İntravitreal enjeksiyon odası ile günübirlik ameliyathane odasının hava kalitesinin ve mikrobiyal yükünün değerlendirilmesi

Amaç: İntravitreal enjeksiyonlar oftalmolojide sık kullanılan tedavi yöntemlerinden biri olmakla beraber görme kaybı ile sonuçlanabilen ciddi enfeksiyonlara neden olabilir. Çalışmamızda, intravitreal enjeksiyonların yapıldığı intravitreal enjeksiyon odası (İEO) ile günübirlik ameliyathane odasının (GAO) partikül, ventilasyon ve mikrobiyal yükünün değerlendirilmesi amaçlanmıştır. Yöntem: İEO ve GAO için ısıtma, havalandırma ve hava durumu “Heating Ventilating and Air Conditioning” (HVAC) performans test sonuçları incelenmiştir. Filtrelerin hava akış ve debileri balometre cihazı ile tespit edilmiştir. Bu ölçüm için filtre boyutlarına uygun başlıklar kullanılmıştır. Ortamların sıcaklık ve nemi, termo higrometre cihazı ile ölçülmüştür. Mikrobiyolojik kontaminasyon, pasif örnek toplama yöntemiyle ortam kültürleri alınarak değerlendirilmiştir. Bu amaçla yerden bir metre yüksekte ve enjeksiyon alanından bir metre uzakta masa üzerine eozin metilen mavisi (EMB) agar, kanlı agar ve Sabouraud %2 dekstroz agar besiyerleri bir saat boyunca açık bırakılmıştır. İnkübasyon sonrası üreyen kolonilerin tanımlanması yapılarak benzer koloniler sayılmıştır. Koloni sayısına göre ortamın metreküpünde mikrobiyal yükünün belirlenmesinde Omeliansky’s formülü kullanılmış ve sonuç, koloni oluşturan ünite (cfu/m3) olarak bildirilmiştir. Bulgular: Metreküpte 0,5 μm büyüklüğündeki partikül sayısı İEO’da 6.350.606, GAO’da ise 85.648 olarak tespit edilmiştir. Saatte hava değişim oranı “Air Change per/hour’’ (ACH) ve “International Organization for Standardization” (ISO) sınıfı, İEO için sırasıyla 2.0 ve ISO 9 olarak bulunurken, GAO için 56.2 ve ISO 7 olarak saptanmıştır. Ortamdaki bakteriyal yoğunluk İEO’da 484.86 cfu/m3 olarak oldukça yüksek saptanırken, GAO’da 65.11 cfu/m3 olarak bulunmuştur. İEO ve GAO’da Staphylococcus epidermidis, Pantoea spp. ve Enterobacter cloacae üremiş olup fungal patojen üremediği tespit edilmiştir. Sonuç: İEO, GAO’ya göre enfeksiyon açısından daha riskli olarak saptanmıştır. İntravitreal enjeksiyonlarda, lokal antisepsi kurallarına sıkı uyum, ultraviyole lambalarının enjeksiyon yapılmadığı zamanlarda açık tutulması ve göz içi enjeksiyonun yapılacağı ortamlarda saatteki hava değişim oranının yüksek olması çok önemlidir. Enfeksiyon gelişimini önlemek açısından intravitreal enjeksiyonların, özel olarak tasarlanmış pozitif basınçlı odalarda yapılması çok daha güvenli olacaktır.

Evaluation of air quality and microbial tests of the intravitreal injection room and the outpatient operating room

Objective: Intravitreal injections are one of the most commonly used treatment methods in ophthalmology, but they can cause serious infections that may result in vision loss. In our study, it was aimed to evaluate the particle, ventilation and microbial load of the intravitreal injection room (IVIR) and the outpatient operating room (OPR) where intravitreal injections were performed. Methods: Heating Ventilating and Air Conditioning (HVAC) performance test results for IVIR and OPR were examined. The air flow and flow rates of the filters were determined with a balometer device. For this measurement, hood suitable for filter sizes were used. The temperature and humidity of the environments were measured with a thermo-hygrometer device. Microbiological contamination was assessed by obtaining media cultures using the passive sample collection method. For this purpose, eosin methylene blue (EMB), blood agar and Sabouraud 2% dextrose agar medium petri dishes were left open for one hour on the table one meter above the ground and one meter away from the injection site. Colonies that reproduced after incubation were identified and similar colonies were counted. By using Omeliansky’s formula to determine the microbial load per cubic meter of medium according to the number of colonies, the result was reported as colony forming units (cfu/m3). Results: The number of 0.5 μm particles per cubic meter was determined as 6,350,606 in the IVIR and 85,648 in the OPR. ACT and the “International Organization for Standardization” (ISO) class were found to be 2.0 and ISO 9 for IVIR, respectively, while 56.2 and ISO 7 for OPR. The bacterial density in the medium was found to be quite high as 484.86 cfu/m3 in IVIR, while it was found as 65.11 cfu/m3 in OPR. Staphylococcus epidermidis , Pantoea spp. and Enterobacter cloacae were grown in IVIR and OPR, and no fungal pathogens were detected. Conclusion: IVIR was found to be risky in terms of infection according to OPR. In intravitreal injections, it is very important to comply with the local antisepsis rules, keep the ultraviolet lamps on when the injection is not made, and have a high rate of air change per hour in the environments where the intraocular injection will be made. It will be much safer to make intravitreal injections in specially designed positive pressure rooms in order to prevent the development of infection.

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1. Bande MF, Mansilla R, Pata MP, Fernández M, Blanco-Teijeiro MJ, Piñeiro A, et al. Intravitreal injections of anti-VEGF agents and antibiotic prophylaxis for endophthalmitis: a systematic review and meta-analysis. Sci. Rep, 2017;7(1): 1-6.
2. Doshi RR, Bakri SJ, Fung AE. Intravitreal injection technique. Semin Ophthalmol, 2011; 26(3):104-13. 3. Fagan XJ, Al-Qureshi S. Intravitreal injections: a review of the evidence for best practice. Clin Exp Ophthalmol, 2013;41(5):500-7.
4. Cheung CS, Wong AW, Lui A, Kertes PJ, Devenyi RG, Lam W-C. Incidence of endophthalmitis and use of antibiotic prophylaxis after intravitreal injections. Ophthalmology, 2012;119(8):1609-14.
5. Bhavsar AR, Sandler DR. Eliminating antibiotic prophylaxis for intravitreal injections: a consecutive series of 18,839 injections by a single surgeon. Retina, 2015;35(4):783-8.
6. Nentwich MM, Yactayo-Miranda Y, Schwarzbach F, Wolf A, Kampik A, de Kaspar HM. Endophthalmitis after intravitreal injection: decreasing incidence and clinical outcome-8-year results from a tertiary ophthalmic referral center. Retina, 2014;34(5):943-50.
7. Shimada H, Hattori T, Mori R, Nakashizuka H, Fujita K, Yuzawa M. Minimizing the endophthalmitis rate following intravitreal injections using 0.25% povidone–iodine irrigation and surgical mask. Graefes Arch Clin Exp Ophthalmol, 2013;251(8):1885-90.
8. Mithal K, Mathai A, Pathengay A, Jalali S, Relhan N, Motukupally SR, et al. Endophthalmitis following intravitreal anti-VEGF injections in ambulatory surgical centre facility: incidence, management and outcome. Br J Ophthalmol, 2013;97(12):1609- 12.
9. Brynskov T, Kemp H, Sørensen TL. No cases of endophthalmitis after 20,293 intravitreal injections in an operating room setting. Retina, 2014;34(5):951-7.
10. Merani R, Hunyor AP. Endophthalmitis following intravitreal anti-vascular endothelial growth factor (VEGF) injection: a comprehensive review. Int J Retin Vitr, 2015;1(1): 1-19.
11. Lau PE, Jenkins KS, Layton CJ. Current evidence for the prevention of endophthalmitis in anti- VEGF intravitreal injections. J Ophthalmol, 2018;8567912:1-8.
12. Deutsche Norm . DIN 1946-4: 2008-12. Ventilation and air conditioning—part 4. Access date: 27 May 2021. Available from:https://kupdf.net/download/ din-din-1946-4_5c4ca74ce2b6f5a63fb94916_pdf.
13. EN ISO 14644-1:2015. Cleanrooms and associated controlled environments - Part 1: Classification of air cleanliness by particle concentration. Geneva: International Organization for Standardization. 2015.
14. EN ISO 14644-2:2015. Cleanrooms and associated controlled environments — Part 2: Monitoring to provide evidence of cleanroom performance related to air cleanliness by particle concentration. Geneva: International Organization for Standardization. 2015.
15. EN ISO 14644-3:2019. Cleanrooms and associated controlled environments - Part 3: Test methods. Geneva: International Organization for Standardization. 2019.
16. 1822-1 ESE. High efficiency air filters (EPA, HEPA and ULPA) - Part 1: Classification, performance testing, marking 2009. Access date: 12 June 2021. Available from: https://weerhuisje.eu/ pdf/EN1822-1-2009_Highefficiencyairfilters_EPA_ HEPA_ULPA_Part1_Classification_performance. pdf.
17. Hava Filtresi Çeşitleri Nelerdir ve Filtre Seçimi Nasıl Yapılır? http://eximany.com/tr/post/hava- filtresi-cesitleri-nelerdir-ve-filtre-secimi-nasil- yapilir. Erişim Tarihi: 01Temmuz 2021.
18. Hayleeyesus SF, Manaye AM. Microbiological quality of indoor air in University Libraries. Asian Pac. J. Trop. Biomed, 2014;4:S312-S7.
19. Federal Standard 209E: Airborne Particulate Cleanliness Classes in Cleanrooms and Clean Zones. Inst of Environmental Sciences. 1992. Access date: 18 June 2021. Available from: http://www.iaqtechnology.com.my/site%20 document/FEDERAL%20STANDARD%20209E%20 FOR%20CLEANROOM%20-%20AN%20OBSOLETE%20 DOCUMENT!.pdf.
20. BS 5295-1:1989. Environmental Cleanliness in Enclosed Spaces Part 1: Specification for Clean Rooms and Clean Air Devices. UK: British Standards Institution. 1989.
21. Lapid-Gortzak R, Traversari R, van der Linden JW, Oberstein SYL, Lapid O, Schlingemann RO. Mobile ultra-clean unidirectional airflow screen reduces air contamination in a simulated setting for intra- vitreal injection. Int Ophthalmol, 2017;37(1):131- 7.
22. Dharan S, Pittet D. Environmental controls in operating theatres. J Hosp Infect, 2002;51(2):79- 84.
23. Kırbaş C. Ameliyathanelerde basınç ve hava akışı uygulaması. IX. Ulusal Tesisat Mühendisliği Kongresi. 06-09 Mayıs, İzmir -Türkiye. 2009.
24. Shaw LF, Chen IH, Chen CS, Wu HH, Lai LS, Chen YY, et al. Factors influencing microbial colonies in the air of operating rooms. BMC Infect Dis, 2018;18(1):1-8.
25. Tabandeh H, Boscia F, Sborgia A, Ciracì L, Dayani P, Mariotti C, et al. Endophthalmitis associated with intravitreal injections: office-based setting and operating room setting. Retina, 2014;34(1):18-23.
26. Xing L, Dorrepaal SJ, Gale J. Survey of intravitreal injection techniques and treatment protocols among retina specialists in Canada. Can. J. Ophthalmol, 2014;49(3):261-6.
27. Samia-Aly E, Cassels-Brown A, Morris DS, Stancliffe R, Somner JE. A survey of UK practice patterns in the delivery of intravitreal injections. Ophthalmic Physiol Opt, 2015;35(4):450-4.
28. Dossarps D, Bron AM, Koehrer P, Aho-Glélé LS, Creuzot-Garcher C. Endophthalmitis after intravitreal injections: incidence, presentation, management, and visual outcome. Am J Ophthalmol, 2015;160(1):17-25.e1.
29. Lidwell O, Lowbury E, Whyte W, Blowers R, Stanley S, Lowe D. Effect of ultraclean air in operating rooms on deep sepsis in the joint after total hip or knee replacement: a randomised study. Br Med J (Clin Res Ed), 1982;285(6334):10-4.
30. Seal D, Clark R. Electronic particle counting for evaluating the quality of air in operating theatres: a potential basis for standards? J Appl Microbiol, 1990;68(3):225-30.
31. Freiberg FJ, Brynskov T, Munk MR, Sørensen TL, Wolf S, Wirth MA, et al. Low endophthalmitis rates after intravitreal anti-vascular endothelial growth factor injections in an operation room: a retrospective multicenter study. Retina, 2017;37(12):2341-6.
32. Pasquarella C, Vitali P, Saccani E, Manotti P, Boccuni C, Ugolotti M, et al. Microbial air monitoring in operating theatres: experience at the University Hospital of Parma. J Hosp Infect, 2012;81(1):50-7.
33. Landrin A, Bissery A, Kac G. Monitoring air sampling in operating theatres: can particle counting replace microbiological sampling? J Hosp Infect, 2005;61(1):27-9.