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General anesthesia impairs thermoregulation and contributes to perioperative hypothermia; core body temperature monitoring is recommended during surgical procedures lasting > 30 min. Zero-heat-flux core body temperature measurement systems enable continuous non-invasive perioperative monitoring. During a previous trial evaluating the benefits of preoperative forced-air warming, intraoperative temperatures were measured with both a zero-heat-flux sensor and a standard naso-/oropharyngeal temperature probe. The aim of this secondary analysis is to evaluate their agreement. ASA I–III patients, scheduled for elective, non-cardiac surgery under general anesthesia, were enrolled. A zero-heat-flux sensor was placed on the participant’s forehead preoperatively. Following induction of anesthesia, a “clinical” temperature probe was placed in the nasopharynx or oropharynx at the anesthesiologist’s discretion. Temperature measurements from both sensors were recorded every 10 s. Agreement was analyzed using the Bland–Altman method, corrected for repeated measurements, and Lin’s concordance correlation coefficient, and compared with existing studies. Data were collected in 194 patients with a median (interquartile range) age of 60 (49–69) years, during surgical procedures lasting 120 (89–185) min. The zero-heat-flux measurements had a mean bias of − 0.05 °C (zero-heat-flux lower) with 95% limits of agreement within − 0.68 to + 0.58 °C. Lin’s concordance correlation coefficient was 0.823. The zero-heat-flux sensor demonstrated moderate agreement with the naso-/oropharyngeal temperature probe, which was not fully within the generally accepted ± 0.5 °C limit. This is consistent with previous studies. The zero-heat-flux system offers clinical utility for non-invasive and continuous core body temperature monitoring throughout the perioperative period using a single sensor.

The purpose of this study was to evaluate the effects of preoperative forced-air warming on intraoperative hypothermia. In this randomized-controlled trial, adult patients scheduled for elective, non-cardiac surgery under general anesthesia were stratified by scheduled surgical duration (< 2.5 hr or ≥ 2.5 hr) and then randomized to a pre-warming group using a BairPaws™ forced-air warming system for at least 30 min preoperatively or to a control group with warmed blankets on request. All patients were warmed intraoperatively via convective forced-air warming blankets. Perioperative temperature was measured using the SpotOn™ temperature system consisting of a single-use disposable sensor applied to the participant’s forehead. The primary outcome was the magnitude of intraoperative hypothermia calculated as the area under the time-temperature curve for core temperatures < 36°C between induction of general anesthesia and leaving the operating room. Secondary outcomes included surgical site infections, packed red blood cell requirements, and 24 hr postoperative opioid consumption. Two hundred participants were analyzed (101 control; 99 pre-warmed). Pre-warmed participants had a lower median [interquartile range] magnitude of hypothermia than controls (0.00 [0.00-0.12] °C·hr−1 vs 0.05 [0.00-0.36] °C·hr−1, respectively; median difference, −0.01°C·hr−1; 95% confidence interval, −0.04 to 0.00°C·hr−1; P = 0.005). There were no between-group differences in the secondary outcomes. A minimum of 30 min of preoperative forced-air convective warming decreased the overall intraoperative hypothermic exposure. While redistribution hypothermia still occurs despite pre- and intraoperative forced-air warming, their combined application results in greater preservation of intraoperative normothermia compared with intraoperative forced-air warming alone. www.clinicaltrials.gov (NCT02177903). Registered 25 June 2014.

Mupirocin decolonization of nasal Staphylococcus aureus prior to surgery decreases surgical-site infections; however, treatment requires 5 days, compliance is low, and resistance occurs. In 2010, 3M Company introduced povidone-iodine (PVP-I)-based skin and nasal antiseptic (Skin and Nasal Prep [SNP]). SNP has rapid, broad-spectrum antimicrobial activity. We tested SNP's efficacy using full-thickness tissue (porcine mucosal [PM] and human skin) explant models and human subjects. Prior to or following infection with methicillin-resistant Staphylococcus aureus (MRSA) (mupirocin sensitive and resistant), explants were treated with Betadine ophthalmic preparation (Bet), SNP, or mupirocin (Bactroban nasal ointment [BN]) or left untreated. One hour posttreatment, explants were washed with phosphate-buffered saline (PBS) plus 2% mucin. One, 6, or 12 h later, bacteria were recovered and enumerated. Alternatively, following baseline sampling, human subjects applied two consecutive applications of SNP or saline to their anterior nares. One, 6, and 12 h after application of the preparation (postprep), nasal swabs were obtained, and S. aureus was enumerated. We observed that treatment of infected PM or human skin explants with SNP resulted in >2.0 log 10 CFU reduction in MRSA, regardless of mupirocin sensitivity, which was significantly different from the values for BN- and Bet-treated explants and untreated controls 1 h, 6 h, and 12 h after being washed with PBS plus mucin. Swabbing the anterior nares of human subjects with SNP significantly reduced resident S. aureus compared to saline 1, 6, and 12 h postprep. Finally, pretreatment of PM explants with SNP, followed by a mucin rinse prior to infection, completely prevented MRSA infection. We conclude that SNP may be an attractive alternative for reducing the bioburden of anterior nares prior to surgery.

Background A major limitation to developing evidence-based approaches to infection prevention is the paucity of real-time, quantitative methods for monitoring the cleanliness of environmental surfaces in clinical settings. One solution that has been proposed is adenosine triphosphate (ATP) bioluminescence assays, but this method does not provide information about the source of the ATP. Materials/Methods To address this gap, we conducted a study in which ATP bioluminescence was coupled with traditional RODAC sampling and matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry to assess which organisms were viable and present. Using this mixed assessment approach, we evaluated cleaning of 5 different types of high-touch surfaces (overhead lights, door handles, anesthesia keyboards, mattresses, and side tables) in operating rooms. Results Whether surfaces tested cleaner after turnaround than they did before turnaround depended on the surface type. Before and after cleaning, flat, covered surfaces (mattresses and side tables) were more likely to pass as “clean” by ATP assay than uncovered, irregularly shaped surfaces (overhead lights, door handles, and anesthesia keyboards). Irregularly shaped surfaces were more likely to pass by RODAC assay than by ATP assay after cleaning. Conclusion Our results suggest that irregularly shaped surfaces in operating rooms may require enhanced covering, cleaning, and monitoring protocols compared to more regularly shaped surfaces.

Background This study aimed to demonstrate the value of adding an active level of a persistent antimicrobial agent, such as chlorhexidine gluconate (CHG), to an alcohol-based surgical hand antiseptic. Methods The persistence of 3 waterless, brushless alcohol-based surgical hand antiseptics, including one product containing CHG, was compared. The test products were applied a total of 12 times over 5 days. Samples of aerobic bacteria were collected on days 1 and 5, on both days immediately after drying and 6 hours later, using the glove juice technique. Relative suppression of regrowth was compared using t tests. Results Using an equivalence margin of 20%, the alcohol plus CHG product showed noninferiority to the alcohol-only products at all sampling points and, based on significantly lower bacterial regrowth ( P = .026), superior persistence to the alcohol-only products after 6 hours of glove wear. Conclusions Given the primary objective of surgical hand antisepsis of reducing resident skin flora for the duration of the surgical procedure, using an alcohol-based hand antiseptic containing CHG appears to be the most appropriate choice for maintaining microbial levels as low as possible for as long as possible.

Objective We describe a randomized blinded study to evaluate the antimicrobial persistence following saline exposure of 2 commercially available skin antiseptic agents. One agent contained iodine povacrylex in alcohol and the second contained chlorhexidine gluconate in alcohol. Method Both agents were applied to the forearms of 36 healthy subjects according to manufacturers' instructions and allowed to dry. The sites were then exposed to either a saline rinse or to a saline-saturated gauze, similar to the challenges that preps would face during most surgical procedures. Two analyses were performed: (1) An indicator organism was seeded onto the treated sites. After 30 minutes, samples were collected from the treated sites and surviving bacterial colonies were enumerated and log reductions calculated. (2) The saline-saturated gauze was analyzed chemically for presence of chlorhexidine or iodine. Results The baseline densities (stated as logarithms of colony forming units “log CFU”) of the sites to which the agents were applied had statistically equivalent microbial densities. Both agents reduced the density of organisms in a statistically significant manner. Chemical analysis of the gauze samples indicated that 35 of 36 samples had detectable chlorhexidine while no samples had detectable iodine (P Conclusion The results indicate that chlorhexidine is removed by saline-soaked gauze while the iodine povacrylex water-insoluble film remains intact under the same conditions. The implication is that similar results may occur in surgery when saline is used.

BACKGROUND: During the year 2012, the organization had the second highest incidence rate of HO-C-Diff in New York State. Best practices were in place for prevention of C-Diff including hand hygiene, contact precautions, hospital-wide disposable thermometer use, prolonged isolation, and bleach cleaning. The facility invested in a UV disinfection system in June 2013 to be used as an addition to the bundle of C-Diff prevention measures. METHODS: A cross sectional design study was conducted that included all inpatients in a 370 licensed bed acute care hospital. The baseline period was 7/1/2012 e 6/30/2013 where all bundle components were in place to prevent C-Diff and a comparison timeframe of 7/1/2013 e 6/30/2014 where all bundle components were in place and the addition of a UV disinfection protocol to the terminal room cleaning process was implemented. An algorithm was used to guide the environmental services department in selecting priority rooms for UV usage. Rooms with C-Diff patients were a top

Background/Objectives: The primary objective of this study was to demonstrate the feasibility of using an ATP bioluminescence assay to monitor the cleanliness of flexible endoscopes after the manual cleaning step of the decontamination and disinfection process. The data obtained from five hospital sites was used to define process control parameters for this step of the cleaning process. These control parameters could then be applied in an auditing fashion to monitor quality control and drive process improvement. Methods: Three types of flexible endoscopes were tested after manual cleaning at five different hospital sites using an ATP Water assay. The method entailed collecting and testing a water sample harvested from the suction/biopsy lumen using a swab-based ATP assay. The amount of ATP, in relative light units (RLUs), was measured with a luminometer. The data collected was used to define pass, caution, and fail values. Results: The figures below show the action limits (pass, caution and fail values) established by the type of scope tested, for each hospital site. Lower RLU values indicate lower contamination levels. Action limits vary by the type of scope being processed. Manual cleaning of colonoscopes resulted in significantly lower pass-caution-fail thresholds than gastroscopes and duodenoscopes. For example, comparing Figures 1, 2, and 3, for hospital site 1; we observe a pass value in RLUs of 140 for colonoscopes, 692 for gastroscopes, and 2,499 for duodenoscopes. Furthermore, action limits for duodenoscopes were significantly higher than the other two types of scopes. We also observed differences in the outcome of manual cleaning by hospital site. For example, referring to Figure 1, the pass value in RLUs for hospital sites 1-5 were 140, 429, 38, 133, and 71 respectively. Comparing the size of the caution ranges in each Figure gives an estimate of the variability for that sites cleaning process. Conclusions: Successful quality control using this method appears highly feasible. The higher pass-caution-fail thresholds observed

ISSUE: Probiotic use has become increasingly popular as a method to restoring normal flora of the gastrointestinal tract. Two hospitals within a large Midwestern health care system have perceived a potential risk of fungemia from Saccharomyces and bacteremia from Lactobacillus and Bifidobacterium in patients with a central venous catheter (CVC). In 2007, a large adult academic hospital (Hospital A) within the health care system removed probiotics (Saccharomyces, Lactobacillus, Bifidobacterium) from their formulary. In 2012, a large community hospital (Hospital B) investigated the removal of probiotics from their formulary as a means to prevent central line associated bloodstream infections (CLABSI). Currently, the infection prevention specialists (IPS) at Hospital B receive a list of patients who have been prescribed a probiotic; the list also identifies whether they or their roommate have a CVC. Physicians of patients with a CVC and on a probiotic are notified of the potential risks. Room assignments are changed so no patient receiving a probiotic shares a room with a patient with a CVC. A second large community hospital within the system (Hospital C) has no known probiotic control program. PROJECT: This project identified whether efforts of the IPS at Hospital B are justified to control fungemia and bacteremia in patients with a CVC. An investigation was done to evaluate the extent of the problem, which included a thorough literature review and an analysis of bloodstream infections caused by Saccharomyces, Lactobacillus and Bifidobacterium. RESULTS: The literature search concluded that CVCs are a possible risk factor for bacteremia and fungemia associated with probiotics. Between November 1, 2011 and October 31, 2012, Hospital A had 0 days of probiotic usage; Hospital B had 38 probiotic days/1,000 patient days; and Hospital C had 13 probiotic days/1,000 patient days. During this same time frame, central line associated blood stream infection (CLABSI) rates related to Saccharomyces, Lactobacillus and Bifidobacterium organisms were 0.055/1,000 CVC days for Hospital A, 0.049/1,000 CVC days for Hospital B, and 0.162/1,000 CVC days for Hospital C. and 0.162/1,000 CVC days for Hospital C. LESSON LEARNED: Hospital A and Hospital B have different methods of controlling the use of probiotics. However, they have similarly low CLABSI rates related to Saccharomyces, Lactobacillus and Bifidobacterium organisms when compared to Hospital C. A comprehensive probiotic management program may mitigate the risk of CLABSI, but additional evidence is needed before a systemwide recommendation can be made.