Skip to main content Accessibility help

Association of Airborne Microorganisms in the Operating Room With Implant Infections: A Randomized Controlled Trial

  • Rabih O. Darouiche (a1), David M. Green (a2), Melvyn A. Harrington (a3), Bruce L. Ehni (a4), Panagiotis Kougias (a5), Carlos F. Bechara (a6) and Daniel P. O’Connor (a7)...



To evaluate the association of airborne colony-forming units (CFU) at incision sites during implantation of prostheses with the incidence of either incisional or prosthesis-related surgical site infections.


Randomized, controlled trial.


Primary, public institution.


Three hundred patients undergoing total hip arthroplasty, instrumented spinal procedures, or vascular bypass graft implantation.


Patients were randomly assigned in a 1:1 ratio to either the intervention group or the control group. A novel device (Air Barrier System), previously shown to reduce airborne CFU at incision sites, was utilized in the intervention group. Procedures assigned to the control group were performed without the device, under routine operating room atmospheric conditions. Patients were followed up for 12 months to determine whether airborne CFU levels at the incision sites predicted the incidence of incisional or prosthesis-related infection.


Data were available for 294 patients, 148 in the intervention group and 146 in the control group. CFU density at the incision site was significantly lower in the intervention group than in the control group (P<.001). The density of airborne CFU at the incision site during the procedures was significantly related to the incidence of implant infection (P=.021). Airborne CFU densities were 4 times greater in procedures with implant infection versus no implant infection. All 4 of the observed prosthesis infections occurred in the control group.


Reduction of airborne CFU specifically at the incision site during operations may be an effective strategy to reduce prosthesis-related infections. Trial Registration: Identifier: NCT01610271

Infect Control Hosp Epidemiol 2016;1–8


Corresponding author

Address correspondence to Rabih O. Darouiche, MD, Departments of Medicine, Surgery, and Physical Medicine and Rehabilitation, Michael E. DeBakey VAMC, Bldg 100, Rm 4B-370, 2002 Holcombe Blvd, Houston, TX 77030 (


Hide All
1. Kurtz, SM, Lau, E, Watson, H, Schmier, JK, Parvizi, J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty 2012;27:6165.
2. Edmiston, CE Jr, Sinski, S, Seabrook, GR, Simons, D, Goheen, MP. Airborne particulates in the OR environment. AORN J 1999;69:11691179.
3. Stocks, GW, Self, SD, Thompson, B, Adame, XA, O’Connor, DP. Predicting bacterial populations based on airborne particulates: a study performed in nonlaminar flow operating rooms during joint arthroplasty surgery. Am J Infect Control 2010;38:199204.
4. Wan, GH, Chung, FF, Tang, CS. Long-term surveillance of air quality in medical center operating rooms. Am J Infect Control 2011;39:302308.
5. Hamilton, H, Jamieson, J. Deep infection in total hip arthroplasty. Can J Surg 2008;51:111117.
6. Lidwell, OM, Lowbury, EJ, Whyte, W, Blowers, R, Stanley, SJ, Lowe, D. Airborne contamination of wounds in joint replacement operations: the relationship to sepsis rates. J Hosp Infect 1983;4:111131.
7. Ritter, MA. Operating room environment. Clin Orthop Relat Res 1999;369:103109.
8. Andersson, AE, Bergh, I, Karlsson, J, Eriksson, BI, Nilsson, K. Traffic flow in the operating room: an explorative and descriptive study on air quality during orthopedic trauma implant surgery. Am J Infect Control 2012;40:750755.
9. Edmiston, CE Jr., Seabrook, GR, Cambria, RA, et al. Molecular epidemiology of microbial contamination in the operating room environment: is there a risk for infection? Surgery 2005;138:573579.
10. Smith, EB, Raphael, IJ, Maltenfort, MG, Honsawek, S, Dolan, K, Younkins, EA. The effect of laminar air flow and door openings on operating room contamination. J Arthroplasty 2013;28:14821485.
11. Evans, RP. Current concepts for clean air and total joint arthroplasty: laminar airflow and ultraviolet radiation: a systematic review. Clin Orthop Relat Res 2011;469:945953.
12. Knobben, BA, van Horn, JR, van der Mei, HC, Busscher, HJ. Evaluation of measures to decrease intra-operative bacterial contamination in orthopaedic implant surgery. J Hosp Infect 2006;62:174180.
13. Burke, JF. Identification of the sources of staphylococci contaminating the surgical wound during operation. Ann Surg 1963;158:898904.
14. Duhaime, AC, Bonner, K, McGowan, KL, Schut, L, Sutton, LN, Plotkin, S. Distribution of bacteria in the operating room environment and its relation to ventricular shunt infections: a prospective study. Childs Nerv Syst 1991;7:211214.
15. Sehulster, L, Chinn, RY. Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep 2003;52:142.
16. Mangram, AJ, Horan, TC, Pearson, ML, Silver, LC, Jarvis, WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250278.
17. Firth, D. Bias reduction of maximum likelihood estimates. Biometrika 1993;80:2738.
18. Heinze, G, Schemper, M. A solution to the problem of separation in logistic regression. Stat Med 2002;21:24092419.
19. Long, JS. Regression Models for Categorical and Limited Dependent Variables. Thousand Oaks, CA: Sage; 1997:242247.
20. Stocks, GW, O’Connor, DP, Self, SD, Marcek, GA, Thompson, BL. Directed air flow to reduce airborne particulate and bacterial contamination in the surgical field during total hip arthroplasty. J Arthroplasty 2011;26:771776.
21. Panahi, P, Stroh, M, Casper, DS, Parvizi, J, Austin, MS. Operating room traffic is a major concern during total joint arthroplasty. Clin Orthop Relat Res 2012;470:26902694.
22. Darouiche, RO, Wall, MJ Jr, Itani, KM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010;362:1826.
23. Morrison, TN, Chen, AF, Taneja, M, Kucukdurmaz, F, Rothman, RH, Parvizi, J. Single vs repeat surgical skin preparations for reducing surgical site infection after total joint arthroplasty: a prospective, randomized, double-blinded study. J Arthroplasty 2016;31:12891294.
24. Andersson, AE, Petzold, M, Bergh, I, Karlsson, J, Eriksson, BI, Nilsson, K. Comparison between mixed and laminar airflow systems in operating rooms and the influence of human factors: experiences from a Swedish orthopedic center. Am J Infect Control 2014;42:665669.
25. Ayliffe, GA. Role of the environment of the operating suite in surgical wound infection. Rev Infect Dis 1991;13:S800S804.
26. Miner, AL, Losina, E, Katz, JN, Fossel, AH, Platt, R. Deep infection after total knee replacement: impact of laminar airflow systems and body exhaust suits in the modern operating room. Infect Control Hosp Epidemiol 2007;28:222226.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed