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Comprehensive infection control in operation theatres: Current standards, practical strategies, and innovations to enhance surgical safety
* Corresponding author: Mohd Faraz, Department of Radiodiagnosis, J.N. Medical College, Paramedical College, Faculty of Medicine, Aligarh Muslim University, Aligarh, Uttar Pradesh, India. mohammadfaraz638@gmail.com
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Received: ,
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How to cite this article: Ansari Fazil Mohd, Faraz Mohd, Sameer Mohd, Zameer Saqib. Comprehensive infection control in operation theatres: current standards, practical strategies, and innovations to enhance surgical safety. Future Health. doi: 10.25259/FH_33_2025
Abstract
Operating rooms (ORs), also known as surgical theatres, are the heart of surgical procedures, a unit within a hospital. They are designed to provide the patient with a sterile and infection-free environment. However, there is a risk of exposure to infectious agents, such as Staphylococcus aureus (including MRSA), Pseudomonas aeruginosa, and Streptococcus species. They affect the superficial skin, but in cases of severe infection, they lead the infection to deeper tissues, and the organs or contents (muscle layer, fascia, soft tissues, and blood vessels) that are exposed during the surgical procedure increase the risk of infection, eventually resulting in surgical site infection (SSI). There may be several postoperative complications, such as a delay in the healing of the wound or opening of the wound completely or partially due to SSI. To reduce contamination of pathogens, we practice preventive strategies with their advancements, like the practice of double gloving, which is used to reduce the risk of needle stick and other sharp injury traumas. The rate of single glove puncture during the surgical procedures was 90.2%, and with the combination of two gloves, it was 23%. In an OT, around 10,000 skin scales are shed per minute by the operating staff. However, about 10% of people have bacterial clumps that could lead to a postoperative complication. Control of contamination in airflow systems can be done using vertical laminar flow with high efficiency particulate air (HEPA) filters, which remove 0.3 mm particles with an efficiency of 99.9%. Installation of the ultra clean ventilation (UCV) system in the OT reduced the joint sepsis to 1 and 10 biological contaminant particles per cubic meter (BCP/m3). Heating, ventilation, and air conditioning (HVAC), which controls the temperature, relative humidity, and air current. The study on the Efficacy of Nosocomial Infection Control (SENIC) showed that SSIs were reduced by 38% as a result of infection control teams, surveillance, and feedback of observed data. The surgical scrubs used in the OT were washed and reused, but the overall performance was affected due to contaminated stains and wear and tear. The number of washes affected the quality of the material, which increased the chances of exposure to pathogens. Polypropylene scrub suits are associated with lower bacterial contamination for single-use purposes, which reduces the risk of cross-contamination as compared to traditional scrubs. By using antibiotic combinations, a wide spectrum of pathogens can be treated. Nanotechnology carries the nanoparticles, which encapsulate the antibiotics, to release at localized surgical sites, which ultimately aims to enhance the efficiency and reduce the adverse effects of antibiotics. The implant is coated with an antimicrobial material that provides resistance towards the microorganisms within the blood during the surgical procedure. Further study shows that by analyzing the patient’s genetic makeup, the target genomic site is exposed to effective antibiotics. Knowledge and practice of health care workers (HCWs) also play a crucial role in the prevention of SSI. This paper aims to summarize the methods to minimize the SSI and focus on the prevention practice strategies with their advancement.
Keywords
Cross infection
Health care workers
Operating rooms
Prevention
Surgical site infection
INTRODUCTION
Operating rooms (ORs) are also known as surgical theaters. It is considered the heart of surgical procedures in a hospital. They are designed to prevent crowding of healthcare professionals by providing enough space to control airborne contaminants, along with providing a sterile and infection-free environment.1 However, the threat of postoperative contamination is present at the end of all surgical procedures. Several components put up to this threat, including patient attributes, sterile field, and ORs. Infection control strategies are crucial for the care of surgery-related infections. In the 1950s, it was demonstrated by the United States. Consequently, hospitals all around the world are actively addressing the issue of surgical site infections (SSIs).2 The main cause of SSI is bacterial contamination of Staphylococcus aureus. SSI is spread by the shedding of infected skin squamous cells of staff members to others. However, many studies show different techniques to prevent SSIs, such as indirect (relying on reviewing medical records and data resources) and direct methods (involving the real-time observation of the surgical site). Despite these techniques, the postoperative risk of exposure to pathogens is due to poor antisepsis techniques, improper use of PPE equipment, and not following the standard protocols provided by the Standard Infection Control Practices, as stated by the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) guidelines.3 This review aims to increase the awareness among healthcare professionals about the infection control techniques and preventative measures that have been developed to lower the risk of SSIs.
SOURCE OF INFECTION IN THE OPERATION THEATRE (OT)
Infection can arise from different sources in the operation theatre (OT), which can be classified as endogenous (infections from the patient) and exogenous (infections from the environment), as shown in Figure 1.
- Sources of infection in operation theater: endogenous (patient-derived) and exogenous (airborne particles, surgical instruments, surfaces, personnel contamination).
Endogenous sources (infections from the patient)
Endogenous sources of infection refer to the shedding of squamous or microorganisms that originate from the patient’s own body. They are present inside or outside the patient’s body without causing harm. Furthermore, when they enter sterile areas during or after surgery, they cause severe infection through different sources.4
Patient skin flora and Mucous membranes
Staphylococcus epidermidis is found on the skin of patients, nasal passages, and originates from the patient’s own body. It is also present on devices such as prosthetic joints, urinary catheters, heart valves, and pacemakers.5 The most common types of Staphylococcus aureus infecting the skin, deeper tissues, or organs are methicillin-sensitive (MSSA) or methicillin-resistant (MRSA).6 The mucous membrane is found in the lining of the mouth, nose, respiratory tract, gastrointestinal tract, and genitourinary tract. These membranes are rich in blood supply and moist, making them microbial growth environments. E. coli and Enterococcus during the abdominal surgery may spill into the peritoneal cavity, leading to peritonitis.7 Staphylococcus aureus and Klebsiella pneumoniae can cause ventilator-associated pneumonia (VAP). When a surgeon touches the breached mucous membrane, the chances of the spread of infection to the sterile surgical site increase.8
Infected colonized tissues
Colonization refers to the presence of microbial pathogens (bacteria, fungi, or viruses) on an abscess, cellulitis site, or any other anatomical deformity at a tissue site without any active infection signs (pyrexia, myalgia, inflammation, or purulent discharge). Colonization of pathogens will not be harmful to tissues until they expose immunocompromised patients and surgical wounds.9 Patients who have septicemia or bacteremia may have the pathogen circulating in their blood, leading to infection at the surgical site.
Exogenous sources (infections from external sources)
These pathogens are present in the external source of the OT environment, which includes the OT team, surgical instruments, and medical equipment.
Hands of the surgeon
The hands of surgeons and healthcare professionals are one of the most common external sources of infections in the OT. Even with gloves, improper hand hygiene can lead to microbial infection, such as SSIs or HAIs.10 The most common types include Staphylococcus aureus, multidrug-resistant organisms (MDROs), and Streptococcus spp, which lead to severe consequences, including infection risk, delayed wound healing, longer stays leading to increased allowances for patients, and also the requirement for repeat surgery or antibiotics.
OT environment and surgical devices
In 1998, it was stated by Gosden, Macgowan, and Bannister that around 10,000 skin scales are shed per minute by the operating staff. However, about 10% of people have bacterial clusters that could lead to a postoperative complication related to SSI. Increased movement within the ORs, poor air filtration, or improper airflow can reintroduce the settled particles in the air and transfer to surgical instruments or patient wounds.11 High humidity (>60%) causes condensation, which promotes growth, and low humidity (<30%) leads to cracks in sterile packaging. High temperatures (>22°C) promote bacterial growth, and low temperatures lead to vasoconstriction, reducing oxygen supply.12 Improperly sterilized anesthesia machines, ventilators, suction devices, and reusable medical devices (like laparoscopic instruments, orthopedic tools, and endoscopes) develop biofilms of bacteria like Clostridium difficile or Klebsiella pneumoniae. The pathogens survive on improperly cleaned instruments contaminated with blood, fat, and tissue.13
SURGICAL SITE INFECTIONS (SSIs)
Infections that occur in the wound created during the surgical procedures, due to the range of microorganisms colonized over the skin, lead to SSIs. These are considered infections that appear within 30 days of surgery or one year after the implant.14 These affect the superficial skin, but in cases of severe infection, they lead the infection to deeper tissues and the organs or contents (muscle layer, fascia, soft tissues, blood vessels) that are exposed during the surgical procedure.15 The CDC describes the three different types of SSIs, as shown in Figure 2.
- Types of Surgical Site Infection (SSI): Superficial (skin, subcutaneous tissue), Deep (fascia, muscle), and Organ/Space (internal organs, cavities).
Superficial incision infection
It mainly occurs at the surgical incision site and consists of superficial skin and subcutaneous tissue. It develops within 30 days of surgery due to poor aseptic practices. Patient risk factors may also include diabetes, obesity, smoking, immunosuppression, and poor nutrition.16 The common pathogens for SSI include Staphylococcus aureus, including MRSA, Pseudomonas aeruginosa, and Streptococcus species. There may be several postoperative complications, such as causing a delay in the healing of the wound or opening of the wound completely or partially due to infection.17
Deep incision infection and organ or space infection
It affects the deep soft tissues such as the muscular layers and fascial sheath. The anatomical content, innards, or cavity that is manipulated during the surgical procedures may come into contact the contaminated instruments, poor surgical technique, and long surgeries.18 This type of SSI is indicated by the presence of pus or abscess, fever (> 38°C), wound dehiscence, due to which the whole wound will be exposed with a foul smell. The common sites are the peritoneal cavity, pleural cavity, joint spaces, and meninges. Organ or space infection involves the organ or space, excluding the skin, subcutaneous tissue, and muscle.19 If no implant is present, infection appears within 30 days of surgery or one year after the implant. When a drain is positioned inside an organ, pus discharged from the drain indicates this kind of SSI, and swelling around organs leads to repeat surgery, longer hospital stays, and organ dysfunction.20
STANDARD INFECTION CONTROL AND PRACTICES
Standard infection control practices are based on guidelines from the CDC, WHO, and other health organizations to prevent HAIs or SSIs. Cross-contamination can be prevented by ventilation, patients, staff, equipment, and surfaces, and standard infection control methods, as mentioned in Figure 3.
- Shows the standard infection control and practices.
Double gloving to reduce surgical cross-infection
As the glove puncture is not easily visible by needle puncture during the surgical procedure, we take double-gloving measures to prevent cross-contamination. The rate of single glove puncture or damage during surgical procedures was 90.2%, and with the combination of two, it leads to 23%.21 The study showed that the probability of large punctures includes the left hand 54% as compared to the right hand 41%, and the first three fingers, among which have 73% on the first two fingers.22 Statistical analysis has been shown in Figure 4. The practice of reinforced gloving is to lower the chances of needle sticks and other sharp injury traumas. A Cochrane review explains that the use of double gloving reduces the risk of perforation by 71% as compared to single gloving.23
- Glove Puncture Rate: Increases with longer surgical duration-higher percentage of punctured gloves seen in prolonged procedures.
Personal protective equipment (PPE) and staff clothing
Personal protective equipment (PPE) prevents the exposure of infectious body fluids, secretions, and excretions between healthcare staff and patients. It creates a barrier that protects the surgical site from cross-contamination of infected agents like bacteria, viruses, and other pathogens.24 Proper use of face masks, which ensures the avoidance of inhalation of droplet transmission; gloves, which protect hands from contaminated body fluids; gowns, which protect the HCWs skin or clothes from splashes. Traditionally, the scrubs are washed and reused, but the overall performance was affected due to contaminated stains, wear and tear, number of washes affected their material quality. Polypropylene scrub suits are associated with lower bacterial contamination for single-use purposes only, which reduces the risk of cross-contamination as compared to traditional scrubs.25
Clean air
Respiratory aerosols or fibers of drapes and skin squamous cells contain microorganisms released from HCWs, leading to SSIs. To remove these infectious microbes, a proper ventilation system with high-pressure airflow is used in ORs to prevent the flow from less sterile areas to more sterile areas, and the laminar flow system with HEPA filters removes 0.3 mm particles with an efficiency of 99.9%.26 The inconvenience in vertical flow is that sometimes the head of the surgeon is above the incision area, and the flow from top to bottom leads pathogens towards the surgical site.27 To prevent this contamination, horizontal flow is used as an alternative, but the horizontal flow is disrupted due to the surgical team, OR lamp, and improper positioning of the HCWs. Control of contamination in airflow systems includes HVAC, which controls the temperature, relative humidity, and air current.28
ADVANCED INFECTION PREVENTION STRATEGIES
Advanced infection prevention strategies include the techniques that go beyond aseptic techniques and focus on leading-edge technology, strict environmental controls, and innovative practices to minimize HAIs.29
Advanced environmental controls
The study shows that the air exchange per hour is 20 to obtain per cubic meter colony-forming units (CFUs) for 50-150 biological contaminant particles (BCP). For an empty OR, the values range from 35 CFU/m3 and should not exceed the study’s finding that the air exchange per hour is 20 to obtain 50-150 BCP CFUs during the process of 180 CFU/m3. With the use of ultra-clean, the threshold is less than 10 CFU/m3. Utilizing the body exhaust gowns, the limit is set at 1 CFU/m3 to prevent contamination at the wound site. The study shows that after the installation of the UCV system in the operating theater, the joint sepsis was reduced to 10 and 1 BCP/m3.30
Surveillance and monitoring
It involves the collection of data from the patient case study by direct method (based on daily observation); it is the standard gold method used by surgical staff and health care providers, and by indirect method (analyzes the data of inpatients or outpatients), including the patient’s pathological and medical history, operative history. A study shows that the indirect method is more convenient, with a sensitivity of 84%-89% and a specificity of 99.8%, as compared to the direct method. The administrative data is used to reduce the load of hospital SSIs through the application of algorithms, machine learning, and electronic health records (EHRs).31 The Study on the Efficacy of Nosocomial Infection Control (SENIC) conducted in 1985 demonstrated that infection control teams, surveillance, and feedback of observed data led to a 38% reduction in SSIs.32
Antimicrobial Stewardship Programs
Before the surgery, there will be an administration of antimicrobial agents through intravenous administration to prevent the SSIs. So, at the time of incision, the adequate serum and tissue concentration is maintained, followed by the time of administration and half-life.33 The study shows that using the oral antimicrobial agent decreases the chances of SSI in surgical procedures, where entry into the colon has taken place or in gynecologic oncology surgery. The study shows that the administration of antibiotics before skin incision and stopping after 24 hours of duration, and the administration of antibiotics after incision, will not decrease the SSIs, and it also contributes to Clostridioides difficile infection and acute kidney injury.34
ROLE OF THE HEALTHCARE WORKER IN INFECTION CONTROL
The guidelines provided by the WHO to prevent the SSIs also reduce the patient’s stay at the healthcare institution to lessen exposure to microbial pathogens. It includes the preoperative bathing of the patient, hand hygiene, and antibiotics at the exact time before the incision. Pre- and postoperative glycemic control of the patient, prophylactic wound irrigation technique during the dressing, sutures with antimicrobial properties, polyethylene glycol, and sodium phosphate are administered as a part of mechanical bowl preparation (MBP) to decrease the intra luminal fecal matter by voiding of colon content, nutrition, surgical techniques, and immunosuppressive agents before surgery to prevent graft rejection. The different methodologies practiced with efficient knowledge by healthcare workers, the National Institute for Health and Care Excellence (NICE) states that healthcare professionals emphasize informing patients about their SSIs, the treatment procedure, wound management, and wound healing.35
FUTURE PERSPECTIVE
By applying the knowledge of minimally invasive surgery, or laparoscopic surgery (cholecystectomy, appendectomy, hysterectomy, and hernia repair), where small incisions are made to pass the camera (laparoscope) and other specialized surgical instruments. The pinhole incision made, which ultimately aims to reduce blood loss, less wear and tear or damage to anatomical content, and lower the risk of postoperative complications like hernia or adhesions, early healing is provided, and also the economic burden on the patient.36 The study shows that nanotechnology carries the nanoparticles, which encapsulate antibiotics, to release at localized surgical sites, which ultimately aims to enhance the efficiency, reduce the antibiotic adverse effects, and also reduce the high doses of antibiotics. By using antibiotic combinations, we reduce the risk of antibiotic resistance and a broad spectrum of pathogens by balancing antimicrobial stewardship.37 Many studies show that the implants are coated with antimicrobial material provides resistance towards the microorganisms within the blood during the surgical procedure. Further study shows that by analyzing the patient’s genetic makeup, the target genomic site is exposed to effective antibiotics.38
CONCLUSION
This paper provides the prevention strategies or standard protocol practices guided by the CDC and WHO to prevent HAIs or SSIs. Polypropylene scrub suits are associated with lower bacterial contamination for single-use purposes, and double gloving reduces surgical cross-infection. However, the findings of the laminar flow system with a HEPA filter, which removes particles of size 0.3 mm with an efficiency of 99.9%. The installation of the UCV system in the operating theater reduced the joint sepsis to 10 and 1 BCP/m3. Infection control teams, surveillance, and feedback of observed data led to a 38% reduction in SSIs. Based on the findings in this study, we analyzed the patient’s genetic makeup to target the genomic site that met the exposure of effective antibiotics and showed fewer adverse drug allergic reactions. Using antibiotic combinations or rotational antibiotics, the healthcare professionals adopt an approach towards the reduction of bacteria resistant to antibiotics.
Author contribution
M.F.A: Conception and design of the study, data collection, methodology, initial drafting of the manuscript. M.F.: Final Literature review, critical revision and editing of the manuscript. M.S.: Literature review, critical revision and editing of the manuscript. S.Z.: Literature review, critical revision and editing of the manuscript. All authors reviewed the manuscript for important intellectual content, approved the final version, and agree to be accountable for all aspects of the work.
Ethical approval
Institutional Review Board approval is not required.
Declaration of patient consent
Patient’s consent not required as there are no patients in this study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of Artificial Intelligence (AI)-Assisted Technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
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