The importance of targeting intraoperative transmission of bacteria with antibiotic resistance and strain characteristics

Published:August 01, 2022DOI:


      Evidence-based intraoperative infection control measures can reduce Staphylococcus aureus transmission and infections. We aimed to determine whether transmitted S. aureus isolates were associated with increased risk of multidrug resistance and associated traits.


      S. aureus isolates obtained from intraoperative environmental, patient skin, and provider hand reservoirs among 274 operating room case pairs (1st and 2nd case of the day) across 3 major academic medical centers from March 2009 to February 2010 underwent systematic-phenotypic-genomic analysis to identify clonal transmission events. The association of clonal S. aureus transmission with multidrug resistance and resistance traits was investigated. Transmission dynamics were characterized.


      Transmitted isolates (N=58) were associated with increased risk of multi-drug antibiotic resistance [33% (19/58) transmitted vs. 10% (12/115) other isolates, risk ratio 3.14, 99% CI 1.34-7.38, P=0.0006]. Transmission was associated with a significant increase in resistance traits including mecA [40% transmitted isolates vs. 17% other isolates, risk ratio 2.28, P=0.0026] and ant (6)-Ia [26% transmitted isolates vs. 9% other isolates, risk ratio 2.97, P=0.0050]. Provider hands were a frequent reservoir of origin, between-case a common mode of transmission, and patient skin and provider hands frequent transmission locations for multidrug resistant pathogens.


      Intraoperative S. aureus transmission was associated with multidrug resistance and resistance traits. Proven infection control measures should be leveraged to target intraoperative transmission of multidrug resistant pathogens.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Antimicrobial Resistance Collaborators
        Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis.
        Lancet. 2022; (published online Jan 20.doi: 10.1016/S0140-6736(21)02724-0. Epub 2022 Jan 19)
        • Laxminarayan R
        • Duse A
        • Wattal C
        • et al.
        Antibiotic resistance-the need for global solutions.
        Lancet Infect Dis. 2013; 13 (Epub 2013 Nov 17): 1057-1098
        • Boucher HW
        • Talbot GH
        • Bradley JS
        • et al.
        Bad Bugs, no Drugs: no ESKAPE! An update from the infectious diseases society of America.
        Clin Infect Dis. 2009; 48: 1-12
        • Holden MT
        • Hsu LY
        • Kurt K
        • et al.
        A genomic portrait of the emergence, evolution, and global spread of a methicillin-resistant Staphylococcus aureus pandemic.
        Genome Res. 2013; 23 (Epub 2013 Jan 8): 653-664
        • Howden BP
        • Davies JK
        • Johnson PDR
        • Stinear TP
        • Grayson ML
        Reduced vancomycin susceptibility in Staphylococcus aureus, including vancomycin-intermediate and heterogeneous vancomycin-intermediate strains: resistance mechanisms, laboratory detection, and clinical implications.
        Clin Microbiol Rev. 2010; 23: 99-139
        • Loftus R.
        • Brown JR
        • Koff MD
        • et al.
        Multiple reservoirs contribute to intraoperative bacterial transmission.
        Anesth Analg. 2012; 114: 1236-1248
        • Loftus RW
        • Dexter F
        • Robinson ADM.
        High-risk staphylococcus aureus transmission in the operating room: a call for widespread improvements in perioperative hand hygiene and patient decolonization practices.
        Am J Infect Control. 2018; 46 (Epub 2018 Jun 12): 1134-1141
        • Magill SS
        • Hellinger W
        • Cohen J
        • et al.
        Prevalence of healthcare-associated infections in acute care hospitals in Jacksonville, Florida.
        Infect Control Hosp Epidemiol. 2012; 33 (Epub 2012 Jan 12): 283-291
        • Vogel TR
        • Dombrovskiy VY
        • Lowry SF.
        Impact of infectious complications after elective surgery on hospital re-admission and late deaths in the U.S. Medicare population.
        Surg Infect (Larchmt). 2012; 13 (307-1Epub 2012 Oct 19)
        • Awad SS.
        Adherence to surgical care improvement project measures and postoperative surgical site infections.
        Surg Infect (Larchmt). 2012; 13 (Epub 2012 Aug 22): 234-237
        • Kirkland KB
        • Briggs JP
        • Trivette SL
        • Wilkinson WE
        • Sexton DJ.
        The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs.
        Infect Control Hosp Epidemiol. 1999; 20: 725-730
        • Menz BD
        • Charani E
        • Gordon DL
        • Leather AJM
        • Moonesinghe SR
        • Phillips CJ.
        Surgical antibiotic prophylaxis in an era of antibiotic resistance: common resistant bacteria and wider considerations for practice.
        Infect Drug Resist. 2021; 14: 5235-5252
        • Reichman DE
        • Greenberg JA.
        Reducing surgical site infections: a review.
        Rev Obstet Gynecol. 2009; 2: 212-221
        • O'Neill J.
        Antimicrobial resistance: tackling a crisis for the health and wealth of nations.
        2014 (Review Paper-Tackling a crisis for the health and wealth of nations_1.pdf (Last accessed, July, 2022))
        • Teillant A
        • Gandra S
        • Barter D
        • Morgan DJ
        • Laxminarayan R.
        Potential burden of antibiotic resistance on surgery and cancer chemotherapy antibiotic prophylaxis in the USA: a literature review and modeling study.
        Lancet Infect Dis. 2015; 15 (Epub 2015 Oct 22): 1429-1437
        • Loftus RW
        • Koff MD
        • Brown JR
        • et al.
        Transmission dynamics of gram-negative bacterial pathogens in the anesthesia work area.
        Anesth Analg. 2015; 120: 819-826
        • Hadder B
        • Patel HM
        • Loftus RW.
        Dynamics of intraoperative Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter transmission.
        Am J Infect Control. 2018; 46 (Epub 2018 Feb 12): 526-532
        • Stulberg JJ
        • Delaney CP
        • Neuhauser D
        • Aron DC
        • Pingfu Fu
        • Koroukian SM
        Adherence to surgical care improvement project measures and the association with postoperative infections.
        JAMA. 2010; 23 (303): 2479-2485
        • Daeschlein G.
        Antimicrobial and antiseptic strategies in wound management.
        Int Wound J. 2013; 10: 9-14
        • Huang C
        • Leavitt T
        • Bayer LR
        • Orgill DP.
        Effect of negative pressure wound therapy on wound healing.
        Curr Probl Surg. 2014; 51 (Epub 2014 Apr 26): 301-331
        • Loftus RW
        • Dexter F
        • Goodheart MJ
        • et al.
        The effect of improving basic preventive measures in the perioperative arena on staphylococcus aureus transmission and surgical site infections.
        A Randomized Clinical Trial JAMA Netw Open. 2020; 2e201934
        • Wall RT
        • Datta Subhradeep
        • Dexter F
        • et al.
        Effectiveness and feasibility of an evidence-based intraoperative infection control program targeting improved basic measures: a post-implementation prospective case-cohort study.
        J Clin Anesth. 2022; 77 (Epub 2021 Dec 17)110632
        • Koff MD
        • Loftus RW
        • Burchman CC
        • et al.
        Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a novel device.
        Anesthesiology. 2009; 110: 978-985
        • Loftus RW
        • Brindeiro BS
        • Kispert DP
        • et al.
        Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a passive catheter care system.
        Anesth Analg. 2012; 115 (Epub 2012 Nov 9): 1315-1323
        • Zuckerman JB
        • Zuaro DE
        • Prato BS
        • et al.
        Bacterial contamination of cystic fibrosis clinics.
        J Cyst Fibros. 2009; 8 (Epub 2009 Feb 28): 186-192
        • Loftus RW
        • Muffly MK
        • Brown JR
        • et al.
        Hand contamination of anesthesia providers is an important risk factor for intraoperative bacterial transmission.
        Anesth Analg. 2011; 112 (Epub 2010 Aug 4): 98-105
        • von Eiff C
        • Becker K
        • Machka K
        • Stammer H
        • Peters G.
        Nasal carriage as a source of staphylococcus aureus bacteremia.
        N Engl J Med. 2001; 344: 11-16
        • Schweizer ML
        • Chiang HY
        • Septimus E
        • et al.
        Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery.
        JAMA. 2015; 313: 2162-2171
        • Loftus R.
        • Dexter F
        • Robinson ADM.
        • Horswill AR.
        Desiccation tolerance is associated with staphylococcus aureus hyper transmissibility, resistance, and infection development in the operating room.
        J Hosp Infect. 2018; 100 (Epub 2018 Jun 30): 299-308
        • Clinical Laboratory Standards Institute.
        Performance standards for antimicrobial disk susceptibility tests.
        Approved standard-9th ed. CLSI document M2-A9. 26:1. Clinical Laboratory Standards Institute, Wayne, PA2006
        • Hasman H
        • Saputra D
        • Sicheritz-Ponten T
        • et al.
        Rapid whole-genome sequencing for detection and characterization of microorganisms directly from clinical samples.
        J Clin Microbiol. 2014; 52 (Epub 2013 Oct 30): 139-146
      1. Last accessed July, 2022.

        • Zerbino DR
        • Velvet BE.
        Algorithms for de novo short read assembly using de Bruijn graphs.
        Genome Res. 2008; 18 (Epub 2008 Mar 18): 821-829
        • Nesta
        Antibiotic resistant bacteria: 10 of the worst. 2022; (Last accessed July)
        • Haley RW
        • Quade D
        • Freeman HE
        • Bennett JV.
        The SENIC Project. Study on the efficacy of nosocomial infection control (SENIC Project). Summary of study design.
        Am J Epidemiol. 1980; 111: 472-485
        • Baker MA
        • Sands KE
        • Huang SS
        • Kleinman K
        • Septimus EJ
        • Varma N.
        The impact of COVID-19 on healthcare-associated infections.
        Clin Infect Dis. 2021; : ciab688
        • Durkin MJ
        • Dicks KV
        • Baker AW
        • et al.
        Seasonal variation of common surgical site infections: does season matter?.
        Infect Control Hosp Epidemiol. 2015; 36 (Epub 2015 May 26): 1011-1016
        • Dexter F
        • Ledolter J
        • Wall RT
        • Datta S
        • Loftus RW.
        Sample sizes for surveillance of S. aureus transmission to monitor effectiveness and provide feedback on intraoperative infection control including for COVID-19.
        Perioperative Care Oper Room Manag. 2020; 20100115
        • Loftus RW
        • Dexter F
        • Evans LC
        • Robinson ADM
        • Odle A
        • Perlman S.
        An assessment of the impact of recommended anesthesia work area cleaning procedures on intraoperative SARS-CoV-2 contamination, a case-series analysis.
        J Clin Anesth. 2021; 73 (Epub 2021 May 25)110350
        • Loftus Dexter F
        • Evans LC
        • Robinson A
        • Odle A
        • Perlman S.
        Evidence-based intraoperative infection control measures plus feedback are associated with substantial attenuation of SARS-CoV-2 (COVID-19).
        Br J Anaesth. 2022; (S0007-091200200-8)