Discussion
Sources of bacterial contamination of surgical wounds remain unclear. Despite routine protocols such as pre-surgical hand asepsis, surgical site preparation, and strict aseptic technique, 21% of surgical gloves in this study were contaminated with bacteria. This is a relatively high contamination rate of gloves worn by small animal surgeons, indicating that contamination of surgical wounds is likely a common occurrence with gloves being one source. Only 2 dogs developed SSI, both clean orthopedic procedures (TPLO), with 1 case noted to have glove contamination. Tibial plateau leveling osteotomy is a surgical procedure associated with a high SSI rate and reasons for this association are unknown. There was no statistical association between glove contamination and SSI; however, a study with a larger sample size is required to further evaluate this association.
Surgical time was not associated with bacterial contamination of gloves although it is expected that increased handling of the patients’ skin and exposure to the operating room air occur with longer surgical procedures. Surgical (and anesthesia) time has been previously associated with SSI in veterinary surgery (3) and additional study into this association is required.
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Many human surgeons performing total joint replacement recommend double gloving followed by systematic outer glove renewals to limit intra-operative contamination of the surgical site and reduce the risk of exposure of the surgeon to blood borne pathogens (8-10). In 1 study, this practice rendered glove samples from subsequent stages during surgery negative for bacteria in 80% of cases (8). Additionally, a study by Ward et al (11) evaluating the effect of double gloving on subsequent contamination found that outer glove exchange 1 hour into a clean orthopedic procedure reduced the contamination rate from 23% to 10% (11). Based on the relatively high rate of glove contamination found in this study, similar recommendations should be considered in veterinary surgery for patients at high risk for SSI, particularly procedures in which an implant is placed.
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A standardized technique for sampling surgical gloves does not exist; however, we may have underestimated the level of bacterial glove contamination. Other studies have used enrichment media to lower the threshold for bacterial detection. We did not use enrichment for bacterial growth, which allowed for enumeration but may have underestimated the incidence of bacterial contamination. There may have also been some residual action of chlorhexidine on hands or surgical gloves that had been in contact with the patient’s skin following presurgical asepsis, although the dilution that occurred during sampling likely negates any realistic impact. Future study of glove contamination should consider a combination of direct and enrichment methods, along with identification of recovered bacteria.
We found a relatively high level of bacterial contamination on surgeons’ gloves following a variety of small animal surgical procedures. Although SSIs in veterinary medicine likely have a multifactorial etiology, reducing intra-operative contamination of surgical wound is an important measure towards SSI prevention. The role of glove contamination and development of SSI is not fully established. Regardless, in patients at high risk of SSI or in surgical procedures where SSI would have devastating consequences (e.g., total joint arthroplasty), double gloving with periodic glove changes or removal of the outer glove prior to key points in the surgical procedure (e.g., handling of implant) should be considered to reduce intra-operative contamination of the surgical wound (11). CVJ
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