Prevention of Surgical infection

Undergraduate level presentation on Prevention of Surgical infection covering the topics of:
History
Definition
Classification
Risk factors
Surgical Site Infection (SSI)
Tetanus
Gas gangrene

1. Surgical Infections & their Prevention Kaung Thet Han (RN 12) Kyaw Khan Zaw (RN 17) Kyaw San Lin (RN 21) Final Part 2 M.B.B.S. 1

2. Scope of this Presentation History Definition Classification Risk factors Surgical Site Infection (SSI) Tetanus Gas gangrene 2

3. History has been documented for 4000–5000 years 3

4. Egyptians had some concepts about infection as they were able to prevent putrefaction, testified by mummification skills. Their medical papyruses also describe the use of salves and antiseptics. Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 4

5. Hippocrates His teachings described the use of antimicrobials, such as wine and vinegar, which were widely used to irrigate open, infected wounds before delayed primary or secondary wound closure . Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 5

6. Galen s recognised that localisation of infection (suppuration) in wounds, inflicted in the gladiatorial arena, often heralded recovery, particularly after drainage (pus bonum et laudabile ). Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 6

7. Koch’s postulates Koch’s postulates proving whether a given organism is the cause of a given disease It must be found in every case. It should be possible to isolate it from the host and grow it in culture. It should reproduce the disease when injected into another healthy host. It should be recovered from an experimentally infected host. Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 7

8. Ignac Semmelweis An Austrian obstetrician showed that puerperal sepsis could be reduced from >10% to < 2% by the simple act of hand washing between cases, particularly between post-mortem examinations and the delivery suite . He was ignored by his contemporaries. Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 8

9. Louis Pasteur recognised through his germ theory that microorganisms were responsible for infecting humans and causing disease . Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 9

10. Joseph Lister Applied this knowledge to the reduction of colonising organisms in compound fractures by using antiseptics. The principles of antiseptic surgery were soon enhanced with aseptic surgery at the turn of the century. As well as killing the bacteria on the skin before surgical incision (antiseptic technique), the conditions under which the operation was performed were kept free of bacteria (aseptic technique). Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 10

11. Alexander Fleming The discovery of the antibiotic penicillin is attributed to Alexander Fleming in 1928, but it was not isolated for clinical use until 1941 by Florey and Chain. Since then, there has been a proliferation of antibiotics with broad-spectrum activity and antibiotics today remain the mainstay of antimicrobial therapy . Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 11

12. 12 Photo credit: KK

13. Definition ‘Infection which may need surgical intervention or caused by surgical procedure.’ Khin Maung Aye et al. Lecture Notes on General Surgery . Surgical Society, MMA, 2006. 13

14. Classification Acute Non-specific Generalized Bacteremia Septicaemia Pyaemia Localized Abcess Cellulitis Carbuncle Specific Generalized Tetanus Gas gangrene Localized Boil Chronic Non-specific Ulcer Sinus Fistula Specific TB Syphilis Actinomycosis 14

15. Risk factors Malnutrition (obesity, weight loss) Metabolic disease (diabetes, uraemia, jaundice) Immunosuppression (cancer, AIDS , steroids, chemotherapy & radiotherapy) Colonisation and translocation in the gastrointestinal tract Poor perfusion (systemic shock or local ischaemia ) Foreign body material Poor surgical technique (dead space, haematoma) Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 15

16. Surgical Site Infection (SSI) A major complication of surgery and trauma 16

17. Definition Surgical site infections (SSIs) are infections of the tissues, organs , or spaces exposed by surgeons during performance of an invasive procedure. F. Charles Brunicardi et al. Schwartz's Principles of Surgery , 10th Edition. McGraw-Hill Education, 2015. 17

18. Classic swinging pyrexia related to a perianastomotic wound abscess that settled spontaneously on antibiotic therapy. Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 18

19. Surgical site infection (SSI) rates relating to wound contamination Martone WJ, Nichols RL. Recognition, prevention, surveillance, and management of surgical site infections: introduction to the problem and symposium overview. Clin Infect Dis. 2001;33:S67-S68. 19

20. Pathogen Sources Endogenous Patient flora skin mucous membranes GI tract Seeding from a distant focus of infection S.I. Berríos -Torres. Surgical Site Infection (SSI) Toolkit . CDC, 2009. 20

21. Pathogen Sources Exogenous Surgical Personnel (surgeon and team) Soiled attire Breaks in aseptic technique Inadequate hand hygiene OR physical environment and ventilation Tools, equipment, materials brought to the operative field S.I. Berríos -Torres. Surgical Site Infection (SSI) Toolkit . CDC, 2009. 21

22. Microbiology of SSIs Staphylococcus aureus 17% Coagulase neg. staphylococci 12% Escherichia coli 10% Enterococcus spp. 8% Pseudomonas aeruginosa 8% Staphylococcus aureus 20% Coagulase neg. staphylococci 14% Escherichia coli 8% Enterococcus spp. 12% Pseudomonas aeruginosa 8% 1986-1989 (N=16,727) 1990-1996 (N=17,671) Michele L. Pearson. Prevention of Surgical Site Infections: Considerations in Measuring Effectiveness. CDC, 2005. 22

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24. Treatment 24

25. Antibiotics Major surgical infections with systemic signs, evidence of spreading infection, cellulitis or bacteraemia need treatment with appropriate antibiotics. Initially  Empirical Best based on culture and sensitivities of isolates harvested at surgery. Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 25

26. Antibiotics Although the identification of organisms in surgical infections is necessary for audit and wound surveillance purposes, it is usually 2–3 days before sensitivities are known. It is illogical to withhold antibiotics until these are available but , if clinical response is poor by the time sensitivities are known , then antibiotics can be changed. This is unusual if the empirical choice of antibiotics is sensible; change of antibiotics promotes resistance and risks complications, such as C. difficile enteritis . Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 26

27. Mixed streptococcal infection of a skin graft with very poor ‘ take’. Initial infection After 5–6 days of antibiotics, infection under control, and the skin grafts are clearly viable Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 27

28. Operation techniques If an infected wound is under tension, or there is clear evidence of suppuration  sutures or clips need to be removed, with curettage if necessary, to allow pus to drain adequately. There is no evidence that subcuticular continuous skin closure contributes to or prevents suppuration. In severely contaminated wounds, such as an incision made for drainage of an abscess  leave the skin open. When the wound is clean and granulating  delayed primary or secondary suture Leaving wounds open after a ‘ dirty’ operation, such as laparotomy for faecal peritonitis, is not practised as widely in the UK as in the US or mainland Europe. Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 28

29. Skin layers left open to granulate after laparotomy for faecal peritonitis. The wound is clean and ready for secondary closure. Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 29

30. Wanna have some??? xD 30 Photo credit: KK

31. Prevention Prevention is better than cure!!! 31

32. PREVENTION IS PRIMARY! Protect patients…protect healthcare personnel… promote quality healthcare! Division of Healthcare Quality Promotion 32

33. Prevention Information for patients and carers Pre-operative measures Patient Ward Intra-operative measures Operating theatres Operating procedures Post-operative measures 33

34. Information for patients and carers Offer patients and carers : clear , consistent information and advice throughout all stages of their care. This should include the risks of surgical site infections, what is being done to reduce them and how they are managed. how to care for their wound after discharge. how to recognise a surgical site infection and who to contact if they are concerned. Use an integrated care pathway for healthcare-associated infections to help communicate this information to both patients and all those involved in their care after discharge. Always inform patients after their operation if they have been given antibiotics . NICE Guideline on Prevention and treatment of surgical site infection , National Institute for Health and Clinical Excellence, 2008. 34

35. Pre-operative measures Preoperative showering Advise patients to shower or have a bath using soap, either the day before, or on the day of, surgery . Hair removal Do not use hair removal routinely to reduce the risk of surgical site infection. If hair has to be removed, use electric clippers with a single-use head on the day of surgery. Do not use razors for hair removal, because they increase the risk of surgical site infection. NICE Guideline on Prevention and treatment of surgical site infection , National Institute for Health and Clinical Excellence, 2008. 35

36. Pre-operative Antiseptic Showers/Baths Most studies examine effects on skin colony counts antiseptic showering decreases colony counts Few studies examine effect on SSI rates No Shower Shower Cruse, 1973 2.3% 1.3% Ayliffe , 1983 4.9% 5.4% Rooter, 1988 2.4% 2.6% 36

37. Pre-operative Shaving/Hair Removal Seropian , 1971 Method of hair removal Razor = 5.6% SSI rates Depilatory = 0.6% SSI rates No hair removal = 0.6% SSI rates Timing of hair removal Shaving immediately before = 3.1% SSI rates Shaving  24 hours before = 7.1% SSI rates Shaving >24 hours before = 20% SSI rates 37

38. Pre-operative measures Patient theatre wear Give patients specific theatre wear that is appropriate for the procedure and clinical setting, and that provides easy access to the operative site and areas for placing devices, such as intravenous cannulas. Consider also the patient's comfort and dignity. Staff theatre wear All staff should wear specific non-sterile theatre wear in all areas where operations are undertaken. Staff leaving the operating area Staff wearing non-sterile theatre wear should keep their movements in and out of the operating area to a minimum. NICE Guideline on Prevention and treatment of surgical site infection , National Institute for Health and Clinical Excellence, 2008. 38

39. Surgical Attire Scrub suits Cap/hoods Shoe covers Masks Gloves Gowns 39

40. Pre-operative measures Nasal decontamination Do not use nasal decontamination with topical antimicrobial agents aimed at eliminating Staphylococcus aureus routinely to reduce the risk of surgical site infection. Mechanical bowel preparation Do not use mechanical bowel preparation routinely to reduce the risk of surgical site infection . Hand jewellery , artificial nails and nail polish The operating team should remove hand jewellery , artificial nails and nail polish before operations. NICE Guideline on Prevention and treatment of surgical site infection , National Institute for Health and Clinical Excellence, 2008. 40

41. Antibiotic prophylaxis Give antibiotic prophylaxis to patients before: clean surgery involving the placement of a prosthesis or implant clean-contaminated surgery contaminated surgery . Do not use antibiotic prophylaxis routinely for clean non-prosthetic uncomplicated surgery. Use the local antibiotic formulary and always consider potential adverse effects when choosing specific antibiotics for prophylaxis. Consider giving a single dose of antibiotic prophylaxis intravenously on starting anaesthesia . For operations in which a tourniquet is used  give prophylaxis earlier NICE Guideline on Prevention and treatment of surgical site infection , National Institute for Health and Clinical Excellence, 2008. 41

42. Antibiotic prophylaxis Before giving antibiotic prophylaxis, consider the timing and pharmacokinetics (for e.g., the serum half-life) and necessary infusion time of the antibiotic. Give a repeat dose of antibiotic prophylaxis when the operation is longer than the half-life of the antibiotic given . Give antibiotic treatment (in addition to prophylaxis) to patients having surgery on a dirty or infected wound. Inform patients before the operation, whenever possible, if they will need antibiotic prophylaxis, and afterwards if they have been given antibiotics during their operation. NICE Guideline on Prevention and treatment of surgical site infection , National Institute for Health and Clinical Excellence, 2008. 42

43. Suggested prophylactic regimens for operations at risk. Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 43

44. Importance of Timing of Surgical Antimicrobial Prophylaxis (AP) Prospective study of 2,847 elective clean and clean-contaminated procedures Early AP (2-24 hrs before incision): 3.8 % Postop AP (3-24 hrs after incision): 3.3 % Periop AP (< 3 hrs after incision): 1.4 % Preop AP (<2 hrs before incision): 0.6% 44

45. There’s some more left… Brace yourselves! xD 45 Photo credit: KK

46. Intra-operative measures Hand decontamination The operating team should wash their hands Prior to the first operation on the list  using an aqueous antiseptic surgical solution, with a single-use brush or pick for the nails, and ensure that hands and nails are visibly clean. Before subsequent operations  washed using either an alcoholic hand rub or an antiseptic surgical solution. If hands are soiled  washed again with an antiseptic surgical solution. Incise drapes Do not use non- iodophor -impregnated incise drapes routinely for surgery as they may increase the risk of surgical site infection. If an incise drape is required, use an iodophor -impregnated drape unless the patient has an iodine allergy. NICE Guideline on Prevention and treatment of surgical site infection , National Institute for Health and Clinical Excellence, 2008. 46

47. Incise drapes 47 http:// multimedia.3m.com/mws/media/191895P/3mtm-incise-drapes-sterile-surface-diagram.jpg last assessed 29th August 2015

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49. Parameters for Operating Room Ventilation Temperature : 68 o -73 o F, depending on normal ambient temp Relative humidity : 30%-60% Air movement : from “clean to less clean” areas Air changes : > 15 total per hour > 3 outdoor air per hour American Institute of Architects, 1996 49

50. Role of Laminar Air Flow (Ultraclean Air) in Preventing SSI Most studies involve only orthopedic operations Lidwell et al: 8,000 total hip and knee replacements ultraclean air : SSI rate  3.4% to 1.6% antimicrobial prophylaxis (AP): SSI rate  3.4% to 0.8% ultraclean air + AP : SSI rate  3.4% to 0.7% 50

51. Intra-operative measures Sterile gowns The operating team should wear sterile gowns in the operating theatre during the operation. Gloves Consider wearing two pairs of sterile gloves when there is a high risk of glove perforation and the consequences of contamination may be serious. Antiseptic skin preparation Prepare the skin at the surgical site immediately before incision using an antiseptic (aqueous or alcohol-based) preparation : povidone -iodine or chlorhexidine are most suitable . If diathermy is to be used, ensure that antiseptic skin preparations are dried by evaporation and pooling of alcohol based preparations is avoided. 51

52. Classification of antiseptics commonly used in general surgical practice. Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 52

53. Intra-operative measures Diathermy Do not use diathermy for surgical incision to reduce the risk of surgical site infection. Maintaining patient homeostasis Maintain patient temperature in line with 'Inadvertent perioperative hypothermia' (NICE clinical guideline 65). Maintain optimal oxygenation during surgery. In particular, give patients sufficient oxygen during major surgery and in the recovery period to ensure that a haemoglobin saturation of more than 95% is maintained. Maintain adequate perfusion during surgery. Do not give insulin routinely to patients who do not have diabetes to optimise blood glucose postoperatively as a means of reducing the risk of surgical site infection. NICE Guideline on Prevention and treatment of surgical site infection , National Institute for Health and Clinical Excellence, 2008. 53

54. Intra-operative measures Wound irrigation and intracavity lavage Do not use wound irrigation to reduce the risk of surgical site infection. Do not use intracavity lavage to reduce the risk of surgical site infection. Antiseptic and antimicrobial agents before wound closure Do not use intraoperative skin re-disinfection or topical cefotaxime in abdominal surgery to reduce the risk of surgical site infection. Wound dressings Cover surgical incisions with an appropriate interactive dressing at the end of the operation. NICE Guideline on Prevention and treatment of surgical site infection , National Institute for Health and Clinical Excellence, 2008. 54

55. Surgical dressings Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 55

56. Surgical dressings Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013. 56

57. Post-operative measures Changing dressings Use an aseptic non-touch technique for changing or removing surgical wound dressings. Postoperative cleansing Use sterile saline for wound cleansing up to 48 hours after surgery. Advise patients that they may shower safely 48 hours after surgery. Use tap water for wound cleansing after 48 hours if the surgical wound has separated or has been surgically opened to drain pus. NICE Guideline on Prevention and treatment of surgical site infection , National Institute for Health and Clinical Excellence, 2008. 57

58. Post-operative measures Topical antimicrobial agents for wound healing by primary intention Do not use topical antimicrobial agents for surgical wounds that are healing by primary intention to reduce the risk of surgical site infection. Dressings for wound healing by secondary intention Do not use Eusol and gauze, or moist cotton gauze or mercuric antiseptic solutions. Use an appropriate interactive dressing. Refer to a tissue viability nurse (or another healthcare professional with tissue viability expertise) for advice on appropriate dressings. NICE Guideline on Prevention and treatment of surgical site infection , National Institute for Health and Clinical Excellence, 2008. 58

59. Post-operative measures Antibiotic treatment of surgical site infection and treatment failure When surgical site infection is suspected (i.e. cellulitis), either de novo or because of treatment failure, give the patient an antibiotic that covers the likely causative organisms. Consider local resistance patterns and the results of microbiological tests in choosing an antibiotic. Debridement Do not use Eusol and gauze, or dextranomer or enzymatic treatments for debridement in the management of surgical site infection. NICE Guideline on Prevention and treatment of surgical site infection , National Institute for Health and Clinical Excellence, 2008. 59

60. Post-operative measures Specialist wound care services. Although there is no direct evidence to support the provision of specialist wound care services for managing difficult to heal surgical wounds, a structured approach to care (including preoperative assessments to identify individuals with potential wound healing problems) is required in order to improve overall management of surgical wounds. To support this, enhanced education of healthcare workers, patients and carers , and sharing of clinical expertise will be required. NICE Guideline on Prevention and treatment of surgical site infection , National Institute for Health and Clinical Excellence, 2008. 60

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62. Tetanus 62

63. Prevention Prophylaxis with tetanus toxoid  best preventative treatment In an established infection  minor debridement of the wound & antibiotic treatment with benzylpenicillin Relaxants may also be required . May require ventilation in severe forms, which may be associated with a high mortality . The use of antitoxin using human immunoglobulin ought to be considered for both at-risk wounds and established infection . 63 Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013.

64. Prevention The toxoid is a formalin-attenuated vaccine and should be given in three separate doses to give protection for a five-year period , after which a single five-yearly booster confers immunity. It should be given to all patients with open traumatic wounds who are not immunised . At-risk wounds  those that present late, when there is devitalisation of tissue or when there is soiling  a booster of toxoid should be given. If not immunised at all  a three-dose course, together with prophylactic benzylpenicillin . T he use of antitoxin is controversial because of the risk of toxicity and allergy. 64 Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013.

65. Gas Gangrene 65

66. Treatment Maximum dose of penicillin Blood transfusion Long incision of muscle Multiple subcutaneous drainage Slough extraction Anti gangrenous serum (polyvalent) 3 amp stat and 6 hrly later Hyperbaric oxygen Treat underlying DM, uraemia, etc. 66 Khin Maung Aye et al. Lecture Notes on General Surgery . Surgical Society, MMA, 2006.

67. Prevention Antibiotic prophylaxis should always be considered in patients at risk, especially when amputations are performed for peripheral vascular disease with open necrotic ulceration. 67 Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery , 26 th Edition. CRC Press, 2013.

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69. Commonly Asked Questions What are tetanus prone wound? Describe aetiology, pathogenesis, clinical features and management of tetanus . (severe/ due to planter space infection following nail prick/ due to septic abortion) *** What is nosocomial infection ? Describe Universal precaution against infection. Describe the control measures of hospital acquired infection outbreak .** Define sterilization . Describe the various methods of sterilization. ** 69

70. Commonly Asked Questions Classify various types of hand infection . Describe the principles of management and management of mid-palmer space infection.** List the various clinical presentations of AIDS encountered in surgical emergency department. Describe the universal precautions for known AIDS case undergoing emergency surgical operation .** How will you reduce the risks of transmission of HIV infection from the patient to health care workers ?** 70

71. Commonly Asked Questions Add notes on: carbuncle, acute paronychia, terminal pulp space infection, ulcer.* Classify the wound regarding the chance of wound sepsis .* Describe management of contaminated wound .* Define wound sepsis. Describe how you will prevent wound sepsis in elective laparotomy .* Classify surgical wounds. Outline the prevention and management of surgical wound infection .* 71

72. Thank you very much for your kind attention!!! Any questions??? 72 Arigato!!! <3