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  Table of Contents  
Year : 2015  |  Volume : 33  |  Issue : 5  |  Page : 115-118

Microbial colonisation of orthopaedic tourniquets: A potential risk for surgical site infection

1 Department of Microbiology, VSS Medical College, Burla, Sambalpur, Odisha, India
2 Department of Orthopaedics, VSS Medical College, Burla, Sambalpur, Odisha, India

Date of Submission29-Oct-2013
Date of Acceptance26-Jul-2014
Date of Web Publication6-Feb-2015

Correspondence Address:
S K Sahu
Department of Microbiology, VSS Medical College, Burla, Sambalpur, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0255-0857.150910

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 ~ Abstract 

Pneumatic tourniquets have been used in orthopaedic surgery to get avascular fields. Sixteen such tourniquets were analysed for microbial colonisation. Samples were taken from two inner and two outer areas of each tourniquet and cultured on sheep blood agar. Eight of these were wiped with Savlon and the rest with Sterillium solution. Post-treatment samples from the same sites were again cultured. After incubation, colonies from each site were identified and counted. It was observed that the tourniquets were colonised with coagulase-negative staphylococci, Staphylococcus aureus, Bacillus, diphtheroids, Pseudomonas, Acinetobacter, enterococci, enterobacteria, and Candida. On treating with Savlon and Sterillium, there was 92.18% and 95.70% reduction in the colony count, respectively.

Keywords: Blood agar, disinfection, hospital infection, methicillin-resistant Staphylococcus aureus, orthopaedic tourniquet

How to cite this article:
Sahu S K, Tudu B, Mall P K. Microbial colonisation of orthopaedic tourniquets: A potential risk for surgical site infection. Indian J Med Microbiol 2015;33, Suppl S1:115-8

How to cite this URL:
Sahu S K, Tudu B, Mall P K. Microbial colonisation of orthopaedic tourniquets: A potential risk for surgical site infection. Indian J Med Microbiol [serial online] 2015 [cited 2020 Sep 25];33, Suppl S1:115-8. Available from:

 ~ Introduction Top

Portable medical equipments such as stethoscopes, otoscopes and blood pressure cuffs become contaminated during routine use, and may result in transmission of antimicrobial-resistant pathogens. [1],[2] Reusable tourniquets are also demonstrated to be contaminated with microbial pathogens. [3],[4],[5] Non-sterile tourniquets are routinely used in orthopaedic surgery in our hospitals to get a bloodless field. These may be contaminated with skin flora since they are not routinely disinfected between cases and pose a potential source of infection of surgical wounds.

Antiseptics and disinfectants are essential parts of infection control practices and aid in the prevention of nosocomial infections. But a common problem is the selection of disinfectants and antiseptics because different pathogens vary in their response to different antiseptics or disinfectants. [6]

In this study, we aimed to define the microbial status of non-sterile tourniquets used in our orthopaedic operating theatre and suggest remedies for their disinfection.

 ~ Materials and Methods Top

This study was conducted at the Department of Microbiology in a tertiary care hospital in association with Department of Orthopaedics. We analysed 16 re-usable orthopaedic tourniquets. Each tourniquet was tagged with a serial number ranging from 1 to 16. On the inner surface of the tourniquets, two areas with dimensions of 2 cm × 2 cm from the proximal and distal parts were labelled with indelible ink as inner proximal and inner distal, respectively. Similarly, corresponding surfaces on the outer surface were labelled as outer proximal and outer distal [Figure 1] and [Figure 2]. These sites were pressed on to 5% sheep blood agar plates which were then incubated at 37°C for 48 h aerobically. After obtaining pre-treatment samples, tourniquets with odd serial numbers were wiped with by a gauge soaked in working solution (1 in 15 aqueous solution) of Savlon liquid (Johnson and Johnson) and tourniquets with even serial numbers were treated with Sterillium liquid (Bode Chemie) and left to dry for 5 min. Post-treatment samples were obtained from the same marked sites and cultured in a similar fashion. After incubation, the colonies were counted and identified on the basis of morphology, Gram stain, and routine biochemical testing. Pre-treatment and post-treatment results were compared on the basis of reduction of colony counts. All samples were collected by the same investigator wearing sterile gloves, gowns, and masks to avoid cross-contamination. [7],[8]
Figure 1: IP: Inner proximal; ID: Inner distal

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Figure 2: OP: Outer proximal; OD: Outer distal

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 ~ Results Top

All the tourniquets were colonised with microorganisms. Colony counts from different spots of the untreated tourniquets ranged from 15 to 68 colonies per spot. The inner surfaces of the tourniquets were more contaminated than the outer surfaces (1459 against 1030 colony counts). Proximal aspects were more contaminated than the distal aspects (1382 against 1107 colony counts). The bacteria isolated are listed in [Table 1]. Staphylococcus spp. were the most predominant bacteria isolated (77.9%), which belonged to coagulase-negative Staphylococcus (CONS, 74.6%), methicillin-resistant Staphylococcus aureus (MRSA, 1.4%), and S. aureus other than MRSA (1.9%). Other bacteria included Bacillus spp. (5.5%), diphtheroids (4.2%), Pseudomonas spp. (3.3%), enterococci (3.2%), Acinetobacter (3.0%), and Enterobactericeae (2.1%). Few of the cultures also yielded growth of Candida (0.8%). After antiseptic treatment, the colony count was significantly reduced. Paired t test was applied to find out the statistical significance and in both comparisons; the P value was < 0.0001. The colony counts per spot after treatment with Savlon were 0-9 and after treatment with Sterillium were 0-5. There was 92.18% and 95.70% reduction of the colony counts on treatment with Savlon and Sterillium, respectively [Table 2].
Table 1: Microorganisms isolated from the specimens

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Table 2: Colony counts before (pre) and after (post) treatment with antiseptics

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 ~ Discussion Top

All tourniquets are stored in a basket in the operation theatre. Surgeons choose an appropriate tourniquet and place it on the operative limb of the patient. This is routinely done without gloves, prior to hand hygiene and after anesthesia induction. The limb of a patient is then prepared for antisepsis till the level of the tourniquet and draped with sterile sheets beyond it. Cultures of tourniquets at our institution demonstrated colonisation with bacteria and fungi. Most of the isolates belonged to the normal flora of the skin. We found that staphylococci, mainly CONS, formed the predominant isolate. They also included drug-resistant strains like MRSA. Staphylococcus is the most common organism that causes deep wound infection. Existing publications on similar studies also concluded that coagulase-negative staphylococci and Bacillus are the predominant isolates. [8],[9],[10] We a lso found Candida (0.8%) isolates from some cases.

Routine decontamination of reusable tourniquets between cases is not usually practised in many hospitals. Being applied in proximity to the wound and in direct contact with the skin before surgery, these devices may pose potential risk of infection of the surgical field. [5],[7],[8],[9] Higher bacterial load increases the risk further. There are reports of increased incidence of orthopaedic surgical site infections (SSI), particularly in total joint arthroplasty, with bacteria like CONS leading to delayed diagnosis and increased morbidity. [10],[11] In our experiment also, CONS is the most common isolate.

One may argue that draping the tourniquets by sterile drapes may preclude them from being a source of contamination of the operating field. However, the passage of bacteria through fabrics has been identified as a potential source of wound contamination, more so when the fabric is moist. [11],[12]

The Association of Operating Room Nurses (AORN) has recommended that the reusable tourniquets should be cleaned, rinsed and dried between patients according to manufacturer's instructions; more extensive cleaning with tuberculocidal disinfectant is necessary in case of blood or body fluid contamination. [13] Nevertheless, a low-cost, easy and practicable solution to this is sought in our experiment. Savlon (chlorhexidine gluconate and cetrimide) is an antiseptic which is popular because its application to open wounds is painless, unlike other antiseptics which cause burning sensation. Sterillium (2-propanol, 1-propanol, and mecetronium ethyl sulphate) is an alcohol-based disinfectant hand rub, which is widely used in hospitals, dries up faster, and possesses excellent bactericidal, fungicidal, and virucidal properties with very good residual effect. Both these antiseptics proved to lessen the microbial load of these non-sterile tourniquets significantly. Though Sterillium has got a better antiseptic action, Savlon is cheap and easily available. We recommend the routine treatment of orthopaedic tourniquets with a disinfectant, preferably an alcohol-based solution, to reduce the risk of contamination of surgical fields.

 ~ References Top

Datta P, Bansal N, Chander J. Hand-held hazards by health-care workers. Indian J Med Microbiol 2013;31:320-1.  Back to cited text no. 1
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Kennedy KJ, Dreimanis DE, Beckingham WD, Bowden FJ. Staphylococcus aureus and stethoscopes. Med J Aust 2003;178:468.  Back to cited text no. 2
Golder M, Chan CL, O'Shea S, Corbett K, Chrystie IL, French G. Potential risk of cross-infection during peripheral-venous access by contamination of tourniquets. Lancet 2000;355:44.  Back to cited text no. 3
Rourke C, Bates C, Read RC. Poor hospital infection control practice in venepuncture and use of tourniquets. J Hosp Infect 2001;49:59-61.  Back to cited text no. 4
Brennan SA, Walls RJ, Smyth E, Mulla TA, O'Byrne JM. Tourniquets and exsanguinators: A potential source of infection in the orthopaedic operating theatre? Acta Orthop 2009;80:251-5.  Back to cited text no. 5
Saha AK, Haque MF, Karmaker S, Mohanta MK. Antibacterial effects of some antiseptics and disinfectants. J Life Earth Sci 2009;3-4:19-21.  Back to cited text no. 6
Ahmed SM, Ahmad R, Case R, Spencer RF. A study of microbial contamination of orthopaedic tourniquets. Ann R Coll Surg Engl 2009;91:131-4.  Back to cited text no. 7
Walsh EF, Ben-David D, Ritter M, Mechrefe A, Mermel LA, DiGiovanni C. Microbial colonization of tourniquets used in orthopaedic surgery. Orthopedics 2006;29:709-13.  Back to cited text no. 8
Berman DS, Schaefler S, Simberkoff MS, Rahal JJ. Tourniquets and nosocomial methicillin resistant Staphylococcus aureus infections. N Engl J Med 1986;315:514-5.  Back to cited text no. 9
Babcock HM, Matava MJ, Fraser V. Postarthroscopy surgical site infections: Review of the literature. Clin Infect Dis 2002;34:65-71.  Back to cited text no. 10
Blom AW, Gozzard C, Heal J, Bowker K, Estela CM. Bacterial strike through of reusable surgical drapes: The effect of different wetting agents. J Hosp Infect 2002;52:52-5.  Back to cited text no. 11
Laufman H, Siegel JD, Edberg SC. Moist bacterial strike-through of surgical materials: Confirmatory tests. Ann Surg 1979;189:68-74.  Back to cited text no. 12
Association of Operating Room Nurses. Recommended practices for use of the pneumatic tourniquet. AORN J 2002;75:379-86.  Back to cited text no. 13


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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