Download Overview of control measures to prevent surgical site infection

Overview of control
measures to prevent
surgical site infection
INTRODUCTION
• Surgical wound infections are the second most
common healthcare-associated infection
• Although usually localized to the incision site,
surgical wound infections can also extend into
adjacent deeper structures; thus, the term surgical
wound infection has now been replaced with the
more suitable name, surgical site infection (SSI).
• CDC define SSIs as infections related to the
operative procedure that occur at or near the
surgical incision (incisional or organ/space) within
30 days of an operative procedure or within one
year if an implant is left in place
GENERAL PRINCIPLES
• The most important factors in the
prevention of surgical site
infection (SSIs) are meticulous
operative techniques and timely
administration of effective
preoperative antibiotics
• A number of interventions have been used over
the years to reduce the risk of SSIs, including :
• Preoperative showering with antimicrobial soaps
• Preoperative application of antiseptics to the
skin of the patient
• Washing and gloving of the surgeon's hands
• Use of sterile drapes
• Use of gowns and masks by operating room
personnel
Skin antisepsis
• Routine application of antiseptics to the skin should be
performed to reduce the burden of skin flora, although
bacteria in hair follicles and sebaceous glands cannot
be sterilized by preoperative antiseptic agents.
• Preoperative skin cleansing with chlorhexidine -alcohol
is superior to povidone-iodine; in a trial of 849 patients
undergoing clean-contaminated surgery, the overall
rate of SSI was significantly lower in the chlorhexidinealcohol group than in the povidone-iodine group (9.5
versus 16 percent).
• Chlorhexidine-alcohol may be superior to iodinealcohol because chlorhexidine is not inactivated by
blood or serum .
• Interventions that do not appear to reduce
the likelihood of SSI include skin preparation
in concentric circles (rather than horizontal
preparation) and use of surgical site markers.
• The benefit of bathing with an antiseptic
preparation prior to surgery to reduce the risk
of SSIs is uncertain . In a meta-analysis of six
trials involving 10,007 participants,
preoperative bathing with
chlorhexidine conferred no benefit over
preoperative bathing with other products for
reduction of SSI .
Barrier devices
• The primary role for barrier devices
(masks, caps, gowns, drapes, and shoe
covers) is to protect operating room
personnel from exposure to infectious
blood or body fluids.
• Their role in SSI prevention is not
supported by rigorous study, but their
routine use is universally accepted in
hospitals where such equipment is
available.
• Gloves provide protection of personnel
from exposure to infectious blood and
body fluids and likely reduce the potential
for transmission of bacteria to patients
from the hands of surgical personnel.
However, there is evidence for bacterial
migration from undetected perforation of
surgical gloves; the risk depends on the
type of surgery performed and the
duration of wear
Surgical hand hygiene
• Surgical hand hygiene consists of preoperative
cleansing of hands and forearms with an antiseptic
agent; this practice is universally accepted.
• Cleansing with aqueous alcoholic solution may be as
effective as traditional hand scrubbing with antiseptic
soap for prevention of SSIs .
• Either antimicrobial soap or an alcohol-based hand rub
may be used
• The recommended duration of scrubbing with alcohol
based hand rubs is shorter than with antimicrobial
soap (varies by product) and scrub brushes are not
required for preoperative hand cleaning by surgical
staff .
Surgical technique
• There is general agreement that good surgical
technique reduces the risk of SSIs.
• Such practices include gentle traction, effective
hemostasis, removal of devitalized tissues,
obliteration of dead space, irrigation of tissues with
saline to avoid excessive drying, use of fine, nonabsorbed monofilament suture material, judicious
use of closed suction drains, and wound closure
without tension .
• The precise role or proportional benefit of each of
these techniques in SSI prevention has not been
quantitated or proven by rigorous study.
ANTIMICROBIAL PROPHYLAXIS
• The goal of antimicrobial prophylaxis is to prevent surgical site
infection (SSI) by reducing the burden of microorganisms at
the surgical site during the operative procedure.
• The efficacy of antibiotic prophylaxis for reducing surgical SSI
has been clearly established.
• Preoperative antibiotics are warranted if there is a high risk of
infection or if there high risk of deleterious outcomes should
infection develop at the surgical site (such in the setting of
immune compromise, cardiac surgery,and/or implantation of
a foreign device).
• Patients who receive prophylactic antibiotics within one to
two hours before the initial incision have lower rates of SSI
than patients who receive antibiotics sooner or later than this
window.
• Antimicrobial therapy administered in the setting
of contaminated wounds is not considered
prophylactic; in such cases, a therapeutic course
of antimicrobial therapy is warranted.
• Errors in selection or dose of prophylactic
antimicrobials are common. Among 34,133
patients undergoing surgery in centers around
the United States, an antimicrobial was
administered within one hour before incision to
only 56 percent of patients, and antimicrobials
were discontinued within 24 hours of surgery in
only 41 percent of patients.
Antibiotic selection
• Cefazolin (1 to 2 g IV) is a first generation cephalosporin active
against streptococci and methicillin susceptible staphylococci; it is
generally appropriate for clean procedures.
• Cefuroxime (1.5 g IV) is a second generation cephalosporin with
broader coverage against gram-negative organisms; it may be
administered in place of cefazolin for thoracic (cardiac and
noncardiac) and orthopedic procedures.
• For procedures that may involve exposure to bowel anaerobes
(including Bacteroides fragilis),cefoxitin (1 to 2 g IV)
or cefotetan (second generation cephalosporins) have broader
coverage including anaerobic activity than the above agents.
However, some gram-negative bacilli such as E. coli have become
resistant to cefoxitin; in such circumstances, reasonable alternatives
includecefazolin plus metronidazole (500 mg IV) or monotherapy
with ampicillin-sulbactam (3 g IV).
• Patients with history of allergy to penicillin manifesting as an
uncomplicated or minor skin rash may be treated with
cephalosporins; allergic cross-reactions to cephalosporins are
infrequent except in patients with severe IgE-mediated reactions to
penicillin. If an IgE-mediated reaction against penicillin has occurred
in the past, cephalosporins should be avoided
• Alternatives to cephalosporins include intravenous vancomycin (15
to 20 mg/kg) or clindamycin (600 to 900 mg) PLUS an agent with
activity against gram-negative bacteria such
as gentamicin ,ciprofloxacin , levofloxacin , or aztreonam . This is
particularly important in patients undergoing colorectal or vascular
surgery involving a groin incision.
• Local resistance patterns should be considered. Vancomycin is
preferable to cephalosporins in locations where methicillin-resistant
Staphylococcus aureus or methicillin-resistant coagulase-negative
staphylococci are a frequent cause of surgical site infections and in
patients who are known to be colonized with methicillin-resistant S.
aureus preoperatively .
Timing of prophylaxis
• Antimicrobial therapy should be
administered within 60 minutes prior to
the surgery to ensure adequate drug
tissue levels at the time of initial incision
(or within 120 minutes ifvancomycin or a
fluoroquinolone is used) . This practice
also reduces the likelihood of antibioticassociated reactions at the time of
induction of anesthesia.
• This practice is supported by a prospective
observational study of 2847 patients undergoing
elective clean or clean-contaminated surgery in
which the rate of SSI was lower among patients who
received antimicrobial prophylaxis within 120
minutes before the incision than those who received
prophylaxis more than two hours prior to incision
(0.6 percent versus 1.4 to 3.8 percent) [ 25 ].
• If the 60-minute window for prophylaxis has past,
administration of antimicrobial therapy 30 to 60
minutes prior to surgery appears to be more
effective than administration immediately before
surgery
Antimicrobial prophylaxis for
gastrointestinal surgery
Nature of operation
Esophageal,
gastroduodenal
Biliary tract
Colorectal
Common pathogens
Enteric gram-negative
bacilli, gram-positive
cocci
Enteric gram-negative
bacilli, enterococci,
clostridia
Enteric gram-negative
bacilli, anaerobes,
enterococci
Recommended
antimicrobials
Adult dosage before
surgery*
•
<80 kg: 1 g IV
≥80 kg: 2 g IV
◊
<80 kg: 1 g IV
≥80 kg: 2 g IV
High risk only:
Δ
cefazolin
High risk only:
Δ§
cefazolin
Oral:
Neomycin PLUS
¥
erythromycin base or
¥
metronidazole
Parenteral:
Δ
Cefoxitin or cefotetan
OR cefazolin
¥
Δ
Δ
<80 kg: 1 g IV
≥80 kg: 2 g IV
500 mg IV
PLUS metronidazole
OR ampicillin������
sulbactam
Appendectomy, non������
perforated
Same as for colorectal
Cefoxitin
Δ
or cefotetan
OR cefazolin
Δ
PLUS metronidazole
1 to 2 g IV
3 g IV
Δ
1 to 2 g IV
<80 kg: 1 g IV
≥80 kg: 2 g IV
500 mg IV
Antimicrobial prophylaxis for
cardiac surgery
Nature of
operation
Common
pathogens
Cardiac surgery
Staphylococcus
aureus, S.
epidermidis
Recommende
d
antimicrobials
Usual adult
dosage*
Cefazolin
<80 kg: 1 g IV
≥80 kg: 2 g IV
OR cefuroxime
1.5 g IV
OR vancomycin
1 g IV
Δ
•
Antimicrobial prophylaxis for
genitourinary surgery
Nature of
operation
Cystoscopy
alone
Common
pathogens
Recommended
antimicrobials
•
Usual adult
dose*
Enteric gramnegative bacilli,
enterococci
High-risk only:
Δ
ciprofloxacin
500 mg orally or
400 mg IV
OR trimethoprim
sulfamethoxazol
e
One 160/800 mg
(double
strength, DS)
tablet orally
Cystoscopy with
manipulation or
upper tract
instrumentation
Enteric gramnegative bacilli,
enterococci
Ciprofloxacin
Open or
laparoscopic
§
surgery
Enteric gramnegative bacilli,
enterococci
Cefazolin
◊
Δ
OR trimethoprim
sulfamethoxazol
e
¥
500 mg orally or
400 mg IV
One 160/800 mg
(double
strength, DS)
tablet orally
<80 kg: 1 g IV
≥80 kg: 2 g IV
Antimicrobial prophylaxis for
gynecologic and obstetric surgery
Procedure
Hysterectomy
(abdominal, vaginal,
laparoscopic, or robotic)
Urogynecology
procedures
Cesarean section
Preferred regimen
Cefazolin, Cefoxitin or
Cefotetan
•
Δ
Dose
Alternative regimens
Dose
<120 kg: 2 g IV
≥120 kg: 3 g IV
1. Ampicillin-sulbactam
3 g IV
2. Clindamycin OR
Vancomycin
600 mg IV
1 g IV
PLUS one of the
following:
Gentamicin OR
Aztreonam OR
Quinolone
Laparoscopy (diagnostic,
tubal sterilization,
operative except for
hysterectomy)
None
Abortion, surgical
Doxycycline
Hysterosalpingogram or
chromotubation
Doxycycline
Other transcervical
procedures:
Hysteroscopy (diagnostic
or operative, including
hysteroscopic
sterilization)
Intrauterine device
insertion
Endometrial biopsy
None
100 mg orally one hour
before procedure and 200
mg orally after procedure
◊
100 mg orally twice daily
for five days
1.5 mg/kg IV
1g IV
400 mg IV
Antimicrobial prophylaxis
for head and neck surgery
Nature of
operation
Incisions
through oral or
pharyngeal
mucosa
Common
pathogens
Anaerobes,
enteric gramnegative bacilli,
S. aureus
Recommended
antimicrobials
Usual adult
dose*
Clindamycin
600 to 900 mg
IV
OR cefazolin
<80 kg: 1 g IV
≥80 kg: 2 g IV
plus
metronidazole
500 mg IV
OR ampicillin•
sulbactam
3 g IV
Antimicrobial prophylaxis
for neurosurgery
Common pathogens
S. aureus, S.
epidermidis
Recommended
antimicrobials
Cefazolin
OR vancomycin
Usual adult dose*
<80 kg: 1 g
≥80 kg: 2 g
•
1 g IV
Antimicrobial prophylaxis
for ophthalmic surgery
Common pathogens
Antimicrobials
Usual adult dose
S. epidermidis, S.
aureus, streptococci,
enteric gram-negative
bacilli, Pseudomonas
spp
Gentamicin,
tobramycin,
ciprofloxacin,
gatifloxacin,
levofloxacin,
moxifloxacin, ofloxacin
or neomycingramicidin-polymyxin
B
Multiple drops topically
over 2 to 24 hours
OR cefazolin
100 mg
subconjunctivally
Antimicrobial prophylaxis
for orthopedic surgery
Common pathogens
S. aureus, S.
epidermidis
Recommended
antimicrobials
Cefazolin
•
OR vancomycin
Usual adult dose*
<80 kg: 1 g IV
≥80 kg: 2 g IV
•Δ
1 g IV
Antimicrobial prophylaxis for
thoracic (noncardiac) surgery
Common pathogens
S. aureus, S.
epidermidis,
streptococci, enteric
gram-negative bacilli
Recommended
antimicrobials
Usual adult dose*
Cefazolin
<80 kg: 1 g IV
≥80 kg: 2 g IV
OR ampicillin•
sulbactam
3 g IV
OR vancomycin
Δ
1 g IV
Antimicrobial prophylaxis
for vascular surgery
Nature of
operation
Common
pathogens
Recommended
antimicrobials
Usual adult
dose*
Arterial surgery
involving a
prosthesis, the
abdominal aorta,
or a groin
incision
S. aureus, S.
epidermidis,
enteric gramnegative bacilli
Cefazolin
<80 kg: 1 g IV
≥80 kg: 2 g IV
Lower extremity
amputation for
ischemia
S. aureus, S.
epidermidis,
enteric gramnegative bacilli,
clostridia
Cefazolin
<80 kg: 1 g IV
≥80 kg: 2 g IV
OR vancomycin
1 g IV
OR vancomycin• 1 g IV
•
HAIR REMOVAL
• Hair removal is commonly performed before many
surgical procedures in order to provide the surgeon
with a "clean" field and to prevent hair from falling
into the surgical site.
• However, most studies have shown an increased
risk for surgical site infections (SSIs) in patients
undergoing preoperative hair removal .
• In one study, the rates of SSI were highest when
shaving was performed compared with clipping the
hair or use of depilatory creams (5.6 compared
with 1.7 and 0.6 percent, respectively).
• In another study, scanning electron
micrographs showed that razors caused
gross skin cuts, clippers caused less injury,
and depilatory agents caused no injury to
the skin surface . The timing of hair
removal is also important. The lowest rates
of SSI were reported when hair was
removed just prior to the surgical incision
• A meta-analysis that examined 11 randomized
controlled trials concluded that there was no
difference in rate of SSIs among patients who
have had hair removed prior to surgery and
those who have not.
• If hair needs to be removed, patients should be
clipped rather than shaved, as patients who
were shaved were more likely to develop SSI
(three trials, 3193 patients, relative risk 2.02,
95% CI, 1.21-3.36)
S. AUREUS DECOLONIZATION
• Nasal carriage of S. aureus is a risk
factor for surgical site infection (SSI).
• Nasopharyngeal decontamination
may be effective for reducing the risk
of postoperative infection in some
situations. Agents
include mupirocin nasal ointment
and chlorhexidine soap
• For circumstances in which the
presence of nasal S. aureus carriage
can be assessed via rapid screening,
decolonization with mupirocin nasal
ointment and chlorhexidine soap may
reduce the risk of hospital-associated
S. aureus infection.
• it was suggested that S. aureus
decolonization with
intranasal mupirocin andchlorhexidine baths
may be appropriate for surgical patients
known to be nasal carriers of S. aureus with a
high risk of deleterious outcomes should S.
aureus infection develop at the surgical site.
• This includes patients who are
immunocompromised, undergoing cardiac
surgery, and/or undergoing implantation of a
foreign device . There is no role for routine
decolonization.
GLUCOSE CONTROL
• Hyperglycemia and diabetes have been
identified as risk factors for deep sternal site
infection after CABG .
• These studies have suggested that a
preoperative blood glucose level of 200 mg/dL or
more or postoperative hyperglycemia is
associated with an increased risk of SSIs.
• each 50 mg/dL blood glucose increase may be
associated with higher mortality and higher
infection rate and longer postoperative hospital
stay by 0.76 days and increased hospitalization
cost
PERIOPERATIVE NORMOTHERMIA
• Mild perioperative hypothermia may
promote surgical site infection (SSI) by
triggering thermoregulatory vasoconstriction.
• However, hypothermia may protect tissue
from ischemia by reducing oxygen
consumption during surgery, an effect
exploited during circulatory arrest in cardiac
surgery. Despite this positive effect, most
surgeons, anesthesiologists, and hospital
epidemiologists acknowledge the benefit of
perioperative normothermia in reducing the
risk of SSI.
• A similar advantage to perioperative
warming has been shown in one
study of clean surgical procedures .
Wound infection was significantly
more common among patients who
were not warmed before surgery (14
versus 5 percent).
Prevention Of Nosocomial UTIs
• The most important measure is to avoid
urinary catheters
• Keep the catheter closed and remove it as
soon as possible
• Alternatives for urinary catheters include
condom catheters and suprapubic
catheters
• Bladder irrigation — Antimicrobial irrigation of the
bladder does not prevent or delay infection;
• Catheter replacement — Urinary catheters should
not be replaced routinely.
• Antimicrobial-coated catheters : variable impact on
infection rates . further studies are necessary before
antimicrobial catheters can be recommended for routine
use.
• Suprapubic catheters :not recommend
• Condom catheters : A reduction in urinary
infections related to condom
catheters is only seen when there is
good cooperation with the use of the
catheter and no unnecessary
manipulation of the device.
• Prophylactic antibiotics : more
studies are necessary before
antibiotic prophylaxis can be
recommended for patients in
general or for specific
subgroups of patients.
Prevention Of Intravenous Catheter
related infections
• ASEPTIC TECHNIQUE :
• Strict adherence to hand washing and aseptic
technique is crucial for reducing catether related
infections .
• Peripheral catheters should be changed at least
every 72-96 hr (after which the risk of infection
rises significantly)
• Change as soon as possible (24-48 hr) any
catheter inserted under less-than-sterile
condition or in the emergency department
• Certainly use no cut-downs
• CVP catheters should be inserted under
sterile conditions _ sterile gloves, gowns,
masks, head covering, and large sterile
drapes reduce infection more than just
sterile gloves and a drape
• Avoid using the jugular or the femoral
route, both of which have higher risks of
infection compared to the subclavian
route
• Avoid multiple-lumen catheters , which
receive multiple ( potentially
contaminating) manipulations by health
care workers
Risk factors and prevention of
hospital-acquired, ventilatorassociated, and healthcareassociated pneumonia in adults
Dr.Bolandnazar
Infectious diseases Specialist
INTRODUCTION
Hospital-acquired (or nosocomial)
pneumonia (HAP), ventilatorassociated pneumonia (VAP), and
healthcare-associated pneumonia
(HCAP) are important causes of
morbidity and mortality despite
improved antimicrobial therapy,
supportive care, and prevention
PREVENTION
Decontamination of the digestive tract:
an attempt to reduce the incidence of
pneumonia in critically ill patients by
diminishing colonization of the upper
respiratory tract.
The methods used include antiseptics in the
oropharynx and nonabsorbable antibiotics
taken orally with or without systemic
antibiotics.
Decontamination of the
oropharynx
Gingival and dental plaque rapidly
becomes colonized with aerobic
pathogens in intensive care unit
(ICU) patients due to poor oral
hygiene and lack of mechanical
elimination.
Based upon the available data, we
recommend performing regular oral
care with an antiseptic solution in
patients receiving mechanical
ventilation.
Chlorhexidine has been best
studied.
chlorhexidine 0.12% oral solution
(15 mL twice daily until 24 hours
after extubation).
Selective decontamination of the
digestive tract
SDD is a strategy that aims to decrease the
incidence of VAP by preventing
oropharyngeal and gastric colonization with
aerobic gram-negative bacilli and Candida
spp, without disrupting the anaerobic flora.
A variety of regimens have been employed.
Most use a combination of a locally
administered nonabsorbable antibiotic (eg,
polymyxin) and an aminoglycoside plus
either amphotericin B or nystatin.
Despite the potential benefits described
above, SDD has not found widespread
favor in North America .
 A major reason for this is concern about
promoting the growth of resistant bacteria.
Compared with North America, SDD is
used more commonly in some countries
in Europe, such as the Netherlands,
where rates of resistant bacteria in
intensive care units are substantially
lower.
Probiotics
Probiotics are defined as live microorganisms of
human origin that are able to tolerate the hostile
gastrointestinal environment such that they persist
in the lower alimentary tract to confer a health
benefit to the host.
In a randomized trial of 146 mechanically
ventilated patients, the enteral administration of the
probiotic Lactobacillus rhamnosus resulted in
significantly lower rates of oropharyngeal and
gastric bacterial colonization as well as subsequent
VAP compared with placebo
Preventing aspiration
Aspiration is a major predisposing
mechanism for both hospital-acquired
pneumonia (HAP) and VAP.
Appropriate patient positioning and
subglottic drainage in ventilated
patients are two important modalities
for the prevention of aspiration.
Patient positioning
Supine positioning appears to
predispose to aspiration and the
development of HAP.
Although no effect of positioning on
mortality has been demonstrated, it
seems prudent to preferentially place
intubated patients in the
semirecumbent position unless
contraindicated.
Subglottic drainage
Drainage of subglottic secretions may
lessen the risk of aspiration and thereby
decrease the incidence of VAP.
Specially designed endotracheal tubes
have been developed to provide continuous
or intermittent aspiration of subglottic
The same devices can also be used for
intermittent aspiration of subglottic
secretions.
The potential economic
impact of widespread use
of subglottic secretion
drainage is unclear
Glucocorticoids
Stress-dose glucocorticoids have been
proposed as a possible method for
preventing HAP in critically ill patients.
Hydrocortisone (200 mg/day for five days
followed by 100 mg on day six and 50 mg
on day seven) was compared with placebo
in a multicenter trial
patients who received hydrocortisone had
a lower risk of HAP at 28 days compared
with patients who received placebo
Hydrocortisone use was also associated
with a shorter duration of mechanical
ventilation and a reduced risk of
hyponatremia, but there was no
difference in mortality compared with
placebo.
Further studies are necessary to more
clearly define the potential benefits and
safety of glucocorticoid use in these
populations