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An investigation and management of an unique outbreak of surgical site infections in operation theater of a tertiary care hospital

Author : Mukul Bajpai, Vinod Raghav, Rig Vardhan, Nandita Hazra, Rakhi Negi, Nikhat Jahan, Prerna Chadha, Nishant Taur, Pratap Shankar, Rakesh Kumar Dixit

Post-operative Surgical site infections due to air borne contamination of air in operation theaters are becoming increasingly important cause of mortality and morbidity due to large number of immuno-compromised and aging patients being taken up for surgery. They can only be prevented by maintaining quality of air in operation theaters by regular air and bio contamination surveillance. To presents outbreak of surgical site infections in our OT complex in spite of following regular protocol for asepsis and surveillance, not only exposing lacunae in surveillance system but also pointed out need to revise guidelines for air sampling and surface decontamination. A prospective observational study, which presents outbreak of post-operative surgical site infections in tertiary care hospital Operation Theater due air borne contamination. Outbreak occurred due to HEPA filter infestation of AC plant by fungus and happened when standard protocol of air surveillance and bio contamination was being followed by hospital; it remained undetected for 3-4 weeks. This study presents complete protocol of air and bio contamination surveillance, discusses reasons why it could not detect airborne contamination, importance of transient contamination and inability of conventional system to detect it due lack of continuous monitoring.


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