Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
Anesth Analg. 2012 Jun;114(6):1236-48. doi: 10.1213/ANE.0b013e31824970a2. Epub 2012 Mar 30.
Intraoperative stopcock contamination is a frequent event associated with increased patient mortality. In the current study we examined the relative contributions of anesthesia provider hands, the patient, and the patient environment to stopcock contamination. Our secondary aims were to identify risk factors for stopcock contamination and to examine the prior association of stopcock contamination with 30-day postoperative infection and mortality. Additional microbiological analyses were completed to determine the prevalence of bacterial pathogens within intraoperative bacterial reservoirs. Pulsed-field gel electrophoresis was used to assess the contribution of reservoir bacterial pathogens to 30-day postoperative infections.
In a multicenter study, stopcock transmission events were observed in 274 operating rooms, with the first and second cases of the day in each operating room studied in series to identify within- and between-case transmission events. Reservoir bacterial cultures were obtained and compared with stopcock set isolates to determine the origin of stopcock contamination. Between-case transmission was defined by the isolation of 1 or more bacterial isolates from the stopcock set of a subsequent case (case 2) that were identical to reservoir isolates from the preceding case (case 1). Within-case transmission was defined by the isolation of 1 or more bacterial isolates from a stopcock set that were identical to bacterial reservoirs from the same case. Bacterial pathogens within these reservoirs were identified, and their potential contribution to postoperative infections was evaluated. All patients were followed for 30 days postoperatively for the development of infection and all-cause mortality.
Stopcock contamination was detected in 23% (126 out of 548) of cases with 14 between-case and 30 within-case transmission events confirmed. All 3 reservoirs contributed to between-case (64% environment, 14% patient, and 21% provider) and within-case (47% environment, 23% patient, and 30% provider) stopcock transmission. The environment was a more likely source of stopcock contamination than provider hands (relative risk [RR] 1.91, confidence interval [CI] 1.09 to 3.35, P = 0.029) or patients (RR 2.56, CI 1.34 to 4.89, P = 0.002). Hospital site (odds ratio [OR] 5.09, CI 2.02 to 12.86, P = 0.001) and case 2 (OR 6.82, CI 4.03 to 11.5, P < 0.001) were significant predictors of stopcock contamination. Stopcock contamination was associated with increased mortality (OR 58.5, CI 2.32 to 1477, P = 0.014). Intraoperative bacterial contamination of patients and provider hands was linked to 30-day postoperative infections.
Bacterial contamination of patients, provider hands, and the environment contributes to stopcock transmission events, but the surrounding patient environment is the most likely source. Stopcock contamination is associated with increased patient mortality. Patient and provider bacterial reservoirs contribute to 30-day postoperative infections. Multimodal programs designed to target each of these reservoirs in parallel should be studied intensely as a comprehensive approach to reducing intraoperative bacterial transmission.
术中开关污染是与患者死亡率增加相关的常见事件。在本研究中，我们检查了麻醉提供者的手、患者和患者环境对开关污染的相对贡献。我们的次要目标是确定开关污染的危险因素，并检查开关污染与 30 天术后感染和死亡率的先前关联。还完成了额外的微生物学分析，以确定术中细菌储库内细菌病原体的流行情况。脉冲场凝胶电泳用于评估储库细菌病原体对 30 天术后感染的贡献。
在一项多中心研究中，在 274 个手术室中观察到开关传输事件，每天的第一例和第二例病例连续研究，以确定病例内和病例间的传输事件。获得储库细菌培养物，并与开关集分离物进行比较，以确定开关污染的来源。病例间传播的定义是从后续病例（病例 2）的开关组中分离出 1 个或多个与前一个病例（病例 1）的储库分离物相同的细菌分离物。病例内传播的定义是从同一病例的开关组中分离出 1 个或多个与细菌储库相同的细菌分离物。对这些储库中的细菌病原体进行鉴定，并评估其对术后感染的潜在影响。所有患者在术后 30 天内接受感染和全因死亡率的随访。
在 548 例中有 23%（126 例）检测到开关污染，确认了 14 例病例间和 30 例病例内传播事件。所有 3 个储库均参与病例间（64%为环境、14%为患者、21%为提供者）和病例内（47%为环境、23%为患者、30%为提供者）开关传播。环境比提供者的手（相对风险 [RR] 1.91，置信区间 [CI] 1.09 至 3.35，P = 0.029）或患者（RR 2.56，CI 1.34 至 4.89，P = 0.002）更有可能成为开关污染的来源。医院地点（比值比 [OR] 5.09，CI 2.02 至 12.86，P = 0.001）和病例 2（OR 6.82，CI 4.03 至 11.5，P < 0.001）是开关污染的显著预测因素。开关污染与死亡率增加有关（OR 58.5，CI 2.32 至 1477，P = 0.014）。患者和提供者手部的术中细菌污染与 30 天术后感染有关。
患者、提供者的手和环境的细菌污染导致开关传播事件，但周围的患者环境是最可能的来源。开关污染与患者死亡率增加有关。患者和提供者的细菌储库导致 30 天术后感染。应深入研究旨在针对这些储库的多模式方案，作为减少术中细菌传播的综合方法。
