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Yeo SY, Chong NFTM, Mat Johar SFN, Wan Abdul Rahman WF, Halim AS. "Ultraviolet C phototherapy as an adjunct wound therapy in full-thickness wound of a rat model". Injury 2022; 53:1837-1847. [PMID: 35523602 DOI: 10.1016/j.injury.2022.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 02/02/2023]
Abstract
Ultraviolet C (UVC) phototherapy is a potential modality to improve wound healing due to its well-known antimicrobial properties, and it promotes the expression of certain growth factors. However, limited data exist to show the clinical effect of UVC in wound healing compared with other advanced modern dressings. This animal preclinical study involved 56 Sprague-Dawley female rats aged 3 months old, weighing between 250 and 300 g, which were acclimatized for one week. Following the creation of a 2 × 2-cm-square full-thickness wound over the dorsum of each rat, they were divided into four treatment groups, namely, the control, UVC, hydrofiber silver, and UVC/hydrofiber silver groups. On Days 2, 4, 7, 10, 14, 21, and 28 postwounding, two rats from each group underwent wound assessment via wound measurement (mm2), calculation of the percentage of wound contracture and percentage of epithelization. Wound specimens were obtained for histological examination of inflammatory cells (neutrophils, lymphocytes and macrophages) and fibroblast cell counts. There was a relationship between wound size reduction and time to heal (P<0.05, R2=0.70) among the four treatment groups. The UVC/hydrofiber silver group had a significantly smaller wound size given the time to heal compared with the control group (P = 0.01) and UVC group (P = 0.02). There were no significant differences in terms of wound contracture and epithelization percentage among the four treatment groups. Histopathological examination revealed a significantly lower mean fibroblast count in the UVC/hydrofiber silver group than in the other groups (P = 0.025). These data suggested that UVC phototherapy did not increase the rate of healing but maintained the integrity of the wound by providing antimicrobial properties and preventing overproduction of fibroblasts. UVC was also safe, as no overt inflammatory response was discovered.
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Affiliation(s)
- Siek Ying Yeo
- Reconstructive Sciences Unit, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia; Department of Plastic Surgery, Hospital Universiti Sains Malaysia, Kelantan, Malaysia
| | - Nicholas Franklin Tow Mun Chong
- Reconstructive Sciences Unit, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia; Department of Plastic Surgery, Hospital Universiti Sains Malaysia, Kelantan, Malaysia
| | - Siti Fatimah Noor Mat Johar
- Reconstructive Sciences Unit, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia; Department of Plastic Surgery, Hospital Universiti Sains Malaysia, Kelantan, Malaysia
| | - Wan Faiziah Wan Abdul Rahman
- Department of Pathology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Ahmad Sukari Halim
- Reconstructive Sciences Unit, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia; Department of Plastic Surgery, Hospital Universiti Sains Malaysia, Kelantan, Malaysia.
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Does UV Light as an Adjunct to Conventional Treatment Improve Healing and Reduce Infection in Wounds? A Systematic Review. Adv Skin Wound Care 2021; 34:1-6. [PMID: 33739951 DOI: 10.1097/01.asw.0000734384.52295.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the effect of UV light on wound healing and infection in patients with skin ulcers or surgical incisions. Outcomes of interest included healing time, wound size and appearance, bacterial burden, and infection. DATA SOURCES Ovid MEDLINE, Embase, Cochrane, PubMed, CINAHL, and Web of Science. STUDY SELECTION Comparative and noncomparative clinical studies were considered, including observational cohort, retrospective, and randomized controlled studies. They addressed the research question: "Does the use of UV light as an adjunct to conventional treatment help improve healing and reduce infection in wounds?" Selection criteria included any English language study in adults who used UV light to improve wound healing and prevent or treat wound infection. DATA EXTRACTION Authors extracted information pertaining to patient demographics, treatment protocols, and the following wound outcomes: appearance, healing time, infection, and bacterial burden. DATA SYNTHESIS The search yielded 30,986 articles, and screening resulted in 11 studies that underwent final analysis. Of these (N = 27,833), seven (64%) demonstrated an improvement in healing outcomes with adjunctive UV therapy, and the results of four (36%) achieved statistical significance. CONCLUSIONS There is limited research on the utility of adjunctive UV therapy to improve wound healing outcomes in humans. The majority of literature included in this review supported improved wound healing outcomes with adjuvant UV therapy. Future well-designed randomized controlled trials will be essential in further determining the benefit and utility of UV therapy in wound healing.
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Choi SI, Jung TD, Cho BY, Choi SH, Sim WS, Han X, Lee SJ, Kim YC, Lee OH. Anti‑photoaging effect of fermented agricultural by‑products on ultraviolet B‑irradiated hairless mouse skin. Int J Mol Med 2019; 44:559-568. [PMID: 31198982 PMCID: PMC6605975 DOI: 10.3892/ijmm.2019.4242] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 06/10/2019] [Indexed: 12/20/2022] Open
Abstract
Processed products from agricultural produce generate a large number of agricultural by‑products that contain a number of functional substances. These are often discarded owing to the lack of suitable processing methods. The present study investigated the anti‑photoaging properties of fermented rice bran (FRB), soybean cake (FSB) and sesame seed cake (FSC) on ultraviolet B (UVB)‑irradiated hairless mouse skin. Results indicated that the oral administration of FRB, FSB and FSC effectively inhibited the UVB irradiation‑induced expression of matrix metalloproteinase (MMP)‑2, MMP‑9, MMP‑3 and MMP‑13. Reverse transcription‑quantitative polymerase chain reaction results also demonstrated that FRB, FSB and FSC significantly inhibited the UVB‑induced expression of the genes encoding tumor necrosis factor‑α, inducible nitric oxide synthase, interleukin (IL)‑6 and IL‑1β when compared with the UVB‑vehicle group (P<0.05). Additionally, collagen degradation and mast cell infiltration were reduced in hairless mouse skin. Furthermore, UVB‑induced wrinkle formation was also significantly reduced in mouse skin compared with the UVB‑vehicle group (P<0.05). These results reveal that fermented agricultural by‑products may serve as potential functional materials with anti‑photoaging activities.
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Affiliation(s)
- Sun-Il Choi
- Department of Food Science and Biotechnology, Kangwon National University, Chuncheon 24341
| | - Tae-Dong Jung
- Department of Food Science and Biotechnology, Kangwon National University, Chuncheon 24341
| | - Bong-Yeon Cho
- Department of Food Science and Biotechnology, Kangwon National University, Chuncheon 24341
| | - Seung-Hyun Choi
- Department of Food Science and Biotechnology, Kangwon National University, Chuncheon 24341
| | - Wan-Sup Sim
- Department of Food Science and Biotechnology, Kangwon National University, Chuncheon 24341
| | - Xionggao Han
- Department of Food Science and Biotechnology, Kangwon National University, Chuncheon 24341
| | - Sang Jong Lee
- STR Biotech Co., Ltd., Chuncheon 24232, Republic of Korea
| | - Young-Cheul Kim
- Department of Nutrition, University of Massachusetts, Amherst, MA 01003, USA
| | - Ok-Hwan Lee
- Department of Food Science and Biotechnology, Kangwon National University, Chuncheon 24341
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Aalirezaie A, Akkaya M, Barnes CL, Bengoa F, Bozkurt M, Cichos KH, Ghanem E, Darouiche RO, Dzerins A, Gursoy S, Illiger S, Karam JA, Klaber I, Komnos G, Lohmann C, Merida E, Mitt P, Nelson C, Paner N, Perez-Atanasio JM, Reed M, Sangster M, Schweitzer D, Simsek ME, Smith BM, Stocks G, Studers P, Talevski D, Teuber J, Travers C, Vince K, Wolf M, Yamada K, Vince K. General Assembly, Prevention, Operating Room Environment: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S105-S115. [PMID: 30348570 DOI: 10.1016/j.arth.2018.09.060] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Affiliation(s)
- Mitchell C Weiser
- Department of Orthopaedic Surgery, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Calin S Moucha
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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Boyle KK, Duquin TR. Antibiotic Prophylaxis and Prevention of Surgical Site Infection in Shoulder and Elbow Surgery. Orthop Clin North Am 2018; 49:241-256. [PMID: 29499825 DOI: 10.1016/j.ocl.2017.11.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Infection after orthopedic procedures is a devastating and serious complication associated with significant clinical and financial challenges to the health care system and unfortunate patient. The time and resource-intensive nature of treating infection after orthopedic procedures has turned attention toward enhancing prevention and establishing quality improvement measures. Prevention strategies throughout the perioperative period include host optimization, risk mitigation, reducing bacterial burden and proper wound management. Understanding the most common offending organisms of the shoulder, Propionibacterium acnes and coagulase negative Staphylococcus species, and their hypothesized mechanism of infection is crucial to selecting appropriate preventative measures.
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Affiliation(s)
- K Keely Boyle
- Department of Orthopaedics, State University of New York at Buffalo, Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215, USA.
| | - Thomas R Duquin
- Department of Orthopaedics, State University of New York at Buffalo, Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215, USA
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Prävention postoperativer Wundinfektionen. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61:448-473. [PMID: 29589090 DOI: 10.1007/s00103-018-2706-2] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Ponnaiya B, Buonanno M, Welch D, Shuryak I, Randers-Pehrson G, Brenner DJ. Far-UVC light prevents MRSA infection of superficial wounds in vivo. PLoS One 2018; 13:e0192053. [PMID: 29466457 PMCID: PMC5821446 DOI: 10.1371/journal.pone.0192053] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/16/2018] [Indexed: 02/02/2023] Open
Abstract
Background Prevention of superficial surgical wound infections from drug-resistant bacteria such as methicillin resistant Staphylococcus aureus (MRSA) currently present major health care challenges. The majority of surgical site infections (SSI) are believed to be caused by airborne transmission of bacteria alighting onto the wound during surgical procedures. We have previously shown that far-ultraviolet C light in the wavelength range of 207–222 nm is significantly harmful to bacteria, but without damaging mammalian cells and tissues. It is important that the lamp be fitted with a filter to remove light emitted at wavelengths longer than 230 nm which are harmful. Aims Using a hairless mouse model of infection of superficial wounds, here we tested the hypothesis that 222-nm light kills MRSA alighting onto a superficial skin incisions as efficiently as typical germicidal light (254 nm), but without inducing skin damage. Methods To simulate the scenario wherein incisions are infected during surgical procedures as pathogens in the room alight on a wound, MRSA was spread on a defined area of the mouse dorsal skin; the infected skin was then exposed to UVC light (222 nm or 254 nm) followed by a superficial incision within the defined area, which was immediately sutured. Two and seven days post procedure, bactericidal efficacy was measured as MRSA colony formation unit (CFU) per gram of harvested skin whereas fixed samples were used to assess skin damage measured in terms of epidermal thickness and DNA photodamage. Results In the circumstance of superficial incisions infected with bacteria alighting onto the wound, 222-nm light showed the same bactericidal properties of 254-nm light but without the associated skin damage. Conclusions Being safe for patient and hospital staff, our results suggested that far-UVC light (222 nm) might be a convenient approach to prevent transmission of drug-resistant infectious agents in the clinical setting.
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Affiliation(s)
- Brian Ponnaiya
- Center for Radiological Research, Department of Radiation Oncology, Columbia University Medical Center, New York, New York, United States of America
- * E-mail:
| | - Manuela Buonanno
- Center for Radiological Research, Department of Radiation Oncology, Columbia University Medical Center, New York, New York, United States of America
| | - David Welch
- Center for Radiological Research, Department of Radiation Oncology, Columbia University Medical Center, New York, New York, United States of America
| | - Igor Shuryak
- Center for Radiological Research, Department of Radiation Oncology, Columbia University Medical Center, New York, New York, United States of America
| | - Gerhard Randers-Pehrson
- Center for Radiological Research, Department of Radiation Oncology, Columbia University Medical Center, New York, New York, United States of America
| | - David J. Brenner
- Center for Radiological Research, Department of Radiation Oncology, Columbia University Medical Center, New York, New York, United States of America
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Kim JE, Oh YJ, Won MY, Lee KS, Min SC. Microbial decontamination of onion powder using microwave-powered cold plasma treatments. Food Microbiol 2017; 62:112-123. [DOI: 10.1016/j.fm.2016.10.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 05/06/2016] [Accepted: 10/02/2016] [Indexed: 01/01/2023]
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Role of Ultraviolet Disinfection in the Prevention of Surgical Site Infections. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 996:255-266. [DOI: 10.1007/978-3-319-56017-5_21] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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El-Azizi M, Khardori N. Efficacy of ultraviolet C light at sublethal dose in combination with antistaphylococcal antibiotics to disinfect catheter biofilms of methicillin-susceptible and methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis in vitro. Infect Drug Resist 2016; 9:181-9. [PMID: 27578990 PMCID: PMC4998029 DOI: 10.2147/idr.s109343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Biofilm formation inside inserted medical devices leads to their failure and acts as a source of refractory infections. The ultraviolet C (UVC) light is a potential therapy that can be used against the biofilm of bacterial pathogens. Objective We evaluated the efficacy of sublethal dose of UVC light with anti-staphylococcal antibiotics against biofilms made from 30 isolates of methicillin-susceptible Staphylococcus aureus and methicillin-resistant S. aureus and S. epidermidis on vascular catheters. Materials and methods A novel biofilm device was used to assess the combined approach. The biofilms on the catheters were irradiated with the UVC light at 254 nm and irradiance of 6.4 mW followed by treatment with vancomycin or quinupristin/dalfopristin at twice their minimum bactericidal concentrations or with linezolid at 64 µg/mL for 24 hours. The catheters were cut into segments and sonicated, and the number of the sessile cells was determined colorimetrically using XTT viable cells assay. The effect of UVC radiation followed by treatment with an antistaphylococcal antibiotic on the viability of the bacteria in the biofilm was visualized using LIVE/DEAD BacLight bacterial viability stain and confocal laser scanning microscopy. Results Exposure of the bacterial biofilms to the UVC light or each of the antibiotics alone was ineffective in killing the bacteria. Treatment of the biofilms with the antibiotics following their exposure to UVC light significantly (P<0.001) reduced the number of viable cells within the biofilms but did not completely eradicate them. Conclusion To our knowledge, this combinatorial approach has not been investigated before. The combined approach can be used as a therapeutic modality for managing biofilm-associated infections by preventing the establishment of biofilms and/or disrupting the formed biofilms on the inserted medical devices with the goal of increasing their usefulness and preventing infectious complications. Further investigations are needed to assess the effectiveness of the combined approach in the clinical settings.
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Affiliation(s)
- Mohamed El-Azizi
- Department of Microbiology, Immunology and Biotechnology, Faculty of Pharmacy and Biotechnology, German University in Cairo, New Cairo City, Egypt
| | - Nancy Khardori
- Department of Internal Medicine, Division of Infectious Diseases, Eastern Virginia Medical School, Norfolk, VA, USA
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Miner AL, Losina E, Katz JN, Fossel AH, Platt R. Infection Control Practices to Reduce Airborne Bacteria During Total Knee Replacement: A Hospital Survey in Four States. Infect Control Hosp Epidemiol 2016; 26:910-5. [PMID: 16417030 DOI: 10.1086/505452] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AbstractObjective:To describe the use of laminar airflow, body exhaust, and ultraviolet lights during total knee replacement (TKR) in four U.S. states.Design:Survey of healthcare facilities.Setting:Hospitals in Illinois, North Carolina, Ohio, and Tennessee that performed TKR during 2000 as identified by Medicare claims data.Participants:Hospitals responding to a mailed questionnaire.Results:Two hundred ninety-five (73%) of 405 eligible hospitals that performed 18,374 primary and revision TKR procedures responded to the questionnaire. Among responding hospitals, 30% reported regular use (for > 75% of procedures) of laminar airflow, 42% reported regular use of body exhaust, and 5% reported regular use of ultraviolet lights. Among hospitals providing complete data, 150 (58%) performing 66% of procedures reported regular use of at least one of these techniques. On regression analyses, laminar airflow was used more often by hospitals with a TKR volume greater than 25 procedures per year (odds ratio [OR], 2.0; 95% confidence interval [CI95], 1.1-3.7) and orthopedic residency programs (OR,2.8;CI95,1.3-6.3), but its use was not significantly related to hospital setting or ownership status.Conclusions:Although these clean air practices are not recommended by any U.S. governmental or professional organization, they are used in nearly two-thirds of TKR procedures. Better information about their impact on current practice and more explicit guidelines may aid decisions about the use of these resource-intensive infection control practices.
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Affiliation(s)
- Andrew L Miner
- Department of Ambulatory Care and Prevention and Channing Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
A 9 year old girl presented to us with complaints of fever and pain in burn wounds with deteriorating health for one month. According to Lund and Broder's chart, burns spanned the posterior trunk (13%), right arm (1.5%), left arm (1.5%), and buttocks (2.5%). The wounds showed improper healing. She had previously underwent split-thickness skin grafting, using skin harvests from thighs and antimicrobial therapy with vancomycin, fluconazole and colomycin with limited clinical improvement. Analgesia was administered. Blood cultures and tissue cultures from the burns indicated polymicrobial wound infection and sepsis, including methicillin resistant Staphylococcus aureus, Klebsiella pneumoniae and Pseudomonas aeruginosa. Despite broad-spectrum antibiotics, fever persisted and condition deteriorated. Antifungals were also administered with no clinical improvement. Eventually another split-thickness skin grafting was done to provide fresh grafts. In due course, ultraviolet light exposure, of wavelength 32-40 nm/W/cm(2), was considered for treatment. In prone position, the wounds were exposed to ultraviolet phototherapy 6-8 h daily for 8 days. Eventually, wound healing and sepsis improved. Antibiotics were optimized and high protein diet was started. Eventually the wounds showed fresh margins and visible signs of healing. With remarkable clinical improvement and no further fever spikes, the patient was eventually discharged. She was advised to shower regularly, apply bandages with acetic acid. On her last outpatient follow up, 2 weeks after discharge, she was doing well, with no complaints of pain or fever. Examination of burns showed clean wounds, with clear margins and good graft uptake. She did not require any further grafting or surgical procedures thereafter.
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Alijanipour P, Karam J, Llinás A, Vince KG, Zalavras C, Austin M, Garrigues G, Heller S, Huddleston J, Klatt B, Krebs V, Lohmann C, McPherson EJ, Molloy R, Oliashirazi A, Schwaber M, Sheehan E, Smith E, Sterling R, Stocks G, Vaidya S. Operative environment. J Orthop Res 2014; 32 Suppl 1:S60-80. [PMID: 24464899 DOI: 10.1002/jor.22550] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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207-nm UV light - a promising tool for safe low-cost reduction of surgical site infections. I: in vitro studies. PLoS One 2013; 8:e76968. [PMID: 24146947 PMCID: PMC3797730 DOI: 10.1371/journal.pone.0076968] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 09/05/2013] [Indexed: 11/19/2022] Open
Abstract
Background 0.5% to 10% of clean surgeries result in surgical-site infections, and attempts to reduce this rate have had limited success. Germicidal UV lamps, with a broad wavelength spectrum from 200 to 400 nm are an effective bactericidal option against drug-resistant and drug-sensitive bacteria, but represent a health hazard to patient and staff. By contrast, because of its limited penetration, ∼200 nm far-UVC light is predicted to be effective in killing bacteria, but without the human health hazards to skin and eyes associated with conventional germicidal UV exposure. Aims The aim of this work was to test the biophysically-based hypothesis that ∼200 nm UV light is significantly cytotoxic to bacteria, but minimally cytotoxic or mutagenic to human cells either isolated or within tissues. Methods A Kr-Br excimer lamp was used, which produces 207-nm UV light, with a filter to remove higher-wavelength components. Comparisons were made with results from a conventional broad spectrum 254-nm UV germicidal lamp. First, cell inactivation vs. UV fluence data were generated for methicillin-resistant S. aureus (MRSA) bacteria and also for normal human fibroblasts. Second, yields of the main UV-associated pre-mutagenic DNA lesions (cyclobutane pyrimidine dimers and 6-4 photoproducts) were measured, for both UV radiations incident on 3-D human skin tissue. Results We found that 207-nm UV light kills MRSA efficiently but, unlike conventional germicidal UV lamps, produces little cell killing in human cells. In a 3-D human skin model, 207-nm UV light produced almost no pre-mutagenic UV-associated DNA lesions, in contrast to significant yields induced by a conventional germicidal UV lamp. Conclusions As predicted based on biophysical considerations, 207-nm light kills bacteria efficiently but does not appear to be significantly cytotoxic or mutagenic to human cells. Used appropriately, 207-nm light may have the potential for safely and inexpensively reducing surgical-site infection rates, including those of drug-resistant origin.
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Gupta A, Avci P, Dai T, Huang YY, Hamblin MR. Ultraviolet Radiation in Wound Care: Sterilization and Stimulation. Adv Wound Care (New Rochelle) 2013; 2:422-437. [PMID: 24527357 DOI: 10.1089/wound.2012.0366] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Indexed: 01/09/2023] Open
Abstract
SIGNIFICANCE Wound care is an important area of medicine considering the increasing age of the population who may have diverse comorbidities. Light-based technology comprises a varied set of modalities of increasing relevance to wound care. While low-level laser (or light) therapy and photodynamic therapy both have wide applications in wound care, this review will concentrate on the use of ultraviolet (UV) radiation. RECENT ADVANCES UVC (200-280 nm) is highly antimicrobial and can be directly applied to acute wound infections to kill pathogens without unacceptable damage to host tissue. UVC is already widely applied for sterilization of inanimate objects. UVB (280-315 nm) has been directly applied to the wounded tissue to stimulate wound healing, and has been widely used as extracorporeal UV radiation of blood to stimulate the immune system. UVA (315-400 nm) has distinct effects on cell signaling, but has not yet been widely applied to wound care. CRITICAL ISSUES Penetration of UV light into tissue is limited and optical technology may be employed to extend this limit. UVC and UVB can damage DNA in host cells and this risk must be balanced against beneficial effects. Chronic exposure to UV can be carcinogenic and this must be considered in planning treatments. FUTURE DIRECTIONS New high-technology UV sources, such as light-emitting diodes, lasers, and microwave-generated UV plasma are becoming available for biomedical applications. Further study of cellular signaling that occurs after UV exposure of tissue will allow the benefits in wound healing to be better defined.
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Affiliation(s)
- Asheesh Gupta
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
- Defense Institute of Physiology and Allied Sciences (DIPAS), Delhi, India
| | - Pinar Avci
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Tianhong Dai
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
| | - Ying-Ying Huang
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
- Department of Pathology, Guangxi Medical University, Nanning, China
| | - Michael R. Hamblin
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
- Harvard–MIT Division of Health Sciences and Technology, Cambridge, Massachusetts
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Yin R, Dai T, Avci P, Jorge AES, de Melo WCMA, Vecchio D, Huang YY, Gupta A, Hamblin MR. Light based anti-infectives: ultraviolet C irradiation, photodynamic therapy, blue light, and beyond. Curr Opin Pharmacol 2013; 13:731-62. [PMID: 24060701 DOI: 10.1016/j.coph.2013.08.009] [Citation(s) in RCA: 164] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 08/15/2013] [Accepted: 08/20/2013] [Indexed: 12/26/2022]
Abstract
Owing to the worldwide increase in antibiotic resistance, researchers are investigating alternative anti-infective strategies to which it is supposed microorganisms will be unable to develop resistance. Prominent among these strategies, is a group of approaches which rely on light to deliver the killing blow. As is well known, ultraviolet light, particularly UVC (200-280 nm), is germicidal, but it has not been much developed as an anti-infective approach until recently, when it was realized that the possible adverse effects to host tissue were relatively minor compared to its high activity in killing pathogens. Photodynamic therapy is the combination of non-toxic photosensitizing dyes with harmless visible light that together produce abundant destructive reactive oxygen species (ROS). Certain cationic dyes or photosensitizers have good specificity for binding to microbial cells while sparing host mammalian cells and can be used for treating many localized infections, both superficial and even deep-seated by using fiber optic delivered light. Many microbial cells are highly sensitive to killing by blue light (400-470 nm) due to accumulation of naturally occurring photosensitizers such as porphyrins and flavins. Near infrared light has also been shown to have antimicrobial effects against certain species. Clinical applications of these technologies include skin, dental, wound, stomach, nasal, toenail and other infections which are amenable to effective light delivery.
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Affiliation(s)
- Rui Yin
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA; Department of Dermatology, Harvard Medical School, Boston, MA, USA; Department of Dermatology, Southwest Hospital, Third Military Medical University, Chongqing, China
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Environmental hygiene in the operating room: cleanliness, godliness, and reality. Int Anesthesiol Clin 2013; 51:93-104. [PMID: 23282724 DOI: 10.1097/aia.0b013e31827da44b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dai T, Vrahas MS, Murray CK, Hamblin MR. Ultraviolet C irradiation: an alternative antimicrobial approach to localized infections? Expert Rev Anti Infect Ther 2012; 10:185-95. [PMID: 22339192 DOI: 10.1586/eri.11.166] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This review discusses the potential of ultraviolet C (UVC) irradiation as an alternative approach to current methods used to treat localized infections. It has been reported that multidrug-resistant microorganisms are equally sensitive to UVC irradiation as their wild-type counterparts. With appropriate doses, UVC may selectively inactivate microorganisms while preserving viability of mammalian cells and, moreover, is reported to promote wound healing. UVC is also found in animal studies to be less damaging to tissue than UVB. Even though UVC may produce DNA damage in mammalian cells, it can be rapidly repaired by DNA repair enzymes. If UVC irradiation is repeated excessively, resistance of microorganisms to UVC inactivation may develop. In summary, UVC should be investigated as an alternative approach to current methods used to treat localized infections, especially those caused by multidrug-resistant microorganisms. UVC should be used in a manner such that the side effects would be minimized and resistance of microorganisms to UVC would be avoided.
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Affiliation(s)
- Tianhong Dai
- Wellman Center for Photomedicine, Massachusetts General Hospital, 40 Blossom Street, Boston, MA 02114, USA
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22
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Brown NM, Cipriano CA, Moric M, Sporer SM, Della Valle CJ. Dilute betadine lavage before closure for the prevention of acute postoperative deep periprosthetic joint infection. J Arthroplasty 2012; 27:27-30. [PMID: 21550765 DOI: 10.1016/j.arth.2011.03.034] [Citation(s) in RCA: 174] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 03/19/2011] [Indexed: 02/01/2023] Open
Abstract
This study evaluated the efficacy of a dilute Betadine (Purdue Pharma, Stamford, Conn) lavage in preventing early deep postoperative infection after total hip (THA) and knee (TKA) arthroplasty. A protocol of dilute Betadine lavage (0.35%) for 3 minutes was introduced to the practice of the senior author in June 2008. A total of 1862 consecutive cases (630 THA and 1232 TKA) performed before this were compared with 688 consecutive cases (274 THA and 414 TKA) after for the occurrence of periprosthetic infections within the first 90 days postoperatively. Eighteen early postoperative infections were identified before the use of dilute Betadine lavage, and 1 since (0.97% and 0.15%, respectively; P = .04). There were no significant demographic differences between the 2 groups. Betadine lavage before wound closure may be an inexpensive, effective means of reducing acute postoperative infection after total joint arthroplasty.
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Affiliation(s)
- Nicholas M Brown
- Columbia University College of Physicians and Surgeons, New York, New York, USA
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23
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Stocks GW, O'Connor DP, Self SD, Marcek GA, Thompson BL. Directed air flow to reduce airborne particulate and bacterial contamination in the surgical field during total hip arthroplasty. J Arthroplasty 2011; 26:771-6. [PMID: 20851565 DOI: 10.1016/j.arth.2010.07.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Accepted: 07/06/2010] [Indexed: 02/01/2023] Open
Abstract
This study evaluated the use of a system that delivers a small field of local, directed air from a high-efficiency particulate air (HEPA) filter to reduce airborne particulate and airborne bacteria in the surgical field during total hip arthroplasty. Thirty-six patients were randomized into 3 groups: with directed air flow, with the directed air flow system present but turned off, and control. Airborne particulate and bacteria were collected from within 5 cm of the surgical wound. All particulate and bacterial counts at the surgical site were significantly lower in the directed air flow group (P < .001). The directed air flow system was effective in reducing airborne particulate and colony-forming units in the surgical field during total hip arthroplasty.
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Evans RP. Current concepts for clean air and total joint arthroplasty: laminar airflow and ultraviolet radiation: a systematic review. Clin Orthop Relat Res 2011; 469:945-53. [PMID: 21161744 PMCID: PMC3048268 DOI: 10.1007/s11999-010-1688-7] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND With the trend toward pay-for-performance standards plus the increasing incidence and prevalence of periprosthetic joint infection (PJI), orthopaedic surgeons must reconsider all potential infection control measures. Both airborne and nonairborne bacterial contamination must be reduced in the operating room. QUESTIONS/PURPOSES Analysis of airborne bacterial reduction technologies includes evaluation of (1) the effectiveness of laminar air flow (LAF) and ultraviolet light (UVL); (2) the financial and potential health costs of each; and (3) an examination of current national and international standards, and guidelines. METHODS We systematically reviewed the literature from Ovid, PubMed (Medline), Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA, NHSEED, CINAHLPLUS, and Google Scholar published until June 2010 focusing on ultraclean air, ultraviolet light, and laminar air. RESULTS High-level data demonstrating substantial PJI reduction of any infection control method may not be feasible as a result of the relatively low rates of occurrence and the expense and difficulty of conducting a large enough study with adequate power. UVL has potentially unacceptable health costs and the Centers for Disease Control and Prevention (CDC) recommends against its use. European countries have standardized LAF and it is used by the majority of American joint surgeons. CONCLUSIONS Both LAF and UVL reduce PJI. The absence of a high level of evidence from randomized trials is not proof of ineffectiveness. The historically high cost of LAF has decreased substantially. Only LAF has been standardized by several European countries. The CDC recommends further study of LAF but recommends UVL not be used secondary to documented potential health risks to personnel.
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Affiliation(s)
- Richard P Evans
- Department of Orthopaedic Surgery, #531, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, AR 72205, USA.
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Howard JL, Hanssen AD. Principles of a clean operating room environment. J Arthroplasty 2007; 22:6-11. [PMID: 17919585 DOI: 10.1016/j.arth.2007.05.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2007] [Accepted: 05/08/2007] [Indexed: 02/01/2023] Open
Abstract
Optimizing the operating room environment is necessary to minimize the prevalence of arthroplasty infection. Reduction of bacterial contamination in the operating room should be a primary focus of all members of the operating room team. However, in recent years, there has been a decline in the emphasis of the basic principles of antisepsis in many operating rooms. The purpose of this review is to highlight important considerations for optimizing the operating room environment. These principles should be actively promoted by orthopedic surgeons in their operating rooms as part of a comprehensive approach to minimizing arthroplasty infection.
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Affiliation(s)
- James L Howard
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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27
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Abstract
Wound healing is a complex pathway that is energy dependent. Nonhealing wounds frequently require the use of physical modalities to achieve healing. There is much debate over which treatment modality to use, with varying clinical results in the literature. This review paper describes a common biochemical pathway that helps the clinician understand, at a molecular level, how the transference of energy to a wound can result in positive clinical results. The mechanisms of action for ultraviolet light, electrical stimulation, and ultrasound are reviewed along with a proposed biochemical roadmap. An emphasis on protein biochemistry is supported with an extensive review of the literature.
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Affiliation(s)
- William J Ennis
- Comprehensive Wound and Disease Management Program, St James Hospital and Healthcare Centers, Olympia Fields Campus, Olympia Fields, IL 60461, USA.
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Pasquarella C, Pitzurra O, Herren T, Poletti L, Savino A. Lack of influence of body exhaust gowns on aerobic bacterial surface counts in a mixed-ventilation operating theatre. A study of 62 hip arthroplasties. J Hosp Infect 2003; 54:2-9. [PMID: 12767840 DOI: 10.1016/s0195-6701(03)00077-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aerobic bacterial surface contamination was studied with and without the use of body exhaust gowns in an operating room equipped with mixed/turbulent ventilation and separate operating and anaesthetic areas during 62 hip joint arthroplasties. In 31 operations conventional gowns were used, and 31 were performed with body exhaust gowns. Bacterial surface contamination was monitored in the operating and anaesthetic area using 9 cm diameter settle plates (1+1) and nitrocellulose membranes (2+2) transferred after sampling to nutrient pads. Compared with conventional clothing, the use of body exhaust gowns did not significantly reduce the microbial contamination (P=0.1-0.7). On the settle plates 1 m from the patient 279+/-326 cfu/m(2)/h were observed with conventional clothing compared with 142+/-227 cfu/m(2)/h with body exhaust gowns. The first membrane located on the patient in the sterile area detected 250+/-590 cfu/m(2)/h with conventional clothing and 210+/-320 cfu/m(2)/h with exhaust gowns. For the second membrane on the floor, the counts were 1790+/-2700 and 1590+/-1590 cfu/m(2)/h. For all operations the settle plates yielded 210+/-287 cfu/m(2)/h in the operating area and 720+/-564 cfu/m(2)/h in the anaesthetic area (P=0.01). Compared with the membrane placed on the anaesthetic equipment the counts on the membrane placed on patient were also significantly lower (P=0.01) while the membranes placed on the floor in each area showed no difference in counts. In conclusion, compared with conventional clothing, the use of body exhaust gowns could not be proven to provide more protection against microbial contamination. The low number of colony forming units found in the operating area was similar to that expected from an ultraclean laminar airflow unit, although achieved with a cheaper and more energy saving system.
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Affiliation(s)
- C Pasquarella
- Department of Public Health, University of Parma, Via Volturno, 39, Parma 43100, Italy.
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29
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30
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Abstract
Sepsis after total joint replacement is related directly to environmental contamination. Therefore, to control the source of environmental contamination, and ultimately sepsis, it must be realized that the operating room personnel are the major source of the bacteria as evidence by the rise in the colony forming units per square foot per hour from 13 units in an operating room without people to greater than 400 units during actual surgery. The use of inclusive gowns, such as hooded body exhaust, is most helpful. However, all operating room personnel including anesthesia personnel, circulating nurses, visitors, and the operating room team must wear inclusive gowns. Face masks and head covers offer no environmental protection. Some type of an environmental control, such as laminar airflow or ultraviolet light, is the most helpful with greater than 90% reduction of airborne bacteria at the wound and 60% reduction of airborne bacteria in the operating room. Therefore, to reduce environmental bacteria contamination the number of personnel in the operating room and the length of time for the actual surgery should be reduced, because wound contamination occurs first by direct fall out from the environment and second by contaminated equipment and gloved hands that initially were contaminated by the environment.
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Affiliation(s)
- M A Ritter
- Center for Hip and Knee Surgery, Kendrick Memorial Hospital, Mooresville, IN 46158, USA
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Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999. [PMID: 10196487 DOI: 10.1016/s0196-6553(99)70088-x] [Citation(s) in RCA: 1942] [Impact Index Per Article: 77.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
EXECUTIVE SUMMARY The "Guideline for Prevention of Surgical Site Infection, 1999" presents the Centers for Disease Control and Prevention (CDC)'s recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.1,2 Part I, "Surgical Site Infection: An Overview," describes the epidemiology, definitions, microbiology, pathogenesis, and surveillance of SSIs. Included is a detailed discussion of the pre-, intra-, and postoperative issues relevant to SSI genesis. Part II, "Recommendations for Prevention of Surgical Site Infection," represents the consensus of the Hospital Infection Control Practices Advisory Committee (HICPAC) regarding strategies for the prevention of SSIs.3 Whenever possible, the recommendations in Part II are based on data from well-designed scientific studies. However, there are a limited number of studies that clearly validate risk factors and prevention measures for SSI. By necessity, available studies have often been conducted in narrowly defined patient populations or for specific kinds of operations, making generalization of their findings to all specialties and types of operations potentially problematic. This is especially true regarding the implementation of SSI prevention measures. Finally, some of the infection control practices routinely used by surgical teams cannot be rigorously studied for ethical or logistical reasons (e.g., wearing vs not wearing gloves). Thus, some of the recommendations in Part II are based on a strong theoretical rationale and suggestive evidence in the absence of confirmatory scientific knowledge.It has been estimated that approximately 75% of all operations in the United States will be performed in "ambulatory," "same-day," or "outpatient" operating rooms by the turn of the century.4 In recommending various SSI prevention methods, this document makes no distinction between surgical care delivered in such settings and that provided in conventional inpatient operating rooms. This document is primarily intended for use by surgeons, operating room nurses, postoperative inpatient and clinic nurses, infection control professionals, anesthesiologists, healthcare epidemiologists, and other personnel directly responsible for the prevention of nosocomial infections. This document does not: Specifically address issues unique to burns, trauma, transplant procedures, or transmission of bloodborne pathogens from healthcare worker to patient, nor does it specifically address details of SSI prevention in pediatric surgical practice. It has been recently shown in a multicenter study of pediatric surgical patients that characteristics related to the operations are more important than those related to the physiologic status of the patients.5 In general, all SSI prevention measures effective in adult surgical care are indicated in pediatric surgical care. Specifically address procedures performed outside of the operating room (e.g., endoscopic procedures), nor does it provide guidance for infection prevention for invasive procedures such as cardiac catheterization or interventional radiology. Nonetheless, it is likely that many SSI prevention strategies also could be applied or adapted to reduce infectious complications associated with these procedures. Specifically recommend SSI prevention methods unique to minimally invasive operations (i.e., laparoscopic surgery). Available SSI surveillance data indicate that laparoscopic operations generally have a lower or comparable SSI risk when contrasted to open operations.6-11 SSI prevention measures applicable in open operations (e.g., open cholecystectomy) are indicated for their laparoscopic counterparts (e.g., laparoscopic cholecystectomy). Recommend specific antiseptic agents for patient preoperative skin preparations or for healthcare worker hand/forearm antisepsis. Hospitals should choose from products recommended for these activitie
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Affiliation(s)
- A J Mangram
- Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Public Health Service, US Department of Health and Human Services, Atlanta, Georgia 30333, USA
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Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999; 20:250-78; quiz 279-80. [PMID: 10219875 DOI: 10.1086/501620] [Citation(s) in RCA: 2736] [Impact Index Per Article: 109.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The “Guideline for Prevention of Surgical Site Infection, 1999” presents the Centers for Disease Control and Prevention (CDC)'s recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.Part I, “Surgical Site Infection: An Overview,” describes the epidemiology, definitions, microbiology, pathogenesis, and surveillance of SSIs. Included is a detailed discussion of the pre-, intra-, and postoperative issues relevant to SSI genesis.
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Affiliation(s)
- A J Mangram
- Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Public Health Service, US Department of Health and Human Services, Atlanta, GA 30333, USA
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33
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Gosden PE, MacGowan AP, Bannister GC. Importance of air quality and related factors in the prevention of infection in orthopaedic implant surgery. J Hosp Infect 1998; 39:173-80. [PMID: 9699136 DOI: 10.1016/s0195-6701(98)90255-9] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Small numbers of organisms can cause orthopaedic implant infections, which give rise to a considerable degree of morbidity and also mortality. The periprosthetic infection rates have been shown to correlate with the number of airborne bacteria within 30 cm of the wound. This is influenced by factors such as the number of operating theatre personnel, their clothing and the type of ventilation system used. Guidance on routine bacteriological monitoring of ultraclean air theatres, based on the Department of Health document Health Technical Memorandum 2025, is discussed. Factors important in minimizing the number of postoperative implant infections such as the use of ultraclean air, ultraviolet radiation, different types of surgical clothing, prophylactic antibiotics and host-related factors are also discussed. The importance of proper scientific investigation into the effectiveness of practical preventative measures in the operating room is emphasized.
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Affiliation(s)
- P E Gosden
- Department of Medical Microbiology, Southmead Health Services NHS Trust, Westbury-on-Trym, Bristol, UK
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34
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Abstract
To minimize postoperative infections, ultraclean laminar airflow (LAF) units equipped with high-efficiency particulate air filters developed for electronic and aerospace technology have been adapted for ORs. Traditionally, the airflow was either vertical or horizontal and, to function properly, encompassed extra side walls inside the OR. Recently, new airstream technology has provided zoned down-flow units that provide an exponential airflow (i.e., resembling an upside-down trumpet mouth). The exponential airflow allows for omission of extra side walls, making them more versatile in clinical use. Each different type of LAF requires knowledge of airstream patterns and how OR team members need to dress and work to prevent contamination of the sterile air and the aseptic areas. This article discusses different LAF systems and related demands on OR clothing and behavior.
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Affiliation(s)
- B Friberg
- Department of Advanced Nursing, Umeå University, Sweden
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