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Making a Difference in Perioperative Infection

Shafer, Steven L. MD

doi: 10.1213/ANE.0000000000000641
Editorials: Editorial

From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California.

Accepted for publication January 6, 2015.

Funding: None.

The author declares no conflicts of interest.

Reprints will not be available from the author.

Address correspondence to Steven L. Shafer, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Dr., MC-5640, Stanford, CA 94305. Address e-mail to

Last month I asserted that “anesthesiologists make a difference” was not a marketing slogan but a statement of fact.1 Some colleagues may think that our job is putting patients to sleep and waking them up. Only anesthesiologists who give lectures put people to sleep. We anesthetize patients, render them vulnerable, keep them alive during the surgical transgression, and subsequently awaken them from the anesthetized state. This daily miracle of anesthesia is only a small fraction of the difference we make in patient care. This issue of Anesthesia & Analgesia features a collection of papers that will make a difference in the rate of hospital-acquired infection.

Anesthesiologists are well positioned to make a difference in perioperative infection. We administer perioperative antibiotics. Our workplace is clean (we think) but outside of the sterile field. We have frequent contact with the patient’s skin and oral-nasal mucosa. Dr. Randy Loftus and his colleagues at the Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, have conducted seminal investigations in the operating room biome. Four of these papers appear in this issue of Anesthesia & Analgesia.

Loftus and colleagues2 examined the transmission of Staphylococcal aureus. They identified 2 S aureus phenotypes, 1 associated with transmission among patients or contaminated surfaces and 1 associated with transmission from provider hands. The patient phenotype of S aureus was more virulent, with a faster doubling time and increased antibiotic resistance. This isolate was associated with inpatient hospitalization before surgery. S aureus isolates from provider hands were substantially less virulent although still cause for concern. Although we need to wash our hands, the findings show that we also need to better clean the operating room to reduce infection risk. Loftus and colleagues3 have similar findings for the mode of transmission of Gram-negative organisms: most transmission occurs from contact with infected surfaces, not provider hands.

Loftus and colleagues4 performed a similar analysis for Enterococcus, an organism that has undergone iatrogenic evolution from a ubiquitous and generally harmless commensal gut bacterium to the second most frequent cause of hospital-acquired infection.5 Along the way, Enterococci have developed and widely shared multiple drug-resistant adaptations. Loftus and colleagues found that unlike S aureus, most transmission of Enterococcus to surgical patients appears to be from our hands. This is within our power to fix.

When it comes to hand washing, we may make a difference we don’t want to make. Loftus and colleagues surveyed anesthesiologists and found that we fail to recognize the need to wash our hands after contact with contaminated patients and environmental reservoirs.6 These findings need to be incorporated in the design of educational programs that teach the fundamentals of infection control.

Recognizing that we make a difference in perioperative infection, Hopf editorializes that “each anesthesia provider {should} take stock of her/his own intraoperative practices and commit to reducing within-patient and between-patient pathogen transmission through decontamination of patient bacterial reservoirs and reducing cross-contamination of provider hands, the anesthetic workspace, and IV access ports.”7 In their colorfully entitled “Fecal Patina in the Anesthesia Work Area” Munoz-Price and Weinstein discuss the spread of vancomycin-resistant enterococci and Gram-negative bacilli.8 The authors editorialize that we should “increase compliance with environmental disinfection of the operating room (between cases and terminal cleaning)” in addition to improved hand washing.

Dr. David Birnbach is another anesthesiologist interested in infection control and the perioperative biome. In this issue of Anesthesia & Analgesia, Birnbach and his colleagues9 from the University of Miami School of Medicine evaluate a novel fluorescent technology to identify contamination of the anesthesia workplace. In a high-fidelity human simulator, they searched the anesthesia workplace for traces of a fluorescent dye placed in the mouth and on the lips of a mannequin. After just a 6-minute simulation focused on intubation, the authors found dye contamination on 100% of the IV hubs, 60% of the door handles, and even on the “unused” computer keyboard. In a second study, Birnbach and colleagues10 used the same simulator to investigate whether the simple act of double gloving would reduce workplace contamination. It did. Double gloving reduced the number of contaminated workplace sites from 20 to 5.

In their accompanying editorial, Drs. Richard Prielipp and Sorin Brull note that double gloving before intubation, and removing the outer glove immediately following intubation, is analogous to surgeons changing their outer glove after draping the patient, a practice shown to reduce the incidence of surgical site infections.11 Accompanied by a sobering and vaguely disgusting table of oral flora (e.g., Propionibacter is associated with acne and is also used in cheese making), the editorial emphasizes changing our workplace routines to decrease contamination and improve patient safety.

Loftus, Koff, and Birnbach12 reviewed these and other papers on bacterial transmission in the anesthesia work area. They note that “bacterial transmission in the anesthesia work area of the operating room environment is a root cause of 30-day postoperative infections affecting as many as 16% of patients undergoing surgery.” In their view, the “evidence suggests that a multimodal approach targeting improvements in intraoperative hand hygiene, patient screening and decolonization, environmental decontamination, and improvements in intravascular handling and design may reduce the risk of postoperative infections.”

Dr. Nikolaus L. Gravenstein and his colleagues at the University of Florida College of Medicine are also working to understand our role in perioperative infection.13 Propofol supports bacterial growth.14,15 Gravenstein and colleagues collected stopcocks and extension tubing from 300 postoperative patients, half of whom received propofol as part of their anesthesia. They found similar rates of contamination 6 hours after surgery between the propofol and non–propofol-containing stopcocks. By 24 hours, the stopcocks from patients who had received propofol had >10 times the colony-forming units. By 48 hours, the stopcocks with propofol had >100 times the number of colony-forming units. As the authors note, this mandates a change in our standard of care. If propofol is used and the IV line is to remain in place, then we need to change the infusion sets, or at least the stopcocks, before patients leave the postanesthesia care unit.

Our making a difference extends beyond the operating room and postanesthesia care unit. Walz and colleagues16 from the Departments of Anesthesiology, Surgery, Infection Control, and Critical Care at the University of Massachusetts Medical School and UMass Memorial Medical Center looked at the efficacy of a “bundled approach” to central line placement in intensive care units. Their bundle included “hand hygiene, education of providers, chlorhexidine skin preparation, use of maximal barrier precautions, a dedicated line cart, checklist, avoidance of the femoral vein for catheter insertion, chlorhexidine-impregnated dressings, use of anti-infective catheters, and daily consideration of the need for the catheter.” They found an astonishing 92% reduction in central line–associated bloodstream infections with the use of this bundled approach.

With so much focus on environmental reservoirs for contamination, hand washing, and the use of double gloves, one might briefly forget our responsibility for timely and appropriate administration of perioperative antibiotics. Fortunately, Ronald Gordon of the U.S. Naval Hospital in San Diego provides a thorough review of the topic.17 Dr. Gordon assessed the clinical pharmacology, including basic pharmacokinetics and pharmacodynamics, that guide perioperative antibiotic delivery. He places our responsibility for antibiotics into the context of our overall responsibility for long-term patient outcome. In their accompanying editorial, Gravenstein and colleagues18 acknowledge the need for scientifically based antibiotic dosing. The authors call for anesthesiologists to investigate and implement novel approaches to improve perioperative antibiotic administration, including the use of continuous antibiotic infusions to maintain tissue antibiotic concentration throughout surgery.

The content of this issue of Anesthesia & Analgesia relates directly to the daily clinical practice of anesthesiologists. Hand washing, double gloving, and keeping a clean workplace are easy. Why wait? After reading this editorial, and the accompanying papers in this issue of Anesthesia & Analgesia, why not change your routine practice starting with your next patient? Quoting actor John Belushi (in a different context): “it don’t cost nothin.”a

Anesthesiologists can make a difference reducing hospital-acquired infection. We make a difference as investigators seeking to understand hospital-acquired infections. We make a difference as clinicians implementing best practices to reduce hospital-acquired infections. As emphasized previously,1 highlighting our role in making a difference in no way minimizes the contributions of our colleagues. Nearly all of these papers involve interdisciplinary research teams consisting of anesthesiologists, surgeons, hospitalists, nurses, and other health care professionals. We are all in this together, working to make a difference to our patients.

Anesthetizing patients and awakening them after surgery safely makes a difference. So does reducing hospital-acquired infections. That’s what we do.

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Dr. Steven L. Shafer is the Editor-in-Chief for Anesthesia & Analgesia. This manuscript was handled by Dr. James G. Bovill, Guest Editor-in-Chief, and Dr. Shafer was not involved in any way with the editorial process or decision.

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Name: Steven L. Shafer, MD.

Contribution: This author helped write the manuscript.

Attestation: Steven L. Shafer approved the final manuscript.

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a John Belushi, Animal House, 1978, directed by John Landis, released by Universal Pictures. Available at: Accessed January 5, 2015.
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1. Shafer SL. Anesthesiologists make a difference. Anesth Analg. 2015;120:497–8
2. Loftus RW, Koff MD, Brown JR, Patel HM, Jensen JT, Reddy S, Ruoff KL, Heard SO, Yeager MP, Dodds TM. The epidemiology of Staphylococcal aureus transmission in the anesthesia work area. Anesth Analg. 2015;120:807–18
3. Loftus RW, Brown JR, Patel HM, Koff MD, Jensen JT, Reddy S, Ruoff KL, Heard SO, Dodds TM, Beach ML, Yeager MP. Transmission dynamics of gram-negative bacterial pathogens in the anesthesia work area. Anesth Analg. 2015;120:819–26
4. Loftus RW, Koff MD, Brown JR, Patel HM, Jensen JT, Reddy S, Ruoff KL, Heard SO, Yeager MP, Dodds TM. The dynamics of Enterococcus transmission from bacterial reservoirs commonly encountered by anesthesia providers. Anesth Analg. 2015;120:827–36
5. Van Tyne D, Gilmore MS. Friend turned foe: evolution of enterococcal virulence and antibiotic resistance. Annu Rev Microbiol. 2014;68:337–56
6. Fernandez PG, Loftus RW, Dodds TM, Koff MD, Reddy S, Heard SO, Beach ML, Yeager MP, Brown JR. Hand hygiene knowledge and perceptions among anesthesia providers. Anesth Analg. 2015;120:837–43
7. Hopf HW. Bacterial reservoirs in the operating room. Anesth Analg. 2015;120:700–2
8. Munoz-Price LS, Weinstein RA. Fecal patina in the anesthesia work area. Anesth Analg. 2015;120:703–5
9. Birnbach DJ, Rosen LF, Fitzpatrick M, Carling P, Munoz-Price LS. The use of a novel technology to study dynamics of pathogen transmission in the operating room. Anesth Analg. 2015;120:844–7
10. Birnbach DJ, Rosen LF, Fitzpatrick M, Carling P, Arheart KL, Munoz-Price LS. Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room. Anesth Analg. 2015;120:848–52
11. Prielipp RC, Brull SJ. If one is good, are two always better? Anesth Analg. 2015;120:706–8
12. Loftus RW, Koff MD, Birnbach DJ. The dynamics and implications of bacterial transmission events arising from the anesthesia work area. Anesth Analg. 2015;120:853–60
13. Cole DC, Baslanti TO, Gravenstein NL, Gravenstein N. Leaving more than your fingerprint on the intravenous line: a prospective study on propofol anesthesia and implications of stopcock contamination. Anesth Analg. 2015;120:861–7
14. Thomas DV. Propofol supports bacterial growth. Br J Anaesth. 1991;66:274
15. Zacher AN, Zornow MH, Evans G. Drug contamination from opening glass ampules. Anesthesiology. 1991;75:893–5
16. Walz JM, Ellison RT III, Mack DA, Flaherty HM, McIlwaine JK, Whyte KG, Landry KE, Baker SP, Heard SOand the CCOC Research Group. and the CCOC Research Group. . The bundle “plus”: effect of a multidisciplinary team approach to eradicate central line-associated bloodstream infections. Anesth Analg. 2015;120:868–76
17. Gordon RJ. Administration of parenteral prophylactic beta-lactam antibiotics in 2014: a review. Anesth Analg. 2015;120:877–87
18. Gravenstein N, Fish JT, Klinker KP, Coursin DB. Prophylactic perioperative antibiotic administration: is it time to infuse our practices with new approaches? Anesth Analg. 2015;120:709–11
© 2015 International Anesthesia Research Society