Surgical site infections linked to contaminated surgical instruments
Background: This study describes an investigation into a sudden increase in surgical siteinfection rate following ‘clean’ surgery. The outbreak involved 15 orthopaedic patients
following metal insertion, and five ophthalmology patients who developed endophthalmitis.
Aim: An outbreak committee was convened in order to find the cause of the sudden
increase in surgical infections.
Methods: The investigation included epidemiological and patient analyses, and environmental
and clinical audits of wards and theatres. Following reports of contaminated
surgical sets, surgical instruments and their packaging were examined using a standardized
laboratory protocol. Clinical staff visited the sterilization plant.
Findings: Skin flora including coagulase-negative staphylococci (CoNS) and Bacillus spp.
were recovered from a range of patient specimens. Eleven patients required further
surgical attention. Microbiological processing of surgical packs revealed CoNS and Bacillus
spp. from inner packaging as well as from instruments themselves. Inspection of the
sterilization plant highlighted inadequate maintenance of autoclave components and poor
handling practices by staff. This was compounded by lapses in inspection of surgical sets
by theatre staff. Cases terminated following a review of operator training, supervision and
staffing at the sterilization plant, in conjunction with formal inspection and reporting of
damp/stained sets by theatre staff.
Conclusions: Post-sterilization contamination of sets containing surgical instruments was
linked with an increased rate of deep surgical site infections in orthopaedic and
ophthalmic patients. The investigation demonstrates the importance of close collaboration
and co-operation between sterile services providers, managers and clinical staff and
offers guidance for reducing the risk of contaminated sterile surgical instruments.
2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
S.J. Dancer et al. / Journal of Hospital Infection 81 (2012) 232 231e238
爱美之心，人皆有之，现在整形手术日益盛行，因手术器械消毒灭菌不当导致的SSI问题也逐渐暴露。 我也来尝试读一下英文文献，先克服自己的心理障碍就行。
麻烦楼主按照版块要求http://bbs.sific.com.cn/thread-79934-1-1.html
调整一下格式，谢谢！！！ 多谢啦！下载学习了！
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