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Current Trends in Sterilisation

of Operation Theatres
TOPIC INITIATED BY Dr.T.V.Rao MD Professor of Microbiology
in Docplexus
A topic of interest to many wider contributions from Many Microbiology and
Medical Professionals from several Institutes globally
Time to end fumigation of operation theaters look for
better alternatives. Fumigation aims to create an environment, which will contain
an effective concentration of fumigant gas at a given temperature, for a
sufficient period of time to kill any live infestations. Fumigation is obsolete in
many developed nations in view of toxic nature of Formalin. Too frequent use and
inhalation are hazardous. Several new safe chemicals are emerging but the
constraint of economy limits the use and several hours of closure of operation
theaters can be curtailed as with fumigation. Aldehydes are potentially
carcinogenic and it is therefore recommended that other agents such as
hydrogen peroxide, hydrogen peroxide with silver nitrate, peracitic acid and
other chemical compounds of formaldehyde should be used in place of the
currently prevalent practice of using formaldehyde. A chemical compound which
is multi-purpose disinfectant is gaining importance as a non-aldehyde compound.
Sodium dodecyl benzene sulfonate is proved to be a safe virucidal, bactericidal,
and fungicidal, mycobactericidal and non-toxic compound. It contains ozone
(potassium peroxymonosulphate), sodium dodecyl benzenesulfonate, sulphuric
acid; and inorganic buffers. It is typically used for cleaning up hazardous spills,
disinfecting surfaces and soaking equipment. Though sodium dodecyl benzene
sulfonate is shown to have a wide spectrum of activity against viruses, some
fungi, and bacteria. However, it is less effective against spores and fungi than
some alternative disinfectants. Several other compounds are emerging in the
Market for safer use, may need better resources for utility and implementation.
Which is the best method for sterilization of operation theaters and why?
Contributed by Dr. A. Kumar
MBBS, MD, FMMC, Fellowship in Infection Control
Thank you Dr. Rao for bringing the topic for discussion. In fact the current
Centres for Disease Control, Atlanta, Georgia, USA, doesn't recommend for
routine fumigation with any of the available disinfectants. The operating theaters
are not classified any more for clean and dirty infected surgical procedures. If
adequate terminal cleaning is performed any operating room can be used for any
kind of surgery. During our internship we used to have septic theaters for
handling dirty/infected operative procedures. Here, we currently operate even
transplant surgical procedures following an abdominal lapartatomy procedure as
well but after adequate terminal cleaning. For cleaning & disinfection of the
operating room, the right disinfectant is chosen and is usually done with infection
control committee consultation & we currently use Clorox solution which is
diluted to 40% and if there is obvious spill of blood or body fluids we disinfect
with 10% Clorox solution or we could even use any of the quaternary ammonium

compounds viz. present tablets 4 tablets in 5 litres of potable water. Each tablet
contains 250mgm quarterly ammonium compound. This product approved
environmental protection agency (EPA). This disinfection procedure takes just
around 25-30 minutes before a new patient is taken in. the most important thing
to be remembered is that right disinfectant is chosen and right contact time is
observed before cleaning is performed. The mops used for these cleaning
process should be frequently changed and if a known infected patient is
operated, colour coded single use mop heads are used. But, if at all a patient
following road traffic accident is brought into the OR, where during evaluation,
you find that the patient is diagnosed with an airborne infectious disease such as
open pulmonary tuberculosis, or a chicken pox with florid lesions, we make sure
we use disinfection with fumigation machine available from Johnson & Johnson
(USA) now take over by the French company & this machine uses calculated
amount of hydrogen peroxide mixed with silver ions and this destroys aerosols
suspended in air. This procedure takes around 30-45 minutes and this product
doesn't damage any of the electronic devices and doesn't leave any residual
toxic chemical following the procedure. Of course this fumigation process is
initiated after thorough terminal cleaning. This product destroys even spores as
per the manufacturer's report. we do face increasing number of patients affected
with Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) & we utilize
this fumigation process with good effect and this product has prevented
occurrence of cross infection among patients with MERS-CoV as it was evident
that after patient discharge from a room, this virus lives in the aerosol for almost
36 hours even after terminal cleaning.
In addition, its mandatory for having all the environmental and engineering
controls in place to have a safe operating room for handling surgical procedures.
Restricted entry of unwarranted staff to the OR. Colour coded zone line
demarcation for permitting staff with street dress and recommendation to
change to the OR dress code beyond the red line.
Always keep the OR closed during surgical procedure
Make sure that the OR is continuously monitored electronically for positive air
pressure (> 18 air exchange / hour).
Keep equipments and machines necessary only for the designated surgical
procedure. because many times we have noticed that c arm machines, operating
microscopes for a neurosurgical procedure or an ENT procedure will be kept in
the OR during an unrelated procedure. If kept unrelated to the procedure, these
unused machines could get colonized from infectious aerosols and if not
adequately disinfected as per the manufacturers recommendation cross
infection could occur between patients.
Many at times, we have noticed that the exhaust vents within the OR would be
obstructed by the OR nursing staff without realizing the importance of the vent.
Always perform surveillance for surgical site infections for all surgical procedures
performed and if you find a cluster of patients with surgical site infection with a
similar organism and antibiogram will warn that some kind of cross infection has
occurred and needs immediate investigation. Even re-admission of surgical
patients will be a cause of concern for cross infection and surgical site infection

or even catheter associated urinary tract infection or hospital acquired


pneumonia or even central line associated blood stream infections.
So, its a team work where the OR chief should get involved in prevention of
infections by working closely with the hospital housekeeping staff, hospital
engineering services who controls the operating room air ventilation system,
involve the hospital infection control team, and others as needed.
The above team should be involved in the decision making before a disinfectant
product is purchased by the hospital management or authorities.

Dr. Polavaram Babu Surgery Paediatrics


Clorox is nothing but regular bleaching powder shall we this powder in diluted
form thro' fumigator for 20 minutes

Dr. A. Kumar
MBBS, MD, FMMC, Fellowship in Infection Control
Dr. Polavaram Babu No, there are Clorox concentrated liquid solutions dedicated
for hospital disinfection use. If needed you should procure this product only
because there are many clorox preparations for household unlabelled as
perfumed preparations.

Dr. Pardeep Bhatia Orthopaedic


Is it available in India? What is trade name?

Dr. A. Kumar says


Dr. Pardeep Bhatia I am not sure about the availability but can try from vendors.
The product is manufactured in France. There was another company from USA
-One of the well-known Indian company has been merged with the French
company & so currently the entire product is supplied only by the French.

Dr. Kalaimani Kandaswamy Anaesthesiology


Thank you Dr.T.V.Rao & Dr.A.Kumar for their timely updates, but still needs more
details as to the products, its availability... But the OT team cannot lax in
adopting strict sterile codes, dress......

Dr. Ajay Mehta Anaesthesiology


It is mandatory for soap and water cleansing and drying .then fumigation,
minimal speaking and movements, of course positive pressure and 18 air
changes. - Changes, which is tricky for the engineering Dept. hepa filters need
changes frequently like in DELHI this adds to costs. We must do that.

Dr. Usha Udgaonkar Microbiology


Nice and very useful write up Dr.T.V Rao and Dr.A Kumar. The word fumigation is
no longer used. I think it is fogging. Fumigation is used for pesticides spraying

Dr. Prabhu Prakash MD

Sir, really very informative post, but its very debatable and having long list of
quarries by all concern sp. OT In charge, Microbiologists and Administrators. Few
days back there was media news in our own----Due to increases Air Count {BCP)
in OT ALL OT'S closed. Sir what is your opinion--- If there is No Need of fogging
-then should we go for OT Air Sampling by Plate Count Method.

Dr. A. Kumar
MBBS, MD, FMMC, Fellowship in Infection Control
Dr. Prabhu Prakash Normally, microbiological air sampling is done using a
machine called as RCS centrifugal air sampling where an agar strip is inserted
into the machine through a socket and you get inside the OR by wearing sterile
protective gears and switch on the machine. During this process, this machine
will suck air in a calculated amount and if the air contains bacteria or fungi, it will
get stuck onto the agar strip. After 10 - 30 minutes of exposure, you can bring
this trip to the microbiology lab and incubate in an aerobic incubator at 37
degree centigrade. After 48 hours, 72 hours & 7 days, we can calculate the
number of aerobic bacteria, saprophytic bacteria and fungi/molds respectively.
During this analysis, not more than 35 colony forming units should be there on
the agar strip to be considered safe for proceeding with surgical procedures in
the tested OR. But exceptions to this colony count is there. Even if certain
organisms such as multi drug or pan drug resistant bacteria of even a single
colony or a fungi or molds would be considered unsafe for operative procedures.
if this error is identified, immediately the HVAC technician from the hospital
engineering services should be called upon for evaluation and check the positive
air pressure along with the air exchange rates. Normally a positive air pressure of
more than or equal to atleast 18 / hour need to be maintained for general
surgical procedures. If orthopedic implant or neurosurgical or cardiovascular or
thoracic surgery is performed these Ors should have more than atlas 24 air
exchanges should be maintained. In addition the air filtering should be through
various high efficiency particulate filters (HEPA) and this should be changed if
there is increase in microbiological colony count on air sampling or if the air
exchange rate is not achieved as per the recommendation. Normally
microbiological air sampling is performed when a new operating room is
constructed or a renovation is conducted. At times, if you notice that infectious
outbreak is identified among patients undergoing operative procedures,
immediately stop the procedures within the OR, investigate the cause and seek
the help of hospital housekeeping services along with air ventilation uncharged
and sort or seek for issues. Once this is sorted out either by change of HEPA
filters or ultra-pure filters where 99.9% of microbes are filtered especially on
transplant ORs you can again perform microbiological air sampling. Based on the
test results you can permit or deny permission for OR team to perform
procedures. Routine cleaning & disinfection of the OR doesn't warrant
microbiological air sampling. In addition, where resources is a limitation
microbiological air sampling could be done by using plain blood agar plate
exposure under the Air condition vents with an exposure time of 60 minutes and
evaluate the results similar to the RCS sampling. Decision to perform this
procedure is always decided by the Infection control physician rather than the
operating room chief or other clinical colleagues. But clinical or surgical
colleagues can always seek for any help or even suggests for air sampling but

final decision is done by the Infection control team or the committee members.
Resources should be always spent on scientific basis and not based on wild
guess. In addition, i would also suggest that the following parameters need to be
recorded on a daily basis for ORs. Daily positive air pressure along with electronic
measurement of air exchange rates (18-24/hour) with positive air pressure,
humidity which is as well monitored electronically maintained between 20-60%.
OR temperature maintained between 18-22 degree centigrade which is as well
recorded electronically. In adding the air ventilation unit for the OR should be
having its own dedicated ventilation and not mixed throughout the hospital.

Dr. Usha Udgaonkar Microbiology


Thanks. For very useful information and equally useful discussion. I have always
felt a thoroughly vigorous soap water cleaning is the best. Fogging not required.
For SSI one should distinguish between infection in OR and ward infection.
Usually, The OR infection is seen on 1st removal the dressing whereas ward
infection of SSI manifests later.

Dr. A. Kumar
Dr. Usha Udgaonkar i do agree that in normal circumstances, fogging or
fumigation is not recommended, but in our clinical situation where we do get lot
of patients suffering from airborne infectious diseases (e.g. open pulmonary
tuberculosis, MERS-Coronavirus infections, at time we do have patients with
florid chicken pox lesions) & such patients if we had to take them for emergency
surgical procedures, following the operative procedures, we had to perform
fumigation of the OR as the ORs are aerosolised with the above viral or bacterial
pathogens risking subsequent patients from acquiring these infectious
pathogens. Hence during these clinical situations, we do perform fumigation with
hydrogen peroxide mixed with silver ions which is available as a commercial
liquid form filled into a automatic machine which fumigates or foggy the entire
OR. This process facilitates the cracks and crevices of the OR to be thoroughly
disinfected with the disinfectant or else our regular terminal may not be able to
disinfect these small cracks on the walls or corners or even the exhaust vents
and HEPA filter A/C vents cannot be disinfected.

Dr. Prabhu Prakash MD


sir recently we are having Klebsiella outbreak in NICU , should we go for fogging
--rest all measures we have taken care but still we are isolating Klebsiella from
NICU

Dr. A. Kumar
MBBS, MD, FMMC, Fellowship in Infection Control
Dr. Prabhu Prakash Outbreak with Klebsiella pneumoniae outbreaks are known to
occur in nurseries and neonatal ICUs. Another common organism associated with
NICU outbreak is with Enterobacter species. We did have this outbreak in our own
NICU few years back. Fogging is not recommended in this situation as cross
infection happens only through contact with contaminated hands of healthcare
providers, at time contaminated through contaminated breast pumps, milk
storage freezers and cold compartments, re-use of milk storage bottles, & other

means. In this case, we do recommend to discharge as many patients as possible


if clinically stable. Stop new admissions in the unit. Decontaminate all the
medical devices as per the manufacturers recommendation & document the
same in a log book or checklist for verification. Perform adequate and
appropriate terminal cleaning using dedicated clean mops with adequate con
tact time with the chemical used for disinfection. Educate and implement
appropriate hand hygiene at all times of patient contact, If possible restrict the
entry of visitors including parents & if not possible educate them for performing
adequate hand hygiene. If these simple and routine measures are implemented
along with a departmental meeting to create awareness among all health care
providers of the paediatric & NICU along with Obstetrics staff, i believe the
outbreak could be controlled and stopped. Fumigation or fogging is not
recommended in this clinical situation.

Dr. T.V Rao MD


Major ideas are documented and converted into pdf for benefit of many the total
document will be posted if the email is sent doctortvrao@gmail.com I can be
contacted on Mob no 8281669524 let all be together make many contribution for
improving the safety of the patients

Dr. Bharti K Anaesthesiology

Excellent information
Dr. Azam Nawaz MS, DNB URO
Very informative but some definite protocol should be standardized and
guidelines issued
Make your best Contributions and make the partner in the desired change
All opinions are Individuals carries no conflict of Interest
Dr.T.V.Rao MD
Professor of Microbiology Freelance Microbiology reporter

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