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High-risk Staphylococcus aureus transmission in the operating room: A call for widespread improvements in perioperative hand hygiene and patient decolonization practices

      Highlights

      • Intraoperative Staphylococcus aureus multilocus sequence type 5 is hypertransmissible and pathogenic.
      • Intraoperative provider hands and patient skin surfaces are confirmed sources of sequence type 5 transmission.

      Background

      Increased awareness of the epidemiology of transmission of pathogenic bacterial strain characteristics may help to improve compliance with intraoperative infection control measures. Our aim was to characterize the epidemiology of intraoperative transmission of high-risk Staphylococcus aureus sequence types (STs).

      Methods

      S aureus isolates collected from 3 academic medical centers underwent whole cell genome analysis, analytical profile indexing, and biofilm absorbance. Transmission dynamics for hypertransmissible, strong biofilm-forming, antibiotic-resistant, and virulent STs were assessed.

      Results

      S aureus ST 5 was associated with increased risk of transmission (adjusted incidence risk ratio, 6.67; 95% confidence interval [CI], 1.82-24.41; P = .0008), greater biofilm absorbance (ST 5 median absorbance ± SD, 3.08 ± 0.642 vs other ST median absorbance ± SD, 2.38 ± 1.01; corrected P = .021), multidrug resistance (odds ratio, 7.82; 95% CI, 2.19-27.95; P = .002), and infection (6/38 ST 5 vs 6/140 STs; relative risk, 3.68; 95% CI, 1.26-10.78; P = .022). Provider hands (n = 3) and patients (n = 4) were confirmed sources of ST 5 transmission. Transmission locations included provider hands (n = 3), patient skin sites (n = 4), and environmental surfaces (n = 2). All observed transmission stories involved the within-case mode of transmission. Two of the ST 5 transmission events were directly linked to infection.

      Conclusions

      Intraoperative S aureus ST 5 isolates are hypertransmissible and pathogenic. Improved compliance with hand hygiene and patient decolonization may help to control the spread of these dangerous pathogens.

      Key Words

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      References

        • Boucher H.W.
        • Talbot G.H.
        • Bradley J.S.
        • Edwards J.E.
        • Gilbert D.
        • Rice L.B.
        • et al.
        Bad bugs, no drugs: no ESKAPE! an update from the Infectious Diseases Society of America.
        Clin Infect Dis. 2009; 48: 1-12
        • Klevens R.M.
        • Morrison M.A.
        • Nadle J.
        • Petit S.
        • Gershman K.
        • Ray S.
        • et al.
        Invasive methicillin-resistant Staphylococcus aureus infections in the United States.
        JAMA. 2007; 298: 1763-1771
        • von Eiff C.
        • Becker K.
        • Machka K.
        • Stammer H.
        • Peters G.
        Nasal carriage as a source of Staphylococcus aureus bacteremia. Study Group.
        N Engl J Med. 2001; 344: 11-16
        • Loftus R.W.
        • Koff M.D.
        • Brown J.R.
        • Patel H.M.
        • Jensen J.T.
        • Reddy S.
        The epidemiology of Staphylococcus aureus transmission in the anesthesia work area.
        Anesth Analg. 2015; 120: 807-818
        • Bode L.G.
        • Kluytmans J.A.
        • Wertheim H.F.
        • Bogaers D.
        • Vandenbroucke-Grauls C.M.
        • Roosendaal R.
        • et al.
        Preventing surgical-site infections in nasal carriers of Staphylococcus aureus.
        N Engl J Med. 2010; 362: 9-17
        • Schweizer M.L.
        • Chiang H.Y.
        • Septimus E.
        • Moody J.
        • Braun B.
        • Hafner J.
        • et al.
        Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery.
        JAMA. 2015; 313: 2162-2171
        • Koff M.D.
        • Loftus R.W.
        • Burchman C.C.
        • Schwartzman J.D.
        • Read M.E.
        • Henry E.S.
        • et al.
        Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a novel device.
        Anesthesiology. 2009; 110: 978-985
        • Loftus R.W.
        • Patel H.M.
        • Huysman B.C.
        • Kispert D.P.
        • Koff M.D.
        • Gallagher J.D.
        • et al.
        Prevention of intravenous bacterial injection from health care provider hands: the importance of catheter design and handling.
        Anesth Analg. 2012; 115: 1109-1119
        • Loftus R.W.
        • Brindeiro B.S.
        • Kispert D.P.
        • Patel H.M.
        • Koff M.D.
        • Jensen J.T.
        • et al.
        Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a passive catheter care station.
        Anesth Analg. 2012; 115: 1315-1323
        • Loftus R.W.
        • Brown J.R.
        • Koff M.D.
        • Reddy S.
        • Heard S.O.
        • Patel H.M.
        • et al.
        Multiple reservoirs contribute to intraoperative bacterial transmission.
        Anesth Analg. 2012; 114: 1236-1248
        • Vogel T.R.
        • Dombrovskiy V.Y.
        • Lowry S.F.
        Impact of infectious complications after elective surgery on hospital readmission and late deaths in the U.S. Medicare population.
        Surg Infect (Larchmt). 2012; 13: 307-311
        • Koff M.D.
        • Brown J.R.
        • Marshall E.J.
        • O'Malley A.J.
        • Jensen J.T.
        • Heard S.O.
        • et al.
        Frequency of hand decontamination of intraoperative providers and reduction of postoperative healthcare-associated infections: a randomized clinical trial of a novel hand hygiene system.
        Infect Control Hosp Epidemiol. 2016; 37: 888-895
        • World Health Organization
        Antimicrobial resistance: global report on surveillance.
        WHO, Geneva (Switzerland)2014
        • The White House, Office of the Press Secretary
        FACT SHEET: Obama Administration Takes Actions to Combat Antibiotic-Resistant Bacteria.
        (Available from)
        • Centers for Disease Control and Prevention
        Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group.
        MMWR Recomm Rep. 2001; 50: 1-35
        • Loftus R.W.
        • Koff M.D.
        • Burchman C.C.
        • Schwartzman J.D.
        • Thorum V.
        • Read M.E.
        • et al.
        Transmission of pathogenic bacterial organisms in the anesthesia work area.
        Anesthesiology. 2008; 109: 399-407
        • Loftus R.W.
        • Dexter F.
        • Robinson A.D.M.
        Methicillin-resistant Staphylococcus aureus has greater risk of transmission in the operating room than methicillin-sensitive S aureus.
        Am J Infect Control. 2018; 46: 520-525
        • Archer N.K.
        • Mazaitis M.J.
        • Costerton W.
        • Leid J.G.
        • Powers M.E.
        • Shirtliff M.E.
        Staphylococcus aureus biofilms: properties, regulation, and roles in human disease.
        Virulence. 2011; 2: 445-459
        • Hekiert A.M.
        • Kofonow J.M.
        • Doghramji L.
        • Kennedy D.W.
        • Chiu A.G.
        • Palmer J.N.
        • et al.
        Biofilms correlate with TH1 inflammation in the sinonasal tissue of patients with chronic rhinosinusitis.
        Otolaryngol Head Neck Surg. 2009; 141: 448-453
        • Shamsudin M.N.
        • Karunanidhi A.
        • van Belkum A.
        • Lung L.T.
        • Sekawi Z.
        • Nathan J.J.
        • et al.
        Quantitative PCR analysis of genes expressed during biofilm development of methicillin resistant Staphylococcus aureus (MRSA).
        Infect Genet Evol. 2013; 18: 106-112
        • Clinical Laboratory Standards Institute
        9th ed. Performance standards for antimicrobial disk susceptibility tests; approved standard. Vol. 26. Clinical Laboratory Standards Institute, Wayne (PA)2006 (CLSI document M2-A9)
        • Edwards J.R.
        • Peterson K.D.
        • Mu Y.
        • Banerjee S.
        • Allen-Bridson K.
        • Morrell G.
        National Healthcare Safety Network (NHSN) report: data summary for 2006 through 2008, issued December 2009.
        Am J Infect Control. 2009; 37: 783-805
        • Haley R.W.
        • Quade D.
        • Freeman H.E.
        • Bennett J.V.
        The SENIC Project. Study on the efficacy of nosocomial infection control (SENIC Project). Summary of study design.
        Am J Epidemiol. 1980; 111: 472-485
        • Prasad K.
        • Jaeschke R.
        • Wyer P.
        • Keitz S.
        • Guyatt G.
        Tips for teachers of evidence-based medicine: understanding odds ratios and their relationship to risk ratios.
        J Gen Intern Med. 2008; 23: 635-640
        • Zou G.
        A modified Poisson regression approach to prospective studies with binary data.
        Am J Epidemiol. 2004; 159: 702-706
        • Lindquist K.
        How can I estimate relative risk using GLM for common outcomes in cohort studies.
        (Available from:)
        • Schultea B.
        • Bierbaumb G.
        • Pohla K.
        • Goerkea C.
        • Wolza C.
        Diversification of clonal complex 5 methicillin-resistant Staphylococcus aureus strains (Rhine-Hesse clone) within Germany.
        J Clin Microbiol. 2013; 51: 212-216
        • Dellinger E.
        • Gordon S.
        Surgical-associated infection in today's operating room.
        (Special Report, Anesthesiology, General Surgery, and OB/GYN News) McMahon Publishing Group, New York (NY)2006
        • McCourt J.
        • O'Halloran D.P.
        • McCarthy H.
        • O'Gara J.P.
        • Geoghegan J.A.
        Fibronectin-binding proteins are required for biofilm formation by community-associated methicillin-resistant Staphylococcus aureus strain LAC.
        FEMS Microbiol Lett. 2014; 353: 157-164
        • Caffau S.
        • Nadali L.
        On the bacterial contamination of anesthetic equipment.
        Friuli Med. 1965; 20: 515-531
        • Friss H.
        • Helms P.
        Bacterial contamination of anesthetic equipment during use.
        Ugeskr Laeger. 1963; 125: 619-623
        • Maslyk P.A.
        • Nafziger D.A.
        • Burns S.M.
        • Bowers P.R.
        Microbial growth on the anesthesia machine.
        AANA J. 2002; 70: 53-56
        • Madar R.
        • Novakova E.
        • Baska T.
        The role of non-critical health-care tools in the transmission of nosocomial infections.
        Bratisl Lek Listy. 2005; 106: 348-350
        • Foweraker J.E.
        The laryngoscope as a potential source of cross-infection.
        J Hosp Infect. 1995; 29: 315-316
        • Leung M.
        • Chan A.H.
        Control and management of hospital indoor air quality.
        Med Sci Monit. 2006; 12: SR17-SR23
        • Edmiston Jr, C.E.
        • Seabrook G.R.
        • Cambria R.A.
        • Brown K.R.
        • Lewis B.D.
        • Sommers J.R.
        • et al.
        Molecular epidemiology of microbial contamination in the operating room environment: is there a risk for infection?.
        Surgery. 2005; 138 (discussion 579-82): 573-579
        • Fukada T.
        • Tachibana C.
        • Tsukazaki Y.
        • Satoh K.
        • Furuya Y.
        • Ohe Y.
        Bacterial contamination of anesthesiologists' hands and the efficacy of handwashing.
        Masui. 1996; 45: 1026-1030
        • Stulberg J.J.
        • Delaney C.P.
        • Neuhauser D.V.
        • Aron D.C.
        • Fu P.
        • Koroukian S.M.
        Adherence to surgical care improvement project measures and the association with postoperative infections.
        JAMA. 2010; 303: 2479-2485
        • Carrel M.
        • Perencevich E.N.
        • David M.Z.
        USA300 methicillin-resistant Staphylococcus aureus, United States, 2000-2013.
        Emerg Infect Dis. 2015; 21: 1973-1980
        • Noto M.J.
        • Kreiswirth B.N.
        • Monk A.B.
        • Archer G.L.
        Gene acquisition at the insertion site for SCCmec, the genomic island conferring methicillin resistance in Staphylococcus aureus.
        J Bacteriol. 2008; 190: 1276-1283
        • Procopio M.A.
        • Rassias A.J.
        • DeLeo J.A.
        • Pahl J.
        • Hildebrandt L.
        • Yeager M.P.
        The in vivo effects of general and epidural anesthesia on human immune function.
        Anesth Analg. 2001; 93: 460-465
        • Reddy S.
        • Loftus R.W.
        Microbial contamination of today's operating room environments.
        IARS 2018 Annual Meeting and International Science Symposium, Chicago (IL)2018 April 28-May 1 (Abstract 1431; Available from)
        • Climo M.W.
        • Yokoe D.S.
        • Warren D.K.
        • Perl T.M.
        • Bolon M.
        • Herwaldt L.A.
        • et al.
        Effect of daily chlorhexidine bathing on hospital-acquired infection.
        N Engl J Med. 2013; 368: 533-542
        • Phillips M.
        • Rosenberg A.
        • Shopsin B.
        • Cuff G.
        • Skeete F.
        • Foti A.
        • et al.
        Preventing surgical site infections: a randomized, open-label trial of nasal mupirocin ointment and nasal povidone-iodine solution.
        Infect Control Hosp Epidemiol. 2014; 35: 826-832
        • Young R.S.
        • O'Regan D.J.
        Cardiac surgical theatre traffic: time for traffic calming measures?.
        Interact Cardiovasc Thorac Surg. 2010; 10: 526-529
        • Parikh S.N.
        • Grice S.S.
        • Schnell B.M.
        • Salisbury S.R.
        Operating room traffic: is there any role of monitoring it?.
        J Pediatr Orthop. 2010; 30: 617-623
        • Shaw L.F.
        • Chen I.H.
        • Chen C.S.
        • Wu H.H.
        • Lai L.S.
        • Chen Y.Y.
        • et al.
        Factors influencing microbial colonies in the air of operating rooms.
        BMC Infect Dis. 2018; 18: 4
        • Jamal M.
        • Ahmad W.
        • Andleeb S.
        • Jalil F.
        • Imran M.
        • Nawaz M.A.
        • et al.
        Bacterial biofilm and associated infections.
        J Chin Med Assoc. 2017; 81: S1726-S4901