Outbreaks in Operating Rooms: How Do They Happen?

Arjun Srinivasan, MD, Associate Director, Healthcare-Associated Infection Prevention Programs, Centers for Disease Control and Prevention, discusses how outbreaks can occur in operating rooms.

Interview Transcript (slightly modified for readability)

“The outbreaks in the operating room, in terms of when they might occur, usually represent a breakdown in some technique; there’s a failure to maintain the sterile technique that the operating team is usually able to maintain. [This] may be because of a lapse in practice, someone forgets to do something that they normally should have done.

Outbreaks also can occur when you have equipment that either is not cleaned properly, or that is in some way defective and can’t be cleaned properly. We’ve seen that before; we’re seeing it currently with an outbreak that’s been described with these heater cooler units, where there’s a challenge of being able to clean them to get the organisms out. The theory is that there is contamination of the machines that’s lead to this national issue, this outbreak of mycobacterial infections in patients undergoing cardiac surgery.

The complicating factor in surgery is, of course, the devices. We use a lot of different devices when we’re doing surgery, particularly when we’re doing really complex surgeries, like cardiac surgery, where we have these heater coolers that have to warm and cool the patients; there’s [also] bypass machines.

There’s just a lot of complexity, and the more moving parts there are, the more things have to go exactly right to keep the infection from happening. And so, that’s often times where we see challenges in the operating room, where we tend to see outbreaks: when there are issues either with one of these techniques or with a device.”