetate forms permitted longer fixation times than the L-lysine free amino form, and they had comparable or better preservation of the staphylococcal glycocalyx. Thus, the usefulness of aldehyde-lysine-based fixatives with minor changes has been enhanced.

The utility of lysine in glutaraldehyde-ruthenium red fixatives for the preservation and/or staining of the fibrous staphylococci glycocalyx was improved by inclusion of paraformaldehyde. Short, 20 min prefixation times for paraformaldehyde-glutaraldehyde fixatives containing lysine, with or without ruthenium red, were compared to an extended overnight fixation. Samples were often lost in fixatives that did not contain paraformaldehyde at extended fixation times hampering the effective use of these fixatives for clinical or environmental applications. Inclusion of paraformaldehyde in the fixation with lysine permitted longer fixation times as well as stabilized the staphylococcal glycocalyx. Thus, the technical usefulness of fixatives employing lysine was significantly improved.

OBJECTIVES The aim of the study was to analyse the susceptibility of unique and non-duplicate aerobic and anaerobic isolates from surgical patients to a novel des-F(6)-quinolone (garenoxacin) and other selected antimicrobial agents. METHODS Eleven hundred and eighty-five aerobic and anaerobic isolates from general, vascular, cardiothoracic and otolaryngologic surgical patients were tested for susceptibility to garenoxacin and seven other antibiotics (ciprofloxacin, moxifloxacin, levofloxacin, piperacillin/tazobactam, imipenem, clindamycin and metronidazole) using the referenced microbroth and agar-dilution method. RESULTS Garenoxacin exhibited greater antimicrobial activity than comparator quinolones such as ciprofloxacin, levofloxacin and other antimicrobials when tested against selected gram-positive organisms. The in vitro aerobic and anaerobic activity of garenoxacin was similar to that of moxifloxacin. All fluoroquinolones tested were effective against most gram-negative facultative anaerobes including Escherichia coli. Garenoxacin and moxifloxacin demonstrated similar in vitro antimicrobial activity against selected anaerobic gram-positive and gram-negative anaerobic bacteria such as members of the Bacteroides fragilis group. Overall, the in vitro activity of the advanced spectrum quinolones against anaerobic surgical isolates compared favourably with selected comparator agents, metronidazole, imipenem and piperacillin/tazobactam. CONCLUSIONS These findings suggest that 82.4% of aerobic surgical isolates were susceptible to a concentration of garenoxacin < or = 1.0 mg/L, whereas 84.5% of the anaerobic isolates were susceptible to a garenoxacin concentration < or = 1.0 mg/L. Garenoxacin may be a valuable surgical anti-infective for treatment of serious head and neck, soft tissue, intra-abdominal and diabetic foot infections.

Fifty isolates of Peptostreptococcus magnus from intraabdominal sepsis, nonpuerperal breast abscess, and diabetic foot infections were examined for collagenase activity using bovine type I collagen. Collagenase production was detected in a higher percentage of strains from nonpuerperal breast and diabetic foot specimens (P less than .001). This enzyme may be responsible for P. magnus playing a more central role in the pathogenesis of nonpuerperal breast abscess and diabetic foot disease than in intraabdominal sepsis.

Ruthenium red, a promising cationic reagent for electron microscopy (EM), has long been an important tool in histology. The reagent was initially used by botanists as a semispecific stain for pectic substances, but it has gradually been embraced by investigators in microbiology and the animal sciences as a stain for anionic glycosylated polymeric substances. Luft developed a reliable method and demonstrated that ruthenium red was a useful reagent for visualizing ultrastructural detail. Many investigators, using modifications of Luft's approach, have identified numerous applications for this important reagent. Ruthenium red has been used to show the ultrastructural detail of bacterial glycocalyces. Strong, sharp and consistent observations of this ultrastructural component of the bacterial cell have given a better understanding its fibrous anionic matrix. Any variations in staining owing to artifactual alteration of the fine delicate ultrastructural features have been overcome by incorporation of diamine lysine into ruthenium red methods, thus providing flexible processing times under less than ideal laboratory sampling conditions. Ruthenium red has broad utility in the biological sciences, and in combination with lysine, it is an excellent EM stain for enhanced visualization of bacterial glycocalyx from culture or from clinical specimens.

To estimate the adequacy of antimicrobial activity of preoperative antibiotics at the time of cesarean delivery as a function of maternal obesity.Twenty-nine patients scheduled for cesarean delivery were stratified according to body mass index (BMI) category, with 10 study participants classified as lean (BMI less than 30), 10 as obese (BMI 30-39.9), and nine as extremely obese (BMI 40 or higher). All patients were given a dose of 2 g cefazolin 30-60 minutes before skin incision. Antibiotic concentrations from adipose samples, collected after skin incision and before skin closure, along with myometrial and serum samples, were analyzed with microbiological agar diffusion assay.Cefazolin concentrations within adipose tissue obtained at skin incision were inversely proportional to maternal BMI (r=-0.67, P.001). The mean adipose concentration was 9.4 plus or minus 2.7 micrograms/g in the lean group of women compared with 6.4 plus or minus 2.3 micrograms/g in the obese group (P=.009) and 4.4 plus or minus 1.2 micrograms/g in the extremely obese group (P.001). Although all specimens demonstrated therapeutic cefazolin levels for gram-positive cocci (greater than 1 microgram/g), a considerable portion of obese and extremely obese did not achieve minimal inhibitory concentrations of greater than 4 micrograms/g for Gram-negative rods in adipose samples at skin incision (20% and 33.3%, respectively) or closure (20.0% and 44.4%, respectively). No significant difference in cefazolin concentration was observed in mean closure adipose, myometrial, or serum specimens across the BMI categories.Pharmacokinetic analysis suggests that present antibiotic prophylaxis dosing may fail to provide adequate antimicrobial coverage in obese patients during cesarean delivery.ClinicalTrials.gov, www.clinicaltrials.gov, NCT00980486.II.