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SARS-CoV-2, declared a pandemic in March 2020, is the current global health challenge. The global bioburden of this virus is increasing at a rapid pace. Many antiviral drugs and vaccines have been registered for clinical trials because of their inhibitory activity observed in vitro. Currently, five types of vaccines have successfully passed Phase IV clinical trial and are being administered in populations worldwide. A plethora of experimental designs have been proposed worldwide in order to find a safe and efficacious treatment option. Therefore, it is necessary to provide baseline data and information to clinicians and researchers so that they can review the current status of therapeutics and efficacy of already developed vaccines. This review article summarizes all therapeutic options that may help to combat SARS-CoV-2.

Background Cutibacterium acnes is a common pathogen associated with surgical site infection after shoulder surgery; current standard of care products are largely ineffective at reducing C acnes bacterial burden before surgery. The purpose of this systematic meta-analysis was to assess the efficacy of peroxide-containing solutions (PCS) in decreasing the C acnes burden on the shoulder. Methods This was a systematic review of all level I and II studies investigating the effect of peroxidase-containing products for skin preparation. We extracted data regarding demographics, treatment details and timing, study methodology, and culture positivity. Forest plots were used to determine the pooled efficacy of peroxide solutions versus control. Results Seven studies with 412 patients were eligible for inclusion. Notable heterogeneity was observed in the manner and timing of peroxide application. Two studies applied PCS at the time of surgery; four studies applied PCS in the 24- to 72-hour period leading up to culture acquisition. Compared with the placebo, peroxide significantly diminished C acnes culture positivity (Hazard Ratio 0.174, P = 0.009). When considering using peroxide-containing products in the period leading up to surgery or at the time of surgery, in addition to standard preparation, the addition of peroxide significantly diminished C acnes culture positivity (HR 0.467, P = 0.004). Owing to study heterogeneity, we could not make notable comparisons based on the timing or duration of benzoyl peroxides application. Conclusions Despite heterogeneity in study design, pooled results of high-quality data suggest that the addition of PCS can markedly reduce C acnes bioburden. This review was not able to identify the ideal regimen for the utilization of PCS for reduction of C acnes burden. Level of evidence Level II.

Sinopsis Antecedentes: Normalmente, las infecciones son tratadas con antimicrobianos (antibióticos, antisépticos, etc.). La resistencia antimicrobiana (AMR, por sus siglas en inglés) se ha convertido en una de las amenazas del siglo XXI más graves para la salud mundial. Las heridas pueden ser una fuente de infección al permitir la entrada libre de microorganismos dentro del cuerpo, incluyendo bacterias resistentes a antimicrobianos. El desarrollo de nuevos antimicrobianos (especialmente, antibióticos) no está siguiendo el ritmo de la evolución de microorganismos resistentes y de formas novedosas de abordar este problema con la urgencia que demanda. Una de estas iniciativas ha sido el desarrollo de programas de protección antimicrobiana (AMS, por sus siglas en inglés), que brindan capacitación a los trabajadores del área de la salud y controlan la prescripción, enfocándose en los antimicrobianos para reducir la probabilidad de que se produzca AMR. El uso de apósitos para herida que utilizan el aislamiento físico y el abordaje de retención, en vez de agentes antimicrobianos, para reducir la carga bacteriana ofrecen un abordaje novedoso para apoyar a los AMS. La fijación bacteriana por los apósitos y su retiro físico, en lugar de la muerte activa, minimiza su daño y, además, previene la liberación de endotoxinas dañinas. Objetivo: Resaltar los AMS para la promoción del uso correcto de antimicrobianos e investigar cómo los apósitos recubiertos con cloruro de dialquilcarbamilo (DACC) pueden ayudar a cubrir las metas de los AMS. Método: Se realizaron búsquedas en las bases de datos de revisiones sistemáticas, Medline, Cochrane y Google Scholar con el fin de identificar artículos publicados que describan los datos relacionados con los AMS, y el uso de una gran variedad de apósitos para heridas para la prevención y/o tratamiento de infecciones de la herida. La evidencia que respalda a los apósitos para heridas alternativos que pueden reducir la biocarga y prevenir y/o tratar la infección de heridas de forma tal que no maten ni dañen a los microorganismos (por ejemplo, fijándose activamente y retirando intactos a los microorganismos de las heridas) fue posteriormente revisada de forma oral. Conclusión: Algunos apósitos para heridas actúan a través de mecanismos que promueven la fijación y absorción física, aislamiento y retiro de microorganismos intactos de la base de la herida (por ejemplo, un apósito para heridas que utiliza la tecnología DACC para prevenir/reducir la infección). Esta es una herramienta valiosa que cumple con los requisitos del AMS (por ejemplo, reducción del uso de antimicrobianos en esquemas de tratamiento de heridas) al reducir la biocarga de la herida sin inducir/seleccionar bacterias resistentes.

A mainstay of personal protective equipment during the coronavirus disease 2019 pandemic is the N95 filtering facepiece respirator. N95 respirators are commonly used to protect healthcare workers from respiratory pathogens, including the novel coronavirus severe acute respiratory syndrome coronavirus 2, and are increasingly employed by other frontline workers and the general public. Under routine circumstances, these masks are disposable, single-use items, but extended use and reuse practices have been broadly enacted to alleviate critical supply shortages during the coronavirus disease 2019 pandemic. Although extended-time single use presents a low risk of pathogen transfer, repeated donning and doffing of potentially contaminated masks presents increased risk of pathogen transfer. Therefore, efficient and safe decontamination methods for N95 masks are needed to reduce the risk of reuse and mitigate local supply shortages. Here, we review the available literature concerning use of germicidal ultraviolet-C (UV-C) light to decontaminate N95 masks. We propose a practical method for repeated point-of-use decontamination using commercially available UV-C cross-linker boxes from molecular biology laboratories to expose each side of the mask to 800-1200 mJ/cm2 of UV-C. We measure the dose that penetrated to the interior of the respirators and model the potential germicidal action on coronaviruses. Our experimental results, in combination with modeled data, suggest that such a UV-C treatment cycle should induce a >3-log-order reduction in viral bioburden on the surface of the respirators and a 2-log-order reduction throughout the interior. We find that a dose 50-fold greater does not impair filtration or fit of 3M 8210 N95 masks, indicating that decontamination can be performed repeatedly. As such, UV-C germicidal irradiation is a practical strategy for small-scale point-of-use decontamination of N95s.

This review focuses on techniques for reconstructing soft tissue injuries in host nationals that can be performed by non-plastic surgeons in a deployed environment. Advances in wound care technology and techniques have created opportunities to bring world-class care to injured host nationals. Negative pressure wound therapy with instillation can reduce bacterial bioburden, decrease the number of operative debridements, and decrease time to wound closure, saving scarce resources in a deployed setting. Perforator-based pedicle flaps can be utilized to cover large soft tissue defects with minimal donor site morbidity and excellent flap survival. Targeted muscle reinnervation can be performed at the time of an amputation to decrease chronic neuropathic pain. Techniques from simple to complex can be learned and successfully performed by the general, trauma, and orthopedic surgeons in austere locations in order to effectively leverage limited resources for the best outcomes for host nationals.

As part of an infection management protocol, antimicrobial dressings offer an appropriate, cost‐effective choice for the management of localised bioburden in chronic wounds. The choice of antimicrobial can impact significantly not only on the treatment outcomes and cost but also on the safety and well‐being of the patient. This retrospective study investigates these outcomes comparing health care records of 2572 patients with open chronic wounds, who were treated either with an Integrated Care Wound Bundle (ICB) including nanocrystalline silver (NCS) dressings (n = 330) or without NCS dressings and not on a ICB (n = 2242) in the community from March 2016 to March 2018. Wounds treated in the NCS dressing treatment bundle had a mean healing time of 10.46 weeks, vs 25.49 weeks for the non‐ICB treated wounds. In addition, the average interval time between dressing changes was in favour of the NCS dressing treatment bundle (3.98 vs 1.87 days), contributing to a substantial reduction in mean treatment labour costs ($1251 vs $6488). The use of a NCS dressing demonstrated improved efficacy and cost effectiveness of labour required for chronic wound management; highlighting the importance of choosing an effective antimicrobial dressing as part of an infection management protocol.

The aim of this study was to summarise the clinical evidence supporting almost 40 years of topical cadexomer iodine (CIOD) use in wound bed preparation by removing barriers to healing such as exudate, slough, bioburden, and infection and allowing chronic wound progression. A systematic review was conducted (Embase/PubMed, November 2020) to identify relevant comparative studies meeting inclusion criteria. Meta‐analyses were performed using a fixed‐effects (I 2

As a consequence of the preference for homologous tissues, bone banks are the primary source of bone and tendon grafts. However, the bacterial, viral, and fungal contamination of these grafts remains a considerable challenge in bone banks and often results in high rates of graft discarding and infections in patients. This study intended to investigate bacterial contamination in 509 bone grafts harvested from 110 multiorgan donors. Specimen collection included bone and soft tissue retrieved from culture-swabbing as well as bone and capsule for histopathology. Microbiological, histopathological, and radiographic analyses were carried out. Secondary sterilization was also conducted using cobalt 60 at the dose of 2.5 × 104 Gy. There were 106 multi-organ donors. Of the 506 grafts, there were 54 Hemi pelvis, 191 femur, 142 tibia, and 119 fibulae. The surface swab contamination rate for all the grafts retrieved was 16.6%, and bone culture from all the grafts was 6.1%. When we looked at the incidence of contamination according to the location than the surface swab contamination rate for hemipelvis was 18 (33.3%), femur 30 (15.7%), tibia 21(14.7%) and fibula 15 (12.6%). The bone cultures were hemipelvis 12 (22.2%) femur 8 (4.1%), tibia 5 (3.5%) and fibula 6 (5.04%). These findings suggest that separate harvesting of the grafts in reverse order may help prevent contamination. The study also recommends discarding all grafts contaminated even with low pathogenicity organisms. However, bioburden needs to be further investigated to be detected and reduced.

Introduction: Quantitative Microbiology involves measurement of an absolute quantity of bacteria per unit of volume. The threshold to distinguish colonisation from infection is 105 CFU/g. Quantitative cultures are used in predicting the risk of post operative infection. Aim: To determine the role of quantitative bacteriology as a predictor of risk of infection in patients with open fractures. Materials and Methods: One hundred patients who had sustained open fractures of long bones were included in the study. During debridement before antiseptic wash, a piece of tissue (muscle/skin) was collected under aseptic precautions for quantitative culture. A quantitative count of ? 104cfu/gm was interpreted as significant microbial burden. These patients were followed up for 6 weeks for development of clinical signs of infection and two swabs were collected by Levine’s technique for semiquantitative culture. Results: The preoperative culture of the debrided tissue of 41% yielded a microbial load of ?104 cfu/gram among which 85.3% had 105 cfu/gram of microbial load. Polymicrobial growth was reported in 12.2% of patients. Postoperatively 39% developed signs of infection Seventy one percent of patients with 105 cfu/gram of microbial load in the preoperative period developed postoperative infection. All patients with polymicrobial growth in the preoperative debridement cultures with ?104 cfu/gm of microbial load, developed infection in the postoperative period. Conclusion: Quantitative Microbiology plays a precise role in predicting the risk of infection as it is valuable in estimating the bacterial bioburden. Polymicrobal etiology can lead to clinical infection if not managed effectively. Keywords: Quantitative, Infection, Bioburden, Fracture, Debridement.

Background Infected wound reconstruction risks persistent infection and potential flap loss. Taking advantage of negative pressure wound therapy with instillation's ability to decrease bioburden, we introduce a novel paradigm “flap plus sub-flap irrigation” for treatment of infected lower extremity wounds. Methods This is a retrospective review of all patients over a 2-year period who underwent wound reconstruction with flap plus sub-flap irrigation. After flap inset, irrigation tubing is placed under the flap and foam sponge placed superficial to the flap edges, with pressure set to −100 mmHg. Fifty milliliters of 0.5% sodium hypochlorite solution instills every 4 h with 15 min of soak time. Sub-flap irrigation is discontinued post-operative day #5. Results Eight patients with mean age of 47 years and mean follow up time of 21 months were identified. Seven patients (88%) had multidrug resistant infections, six (75%) had polymicrobial infections, and five had exposed hardware (63%). Wound etiology was most commonly motor vehicle collision (50%). Flaps included free ALT, (38%), radial forearm (25%), and latissimus dorsi (25%), as well as pedicled rectus femoris (13%). There were no flap losses or persistent infections. Two patients had delayed wound healing, one treated with skin grafting and the other with flap advancement. Conclusion This series demonstrates successful treatment of high-risk infected wounds with flap plus sub-flap irrigation. This strategy may mitigate risk of persistent infection and flap loss. Larger studies and comparative studies are required to elucidate indications and assess relative benefits of this treatment paradigm.

Background: The degree of tissue damage caused by related inflammatory and immunological sequelae poses a major therapeutic treatment problem in burn wounds. Chronic wounds frequently have a significant bioburden and pathogens that are resistant to antibiotics. This review article discusses present research on phototherapy, which is believed to be useful in managing wound bioburden and promoting healing. Objective: To evaluate the wound healing efficacy of polarized light therapy (BLT) against low-level laser therapy (Ga-As laser) in order to determine which is more efficient and successful at speeding burn healing. Subject and methods: The current study enrolled thirty patients having partial thickness thermal burn on the forearm (dermal burn). They were selected from Burn Unit at Legislation Association Hospital for Burns & Oncology. They were randomly assigned into two equal groups: Group (A) that included fifteen patients who received the BLT with mean age of 28.8 ± 2.51 years old and group (B) that enrolled fifteen patients who received LLLT with mean age of 29.6 ± 2.79 years old. Both groups also received traditional physical therapy and conservative treatment for the burn site three times weekly for four weeks. Results: Group A and B showed a significant reduction in colony count and wound surface area after treatment in comparison to that before treatment (p > 0.001). In group A, the colony count and wound surface area decreased by 38.63% and 55.1% respectively, but in group B, by 15.6% and 37.92% respectively. Conclusion: Both polarized light therapy and low-level laser therapy had a therapeutic efficiency on wound healing, but BLT is more efficient and more successful in the acceleration of the burned wounds healing.

This review of the literature concerning bacteria, antibiotics and tissue repair shows there are extensive data supporting microbial interference with wound healing once bacterial burden exceeds 104 CFU per unit of measure, The mechanism of bacterial interference lies largely in prolonging the inflammatory phase of tissue repair. Reducing the microbial bioburden allows tissue repair to continue. Systemic and topical antimicrobials appear critical to reducing the bioburden and facilitating repair. The current controversy over the use of antimicrobials in patients with chronically infected wounds, in particular, revolves around the definition of infection. The reliance on classic clinical signs of inflammation to support antimicrobial use in these patients is tenuous due to the lack of correlation of these signs with the microbial burden known to impair tissue repair.

Background The degree to which daily intensive care unit (ICU) cleaning practices impacts bacterial burden is controversial. The study aimed to assess the utility of using adenosine triphosphate (ATP) bioluminescence assays for monitoring effectiveness of daily cleaning in ICU environments. Methods We sampled 364 total samples from 57 patient rooms and 18 common areas in 3 medical ICUs over 12 weeks, before and after routine daily cleaning. Endpoints were ATP levels (relative light units, RLU) and bacterial bioburden (colony forming units, CFU). Results High-touch surfaces in ICU patient rooms and common areas were contaminated before and after cleaning. Routine cleaning significantly reduced bacterial burden in patient rooms (0.14 log10 CFU reduction, P = .008; 0.21 log10 RLU reduction, P 20 CFUs, the proportion of sites with ATP readings >250 RLU was significantly higher than those with ATP readings ≤250 RLU (90.0% vs 10.0%, P Conclusion Routine cleaning significantly reduced bacterial burden on ICU environment surfaces. Although not an alternative to culture methods, ATP assays may be a useful technique to provide rapid feedback on surface cleanliness in ICU settings.

Presence of bacteria in wounds can delay healing. Addition of a regularly instilled topical solution over the wound during negative‐pressure wound therapy (NPWT) may reduce bioburden levels compared with standard NPWT alone. We performed a prospective, randomised, multi‐centre, post‐market trial to compare effects of NPWT with instillation and dwell of polyhexamethylene biguanide solution vs NPWT without instillation therapy in wounds requiring operative debridement. Results showed a significantly greater mean decrease in total bacterial counts from time of initial surgical debridement to first dressing change in NPWT plus instillation (n = 69) subjects compared with standard NPWT (n = 63) subjects (−0.18 vs 0.6 log10 CFU/g, respectively). There was no significant difference between the groups in the primary endpoint of required inpatient operating room debridements after initial debridement. Time to readiness for wound closure/coverage, proportion of wounds closed, and incidence of wound complications were similar. NPWT subjects had 3.1 times the risk of re‐hospitalisation compared with NPWT plus instillation subjects. This study provides a basis for exploring research options to understand the impact of NPWT with instillation on wound healing.

Study design A prospective multicenter study. Objective The objective of this study was to assess bacterial contamination in current practices of pedicle screw handling and comparing it to a novel method of using an intraoperative, sterile implant guard for screws. Summary of background data Postoperative infections occur at the higher end of 2%-13%, as cited in the literature, and are underestimated due to various reasons in such publications. Despite concerns associated with vancomycin application immediately before closure, it is theoretically impossible to irrigate the screw-bone interface postimplantation. Consequently, any contamination of pedicle screw before implantation is permanent, and has the potential to cause deep-bone infection, or hardware loosening due to encapsulation of biofilm between the bone and the screw. Therefore, continued vigilance and effective preventive measures should be undertaken if available. Materials and methods Two groups of presterile individually-packaged pedicle screws, one incased in a sterile, protective guard (group 1: G) and the other without such a guard (group 2: NG), 31 samples in each group were distributed over 28 spinal fusion surgeries at 5 independent hospitals groups. Each were loaded onto the insertion device by the scrub tech and left on the sterile table. Twenty minutes later, the lead surgeon who had just finished preparing the surgical site, handles the pedicle screw, to check the fit with the insertion device. Then, instead of implantation, it was transferred to a sterile container using fresh sterile gloves for bacterial analysis. Results The standard unguarded pedicle screws presented bioburden in the range of 10 to 10 colonies forming units per screw, whereas the guarded pedicle screws showed no bioburden. Conclusion Standard, current, handling of pedicle screws leads to bacterial contamination, which can be avoided if the screws are sterilely prepackaged with an intraoperative guard (preinstalled).

Deep infections following primary joint replacement cause great suffering to patients and have high treatment costs.1 In the general population, and especially in those that have recent contact with healthcare facilities, the bacteria Staphylococcus aureus often colonise the skin and the upper airways without causing disease. However, indolent in the skin, the same bacteria may cause devastating infection associated with implant devices and not least in orthopaedic surgery. There is extensive literature on specific measures aimed at reducing patients’ own bioburden with S. aureus before surgery summarised in the National Institute of Health and Care guidelines.2 3 Universal strategy is more cost-effective than a ‘screen and treat’ strategy.2 Use of triclosan-coated sutures is recommended by several major public health organisations.2 4 5 In contrast, we found one single publication describing the effect of prolonged decolonisation on the incidence of prosthetic joint infection (PJI) after surgery.6 However, there has been more attention towards postoperative factors on PJI.7 In an overall ‘zero harm’ healthcare improvement project at Drammen Hospital (DH) and Kongsberg Hospital (KH), part of the Vestre Viken Hospital Trust, we aimed to eliminate the incidence of PJI caused by S. aureus . Compliance with the decolonising protocol is a major issue for success. Hence, in this quality improvement project, we developed a highly standardised protocol for all patients admitted for acute (hip only) and planned surgeries (hip, knee, shoulder). The combined intervention included use of triclosan-coated sutures and patient decolonisation on the incidence of …

Objective: To clarify the role of microbiological swabs in surgical decision-making, we investigated the effect of negative-pressure wound therapy (NPWT) and serial surgical debridement on bacterial bioburden in hard-to-heal wounds and ultimately correlated them with the success of surgical closure. Method: All patients were treated with surgical debridement, jet lavage and NPWT before their wounds were finally closed. The treatment effect was assessed by correlating microbiological swabs obtained immediately after intervention with those obtained after removal of the dressings during the following surgical procedures. The result of the last microbiological swab taken before definitive surgical closure was correlated with the requirement for revision surgery. Results: We included the results of 704 microbiological swabs from 97 patients in 110 wound localisations in this monocentric, retrospective study. NPWT did not improve bacterial bioburden in 77% of cases and the duration of NPWT did not affect the result. Furthermore, no significant effect of NPWT could be found for either anaerobic (p=0.96) or aerobic bacteria (p=0.43). In contrast, surgical debridement increased bacterial load in approximately 60% of cases. If sterile wound swabs could be obtained at all, it was during the first four surgical debridements in 60% of patients; after that only 10% became sterile. Conclusions: Sterile microbiological wound swabs before surgical closure were associated with lower rates of revision surgery, while low or medium bacterial loads did not increase revision rates.

Objective:To investigate the frequency of environmental contamination in hospital areas outside patient rooms and in outpatient healthcare facilities.Design:Culture survey.Setting:This study was conducted across 4 hospitals, 4 outpatient clinics, and 1 surgery center.Methods:We conducted 3 point-prevalence culture surveys for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, Clostridioides difficile, Candida spp, and gram-negative bacilli including Enterobacteriaceae, Pseudomonas aeruginosa, Acinetobacter baumanii, and Stenotrophomonas maltophilia in each facility. In hospitals, high-touch surfaces were sampled from radiology, physical therapy, and mobile equipment and in emergency departments, waiting rooms, clinics, and endoscopy facilities. In outpatient facilities, surfaces were sampled in exam rooms including patient and provider areas, patient bathrooms, and waiting rooms and from portable equipment. Fluorescent markers were placed on high-touch surfaces and removal was assessed 1 day later.Results:In the hospitals, 110 (9.4%) of 1,195 sites were positive for 1 or more bacterial pathogens (range, 5.3%–13.7% for the 4 hospitals) and 70 (5.9%) were positive for Candida spp (range, 3.7%–5.9%). In outpatient facilities, 31 of 485 (6.4%) sites were positive for 1 or more bacterial pathogens (range, 2% to 14.4% for the 5 outpatient facilities) and 50 (10.3%) were positive for Candida spp (range, 3.9%–23.3%). Fluorescent markers had been removed from 33% of sites in hospitals (range, 28.4%–39.7%) and 46.3% of sites in outpatient clinics (range, 7.4%–82.8%).Conclusions:Surfaces in hospitals outside patient rooms and in outpatient facilities are frequently contaminated with healthcare-associated pathogens. Improvements in cleaning and disinfection practices are needed to reduce contamination.

Introduction: Wound healing is characterised by haemostatic, inflammatory, proliferative and remodelling phases. In the presence of comorbidities such as diabetes, healing can stall and chronic wounds may result. Infection is detrimental to these wounds and associated with poor outcomes. Wounds are contaminated with microbes and debris, and factors such as host resistance, bacterial virulence, species synergy and bioburden determine whether a wound will deteriorate to critically colonised/infected states. Biofilms are sessile microbial communities, exhibiting high-level antibiotic tolerance and resistance to host defences. Biofilm in critically colonised wounds can contribute to delayed healing. Little is known about clinical presentation and diagnosis of wound biofilms. Objective: To identify from the literature clinical signs, symptoms and biomarkers that may indicate biofilm in chronic wounds. Methods: This review will be guided by the Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews (PRISMA-ScR), and the Joanna Briggs Institute Manual for Evidence Synthesis. Studies of any design in any language recruiting adult patients with venous, diabetic, pressure or mixed arterial-venous ulcers and reporting data on clinical signs/symptoms of biofilm are eligible. Searches of Medline, Embase, CINAHL, Cochrane Central, Scopus, Web of Science, Google scholar and BASE will be conducted from inception to present. Reference scanning and contact with content experts will be employed. Title/abstract screening and full text selection will be executed by two reviewers independently. Discrepancies will be resolved by discussion between reviewers or through third party intervention. Data will be extracted by a single reviewer and verified by a second. Clinical signs and symptoms data will be presented in terms of study design, setting and participant demographic data. Discussion: Understanding biofilm impact on chronic wounds is inconsistent and based largely on in vitro research. This work will consolidate clinical signs, symptoms and biomarkers of biofilm in chronic wounds reported in the literature.

The validation of a radiation sterilization dose involves an initial sterilization dose determination as well as maintenance of that sterilization dose. The procedures for maintenance of the sterilization dose typically include the periodic use of two types of tests: bioburden and dose audits. The details for the procedures are outlined in the ISO radiation sterilization standards. These documents also provide guidelines for recommended actions in response to the results of the two tests. The results for the dose audit are based on the number of positive tests of sterility (TOS) for products that have been irradiated at a verification or experimental dose. When the dose audit yields TOS positives, it is often thought that they indicate a sterilization failure and nonsterile product. The belief that any TOS positive is a failure is an incorrect assumption because of the statistical basis used for the determination of the sterilization dose. This article will outline the truth of what dose audit TOS positives mean in terms of the sterility assurance of product, as well as the consequences of TOS positives.

BACKGROUND The purpose of this study was to compare the efficacy of blue light therapy (BLT) and 5% topical benzoyl peroxide (BPO) gel in combination with standard chlorhexidine (CHX) preparation in eradicating Cutibacterium acnes at the deltopectoral interval measured by positive, quantitative culture findings. METHODS Adult male volunteers were randomized to 1 of 3 treatment groups: BPO, BLT, and BPO followed by BLT. Contralateral shoulders served as matched controls. Volunteers randomized to BPO applied the gel for a total of 5 treatments. In the BLT group, a single 23-minute treatment was administered at an estimated irradiance of 40 mW/cm2 (radiant exposure, 55.2 J/cm2). In the BPO-BLT group, volunteers received both treatments as described earlier. After treatment with either BPO, BLT, or both, a single swab culture was taken from the treatment shoulder. Next, control and treatment shoulders were prepared with CHX, and cultures were taken from each shoulder. Cultures were sent for anaerobic quantitative growth analysis with both polymerase chain reaction and Sanger sequencing confirmation of presumptive C acnes colonies. RESULTS This study enrolled 60 male volunteers, 20 per group, with no loss to follow-up. After treatment but prior to CHX administration, all culture samples in the BPO group and BLT group grew C acnes. Prior to CHX, 16 samples (80%) in the BPO-BLT group grew C acnes. On quantitative analysis, the BPO group and BPO-BLT group had significantly less growth of C acnes compared with the BLT group after treatment but prior to CHX (P < .05 for each). Following CHX administration, the BPO and BPO-BLT groups had significantly fewer positive culture findings (odds ratios of 0.03 and 0.29, respectively) and less quantity of growth compared with their control arms (P < .05). This was not seen in the BLT group. For quantitative between-group analysis, no significant synergistic effects were seen with BPO-BLT compared with BPO alone (P = .688). There was no difference in side effects between groups. CONCLUSION The combination of topical BPO and CHX was effective at eliminating C acnes in most cases. BLT alone did not demonstrate effective antimicrobial properties against C acnes at the radiant exposure administered in this study. Combining BPO and BLT did not lead to significant synergistic antimicrobial effects. Both BPO and BLT are safe with few, transient side effects reported. More work is needed to determine whether BLT at higher radiant exposures or serial treatment results in bactericidal effects against C acnes in vivo.

Chronic wounds affect roughly 6.5 million patients in the US annually. Current standard of therapy entails weekly sharp debridement. However, the sharp technique is associated with significant pain, while having minimal impact on the bioburden. Our study proposes the Er:YAG laser as an alternative method of debridement that may decrease procedural pain, reduce bioburden, and potentially improve overall healing. This pilot study was performed as a prospective, randomized, controlled, crossover clinical trial, containing two groups: (1) one group underwent single laser debridement session first, followed by single sharp debridement session one week later; and (2) the other group underwent single sharp debridement session first, followed by single laser debridement session one week later. Variables analyzed included pain during debridement, pre- and post-debridement wound sizes, pre- and post-debridement bacterial loads and patient preference. Twenty-two patients were enrolled (12 patients in Group 1, plus 10 patients in Group 2). The mean pain score for patients undergoing laser debridement was 3.0 ± 1.7 vs. 4.8 ± 2.6 for those undergoing sharp debridement (p = 0.003). The mean percent change in wound size 1-week post-laser debridement was -20.8% ± 80.1%, as compared with -36.7% ± 54.3% 1-week post-sharp debridement (p = 0.6). The percentage of patients who had a bacterial load in the low/negative category increased from 27.3% to 59.1% immediately after laser debridement (p = 0.04), vs. 54.5% to 68.2% immediately after sharp debridement (p = 0.38). Moreover, there was a sustained decrease in bacterial load 1-week post-laser debridement, as compared with no sustained decrease 1-week post-sharp debridement (p < 0.02). Overall, 52.9% of patients preferred laser debridement vs. 35.3% for sharp debridement. We believe that Er:YAG laser serves as a promising technology in chronic wounds, functioning as a potentially superior alternative to sharp debridement, the current standard of therapy.

Surgical site infections (SSI) of the abdominal wall in renal transplant recipients can on occasion require management with negative pressure wound therapy (NPWT). This is often successful, with a low risk of further complications. However, we describe three cases in which persistent or recurrent surgical site sepsis occurred, whilst NPWT was being deployed in adults with either wound dehiscence or initial SSI. This type of complication in the setting of NPWT has not been previously described in renal transplant recipients. Our case series demonstrates that in immunosuppressed transplant recipients, there may be ineffective microbial or bacterial bioburden clearance associated with the NPWT, which can lead to further infections. Hence recognition for infections in renal transplant patients undergoing treatment with NPWT is vital; furthermore, aggressive management of sepsis control with early debridement, antimicrobial use, and reassessment of the use of wound dressing is necessary to reduce the morbidity associated with surgical site infections and NPWT.

The use of an antimicrobial dressing instead of a non-antimicrobial dressing may increase the number of diabetic foot ulcers healed over a medium-term follow-up period. The study aim was to evaluate the clinical and microbiological efficacy of a silver foam dressing in the management of diabetic foot ulcers. We conducted a single-center, prospective, open, noncontrolled study involving 21 outpatients with diabetic foot ulcers with mild infection. All patients received standard of care for their wounds and a silver foam dressing with silicone adhesive was applied twice per week for wound management during a 6-week treatment period. Soft tissue punch biopsies were taken every second week for qualitative and quantitative microbiological analysis. Wounds were assessed at patient admission, and wound bed tissue was evaluated for presence, quality, and consistency of granulation tissue. Clinical evaluation revealed improvements in wound conditions as a result of treatment with the silver dressing. Wollina wound scores improved significantly, from a mean score of 3.9 ± 1.6 points at inclusion to 6.1 ± 1.3 points at the end of the study (n = 19, P < .001). Treatment with the silver dressing resulted in significant decreases in the bioburden of classically considered diabetic foot ulcer pathogenic organisms such as Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus, Enterobacteriaceae species, Pseudomonas aeruginosa, and other nonfermenting gram-negative bacilli. Findings revealed that the use of silver foam dressing significantly reduced the pathogenic bacterial load and markedly improved the clinical outcome in patients with diabetic foot ulcer with mild infection over a 6-week treatment period.

Hospital associated infections (HAIs), infections acquired by patients during care in a hospital, remain a prevalent issue in the healthcare field. These infections often occur with the use of indwelling medical devices, such as endotracheal tubes (ETTs), that can result in ventilator-associated pneumonia (VAP). When examining the various routes of infection, VAP is associated with the highest incidence, rate of morbidity, and economic burden. Although ETTs are essential for the survival of patients requiring mechanical ventilation, their use comes with complications. The presence of an ETT in the airway impairs physiological host defense mechanisms for clearance of pathogens and provides a platform for oropharynx microorganism transport to the sterile tracheobronchial network. Antibiotics are administered to treat lower respiratory infections; however, they are not always effective and consequently can result in increased antibiotic resistance. Prophylactic approaches by altering the surface of ETTs to prevent the establishment and growth of bacteria have exhibited promising results. In addition, passive surface modifications that prevent bacterial establishment and growth, or active coatings that possess a bactericidal effect have also proven effective. In this review we aim to highlight the importance of preventing biofilm establishment on indwelling medical devices, focusing on ETTs. We will investigate successful antimicrobial modifications to ETTs and the future avenues that will ultimately decrease HAIs and improve patient care. STATEMENT OF SIGNIFICANCE: Infections that occur with indwelling medicals devices remain a constant concern in the medical field and can result in hospital-acquired infections. Specifically, ventilator associated pneumonia (VAP) occurs with the use of an endotracheal tube (ETT). Infections often require use of antibiotics and can result in patient mortality. Our review includes a summary of the recent collective work of antimicrobial ETT modifications and potential avenues for further investigations in an effort to reduce VAP associated with ETTs. Polymer modifications with antibacterial nature have been developed and tested; however, a focus on ETTs is lacking and clinical availability of new antimicrobial ETT devices is limited. Our collective work shows the successful and prospective applications to the surfaces of ETTs that can support researchers and physicians to create safer medical devices.

BACKGROUND Some nurse-driven interventions have successfully reduced rates of healthcare-associated infections, though incidence remains unacceptably high. Bacterial contamination in patient rooms may be a source of exposure for patients and thus a target for future interventions; however, few studies have investigated the role of the patient room on organism acquisition. OBJECTIVES The purpose of this study was to determine the incidence of concurrent detection of bacterial pathogens among patients sharing a hospital room. METHODS We performed a retrospective network analysis using electronic administrative and clinical data collected from all patients admitted in 2006 through 2012 to four New York City hospitals, totaling 2,065 beds within 183 inpatient units. A computerized algorithm identified concurrent organism detection among roommates, defined as two patients who shared a room on at least 1 day and had a first positive culture for the same organism within 3 days following cohabitation. RESULTS In total, 741,271 patient admissions were included. The algorithm identified 373 concurrent detection events: 158 (42%) in which the patients' first positive cultures were drawn after they were no longer sharing a room but within 3 days of cohabitation, 144 (39%) in which the patients' first positive cultures were drawn while they were still sharing a room but on different days, and 71 (19%) in which the patients' first positive cultures were drawn while they were sharing a room on the same day. DISCUSSION Methods to improve environmental decontamination should be included as part of a comprehensive approach to infection prevention in hospitals. Nurses have an important role to play in the planning and implementation of interventions to reduce bioburden in the patient environment.

Background Environmental disinfection with continuously antimicrobial surfaces could offer superior control of surface bioburden. We sought to decide the efficacy of photocatalyst antimicrobial coating in reducing methicillin-resistant Staphylococcus aureus (MRSA) acquisition in high incidence setting. Methods We performed prospective cohort study involving patients hospitalized in medical intensive care unit. A titanium dioxide-based photocatalyst was coated on high touch surfaces and walls. Five months of pre-intervention data were compared with five months of post-intervention data. The incidence rates of multidrug-resistant organism acquisition and the rates of hospital-acquired blood stream infection, pneumonia, urinary tract infection, and Clostridium difficile–associated diseases were compared using Cox proportional hazards regression analysis. Results In total, 621 patients were included. There was significant decrease in MRSA acquisition rate after photocatalyst coating (hazard ratio, 0.37; 95% confidence interval, 0.14–0.99; p = 0.04). However, clinical identification of vancomycin-resistant Enterococcus spp. and multidrug-resistant Acinetobacter baumannii did not decrease significantly. The hazard of contracting hospital-acquired pneumonia during the intervention period compared to baseline period was 0.46 (95% confidence interval, 0.23–0.94; p = 0.03). Conclusions In conclusion, MRSA rate was significantly reduced after photocatalyst coating. We provide evidence that photocatalyst disinfection can be an adjunctive measure to control MRSA acquisition in high-incidence settings. Trial registration ISRCTN Registry (ISRCTN31972004). Registered retrospectively on November 19, 2018. Electronic supplementary material The online version of this article (10.1186/s12879-018-3555-1) contains supplementary material, which is available to authorized users.

Periprosthetic joint infection is a leading cause for failure of contemporary total hip arthroplasty and total knee arthroplasty projected to nearly double in the next decade and reach an economic burden of $1.85 billion in the United Sates by 2030. Although multiple treatments for periprosthetic joint infection have been described, a thorough debridement and joint lavage to decrease bacterial bioburden and to remove biofilm remains a critical component of treatment. Various adjunct antiseptic agents such as chlorhexidine, povidone-iodine, hydrogen peroxide, acetic acid, and chlorine compounds are currently in off-label use in this capacity. Each antiseptic agent, however, has a distinct mechanism of action and targets different organisms, and some combinations of agents may lead to tissue toxicity. In this review, currently available adjunct antiseptic washes will be described in detail based on their mechanism of action and the evidence for their use will be reviewed. Furthermore, this review puts forward an evidence-based treatment algorithm based on the specific causative organism.

The purpose of wound dressing or cover is to provide moist environment, reduce bioburden, promote granulation and epithelisation, shorten duration of inflammatory response, be useful as primary wound dressing and to prevent nosocomial infection...

Summary To determine the variation in practices on meticillin-resistant Staphylococcus aureus (MRSA) surveillance and management of MRSA-colonized patients amongst 17 acute healthcare facilities in Singapore, the Ministry of Health convened a sharing session with Infection Prevention and Control Leads. All hospitals practised close to universal MRSA entry swabbing in keeping with national policy. There were, however, major variations in the response to both positive and negative surveillance swabs across facilities including the role of routine antiseptic bathing and MRSA decolonization. Most undertaking decolonization considered its role to be in ‘bioburden reduction’ rather than longer-term clearance.

Background Hospital acquired infections (HAI) are the most common complication found in the hospital environment. The aim of the study was to examine whether the use of an antimicrobial coating in high-touch areas in an orthopedic ward could reduce bacterial growth and HAI. Methods From December 2017 to February 2018, HAI were registered on two orthopedic wards. A second registration was performed from December 2018 to February 2019. On the second occasion, an antimicrobial organosilane coating was applied just before the study period and thereafter weekly on one ward, while the other ward served as a control. Twenty defined high-touch areas on each ward were cultured before treatment and after 1, 2, 4, 8, 12, 14 and 16 weeks. Samples were cultured for aerobic colony counts, Staphylococcus aureus and E. coli. Results The total aerobic colony counts were 47% lower on the treated ward compared with the non-treated ward over the study period (p = 0.02). The colony counts for Staphylococcus aureus and E. coli were low on both wards. During the first registration period, the incidence of HAI was 22.7% and 20.0% on the non-treated and subsequently treated ward respectively. On the second occasion, after treatment, the incidence was 25.0% and 12.5% (treated ward) respectively (p = 0.0001). Conclusions The use of a long-lasting antimicrobial organosilane coating appears to reduce the bioburden and reduce HAI. Since the incidence of HAI varies substantially over time, longer observation times are needed.

Endoscopy instruments are delicate, expensive and must be handled carefully at all times. Besides the operating doctor, the assistant surgeons, nursing personnel and other assistants must be aware of the functioning of all instruments, accessory devices and their proper dismantling, cleaning and maintenance to ensure longevity of the instruments. As these instruments are complexly built, they are more vulnerable to lodging of bioburden within their crevices. Improper sterilization of reusable instruments can predispose the patient to genital infections and in severe cases even pelvic inflammatory disease.

Cleansing provides an opportunity to remove pathogens from the wound bed, thereby preventing an increase in the bioburden and delayed healing. This article describes the reported efficacy of hypochlorous acid-containing wound cleansers

Background Environmental contamination is an important source of hospital multidrug-resistant organism (MDRO) transmission. Factors such as patient MDRO contact precautions (CP) status, patient proximity to surfaces, and unit type likely influence MDRO contamination and bacterial bioburden levels on patient room surfaces. Identifying factors associated with environmental contamination in patient rooms and on shared unit surfaces could help identify important environmental MDRO transmission routes. Methods Surfaces were sampled from MDRO CP and non-CP rooms, nursing stations, and mobile equipment in acute care, intensive care, and transplant units within 6 acute care hospitals using a convenience sampling approach blinded to cleaning events. Precaution rooms had patients with clinical or surveillance tests positive for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, carbapenem-resistant Enterobacteriaceae or Acinetobacter within the previous 6 months, or Clostridioides difficile toxin within the past 30 days. Rooms not meeting this definition were considered non-CP rooms. Samples were cultured for the above MDROs and total bioburden. Results Overall, an estimated 13% of rooms were contaminated with at least 1 MDRO. MDROs were detected more frequently in CP rooms (32% of 209 room-sample events) than non-CP rooms (12% of 234 room-sample events). Surface bioburden did not differ significantly between CP and non-CP rooms or MDRO-positive and MDRO-negative rooms. Conclusions CP room surfaces are contaminated more frequently than non-CP room surfaces; however, contamination of non-CP room surfaces is not uncommon and may be an important reservoir for ongoing MDRO transmission. MDRO contamination of non-CP rooms may indicate asymptomatic patient MDRO carriage, inadequate terminal cleaning, or cross-contamination of room surfaces via healthcare personnel hands.

Background Lower Clostridium difficile spore counts in feces from C difficile infection (CDI) patients treated with fidaxomicin versus vancomycin have been observed. We aimed to determine whether environmental contamination is lower in patients treated with fidaxomicin compared with those treated with vancomycin/metronidazole. Methods The CDI cases were recruited at 4 UK hospitals (Leeds, Bradford, and London [2 centers]). Environmental samples (5 room sites) were taken pretreatment and at 2–3, 4–5, 6–8, and 9–12 days of treatment, end of treatment (EOT), and post-EOT. Fecal samples were collected at diagnosis and as often as produced thereafter. Swabs/feces were cultured for C difficile; percentage of C difficile-positive samples and C difficile bioburden were compared between different treatment arms at each time point. Results Pre-EOT (n = 244), there was a significant reduction in environmental contamination (≥1 site positive) around fidaxomicin versus vancomycin/metronidazole recipients at days 4–5 (30% vs 50% recipients, P = .04) and at days 9–12 (22% vs 49%, P = .005). This trend was consistently seen at all other timepoints, but it was not statistically significant. No differences were seen between treatment groups post-EOT (n = 76). Fidaxomicin-associated fecal positivity rates and colony counts were consistently lower than those for vancomycin/metronidazole from days 4 to 5 of treatment (including post-EOT); however, the only significant difference was in positivity rate at days 9–12 (15% vs 55%, P = .03). Conclusions There were significant reductions in C difficile recovery from both feces and the environment around fidaxomicin versus vancomycin/metronidazole recipients. Therefore, fidaxomicin treatment may lower the C difficile transmission risk by reducing excretion and environmental contamination., Environmental contamination of the area around patients with Clostridium difficile infection treated with fidaxomicin may be reduced compared with those treated with vancomycin/metronidazole. This may be related to a reduced bioburden in the feces of fidaxomicin-treated patients.

Chronic wounds cause considerable morbidity and utilize significant health care resources. In addition to addressing wound etiology and treating infection, regular debridement is a key component of wound care with a proven ability to accelerate healing. In this regard, a significant innovation in wound care has been the development of ultrasound debridement technology. The purpose of this review is to evaluate the current evidence behind the technology with an emphasis on noncontact low-frequency (NCLF) ultrasound. A number of studies, especially those evaluating NCLF technology, have demonstrated the potential of ultrasound debridement to effectively remove devitalized tissue, control bioburden, alleviate pain, and expedite healing. However, most of the studies are underpowered, involve heterogeneous ulcer types, and demonstrate significant methodological limitations making comparison between studies difficult; there is a paucity of data on cost-effectiveness. Future clinical trials on ultrasound debridement technology must address the design issues prevalent in current studies, and report on clinically relevant endpoints before adoption into best-practice algorithms can be recommended.

Background Capsular contracture is a challenging problem for plastic surgeons despite advances in surgical technique. Breast pocket irrigation decreases bacterial bioburden. Studies have shown that hypochlorous acid (HOCl; PhaseOne Health, Nashville, TN) effectively penetrates and disrupts biofilms; however, there are limited clinical data regarding this irrigation in breast augmentation. Objectives The aim of this study was to investigate the effects of HOCl pocket irrigation in revision breast augmentation by evaluating rates of capsular contracture recurrence, infection, and allergic reactions. Methods We performed an institutional review board–approved retrospective chart review of revision breast augmentation cases for Baker grade III/IV capsular contractures in which pockets were irrigated with HOCl. Data were obtained from 3 board-certified plastic surgeons. Results The study included 135 breasts in 71 patients, who ranged in age from 27 to 77 years (mean, 53.7 years). Follow-up ranged from 12 to 41 months (mean, 20.2 months). Postoperatively, there were 2 unilateral Baker grade III/IV recurrences at 13 months and 1 bilateral Baker grade II recurrence at 3 months. There were no infections or allergic reactions. The overall Baker grade III/IV capsular contracture recurrence rate was 0% at 12 months and 1.5% at 15 months. Conclusions Breast pocket irrigation decreases bioburden, which may influence capsular contracture recurrence. We evaluated 3 varied applications of HOCl in revision aesthetic breast surgery and found a low capsular contracture recurrence rate and no adverse reactions. We plan to report our findings with HOCl in primary breast augmentation in the future, and other studies are being conducted on the efficacy of HOCl in aesthetic surgery. Level of Evidence: 4

Pandemic coronavirus disease-2019 (COVID-19) gives ample reason to generally review coronavirus (CoV) containment. For establishing some preliminary views on decontamination and disinfection, surrogate CoVs have commonly been assessed. This review serves to examine the existing science in regard to CoV containment generically and then to translate these findings into timely applications for COVID-19. There is widespread dissemination of CoVs in the immediate patient environment, and CoVs can potentially be spread via respiratory secretions, urine, and stool. Interpretations of the spread however must consider whether studies examine for viral RNA, virus viability by culture, or both. Presymptomatic, asymptomatic, and post-14 day virus excretion from patients may complicate the epidemiology. Whereas droplet spread is accepted, there continues to be controversy over the extent of possible airborne spread and especially now for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). CoVs are stable in body secretions and sewage at reduced temperatures. In addition to temperature, dryness or relative humidity, initial viral burden, concomitant presence of bioburden, and the type of surface can all affect stability. Generalizing, CoVs can be susceptible to radiation, temperature extremes, pH extremes, peroxides, halogens, aldehydes, many solvents, and several alcohols. Whereas detergent surfactants can have some direct activity, these agents are better used as complements to a complex disinfectant solution. Disinfectants with multiple agents and adverse pH are more likely to be best active at higher water temperatures. Real-life assessments should be encouraged with working dilutions. The use of decontamination and disinfection should be balanced with considerations of patient and caregiver safety. Processes should also be balanced with considerations for other potential pathogens that must be targeted. Given some CoV differences and given that surrogate testing provides experimental correlates at best, direct assessments with SARS-CoV, Middle East respiratory syndrome-related coronavirus (MERS-CoV), and SARS-CoV-2 are required.

Routine manual cleaning and disinfection of the health care environment is often suboptimal. Residual contamination poses an infection risk, particularly for immunocompromised patients. This study evaluates the efficacy of dry hydrogen peroxide (DHP) on microbial surface contamination in a pediatric oncology intensive care unit.Surface samples from 5 high-touch and 2 low-touch surfaces were obtained for culture and adenosine triphosphate readings after manual cleaning on multiple days in 4 intensive care unit rooms, before and after DHP was deployed. Air samples were collected as well at the study site. Data outcomes were measured in terms of total colony-forming units for the cultures and relative light units for adenosine triphosphate.The overall mean surface microbial burden was significantly reduced in the intervention group compared to the control group (mean 5.50 vs 11.77, P.001). These reductions in colony-forming units were seen across all sampling sites in the intervention group. A reduction in the mean relative light units levels was also noted in the intervention group when compared to the control group (172.08 vs 225.83, P.006). Reductions with the air samples were also noted (P = .139).Study demonstrates that DHP was effective in reducing microbial surface contamination and improves quality of environmental cleaning.

The assessment and control of microbial contamination in health care facilities is presently a mandatory and vital part of strategies to prevent and control hospital-acquired infections. This study aims to assess the bioburden with two passive sampling methods (30 ventilations grids swabs and 16 electrostatic dust collectors (EDCs)) at Clinical Pathology Services. The fungal burden was characterized through molecular tools, antifungal resistance, and the mycotoxins and cytotoxicity profile. Total bacteria presented the highest prevalence in both matrixes, whereas Gram-bacteria presented the lowest. Swabs presented a higher prevalence (27.6%) for fungal burden. Chrysonilia sitophila presented the highest prevalence in swabs, whereas for EDCs, C. sitophila and Mucor sp. were the most prevalent. Concerning Aspergillus genera on swabs, section Flavi was the one with the highest prevalence (58.02%), whereas, for EDCs, section Versicolores was the only section observed (100%). Aspergillus section Fumigati was detected in 10 swabs and 7 EDC samples and Aspergillus section Versicolores was detected in one EDC sample. Fungal growth on azole-supplemented media was observed in eight EDC samples. No mycotoxins were detected in any of the samples. A low cytotoxic effect was observed in two sites upon incubation of collected samples with A549 and SK cells and in two other sites upon incubation of collected samples with SK cells only. A medium cytotoxic effect was observed with one EDC sample upon incubation with A549 cells. This study reinforces the need of determination of the azole resistance profile for fungal species and allowed a preliminary risk characterization regarding the cytotoxicity. An intervention including the use of a ultraviolet with wavelength between 200 nm and 280 nm (UVC)&mdash, emitting device and an increased maintenance and cleaning of the central heating, ventilation, and air conditioning (HVAC) systems should be ensured to promote the reduction of microbial contamination.

We describe an evidence-based approach for optimization of infection control and operating room management during the coronavirus disease 2019 (COVID-19) pandemic. Confirmed modes of viral transmission are primarily, but not exclusively, contact with contaminated environmental surfaces and aerosolization. Evidence-based improvement strategies for attenuation of residual environmental contamination involve a combination of deep cleaning with surface disinfectants and ultraviolet light (UV-C). (1) Place alcohol-based hand rubs on the intravenous (IV) pole to the left of the provider. Double glove during induction. (2) Place a wire basket lined with a zip closure plastic bag on the IV pole to the right of the provider. Place all contaminated instruments in the bag (eg, laryngoscope blades and handles) and close. Designate and maintain clean and dirty areas. After induction of anesthesia, wipe down all equipment and surfaces with disinfection wipes that contain a quaternary ammonium compound and alcohol. Use a top-down cleaning sequence adequate to reduce bioburden. Treat operating rooms using UV-C. (3) Decolonize patients using preprocedural chlorhexidine wipes, 2 doses of nasal povidone-iodine within 1 hour of incision, and chlorhexidine mouth rinse. (4) Create a closed lumen IV system and use hub disinfection. (5) Provide data feedback by surveillance of Enterococcus, Staphylococcus aureus, Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter spp. (ESKAPE) transmission. (6) To reduce the use of surgical masks and to reduce potential COVID-19 exposure, use relatively long (eg, 12 hours) staff shifts. If there are 8 essential cases to be done (each lasting 1-2 hours), the ideal solution is to have 2 teams complete the 8 cases, not 8 first case starts. (7) Do 1 case in each operating room daily, with terminal cleaning after each case including UV-C or equivalent. (8) Do not have patients go into a large, pooled phase I postanesthesia care unit because of the risk of contaminating facility at large along with many staff. Instead, have most patients recover in the room where they had surgery as is done routinely in Japan. These 8 programmatic recommendations stand on a substantial body of empirical evidence characterizing the epidemiology of perioperative transmission and infection development made possible by support from the Anesthesia Patient Safety Foundation (APSF).

Distal limb wounds are common injuries sustained by horses and their healing is fraught with complications due to equine anatomy, prevalence of infection, and challenges associated with wound management. Gallium is a semi-metallic element that has been shown to possess antimicrobial properties and aid in wound healing in various preclinical models. The effects of Gallium have not been studied in equine wound healing. Therefore, the objective of this study was to compare healing rates between gallium-treated and untreated wounds of equine distal limbs and to demonstrate the antimicrobial effects of gallium on wounds inoculated with S. aureus. Using an established model of equine wound healing we demonstrated beneficial effects of 0.5% topical gallium maltolate on equine wound healing. Specifically we documented reduced healing times, reduced bioburden, and reduced formation of exuberant granulation tissue in wounds treated with gallium maltolate as compared with untreated wounds. Gallium appeared to exert its beneficial effects via its well-described antimicrobial actions as well as by altering the expression of specific genes known to be involved in wound healing of horses and other animals. Specifically, gallium maltolate appeared to increase expression of transforming growth factor-β in both infected and un-infected wounds. Further work is needed to document the effects of gallium on naturally occurring equine wounds and to compare the effects of gallium with other wound treatment options. These data, however, suggest that gallium may be an attractive and novel means of improving equine distal limb wound healing.

Staphylococcus aureus is a common cause of surgical site infection (SSI) in orthopedic surgery and causes significant morbidity as a complication of prosthetic joint procedures. Prevention of infections via presurgical staphylococcal decolonization protocols, methicillin-resistant Staphylococcus aureus (MRSA) screening, and preoperative antibiotic prophylaxis attempt to manipulate the microbiome to create low bioburden of Staphylococcus aureus perioperatively. There are variable protocols for decolonization, but most commonly 5 days of a combination of chlorhexidine bathing, mupirocin nasal ointment, and chlorhexidine mouthwash are used to decrease bioburden of Staphylococcus from skin surfaces, as well as known staphylococcal reservoirs: the oropharynx and nasal mucosa. MRSA screening informs presurgical antibiotic prophylaxis choice; MRSA-colonized patients should receive standard cefazolin along with vancomycin to prevent MRSA SSI. Published evidence suggests that these interventions can significantly decrease the rates of staphylococcal SSIs in patients undergoing orthopedic surgery.

Este artículo se encuentra disponible en la siguiente URL: https://www.thieme-connect.com/products/ejournals/pdf/10.1055/s-0040-1701541.pdf Objective The purpose of this research was to investigate the effect per se of two shaping and cleaning techniques on the reduction of an in vitro multispecies biofilm. Materials and Methods A total of 39 freshly extracted monoradicular teeth for periodontal reason were decoronated. Roots were sectioned longitudinally. After autoclaving, a specific stressed biofilm was grown on the root halves that were subsequently reassembled in a silicone index. Two treatments (n = 9 each)—RaCe (Schottlander; Letchworth Garden City, United Kingdom) and ProTaper Gold (PTG; Dentsply Maillefer, Baillagues, Switzerland)—were tested; three noninstrumented samples served as a control group and three were rinsed with saline. Posttreatment samples were taken at three different levels of the root. Colony-forming units were counted after incubations. Additionally, three treatments (n = 5 each)—RaCe, PTG, and saline only—were evaluated under a confocal laser scanning microscope (CLSM). Statistical Analysis Statistical analysis was conducted using Tukey’s test and analysis of variance to evaluate the post-instrumentation bioburden. Results Both instrumentations were able to reduce the biofilm; however, differences were not present between them (p > 0.05). CLSM showed biofilm killing and disruption through mechanical shaping alone. Conclusions Intraradicular biofilm is reduced with mechanical shaping. There was no difference between RaCe and PTG systems in biofilm reduction despite differences in design, file sequence, and rotational speed.

The use of atmospheric low-temperature plasma (AP) on chronic wounds and its effect on microbial bioburden in open wounds has not been explored with a systematic review and meta-analysis. PRISMA guidelines were followed and PubMed, Embase, CENTRAL, and CINAHL databases searched for randomised controlled trials (RCTs), which compared AP with no AP for the management of open, chronic wounds. The primary outcomes of reduction of bioburden or wound size were included. Meta-analyses were performed; odds ratio (OR) and 95% confidence intervals (CIs) were extracted and pooled in a random effects model. Four RCTs investigated the effect of AP on chronic wound healing. Chronic wounds treated with AP did not show a significant improvement in healing (AP vs control: OR = 1.46; 95% CI = 0.89-2.38; P = 0.13). Five further RCTs investigated the reduction of bioburden in wounds, but AP demonstrated no significant reduction of bioburden (AP vs control: OR = 0.85; 95% CI = 0.45-1.62; P = 0.63). All nine RCTs recorded the presence of any severe adverse events (SAEs) in the 268 patients studied, with only one unrelated SAE identified in each group (AP vs control: OR = 1.00; 95% CI = 0.05-19.96; P = 1.00). Use of AP in wound care is safe, but the retrieved evidence and meta-analysis show that there is no clinical benefit of AP in chronic open wounds using currently available AP device settings.

The characteristic clinical signs of chronic wounds, which remain in a state of prolonged inflammation, include increased production of devitalised tissue and exudate, pain and malodour. The presence of necrotic tissue, slough and copious exudate encourages microbial proliferation, potentially resulting in planktonic and/or biofilm infection. For patients, the consequences can include leakage of exudate, pain and reduced mobility, which can impair their ability to socialise and perform activities of daily living. This can severely reduce their quality of life and wellbeing. Concentrated surfactant-based gels (Plurogel and Plurogel SSD) are used in wound cleansing to help manage devitalised tissue. In vitro studies indicate they can sequester planktonic microbes and biofilm from the wound bed, although there is, limited clinical evidence to support this. A group of health professionals who have used this concentrated surfactant gel, in combination with standard care, in their clinical practice for several years recently met at a closed panel session. Here, they present case studies where topical application of these gels resulted in positive clinical outcomes in previously long-standing recalcitrant wounds. In all cases, the reduction in inflammation and bioburden alleviated symptoms that previously severely impaired health-related quality of life and wellbeing.

Background A 2015 study matching use of disposable and reusable sharps containers (DSCs, RSCs) with Clostridium difficile infection (CDI) incidence found a decreased incidence with DSCs. We conducted microbiologic samplings and examined the literature and disease-transmission principles to evaluate the scientific feasibility of such an association. Methods (i) 197 RSCs were sampled for C. difficile at processing facilities; (ii) RSCs were challenged with high C. difficile densities to evaluate efficacy of automated decontamination; and (iii) 50 RSCs and 50 DSCs were sampled in CDI patient rooms in 7 hospitals. Results were coupled with epidemiologic studies, clinical requirements, and chain-of-infection principles, and tests of evidence of disease transmission were applied. Results C. difficile spores were found on 9 of 197 (4.6%) RSCs prior to processing. Processing completely removed C. difficile. In CDI patient rooms, 4 of 50 RSCs (8.0%) and 8 of 50 DSCs (16.0%) had sub-infective counts of C. difficile (P = .27). DSCs were in permanent wall cabinets; RSCs were removed and decontaminated frequently. Conclusion With C. difficile bioburden being sub-infective on both DSCs and RSCs, sharps containers being no-touch, and glove removal required after sharps disposal, we found 2 links in the chain of infection to be broken and 5 of 7 tests of evidence to be unmet. We conclude that sharps containers pose no risk of C. difficile transmission.

PURPOSE To elucidate the bioburden of a lens care system in patients with contact lens (CL)-related keratitis. METHODS In this prospective case-control study, the CL storage case was used as the target of bioburden assessment. Participants were CL wearers with (n = 26) or without (n = 24) keratitis in southern Taiwan. The case fluid sample was consecutively collected and assessed using a dot hybridization assay (DHA) for bioburden assessment. The DHA was composed of 3 universal bacterial probes for detecting all bacteria, genus-specific probes for Pseudomonas and Acinetobacter, and 1 probe for Acanthamoeba. The receiver operating characteristic curve was used to analyze the differentiating performance of a probe. RESULTS The storage case bioburden was significantly higher in those with CL-related keratitis than in control subjects; patients with CL-related keratitis had stronger standardized signals in all universal bacterial probes. Moreover, in the cases of these patients, the bioburden was significantly heavier in confirmed infectious keratitis than in presumed noninfectious keratitis. Receiver operating characteristic analysis showed that stronger signals in all 3 universal bacterial probes and the Pseudomonas probe might suggest that the wearers have infectious keratitis. Only the storage case of the Acanthamoeba keratitis case showed positive detection by the Acanthamoeba probe. CONCLUSIONS A heavier bioburden in the lens storage case was associated with a higher risk of CL-related keratitis and infectious keratitis. Inappropriate maintenance of the CL will lead to microbial contamination and transfer the pathogen onto the ocular surface causing keratitis accordingly. The DHA assessment for the lens storage case might provide an alternative way to differentiate infectious from noninfectious CL-related keratitis.

OBJECTIVE: Critical colonization or local infection is very common in chronic wounds, but clinically problematic. Because therapeutic options for these conditions are limited in number and efficacy, the study authors tested a new acid-oxidizing solution (AOS [Nexodyn]; APR Applied Pharma Research S.A., Balerna, Switzerland) to determine its ancillary antimicrobial properties and potential support for wound healing. DESIGN AND SETTING: This open-label clinical case series was conducted with a prospective, single-arm design at the Federal County Hospital in Bregenz, Austria. PATIENTS: In the study, 30 patients with critically colonized or locally infected chronic leg ulcers of any origin were included. INTERVENTIONS: The AOS was applied on each leg ulcer at every dressing change for 35 days. MAIN OUTCOME MEASURES: The tolerability and performance of the AOS were assessed by evaluating the ulcer characteristics and comparing them with those at baseline. The clinical course of wounds was analyzed using standard measures for bioburden, local infection, pain, pH, and wound healing. MAIN RESULTS: Application of the solution was well tolerated, and no adverse events were recorded. In all patients, local infection was overcome, and wound bed pH and wound area decreased significantly. In addition, patient pain levels decreased to a level where interventions were not required after study day 7. In 37% of all patients, a complete resolution of chronic ulcers was achieved by the end of the study period. CONCLUSION: According to these results, the AOS seems to be a valid and highly tolerable treatment to support wound healing in locally infected ulcers. Nevertheless, larger controlled cohort studies are needed to substantiate these findings.

Background The early diagnosis of infection or sepsis in burns are important for patient care. Globally, a large number of burn centres advocate quantitative cultures of wound biopsies for patient management, since there is assumed to be a direct link between the bioburden of a burn wound and the risk of microbial invasion. Given the conflicting study findings in this area, a systematic review was warranted. Methods Bibliographic databases were searched with no language restrictions to August 2015. Study selection, data extraction and risk of bias assessment were performed in duplicate using pre-defined criteria. Substantial heterogeneity precluded quantitative synthesis, and findings were described narratively, sub-grouped by clinical question. Results Twenty six laboratory and/or clinical studies were included. Substantial heterogeneity hampered comparisons across studies and interpretation of findings. Limited evidence suggests that (i) more than one quantitative microbiology sample is required to obtain reliable estimates of bacterial load; (ii) biopsies are more sensitive than swabs in diagnosing or predicting sepsis; (iii) high bacterial loads may predict worse clinical outcomes, and (iv) both quantitative and semi-quantitative culture reports need to be interpreted with caution and in the context of other clinical risk factors. Conclusion The evidence base for the utility and reliability of quantitative microbiology for diagnosing or predicting clinical outcomes in burns patients is limited and often poorly reported. Consequently future research is warranted.