Abstract
Background: Pre-operative surgical asepsis is essential for preventing surgical site infections (SSI), yet evidence on pre-operative contamination and associated factors in Ugandan operating theatres remains limited. This study assessed the proportion of pre-operative surgical asepsis, the microorganisms involved in contamination, and factors associated with pre-operative contamination at Mbarara Regional Referral Hospital (MRRH), Uganda. Methodology: A hospital-based cross-sectional study was conducted between June and September 2022 among 71 surgical procedures. Four microbiological swabs were collected from each procedure before skin incision, including the patient's surgical site, surgeon glove-gown interface, assistant surgeon glove-gown interface, and Cheatle forceps. Pre-operative surgical asepsis was defined as the absence of pathogenic bacterial growth in all four specimens. Descriptive statistics summarized contamination patterns, while Fisher's exact test assessed factors associated with pre-operative asepsis. Results: Overall pre-operative surgical asepsis was 77.5% (95% CI 66.0–85.9). Staphylococcus aureus was the predominant isolate (16.9%), followed by Klebsiella pneumoniae (7.0%). Cheatle forceps had the highest contamination rate (15.5%), while no contamination occurred at the prepared surgical site. In multivariable analysis, surgeon scrubbing for less than one minute (AOR 6.37, 95% CI 1.03–39.47; p = 0.047) and assistant surgeon open gloving (AOR 9.18, 95% CI 2.25–37.34; p = 0.002) were independently associated with pre-operative contamination. Conclusion: Approximately one in five surgical procedures demonstrated pre-operative contamination, predominantly involving the Cheatle forceps and glove gown interfaces. Staphylococcus aureus was the predominant isolate. Surgeon scrubbing for less than one minute and assistant surgeon open gloving were independently associated with pre-operative contamination. Strengthening adherence to the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) recommended surgical hand preparation duration, closed-gloving techniques, appropriate handling of sterile equipment, and routine microbiological surveillance may improve pre-operative surgical asepsis in resource limited operating theatres.
Keywords
Pre-operative Surgical Asepsis, Surgical Site Infection, Operating Theatre, Bacterial Contamination
1. Background
Pre-operative surgical asepsis (POSA) is the absence of pathogenic microorganisms before an invasive surgical procedure and is a fundamental strategy for preventing surgical site infections (SSIs)
. SSIs remain a major cause of postoperative morbidity and healthcare costs, arising from patient-, procedure-, and health system-related factors
. Consequently, international guidelines emphasize adherence to standardized pre-operative aseptic practices, including instrument sterilization, surgical hand preparation, sterile gowning and gloving, and surgical site antisepsis
.
Proper sterilization of surgical instruments requires standardized cleaning, packaging, autoclaving, storage, and routine quality assurance using biological and chemical indicators
| [5] | Rutala WA, Weber DJ, Healthcare Infection Control Practices Advisory Committee. Guideline for disinfection and sterilization in healthcare facilities, 2008. Updated May 2019. Centers for Disease Control and Prevention 2019,
https://stacks.cdc.gov/view/cdc/134910 |
[5]
. Similarly, surgical hand preparation aims to eliminate transient microorganisms and reduce resident skin flora, thereby minimizing microbial transfer during surgery
. Recommended surgical hand-preparation practices emphasize adequate duration and technique, but compliance remains inconsistent in many low-resource settings
| [8] | World Health Organization. (2009). WHO guidelines on hand hygiene in health care: First global patient safety challenge—Clean care is safer care.
https://www.who.int/publications/i/item/9789241597906 |
| [39] | Ellingson K, Haas JP, Aiello AE, Kusek L, Maragakis LL, Olmsted RN, et al. Strategies to prevent healthcare-associated infections through hand hygiene. Infect Control Hosp Epidemiol. 2014 35(8): 937-960. https://doi.org/10.1086/677145 |
[8, 39]
.
Appropriate surgical site preparation is equally important because most pathogens causing SSIs originate from the patient's endogenous skin flora
| [9] | Darouiche RO, Wall MJ Jr, Itani KMF, Otterson MF, Webb AL, Carrick MM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med. 2010 362(1): 18-26. https://doi.org/10.1056/NEJMoa0810988 |
[9]
. Current WHO guidelines recommend alcohol-based chlorhexidine solutions because of their rapid and sustained antimicrobial activity, although iodine-based preparations remain in use depending on surgical indication, availability, and cost
| [10] | Hemani ML, Lepor H. Skin preparation for the prevention of surgical site infection: which agent is best? Rev Urol. 2009 Fall 11(4): 190-195. |
| [11] | World Health Organization. Global guidelines for the prevention of surgical site infection. Geneva: World Health Organization 2016: https://www.who.int/publications/b/31381 |
[10, 11]
. In addition, contamination during gowning and gloving has been associated with glove-donning technique, with closed gloving consistently demonstrating lower contamination than open gloving
.
Despite established infection prevention guidelines, important gaps remain in many resource-limited hospitals. And although Uganda continues to report a relatively high burden of SSIs, few studies have investigated the extent of microbial contamination occurring before skin incision or evaluated factors associated with inadequate pre-operative surgical asepsis. Previous Ugandan studies have primarily focused on postoperative SSI prevalence and antimicrobial susceptibility patterns rather than contamination occurring within the operating theatre itself
| [15] | Lubega A, Bazira J, Najjuka JL. Incidence and etiology of surgical site infections among emergency postoperative patients in Mbarara Regional Referral Hospital, South Western Uganda. Surg Res Pract. 2017 2017: 6365172.
https://doi.org/10.1155/2017/6365172 |
| [16] | Ariho SB, Lule H, Agwu E, Shaban A. Abdominal surgical site infection incidence, risk factors, and antibiotic susceptibility at a university teaching hospital in western Uganda: a cross-sectional study. East Cent Afr J Surg. 2020 25(4):
https://www.utupub.fi/items/4e38a020-2d95-44da-bb8b-95affc12eadc |
[15, 16]
.
Mbarara Regional Referral Hospital is a major teaching and referral hospital serving southwestern Uganda. The sterility related concerns at the hospital include lack of modern technologies in monitoring the sterilization and storage processes of re-usable equipment such as such as Cheatle forceps which once opened can used for a repeated number of surgical procedures before re-sterilizing it, variable surgical hand preparation practices and surgical site antiseptics, use of non-water proof gowns and patients’ drapes. Thus understanding the magnitude and determinants of pre-operative contamination is essential for strengthening infection prevention and control programs, improving compliance with evidence-based aseptic practices, and ultimately reducing SSI incidence.
Therefore, this study aimed to determine the proportion of adequate pre-operative surgical asepsis, identify bacterial contaminants isolated before skin incision, and determine factors associated with pre-operative contamination among surgical procedures performed at Mbarara Regional Referral Hospital.
2. Methods
2.1. Study Design and Setting
A hospital-based descriptive cross-sectional study was conducted between June and September 2022 in the operating theatre complex of Mbarara Regional Referral Hospital (MRRH), a regional referral and teaching hospital serving southwestern Uganda. The theatre complex comprises five operating rooms providing elective and emergency surgical services across multiple surgical specialties.
2.2. Study Population
The study included adult patients undergoing clean elective or emergency surgical procedures together with their operating surgeons, assistant surgeons, and the Cheatle forceps used during each procedure. Procedures involving contaminated wounds, highly contaminated anatomical sites, or compromised sterile gowns were excluded.
2.3. Sample Size and Sampling
A minimum sample size of 71 surgical procedures was calculated using Daniel's finite population formula with a presumed prevalence of 50%, a 95% confidence level, and a 5% margin of error. Eligible procedures were consecutively enrolled until the required sample size was attained. Four microbiological swabs were collected from each procedure, giving a total of 284 specimens.
2.4. Data Collection
Data were collected using a structured interviewer-administered questionnaire, direct observation of pre-operative aseptic practices, and microbiological specimen collection. A pretested modified Royal College of Surgeons (2014) Good Surgical Practice checklist was used
to assess adherence to standard aseptic procedures. The scrubbing duration for both the surgeons and assistant surgeons was recorded on a digital clock by a member of the research unknown to the participants through unobtrusive observation. Immediately before skin incision, a dry swab was aseptically taken from the prepared surgical site, surgeon glove-gown interface, assistant surgeon glove-gown interface, and a pre-moistened swab from the tip of the shaft of the Cheatle forcep used in the procedure. Specimens were transported in a leak-proof biohazard specimen bag within 15 minutes to the microbiology laboratory for culture and organism identification.
2.5. Study Variables
The primary outcome was pre-operative surgical asepsis, defined as the absence of pathogenic bacterial growth in all four microbiological specimens collected before skin incision. Independent variables included patient characteristics, healthcare provider factors (including hand preparation, gowning and gloving practices), and theatre-related factors.
2.6. Laboratory Procedures
Swab was emulsified in 1ml of sterile saline, which was then introduced into a sterile petri-dish with addition of agar. Once solidified it was incubated at 35–37°C for up to 48 hours. The colonies that appeared were counted and reported as colony forming units per ml then sub-cultured onto blood and MacConkey agar and incubated at 35–37°C for up to 48 hours. A Gram stain procedure was then performed on each colony followed by a catalase test, coagulase test, Dnase test and mannitol fermentation test on Gram positive cocci prior to confirming
Staphylococcus aureus. A citrate test, Indole test, Hydrogen sulfide test, motility test and triple sugar iron tests were performed on gram negative bacilli prior to confirmation of
Klebsiella species. Antimicrobial susceptibility testing was performed using the Kirby–Bauer disk diffusion method according to Clinical and Laboratory Standards Institute (CLSI) guidelines
.
2.7. Data Analysis
Data were entered, cleaned, and analyzed using STATA version 18.0 (StataCorp, College Station, TX, USA). Categorical variables were summarized using frequencies and percentages, while continuous variables were summarized using means with standard deviations or medians with interquartile ranges, as appropriate. Associations between explanatory variables and pre-operative contamination were initially assessed using bivariable logistic regression. Variables with a bivariable p value <0.20 and those considered clinically relevant were entered into a multivariable logistic regression model. Crude odds ratios (CORs) and adjusted odds ratios (AORs) with 95% confidence intervals were reported. Statistical significance was set at p <0.05.
2.8. Data Quality Assurance
Standardized data collection tools, trained research assistants, daily data checks, and standardized laboratory procedures were used to ensure data quality throughout the study.
2.9. Ethical Clearance
We received clearance from the Mbarara University of Science and Technology Research Ethics Committee (MUST-REC IRB) under Approval No. MUST-2022-399 and administrative clearance from the Mbarara Regional Referral Hospital. Written informed consent was obtained from all participants before enrolment, and the study was conducted in accordance with the Declaration of Helsinki as well as the Uganda National Council for Science and Technology (UNCST) guidelines for research involving human participants. The datasets generated and analysed during this study, together with the corresponding STATA do-files, are available from the corresponding author upon reasonable request.
3. Results
3.1. Characteristics of the Study Participants
A total of 71 participants were enrolled in the study, with a mean age of 44.0 ± 19.4 years. Most participants were male (69.0%) and aged ≥50 years (45.1%). The commonest occupation was peasant farming (42.2%). Approximately one third of participants had been ill for less than one week (33.8%) or for more than four weeks (32.4%). Most participants (87.3%) had a pre-operative hospital stay of less than one week and 16.9% underwent pre-operative surgical site shaving.
Table 1. Characteristics of the study participants.
Characteristic | n (%) |
Age group (years) | |
18–29 | 23 (32.4) |
30–49 | 16 (22.5) |
≥50 | 32 (45.1) |
Sex | |
Male | 49 (69.0) |
Female | 22 (31.0) |
Occupation | |
Peasant | 30 (42.2) |
Unemployed | 18 (25.4) |
Manual worker | 9 (12.7) |
Formal employment | 8 (11.2) |
Business | 6 (8.5) |
Duration of illness | |
<1 week | 24 (33.8) |
1–2 weeks | 13 (18.3) |
2–4 weeks | 11 (15.5) |
>4 weeks | 23 (32.4) |
Pre-operative hospital stay | |
<1 week | 62 (87.3) |
≥1 week | 9 (12.7) |
Pre-operative surgical-site shaving | |
Yes | 12 (16.9) |
No | 59 (83.1) |
3.2. Surgical Procedure Characteristics
Most procedures were emergency surgeries (74.7%). Abdominal procedures accounted for the largest proportion of operations (69.0%). Chlorhexidine (0.3% chlorhexidine gluconate, 0.6% cetrimide) was used for surgical-site preparation in 97.2% of procedures, while 5% iodine was used in 2.8%.
Table 2. Surgical procedure characteristics (N=71).
Characteristic | n (%) |
Procedure indication | |
Elective | 18 (25.3) |
Emergency | 53 (74.7) |
Surgical site | |
Abdomen | 49 (69.0) |
Head | 12 (17.0) |
Lower limb | 5 (7.0) |
Chest | 3 (4.2) |
Upper limb | 2 (2.8) |
Skin antiseptic used | |
Chlorhexidine (0.3% chlorhexidine gluconate, 0.6% cetrimide) | 69 (97.2) |
Iodine (5%) | 2 (2.8) |
3.3. Surgeon and Assistant Surgeon Characteristics
Approximately half of both the surgeons and assistant surgeons scrubbed for less than one minute (50.7% and 53.5%, respectively). Medicated soap was the most commonly used antiseptic for surgical hand preparation among surgeons (57.8%) and assistant surgeons (60.6%), while the closed gloving technique was the predominant method in both groups, although it was less frequently used by assistant surgeons (69.0%) than surgeons (84.5%).
Table 3. Surgeon and assistant surgeon characteristics (N=71 in each group).
Characteristic | Surgeons n (%) | Assistant surgeons n (%) |
Scrubbing duration | | |
<1 minute | 36 (50.7) | 38 (53.5) |
1–2 minutes | 35 (49.3) | 33 (46.5) |
Hand antiseptic used | | |
Medicated soap | 41 (57.8) | 43 (60.6) |
Non-medicated soap | 24 (33.8) | 25 (35.2) |
Chlorhexidine (0.3% chlorhexidine gluconate, 0.6% cetrimide) | 5 (7.0) | 3 (4.2) |
Alcohol (70%) | 1 (1.4) | 0 (0.0) |
Scrubbing technique | | |
Mechanical scrub | 70 (98.6) | 71 (100.0) |
Alcohol hand rub only | 1 (1.4) | 0 (0.0) |
Gowning technique | | |
Unassisted gown-first | 71 (100.0) | 71 (100.0) |
Gloving technique | | |
Open | 11 (15.5) | 22 (31.0) |
Closed | 60 (84.5) | 49 (69.0) |
3.4. Pre-operative Asepsis by Sampled Site
Among the 71 surgical procedures, n=55 (77.5%; 95% CI: 66.0–85.9) achieved completely no detectable bacterial growth pre-operative, while n=16 (22.5%) demonstrated bacterial contamination out of which 11 resulted from a single source and 5 from two sources within the same procedure, hence 21 contaminated swabs. The prepared surgical site remained completely aseptic (100%), whereas contamination was highest on the Cheatle forceps (15.5%), followed by the assistant surgeon glove gown interface (8.5%) and surgeon glove gown interface (5.6%).
Table 4. Pre-operative asepsis by sampled site. (N = 71).
Sampled site | Total (N) | Aseptic n (%) | Contaminated n (%) |
Patient surgical site | 71 | 71 (100.0) | 0 (0.0) |
Surgeon glove–gown interface | 71 | 67 (94.4) | 4 (5.6) |
Assistant surgeon glove–gown interface | 71 | 65 (91.5) | 6 (8.5) |
Cheatle forceps | 71 | 60 (84.5) | 11 (15.5) |
Overall | 71 | 55 (77.5) | 16 (22.5) |
3.5. Bacterial Isolates and Distribution by Sampled Site
Among the 71 surgical procedures, bacterial contamination was identified in a total of 16 (22.5%) procedures. Staphylococcus aureus was the predominant contaminant (12/71, 16.9%), followed by Klebsiella pneumoniae (5/71, 7.0%). Most S. aureus isolates were recovered from the Cheatle forceps (12.7%), whereas K. pneumoniae was isolated mainly from the assistant surgeon glove–gown interface (5.6%). Multiple bacterial isolates were recovered from some contaminated procedures, 1 swab had a growth of both S. Areus and K pneumonia making the total number of isolates to exceed the number of contaminated procedures. No bacterial growth was detected from prepared surgical-site swabs.
Table 5. Bacterial isolates and distribution by sampled site.
Organism | Procedures contaminated n (%) | Patient | Surgeon | Assistant surgeon | Cheatle forceps |
Staphylococcus aureus | 12 (16.9) | 0 | 3 (4.2) | 3 (4.2) | 9 (12.7) |
Klebsiella pneumoniae | 5 (7.0) | 0 | 1 (1.4) | 4 (5.6) | 2 (2.8) |
3.6. Antibiotic Susceptibility Profile of Bacterial Isolates
All Staphylococcus aureus and Klebsiella pneumoniae isolates were susceptible to ceftriaxone. Staphylococcus aureus demonstrated complete resistance to penicillin, while variable susceptibility was observed for azithromycin, chloramphenicol, tetracycline, and oxacillin. All K. pneumoniae isolates were susceptible to azithromycin, ciprofloxacin, clindamycin, and ceftriaxone, with reduced susceptibility to tetracycline and chloramphenicol.
Table 6. Antibiotic susceptibility profile of bacterial isolates.
Organism | Antibiotic | Sensitive n (%) | Resistant n (%) |
Staphylococcus aureus (n=12) | Penicillin | 0 (0.0) | 12 (100.0) |
| Azithromycin | 9 (75.0) | 3 (25.0) |
| Ciprofloxacin | 12 (100.0) | 0 (0.0) |
| Clindamycin | 11 (91.7) | 1 (8.3) |
| Ceftriaxone | 12 (100.0) | 0 (0.0) |
| Tetracycline | 10 (83.3) | 2 (16.7) |
| Chloramphenicol | 8 (66.7) | 4 (33.3) |
| Oxacillin | 11 (91.7) | 1 (8.3) |
Klebsiella pneumoniae (n=5) | Azithromycin | 5 (100.0) | 0 (0.0) |
| Ciprofloxacin | 5 (100.0) | 0 (0.0) |
| Clindamycin | 5 (100.0) | 0 (0.0) |
| Ceftriaxone | 5 (100.0) | 0 (0.0) |
| Tetracycline | 4 (80.0) | 1 (20.0) |
| Chloramphenicol | 4 (80.0) | 1 (20.0) |
3.7. Factors Associated with Pre-operative Contamination
In bivariable analysis, surgeon scrubbing for less than one minute (COR 10.50, 95% CI 2.17–50.81; p = 0.003) and assistant surgeon open gloving (COR 13.50, 95% CI 3.60–50.68; p < 0.001) were associated with increased odds of pre-operative contamination. After adjustment, surgeon scrubbing for less than one minute remained associated with approximately six fold higher odds of contamination (AOR 6.37, 95% CI 1.03–39.47; p = 0.047), while assistant surgeon open gloving was associated with approximately ninefold higher odds (AOR 9.18, 95% CI 2.25–37.34; p = 0.002). Assistant surgeon scrubbing duration was not independently associated with contamination (AOR 0.98, 95% CI 0.21–4.57; p = 0.983).
Table 7. Logistic regression analysis of factors associated with pre-operative contamination.
Variable | Crude OR (95% CI) | P-value | Adjusted OR (95% CI) | P-value |
Surgeon scrub duration | | | | |
1–2 minutes | 1.00 | — | 1.00 | — |
<1 minute | 10.50 (2.17–50.81) | 0.003 | 6.37 (1.03–39.47) | 0.047 |
Assistant surgeon scrub duration | | | | |
1–2 minutes | 1.00 | — | 1.00 | — |
<1 minute | 2.28 (0.70–7.44) | 0.171 | 0.98 (0.21–4.57) | 0.983 |
Assistant surgeon gloving technique | | | | |
Closed gloving | 1.00 | — | 1.00 | — |
Open gloving | 13.50 (3.60–50.68) | <0.001 | 9.18 (2.25–37.34) | 0.002 |
4. Discussion
The study shows a 77.5% rate of pre-operative surgical asepsis, indicating that nearly one in five surgical procedures had bacterial contamination before skin incision (22.5% contamination). This contamination rate is comparable to that reported in Palestine
| [19] | Al Laham NA. Prevalence of bacterial contamination in general operating theatres in selected hospitals in the Gaza Strip, Palestine. J Infect Public Health. 2012 5(1): 43-51.
https://doi.org/10.1016/j.jiph.2011.10.006 |
[19]
, but higher than findings from Baghdad
| [18] | Ensayef S, Al-Shalchi S, Sabbar M. Microbial contamination in the operating theatre: a study in a hospital in Baghdad. East Mediterr Health J. 2009 15(1): 219-223.
https://doi.org/10.26719/2009.15.1.219 |
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and lower than those reported in Bangladesh
| [17] | Rahman M, Shamsuzzaman AK, Sirajee A, Miah AG, Hossain MA. Pattern of bacteria and their antimicrobial susceptibility isolated from inanimate objects and hospital personnel. Mymensingh Med J. 2003 12(2): 104-107. |
[17]
. These differences are likely attributable to variations in microbiological sampling methods and operating theatre practices across study settings. The prepared surgical site remained free of bacterial contamination in the present study. This finding is consistent with evidence supporting effective preoperative skin antisepsis, particularly chlorhexidine-alcohol compared with povidone-iodine in clean-contaminated surgery
| [9] | Darouiche RO, Wall MJ Jr, Itani KMF, Otterson MF, Webb AL, Carrick MM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med. 2010 362(1): 18-26. https://doi.org/10.1056/NEJMoa0810988 |
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. In contrast, contamination occurred mainly at the glove-gown interfaces and on Cheatle forceps, emphasizing the importance of theatre personnel practices and reusable sterile equipment as potential sources of pre-operative contamination
| [12] | Fraser JF, Young SW, Valentine KA, Probst NE, Spangehl MJ. The gown-glove interface is a source of contamination: a comparative study. Clin Orthop Relat Res. 2015 473(7): 2291-2297. https://doi.org/10.1007/s11999-014-4094-8 |
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https://doi.org/10.1016/j.jiph.2011.10.006 |
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https://doi.org/10.1007/s12262-014-1116-4 |
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[12, 13, 19, 24, 25]
. And although there was an observed association between the antiseptic agent used by assistant surgeons and bacterial contamination, this should be interpreted cautiously. This finding just identifies a potential relationship within the study setting but does not demonstrate that one antiseptic agent is more effective than another. The observational design, sample size, and possible influence of other aseptic practices limit causal interpretation.
Only two organisms were isolated, Staphylococcus aureus and Klebsiella pneumoniae, with S. aureus predominating. This finding is consistent with reports of staphylococci as important operating-theatre contaminants
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, whereas Matinyi et al. reported Pseudomonas aeruginosa as the predominant organism in operating theatres in eastern Uganda
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[27]
. The difference may reflect variation in sampling sites and inclusion of air and environmental samples. Recovery of K. pneumoniae from glove-gown interfaces may indicate transient contamination associated with inadequate hand preparation, while its previous identification among postoperative SSI pathogens at MRRH provides local microbiological context
.
All isolates in the present study were susceptible to ceftriaxone. However, because only a small number of isolates were recovered, this finding should not by itself be interpreted as evidence that ceftriaxone should be used as the preferred prophylactic agent. Local studies have documented susceptibility of postoperative wound isolates to ceftriaxone while also demonstrating substantial antimicrobial resistance, supporting continued surveillance and antimicrobial stewardship
| [15] | Lubega A, Bazira J, Najjuka JL. Incidence and etiology of surgical site infections among emergency postoperative patients in Mbarara Regional Referral Hospital, South Western Uganda. Surg Res Pract. 2017 2017: 6365172.
https://doi.org/10.1155/2017/6365172 |
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.
Assistant surgeon open gloving was the strongest independent predictor of pre-operative contamination, increasing the adjusted odds approximately ninefold compared with closed gloving. This association is biologically plausible because the glove-gown interface is recognized as a potential contamination pathway
| [12] | Fraser JF, Young SW, Valentine KA, Probst NE, Spangehl MJ. The gown-glove interface is a source of contamination: a comparative study. Clin Orthop Relat Res. 2015 473(7): 2291-2297. https://doi.org/10.1007/s11999-014-4094-8 |
[12]
. Experimental studies have also demonstrated differences in gown contamination according to glove-donning technique, including lower contamination with closed techniques and very low contamination with gloves-first approaches in specific experimental settings
. The results therefore support strengthening closed gloving practice among assistant surgeons.
Greater contamination was initially observed among assistant surgeons using non-medicated soap, but this factor was not identified as an independent predictor in the final multivariable model. The finding should therefore be interpreted as an unadjusted observation rather than evidence of an independent effect. Nthumba et al. found no clinically significant difference in SSI between plain soap and water and alcohol-based handrub when appropriate preparation protocols were used
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[29]
. Evidence also supports alcohol-based preparations as effective alternatives to conventional surgical hand scrubbing under appropriate conditions
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https://doi.org/10.1001/jama.288.6.722 |
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https://doi.org/10.1177/175045891202200205 |
| [34] | Shen NJ, Pan SC, Sheng WH, Tien KL, Chen ML, Chang SC, et al. Comparative antimicrobial efficacy of alcohol-based hand rub and conventional surgical scrub in a medical center. J Microbiol Immunol Infect. 2015 48(3): 322-328.
https://doi.org/10.1016/j.jmii.2013.08.005 |
[30-34]
.
Surgeon scrubbing for less than one minute independently increased the odds of pre-operative contamination approximately sixfold. This observed higher frequency of contamination among participants may indicate a potential relationship between scrub duration and aseptic outcomes. This finding is consistent with experimental evidence showing that surgical hand-scrub duration influences subsequent bacterial counts
| [35] | Wheelock SM, Lookinland S. Effect of surgical hand scrub time on subsequent bacterial growth. AORN J. 1997 65(6): 1087-1098. https://doi.org/10.1016/S0001-2092(06)62949-9 |
| [36] | Jones D. A 2 minute surgical hand scrub was associated with higher, but not clinically significant, bacteria counts compared with a 3 minute hand scrub. Evid Based Nurs. 1998 1(2): 47. https://doi.org/10.1136/ebn.1.2.47 |
| [38] | Aksoy A, Caglayan F, Cakmak M, Apan T, Gocmen J, Cakmak A, et al. An investigation of the factors that affect surgical hand disinfection with povidone-iodine. J Hosp Infect. 2005 61(1): 15-19. https://doi.org/10.1016/j.jhin.2004.11.021 |
[35, 36, 38]
, while systematic evidence indicates that surgical hand antisepsis practices and their duration can affect microbial burden and SSI prevention
. The absence of visible timing devices at the scrub stations may have contributed to poor adherence hence representing a simple, modifiable barrier to compliance with recommended surgical hand preparation. In contrast, assistant surgeon scrub duration was not independently associated with contamination after adjustment, suggesting that its crude relationship may have been explained by gloving technique or other correlated practices. The adjusted estimates had wide confidence intervals, particularly for surgeon scrubbing duration, reflecting the small number of contaminated procedures. The magnitude of these associations should therefore be interpreted cautiously and confirmed in larger multicentre studies because this study was not designed to establish an optimal scrub duration, and the limited representation of longer preparation times hence preventing meaningful comparisons of extended protocols. Therefore, the findings should not be interpreted as establishing a minimum effective or optimal duration.
Strengths and limitations
This study is among the few Ugandan studies to combine direct observation of operating theatre practices with microbiological confirmation of pre-operative contamination. Standardized laboratory procedures and validated data collection tools strengthened the reliability of the findings. However, the cross-sectional single-centre design limits causal inference and generalizability, and postoperative follow-up was not undertaken to determine subsequent surgical site infections. There might have been an Observer effects (Hawthorne effect) which may have influenced participants’ practices, and adherence to aseptic procedures leading to overestimation of routine adherence to aseptic procedures and an underestimation of contamination. This was minimized, by the switching of research assistants and the researchers making frequent visits to the operating theatre to familiarize participants with their presence. The detection of contamination depended on the culture-based methods used to collect and analyze the specimens which might have been affected by specimen collection, transport and processing, microbial load, culture media, and incubation conditions. And the study focused on bacterial contaminants, hence other microbes such as fungi, and viruses may have been missed thus underestimating the full range of microbial contamination. The study could not establish whether the organisms recovered from the different sampling sites shared a common source or it was transmitted between sites.
5. Conclusion and Recommendations
Pre-operative surgical asepsis was achieved in most procedures; however, approximately one in five demonstrated bacterial contaminations, predominantly involving Cheatle forceps and glove–gown interfaces. Staphylococcus aureus was the predominant isolate. Surgeon scrubbing for less than one minute and assistant surgeon open gloving were independently associated with contamination. Strengthening adherence to recommended surgical hand-preparation duration, closed gloving, appropriate sterile-equipment handling and routine microbiological surveillance may improve operating theatre asepsis. Larger prospective multicentre studies incorporating postoperative SSI surveillance are needed to confirm these findings.
Abbreviations
POSA | Pre-Operative Surgical Asepsis |
SSIs | Surgical Site Infections |
WHO | World Health Organization |
CDC | Centers for Disease Control and Prevention |
MRRH | Mbarara Regional Referral Hospital |
CLSI | Clinical and Laboratory Standards Institute |
MUST-REC | Mbarara University of Science and Technology Research Ethics Committee |
UNCST | Uganda National council for Science and Technology |
Acknowledgments
We express our sincere gratitude to the healthcare workers at Mbarara Regional Referral Hospital for their participation and cooperation during data collection. We also extend our appreciation to the Mbarara University of Science and Technology Research Ethics Committee for their guidance and ethical oversight throughout the study.
Author Contributions
Edwin Onsongo Ondicho: Conceptualization, Data curation, Writing – original draft
Yakobo Nsubuga: Formal Analysis, Writing – original draft, Writing – review & editing
Joel Bazira: Conceptualization, Resources, Supervision, Writing – review & editing
Daniel Kisitu Kyengera: Conceptualization, Data curation, Supervision, Writing – original draft, Writing – review & editing
Conflicts of Interest
The authors declare no conflicts of interest.
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APA Style
Ondicho, E. O., Nsubuga, Y., Bazira, J., Kyengera, D. K. (2026). Pre-Operative Surgical Asepsis and Associated Factors in Operating Theatres at a Tertiary Hospital in Southwestern Uganda: A Cross-Sectional Study. European Journal of Clinical and Biomedical Sciences, 12(4), 67-76. https://doi.org/10.11648/j.ejcbs.20261204.12
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Ondicho, E. O.; Nsubuga, Y.; Bazira, J.; Kyengera, D. K. Pre-Operative Surgical Asepsis and Associated Factors in Operating Theatres at a Tertiary Hospital in Southwestern Uganda: A Cross-Sectional Study. Eur. J. Clin. Biomed. Sci. 2026, 12(4), 67-76. doi: 10.11648/j.ejcbs.20261204.12
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AMA Style
Ondicho EO, Nsubuga Y, Bazira J, Kyengera DK. Pre-Operative Surgical Asepsis and Associated Factors in Operating Theatres at a Tertiary Hospital in Southwestern Uganda: A Cross-Sectional Study. Eur J Clin Biomed Sci. 2026;12(4):67-76. doi: 10.11648/j.ejcbs.20261204.12
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@article{10.11648/j.ejcbs.20261204.12,
author = {Edwin Onsongo Ondicho and Yakobo Nsubuga and Joel Bazira and Daniel Kisitu Kyengera},
title = {Pre-Operative Surgical Asepsis and Associated Factors in Operating Theatres at a Tertiary Hospital in Southwestern Uganda: A Cross-Sectional Study},
journal = {European Journal of Clinical and Biomedical Sciences},
volume = {12},
number = {4},
pages = {67-76},
doi = {10.11648/j.ejcbs.20261204.12},
url = {https://doi.org/10.11648/j.ejcbs.20261204.12},
eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ejcbs.20261204.12},
abstract = {Background: Pre-operative surgical asepsis is essential for preventing surgical site infections (SSI), yet evidence on pre-operative contamination and associated factors in Ugandan operating theatres remains limited. This study assessed the proportion of pre-operative surgical asepsis, the microorganisms involved in contamination, and factors associated with pre-operative contamination at Mbarara Regional Referral Hospital (MRRH), Uganda. Methodology: A hospital-based cross-sectional study was conducted between June and September 2022 among 71 surgical procedures. Four microbiological swabs were collected from each procedure before skin incision, including the patient's surgical site, surgeon glove-gown interface, assistant surgeon glove-gown interface, and Cheatle forceps. Pre-operative surgical asepsis was defined as the absence of pathogenic bacterial growth in all four specimens. Descriptive statistics summarized contamination patterns, while Fisher's exact test assessed factors associated with pre-operative asepsis. Results: Overall pre-operative surgical asepsis was 77.5% (95% CI 66.0–85.9). Staphylococcus aureus was the predominant isolate (16.9%), followed by Klebsiella pneumoniae (7.0%). Cheatle forceps had the highest contamination rate (15.5%), while no contamination occurred at the prepared surgical site. In multivariable analysis, surgeon scrubbing for less than one minute (AOR 6.37, 95% CI 1.03–39.47; p = 0.047) and assistant surgeon open gloving (AOR 9.18, 95% CI 2.25–37.34; p = 0.002) were independently associated with pre-operative contamination. Conclusion: Approximately one in five surgical procedures demonstrated pre-operative contamination, predominantly involving the Cheatle forceps and glove gown interfaces. Staphylococcus aureus was the predominant isolate. Surgeon scrubbing for less than one minute and assistant surgeon open gloving were independently associated with pre-operative contamination. Strengthening adherence to the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) recommended surgical hand preparation duration, closed-gloving techniques, appropriate handling of sterile equipment, and routine microbiological surveillance may improve pre-operative surgical asepsis in resource limited operating theatres.},
year = {2026}
}
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TY - JOUR
T1 - Pre-Operative Surgical Asepsis and Associated Factors in Operating Theatres at a Tertiary Hospital in Southwestern Uganda: A Cross-Sectional Study
AU - Edwin Onsongo Ondicho
AU - Yakobo Nsubuga
AU - Joel Bazira
AU - Daniel Kisitu Kyengera
Y1 - 2026/11/06
PY - 2026
N1 - https://doi.org/10.11648/j.ejcbs.20261204.12
DO - 10.11648/j.ejcbs.20261204.12
T2 - European Journal of Clinical and Biomedical Sciences
JF - European Journal of Clinical and Biomedical Sciences
JO - European Journal of Clinical and Biomedical Sciences
SP - 67
EP - 76
PB - Science Publishing Group
SN - 2575-5005
UR - https://doi.org/10.11648/j.ejcbs.20261204.12
AB - Background: Pre-operative surgical asepsis is essential for preventing surgical site infections (SSI), yet evidence on pre-operative contamination and associated factors in Ugandan operating theatres remains limited. This study assessed the proportion of pre-operative surgical asepsis, the microorganisms involved in contamination, and factors associated with pre-operative contamination at Mbarara Regional Referral Hospital (MRRH), Uganda. Methodology: A hospital-based cross-sectional study was conducted between June and September 2022 among 71 surgical procedures. Four microbiological swabs were collected from each procedure before skin incision, including the patient's surgical site, surgeon glove-gown interface, assistant surgeon glove-gown interface, and Cheatle forceps. Pre-operative surgical asepsis was defined as the absence of pathogenic bacterial growth in all four specimens. Descriptive statistics summarized contamination patterns, while Fisher's exact test assessed factors associated with pre-operative asepsis. Results: Overall pre-operative surgical asepsis was 77.5% (95% CI 66.0–85.9). Staphylococcus aureus was the predominant isolate (16.9%), followed by Klebsiella pneumoniae (7.0%). Cheatle forceps had the highest contamination rate (15.5%), while no contamination occurred at the prepared surgical site. In multivariable analysis, surgeon scrubbing for less than one minute (AOR 6.37, 95% CI 1.03–39.47; p = 0.047) and assistant surgeon open gloving (AOR 9.18, 95% CI 2.25–37.34; p = 0.002) were independently associated with pre-operative contamination. Conclusion: Approximately one in five surgical procedures demonstrated pre-operative contamination, predominantly involving the Cheatle forceps and glove gown interfaces. Staphylococcus aureus was the predominant isolate. Surgeon scrubbing for less than one minute and assistant surgeon open gloving were independently associated with pre-operative contamination. Strengthening adherence to the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) recommended surgical hand preparation duration, closed-gloving techniques, appropriate handling of sterile equipment, and routine microbiological surveillance may improve pre-operative surgical asepsis in resource limited operating theatres.
VL - 12
IS - 4
ER -
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