170 • JID 2005:192 (1 July) • Kainer et al.
M A J O R A R T I C L E
Saline-Filled Breast Implant Contamination
with
Curvularia
Species among Women
Who Underwent Cosmetic Breast Augmentation
Marion A. Kainer,1,2,5,aHoma Keshavarz,1,4Bette J. Jensen,2Matthew J. Arduino,2Mary E. Brandt,3Arvind A. Padhye,3William R. Jarvis,2,band Lennox K. Archibald2,a
1Epidemic Intelligence Service, Division of Applied Public Health Training, Epidemiology Program Office, and Divisions of2Healthcare Quality Promotion,3Bacterial and Mycotic Diseases, and4Public Health Surveillance and Informatics, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia;5Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
Background. During December 2000–July 2001, black sediment was noted in saline-filled silicone breast
implants of women who had undergone revision surgery at facility A.Curvulariafungus was isolated from implant
saline.
Methods. To identify risk factors for contamination with Curvularia species, we performed case-control, retrospective cohort, and laboratory studies and conducted procedural reviews. A case patient was defined as any woman who underwent revision surgery at facility A between January 2000 and June 2001 and had black sediment in her implants.
Results. Five patients met the case definition. Contamination was associated with having had surgery performed
in operating room (OR) 2 (4/88 vs. 1/140;Pp.07) and a longer duration of surgery (P!.001). A longer duration
spent in the OR was an additional risk factor (Pp.005).Curvulariafungus was isolated from the sterile supply
room, where saline bottles had been stored under a water-damaged ceiling, and from the corridor outside OR 2; it was also found more commonly from facility A personnel than from non–facility A personnel (12/34 vs. 4/60; ). Saline was warmed in a cabinet opposite OR 2, which was maintained at negative pressure differentials, P!.001
then was poured into bowls open to the OR 2 environment before injection into implants.
Conclusion. Surgeons should always use closed systems to inflate breast implants. Surgery center infection control measures must include moisture control and balanced ventilation systems.
During 2000, 187,755 women underwent cosmetic breast augmentation (CBA) surgery in the United States, an increase of 476% compared with 1992 [1, 2]. Most aug-mentations (94%) used saline-filled silicone shell pros-thetic breast implants (SALBIs) [1]. Recognized compli-cations with SALBIs include leakage, capsular contracture, and infection [3]. The incidence of infection after CBA
surgery is!2% [4–7], and there have been few case reports
of fungal contamination of SALBIs [8–10]. In this article,
Received 20 September 2004; accepted 28 January 2005; electronically pub-lished 18 May 2005.
a
Present affiliations: Tennessee Department of Health, Nashville, Tennessee (M.A.K.); Regeneration Technologies, Inc., Alachua, Florida (L.K.A.).
b
W.R.J. is now retired and in private practice.
Reprints or correspondence: Dr. Marion A. Kainer, Tennessee Dept. of Health, 4th Fl., Cordell Hull Bldg., 425 5th Ave. N, Nashville, TN 37247 (marion.kainer@ state.tn.us).
The Journal of Infectious Diseases 2005; 192:170–7
2005 by the Infectious Diseases Society of America. All rights reserved. 0022-1899/2005/19201-0024$15.00
we describe an investigation of an outbreak ofCurvularia
species contamination of SALBIs of women who had un-dergone CBA surgery.
From 22 December 2000 through 21 July 2001, mac-roscopically visible black sediment was noted in the SALBIs in 5 women who had undergone revision
sur-gery and SALBI removal.Curvulariafungus, a
fast-grow-ing dematiaceous fungus commonly found in soil, was cultured from the implant fluid in all 5 women. Two surgeons (surgeons X and Y) performed CBA
proce-Presented in part: 40th Annual Meeting of the Infectious Diseases Society of America, Chicago, 24–27 October 2002 (abstract 416).
Financial support: The investigation upon which this study is based was conducted while the authors were employees of the Centers for Disease Control and Prevention. The US Public Health Service underwrote all funding for this investigation.
Since submitting this manuscript, M.A.K. has provided professional clarification and interpretation on the results of this investigation to attorneys involved in pending court cases regarding this incident.
The use of trade names is for identification only and does not imply endorsement by the US Public Health Service or the US Department of Health and Human Services.
dures at a freestanding ambulatory surgical facility (facility A) and at medical center B, located 2 miles away. Surgeon X had performed all 5 initial CBAs at facility A during 1 June–12 Sep-tember 2000. When preliminary investigations by facility A per-sonnel did not identify a source of contamination, the Centers for Disease Control and Prevention (CDC) was invited to assist in an investigation. We report the findings of the outbreak in-vestigation conducted in July–August 2001, which identified the
source and risk factors for contamination withCurvularia
spe-cies, and provide recommendations for the prevention of fungal contamination of operating rooms and SALBIs and future sim-ilar outbreaks.
PATIENTS AND METHODS
To identify risk factors for contamination of SALBIs with
Cur-vulariaspecies, we conducted analytic epidemiologic (case-con-trol and retrospective cohort) studies, review of practices and procedures at facility A, and laboratory studies.
Case Definition and Ascertainment
A case patient was defined as any woman with macroscopic
fungal contamination of ⭓1 of her SALBIs who previously
underwent CBA surgery at facility A between 1 January 2000 and 28 June 2001. To ascertain case patients, we interviewed surgical and operating room (OR) staff and reviewed micro-biology laboratory and patient medical records.
Epidemiologic Studies
Case-control study. A control patient was defined as a woman with 2 macroscopically clear SALBIs, as determined by direct visual inspection during revision surgery at facility A or medical center B. Both case and control patients had to have had a revision of a previous CBA procedure. Factors assessed included patient demographic data; indication for surgery; date, time, and duration of the surgical procedure; incision site; type of SALBI (manufacturer, lot number, style, and size); volume of saline injected; OR; operating staff; ancillary OR staff; and se-verity of illness, as measured by the American Society of An-esthesiologists (ASA) score. “OR time” was defined as the in-terval between arrival in the OR and incision closure.
Cohort study. Because the risk for fungal contamination might have been present only during May–September 2000 (i.e., the cohort study period), we conducted a cohort study of women whose original CBA surgery was performed by surgeon X dur-ing this period. Women who had had SALBIs but did not undergo revision surgery and remained asymptomatic were deemed noncase patients. We recognized a priori that misclas-sifying case patients as presumed noncase patients would bias our findings toward the null hypothesis that there was no dif-ference between case and noncase patients. Because of this
lim-itation, we also considered the direction and magnitude of statistical associations.
Review of Practices and Procedures
Surgical procedures and practice review. We interviewed the surgeons and OR ancillary staff and observed a CBA procedure performed by surgeon X. We reviewed facility A’s architectural plans and inspected the entire facility. We traced and recorded the path through which saline bottles and packaged SALBIs were transferred from storage in the sterile supply room to the OR.
Health care worker assessment and survey. We adminis-tered a questionnaire to facility A clinical and nonclinical staff. Information collected included history of sinus or skin prob-lems, fungal infections, use of artificial fingernails, and exposure to plants or soil. We also examined the hands and fingernails of facility A staff.
Facility A Review
We reviewed the layout of the ORs at facility A. In addition, we inspected the heating, ventilation, and air conditioning (HVAC) systems and the air duct interiors on 6 August 2001. We reviewed available engineering, general, and preventive maintenance re-cords and specifications of the HVAC unit at facility A. Flutter strips were used to verify the direction of airflow from ORs to the corridor.
Microbiologic Studies
Personnel cultures. In August 2001, we cultured nasal mucus, fingernail clippings, and hands (by the Handiwipe method [11]) of facility A personnel. To determine the prevalence of nasal
colonization byCurvulariaspecies in this region of the United
States, we obtained cultures from OR personnel at medical cen-ter B, none of whom had worked at facility A during the pre-ceding 12 months.
To establish whether colonized facility A staff could
poten-tially shedCurvulariafungus, we placed settle plates at
oper-ating-table height in a small, designated room at another facility and left them for 20 min with the room empty. Next, the procedure was repeated with a person in the room; new settle plates were placed in the same format and for the same du-ration, within a 3-foot radius of the person being assessed.
Environmental cultures. In August 2001, we obtained tar-geted surface cultures of the sterile supply room, saline bottles, a saline bottle warmer, inlet and outlet ventilation grilles, air duct interiors, and moist or water-damaged walls and ceilings. We cultured water condensate specimens from OR portable dehu-midifiers. Settle plates were placed in the sterile supply room and the saline warmer for 20 min. Air sampling was performed using an air sampler (SAS Super 90; International PBI).
172 • JID 2005:192 (1 July) • Kainer et al.
Statistical Analysis
Data were collected on standardized forms and analyzed us-ing Epi Info (version 6.04; CDC) and SAS statistical software
(version 6.12; SAS Institute). Thex2test or Fisher’s exact test,
where appropriate, was used to compare categorical variables; the Kruskal-Wallis test was used to compare continuous vari-ables. Because fungal contamination involving 2 SALBIs in the same patient were not independent events, analyses were per-formed at the patient level and not at the breast implant level. RESULTS
Case Patient Characteristics
Five patients met the case definition. Two were symptomatic, and 3 were asymptomatic—that is, SALBI fungal contamination was an incidental finding at revision surgery (table 1). The median age of case patients was 24 years (range, 21–49 years). The 5 explanted SALBIs were round and smooth; 3 were man-ufactured by the Mentor Corporation and 2 were manman-ufactured by the McGhan Medical Corporation; the lot numbers for im-plants of each brand differed from one another. Normal sterile saline for irrigation (Baxter Healthcare Corporation) was used to fill the breast implants in the OR; lot and serial numbers were not available for the saline bottles.
One woman had her initial CBA surgery in 1995 and un-derwent her first surgical revision in June 2000, to correct sym-mastia (i.e., medial confluence of the breasts producing a web across the midline). At her revision surgery in June 2000, both SALBIs were macroscopically clear. Saline was removed from each SALBI and replaced with fresh normal saline; the 2 SALBIs were then reimplanted. When this woman underwent further revision surgery, for cosmetic reasons, in July 2001, 1 of the 2 SALBIs contained black sediment that was macroscopically
ap-parent and was later identified asCurvularia lunata(figure 1).
Epidemiologic Studies
Case-control study. The 5 case patients and 17 control pa-tients were similar in age, ASA score, volume of saline used to fill the breast implants, time of surgical procedure, and rank placement (e.g., first) on the operating list. In contrast, case patients were more likely than control patients to have under-gone their operation on or after 1 May 2000 (5/5 vs. 5/17; odds
ratio, undefined;Pp.01) (figure 2), to have had their surgical
procedure performed by surgeon X (5/5 vs. 4/17; odds ratio,
undefined;P!.005), to have had a periareolar incision (4/5 vs.
2/17; odds ratio, 30.0 [95% confidence interval {CI}, 2.1–421];
), and to have undergone ⭓2 procedures at the same
P!.01
time as CBA (2/5 vs. 0/17; odds ratio, undefined;P!.05). In
addition, case patients were significantly more likely than con-trol patients to have had a longer duration of anesthesia
(me-dian, 82 vs. 62 min;P!.05) and duration of surgery (median,
66 vs. 45 min;P!.05) and to have a longer OR time (median,
107 vs. 67 min;P!.05).
Of the 5 case patients, 4 had surgery performed in OR 2, whereas 6 of 17 control patients had surgery performed in OR
2 (odds ratio, 7.3 [95% CI, 0.66–81.4];Pp.14). Compared
with patients operated on by surgeon Y, patients operated on by surgeon X had significantly longer OR (median, 107 vs. 62
min;P!.001), anesthesia (median, 85 vs. 61 min; P!.001),
and surgery (median, 66 vs. 40 min;P!.001) times. In
tion, longer OR times were significantly associated with addi-tional procedures, such as mastopexy (median, 191 vs. 67 min;
) and periareolar incisions (median, 159 vs. 69 min;P
P!.05
!.001). The periareolar approach was used only by surgeon X
(6/9 vs. 0/13;Pp.001). When the analysis was restricted to
surgeon X, 4 of 5 case patients versus 1 of 4 control patients had surgery performed in OR 2 (odds ratio, 25 [95% CI, 0.5–
280.1];Pp.2). Indications for revision surgery for the 17
con-trol patients included deflation (15), requesting larger implants (3), contracture (2), and bacterial infection (1).
Cohort study. From 1 May through 30 September 2000, 121 women were operated on by surgeon X. Becoming a case patient was associated with OR time, time under anesthesia or surgery, having a periareolar incision, and undergoing addi-tional surgical procedures. Women undergoing surgery in OR
2 were at a higher risk of contamination withCurvulariaspecies
(4/49 vs. 1/72; relative risk, 5.9 [95% CI, 0.7–51.0];Pp.16).
When we conducted multivariate analyses of the data, inde-pendent risk factors associated with becoming a case patient
included OR time (Pp.005) and having surgery performed
in OR 2 (adjusted OR, 5.2;Pp.15).
Review of Practices and Procedures
Surgical procedures and practice review. Before 1 February 2001, surgeons X and Y used the “open bowl” technique to fill the silicone shell of the inflatable saline breast implant. A sterile bowl was placed on the instrument tray before the woman arrived in the OR. Sterile saline for irrigation was poured from a bottle into the bowl, where it was exposed to the air and environment until it was drawn into a syringe and injected into the breast implant.
After 31 January 2001, when the surgeons became aware of the first 2 case patients, surgeon X started using a closed system, whereas Surgeon Y began covering the open bowl with a sterile drape. Surgeon X transferred his practice to medical center B in April 2001, and surgeon Y retired on 28 June 2001 (figure 2).
Health care worker assessment and survey. Nineteen (56%) of 34 staff members reported having sinus problems in August 2001; all but 1 had sinus problems during May–September 2000. Two staff members reported fungal infection of fingernails, and 3 reported fungal infection of toenails. Eight (24%) staff members
Table 1. Characteristics of case patients at facility A, 1 January 2000–28 June 2001. Case patient Surger y date Procedure(s) OR Incision type OR time, min Revision surger y date Reason for revision surger y Operative findings 1 1 Jun 2000 Cor rection of symmastia, removal and replacement of SALBIs with new saline (same implants) 2 Periareolar 211 21 Jul 2001 Further cor rection of symmastia, no symptoms of infection No acute or chronic tissue inflammation 2 18 Jul 2000 Bilateral augmentation mammoplasty 1 Inframammar y 69 19 Jul 2001 Partial deflation, no symptoms of infection No acute or chronic tissue inflammation 3 10 Aug 2000 Bilateral augmentation mammoplasty 2 Periareolar 107 21 Dec 2000 Unilateral capsular contracture Chronic tissue inflammation (capsula r contracture) 4 31 Aug 2000 Bilateral augmentation mammo-plasty , mastopexy , fat grafts 2 Periareolar 171 29 May 2001 Neck pain, possibly secondar y to weight of breast implants; no local symptoms No acute or chronic tissue inflammation 5 12 Sep 2000 Bilateral augmentation mammoplasty 2 Periareolar 95 26 Jan 2001 Painful, warm, swollen breast Acute inflammation, red capsule, swelling NOTE. OR, operating room; SALBI, saline-filled breast implant.
174 • JID 2005:192 (1 July) • Kainer et al.
Figure 1. A removed saline-filled silicone breast implant with black sediment that was later identified asCurvularia lunata
wore artificial fingernails. Twenty-one (62%) were gardeners, and 24 (71%) had handled soil during leisure time.
Facility A Review
Operating rooms. Facility A contained 4 ORs. A warming cabinet for saline bottles was located directly opposite and 6 feet away from OR 2. This cabinet was opened 60–70 times per day.
Sterile supply room. Before 1 July 2001, saline bottles were stored in the sterile supply room on a metal grille shelf, directly under a portion of sheetrock ceiling that had sustained water damage in 1998 following a roof leak. Portions of the sheetrock ceiling had moisture content of 28%, probably because of an ongoing leak from the roof.
Review of the HVAC system. The HVAC system was replaced in late May/early June 2000. There was no moisture in the air ducts. According to the OR design specifications, return air should have had a flow rate of 800 cubic feet/min (cfm) and an exhaust air rate of 190 cfm, resulting in a net positive pressure in the OR. There was no documentation to demonstrate that the HVAC was balanced or to confirm the direction of airflow after the new HVAC was installed in June 2000. On 6 August 2001, the inflow rate of the supply air to OR 2 was 1235 cfm, and the outflow was 1520 cfm—a deficit of 285 cfm. Thus, OR 2 was maintained at negative pressure to the surrounding area; flutter strips demonstrated airflow from the corridor into the OR. OR 3 also was at negative pressure, whereas OR 1 and OR 4 were at positive pressure to the surrounding areas.
Microbiologic Studies
Personnel cultures. Cultures were obtained from 34 facility
A and 60 medical center B staff members.C. lunatawas isolated
from nasal mucus in 12 (35%) facility A versus 4 (6.7%) med-ical center B staff members (prevalence ratio, 5.3 [95% CI, 1.9–
15.1];P!.001). One of 12 facility A staff members with positive
nasal cultures also had hand cultures positive for C. lunata,
and another had a positive toenail clipping culture. Although C. lunatawas isolated from the nasal mucus of surgeon X, his
hand and settle plate cultures were negative.C. lunatawas not
isolated from surgeon Y. Isolation ofC. lunatafrom facility A
staff members was not statistically associated with sinus symp-toms or exposure to plants or soil.
Environmental cultures. C. lunatawas isolated from 2 of 18 air samples. One was obtained in the sterile supply room under the water-damaged ceiling, where the saline bottles were stored, and 1 was obtained from the corridor between OR 2 and the warming cabinet. Each air sample filtered 500 L of air.
None of the other 179 environmental cultures grewCurvularia
species. The number of fungal colony-forming units per cubic meter of air obtained in OR 2 was 66, versus 8 in OR 3; all other conditions were identical.
DISCUSSION
The factors that contributed to contamination of SALBIs with Curvulariaspecies among women who underwent CBA surgery at facility A included the open bowl method, which led to contamination of the saline, and engineering conditions that promoted fungal growth and contamination of the sterile sup-ply room and ORs. Having surgery performed in OR 2 and OR time were associated with increased risk of contamination
of implanted SALBIs withCurvulariaspecies.
The saline used to fill the silicone shells was likely contam-inated while sitting in an open bowl before or during surgery. Our investigation suggests that the silicone shells themselves
Figure 2. Time line of key events for women (np22) who had cosmetic breast augmentations with saline-filled silicone breast implants and subsequently underwent revision surgery, by month of procedure and surgeon, January 2000–June 2001.
were not contaminated at the manufacturer for the following reasons: (1) the SALBI shells had different lot numbers and were produced by 2 manufacturers, and (2) the SALBI of the first case patient became infected only after the saline of 5-year-old, previously macroscopically clear SALBIs was replaced. In 1995, Young et al. were concerned that the open bowl method might have resulted in contamination of injectable saline [8]. Although both the McGhan and Mentor Corpora-tions provide a closed filling system, such a system is not ac-tively promoted.
More than 7.4 million persons in the United States under-went cosmetic plastic surgery during 2000; 2.5% of these were women who underwent CBA surgery [1]. An additional 78,832 women underwent breast reconstructive surgery; 75% of im-plants used in these procedures were SALBIs [2]. This, however, might be an underestimate of the actual number of CBA sur-gical procedures performed annually, since increasing numbers of nonsurgeons are now performing cosmetic surgical proce-dures [12]. In most states today, increasing numbers of wom-en are electing to have their CBA surgery performed under local anesthesia (e.g., intercostal nerve block) in outpatient clinics, ambulatory surgery centers, or physician offices, where one would expect the risks for complications, including infec-tion, to be substantial. In fact, there have been a few case reports of fungal contamination involving SALBIs; these fungi include Aspergillusspecies,Curvulariaspecies, andPaecilomycesspecies [8–10]. In general, however, infection after augmentation mam-moplasty remains uncommon.
Our investigation showed that long OR time and duration of
surgery were risk factors for contamination withCurvularia
spe-cies. The surgical technique that uses the periareolar surgical incision approach takes longer than do other incisional ap-proaches for CBA surgery. In addition, women who elected to undergo other procedures at the same time as their CBA surgery would have spent a longer time in the OR. Thus, undergoing CBA surgery involving the periareolar incision approach and undergoing additional procedures at the same time as CBA rep-resent surrogate markers for a longer-than-anticipated OR time; hence, their significant association with SALBI contamination during the study period. The strong association with OR time, a marker for duration of exposure of saline in the open bowl to the environment, suggests that fungal spores in the OR air or environment extrinsically contaminated the saline.
We constructed a hypothesis to explain the sequential mode of SALBI contamination: (1) the moist sheetrock ceiling in the sterile supply room provided favorable growth conditions for C. lunata; (2) fungal spores, via air currents, dust, or water droplets, settled from the ceiling onto the surface of the saline bottles stored directly under the water-damaged ceiling; and (3) the contaminated saline bottles then were placed into the warming cabinet, where the constant opening and closing of the cabinet door resulted in air drafts laden with fungal spores. The airborne fungal spores then were drawn into OR 2, which was at profound negative pressure and was located directly op-posite the warming cabinet. This scenario would explain why women who underwent their surgical procedure in OR 2 were the ones most at risk of having their SALBIs contaminated with C. lunata.According to the American Institute of Architects Academy of Architecture for Health and the CDC’s guidelines for prevention of surgical site infections, air movement relative
176 • JID 2005:192 (1 July) • Kainer et al.
to surrounding areas should be outward from ORs [13, 14]. On the basis of the findings of the investigation and the plau-sibility of our hypothesis, we made several recommendations aimed at controlling the present outbreak and preventing re-currences (see the Appendix). These recommendations were immediately implemented by the facility A administration.
In addition, facility A contacted 384 women by registered mail; all had SALBI insertions between April 2000 and January 2001 at facility A. Women were counseled and offered revision surgery at no cost. As of January 2005, 224 women had un-dergone revision surgery; implants were visually inspected, and implant fluid was sent to the CDC for fungal culture. Two con-taminated breast implants were identified: 1 from the other breast of case patient 2 and 1 from a woman whose surgery
was performed in October 2000.Curvularia species were not
isolated from implant fluid that was macroscopically clear. The attack rate for SALBI contamination was 3.75% for the risk period of June 2000–January 2001.
In this outbreak, personnel nasal cultures were a useful ad-junct to high-volume air samplers, since each staff member’s nose effectively filtered 3000 L of air over an 8-h shift—that is, 6-fold the volume of 1 air sampler. Personnel cultures reflect the large volume of air filtered, as well as exposure to prior environmental conditions. There are no other published data
on the prevalence or persistence of nasal colonization by
Cur-vulariaspecies in this region of the United States.
Our investigation had some limitations. First, women who were asymptomatic and whose SALBI contamination status therefore was not known were presumed to be noncase patients for the cohort study analysis. This presumption resulted in potential misclassification of cases and reduced power. Second, the limited number of revision surgical procedures in women operated on by surgeon Y during May–September 2001 resulted in the potential for major case-ascertainment bias and pre-vented us from determining whether surgeon X was linked
epidemiologically to the transmission ofCurvulariaspecies.
In summary, a combination of factors, such as poor moisture
control in the sterile supply room that facilitated Curvularia
spores in the facility A environment, the maintenance of the OR at negative rather than positive air pressure differentials, and the absence of a closed-system protocol for injecting saline
into SALBIs, all contributed to SALBI contamination with
Cur-vulariaspecies. These findings are in keeping with health care–
associated outbreaks involving other fungi, such asAspergillus
species [15–17]. Ambulatory or outpatient surgical centers need to (1) follow hospital recommendations for regular mainte-nance of HVAC systems and balancing of airflow in ORs; (2) follow infection control guidelines; and (3) include infection control staff in all stages of planning, construction, and ren-ovation of health care facilities and HVAC systems. This out-break investigation provides scientific evidence to support the
recommendation that ORs should be at positive pressure rel-ative to the surrounding areas and that a closed system should be used when injecting sterile saline into SALBIs.
Acknowledgments
We are grateful to the clinicians, patients, health care workers, and public health staff at facility A who assisted in this investigation. Also, we thank the facility A administration for implementing the recommendations that followed the investigation.
APPENDIX
RECOMMENDATIONS
1. Use only a closed system to fill saline-filled silicone breast
implants; do not use open systems, such as the “open bowl” method.
2. Balance the heating, ventilation, and air-conditioning
(HVAC) system in each operating room and provide infection control and administrative staff with documentation that bal-ancing has been performed whenever adjustments to the air-handling unit are made or the operating rooms (ORs) undergo structural renovations [13].
3. Measure and document direction of airflow from the
OR to the surrounding areas on a weekly basis and each time the HVAC system is balanced [13]. A flutter strip can be used to assess the direction of airflow across entrances to ORs.
4. Remove and replace all water-damaged or moist
build-ing materials. Correct roof leaks and address any other causes of water damage.
5. Involve infection control staff in all stages (including
planning) of construction, demolition, and renovation of health care facility structures and the HVAC system [13].
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