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Device Related Infections
Jeffrey R. Scott, Ph.D.
Definitions
Infection
a. Invasion by and multiplication of pathogenic microorganisms in a bodily
part or tissue, which may produce subsequent tissue injury and progress to
overt disease through a variety of cellular or toxic mechanisms.
b. An instance of being infected.
c. An agent or a contaminated substance responsible for one's becoming
infected.
d. The pathological state resulting from having been infected.
Pus
A generally viscous, yellowish-white fluid formed in infected tissue,
consisting of white blood cells, cellular debris, and necrotic tissue.
Invasion by and multiplication of pathogenic microorganisms in a bodily part
or tissue, which may produce subsequent tissue injury and progress to
Clinical Symptoms of a
General Infection Post-op
Malaise: One of the most common symptoms of a systemic infection, or an
infection that is moving through your body, is that you will feel tired and
lacking in energy. You may sleep more than usual, or not feel up to doing
your normal activities. These feelings are also common for patients who are
recovering from surgery who do not have an infection. The difference is that
when recovering from surgery most people feel a bit better each day, rather
than feeling better for a few days then suddenly feeling exhausted and
lethargic as can happen with infection.
Fever: A fever is often accompanied by feeling chilled. A fever can also
decrease your appetite, lead to dehydration and a headache. A low-grade
fever (100 F or less) is common in the days following surgery, a fever of 101
or more should be reported to the surgeon.
Clinical Symptoms of a
Surgical Site Infection
Hot Incision: An infected incision may feel hot to the touch. This happens as
the body sends infection fighting blood cells to the site of infection.
Swelling/Hardening of the Incision: An infected incision may begin to
harden as the tissue underneath are inflamed. The incision itself may begin
to appear swollen or puffy as well.
Redness: An incision that gets red, or has red streaks radiating from it to the
surrounding skin may be infected. Some redness is normal at the incision
site, but it should decrease over time, rather than becoming more red as the
incision heals.
Drainage From the Incision: Foul-smelling drainage or pus may begin to
appear on an infected incision. It can range in color from blood-tinged to
green, white or yellow. The drainage from an infected wound may also be
thick, and in rare cases, chunky.
Pain: Due to increase blood flow, white cell accumulation, and swelling
Leukocyte Recruitment
Microvascular Unit
Intravital Video Microscopy
History of Aseptic Technique
Hippocrates (circa 460–370 BC) may have been the first to hold an opinion on suppuration, asserting that the formation of pus was not
a natural component in the healing process and suppuration should be avoided. His recommendations for managing wounds were
similar to those of the Sumerians: cleansing with wine, applying a bandage, and then pouring wine on the bandage. [4]
Claudius Galen (circa A.D. 130–200), a surgeon to the gladiators in Pergamum, idealized Hippocrates and championed
Hippocratic doctrines in the practice of medicine. Galen was a prolific writer on the science of medicine and became an
outspoken proponent for experimentation, encouraging the questioning of established doctrines to expand scientific
knowledge. His works were translated into many languages and became the lexicon for medical practice until the modern era.
Many of his assertions proved true; however, one very important assumption was horrifically incorrect: that the formation of
pus was essential for wound healing. This deviation from the Hippocratic dogma is one that would plague surgeons and hinder
surgical progress until the time of Lister.[1]
Suppuration :
The formation or
discharge of pus.
That surgeons welcomed the sight of a purulent wound may be explained by the environment in which they were forced to practice.
Wounds could be classified into two different categories: those with suppuration and those without. Wounds productive of a creamy,
yellow ooze tended to run a chronic course, taking months to heal, but the patients were generally free of systemic symptoms. [15] As
Alexander[1] recounts, it was noted by Steven Smith as late as 1887 that "amputation wounds rarely, if ever, recovered at Bellevue,
except after long-continued suppuration." Conversely, a thin, watery discharge was associated with a fatal outcome, with the patient
dying of sepsis within days. With an infection rate of almost 100%, a purulent wound represented the lesser of the two evils.
Therefore, it is of little wonder that even the most conscientious surgeons preferred and even encouraged the formation of pus.
As a result, operations were performed with little regard for a sterile environment. Surgeons' hands, rarely washed, were placed
directly into the patient's wounds. Frequently, onlookers were encouraged to "take a feel" for educational purposes. [1] Surgical
instruments were crudely wiped, placed back into their velvet carriers, and reused, some having been sharpened on the sole of the
surgeon's boot.[15] The floors of the surgical wards were covered with human feces, urine, blood, and pus, and the hospital walls
displayed a collage of phlegm. Consequently, infection was a major cause of death, with 80% of operations plagued by "hospital
gangrene" and a nearly 50% mortality rate.[1] The stench of dead bodies and infectious byproducts led some to believe that putrid
wounds were caused by particles in the air or bad "humors." In 1880, William Halsted reportedly operated in tents outside of
Bellevue Hospital for better ventilation.[17] The prevailing view was that if infectious particles did exist, then they arose by
spontaneous generation.
History of Infection Control and its Contributions to the Development and Success of Brain Tumor Operations
Jason T. Miller, BS; Scott Y. Rahimi, MD; Mark Lee, MD, PHD
Authors and Disclosures
Posted: 05/09/2005; Neurosurg Focus. 2005;18(4):1-5. © 2005 American Association of Neurological Surgeons
History of Aseptic Technique
Louis Pasteur was a French chemist and biologist who proved the germ theory of disease and invented the process of
pasteurisation.
Louis Pasteur was born on 27 December 1822 in Dole in the Jura region of France. His father was a tanner. In 1847, he
earned a doctorate from the École Normale in Paris. After several years research and teaching in Dijon and Strasbourg, in
1854, Pasteur was appointed professor of chemistry at the University of Lille. Part of the remit of the faculty of sciences was
to find solutions to the practical problems of local industries, particularly the manufacture of alcoholic drinks. He was able to
demonstrate that organisms such as bacteria were responsible for souring wine and beer (he later extended his studies to
prove that milk was the same), and that the bacteria could be removed by boiling and then cooling the liquid. This process is
now called pasteurisation.
Pasteur then undertook experiments to find where these bacteria came from, and was able to prove that they were
introduced from the environment. This was disputed by scientists who believed they could spontaneously generate. In 1864,
the French Academy of Sciences accepted Pasteur's results. By 1865, Pasteur was director of scientific studies at the École
Normale, where he had studied. He was asked to help the silk industry in southern France, where there was an epidemic
amongst the silkworms. With no experience of the subject, Pasteur identified parasitic infections as the cause and advocated
that only disease-free eggs should be selected. The industry was saved.
Pasteur's various investigations convinced him of the rightness of the germ theory of disease, which holds that germs attack
the body from outside. Many felt that such tiny organisms as germs could not possibly kill larger ones such as humans.
Pasteur now extended this theory to explain the causes of many diseases - including anthrax, cholera, TB and smallpox - and
their prevention by vaccination. He is best known for his work on the development of vaccines for rabies. In 1888, a special
institute was founded in Paris for the treatment of diseases. It became known as the Institut Pasteur. Pasteur was its director
until his death on 28 September 1895. He was a national hero and was given a state funeral.
Louis Pasteur
BBC
History of Aseptic Technique
Louis Pasteur (1822–1895) vanquished the long-held myth of spontaneous generation and attributed fermentation and
meat putrefaction to living microscopic organisms. It was the simplicity and rationality of his experiments that persuaded
many of his contemporaries to adopt germ theory.[7, 11]
Joseph Lister (1827–1912), a professor of surgery at Glasgow, was the first to see the connection between Pasteur's
discovery of the fermentation process and the suppuration of wounds. In April 1867 he published his ground-breaking
paper on antisepsis, stating that "all the local inflammatory mischief and general febrile disturbance which follow severe
injuries are due to the irritating and poisoning influence of decomposing blood or sloughs." Lister began applying
carbolic acid to compound fracture wounds. The wound healed without suppuration, amputation was averted, and the
mortality rate from amputation plummeted from 45 to 15%.[1]
Improving on listerian practices, in 1891 Ernst von Bergmann introduced heat sterilization of instruments, which proved
superior to chemical sterilization.
Sterile gowns and caps were introduced in 1883 by Gustav Neuber of Kieland, and then the surgical mask by Mikulicz in
1897.[11]]
The use of rubber gloves became widespread after 1890 when William Stewart Halsted (1852–1922) commissioned the
Goodyear rubber company to fashion gloves for his nurse to protect her hands from the mercuric chloride solutions used
to disinfect the instruments.[13]
Joseph Lister
History of Infection Control and its Contributions to the Development and Success of Brain Tumor Operations
Jason T. Miller, BS; Scott Y. Rahimi, MD; Mark Lee, MD, PHD
Authors and Disclosures
Posted: 05/09/2005; Neurosurg Focus. 2005;18(4):1-5. © 2005 American Association of Neurological Surgeons
Early Asepsis
Joseph Lister
Carbolic Spray
Use of Rubber Gloves
1890
Photograph of Harvey Cushing and William Halsted in the operating room.
(Courtesy of Historical Section of the National Library of Medicine, Bethesda, Maryland.)
History of Infection Control and its Contributions to the Development and Success of Brain Tumor Operations
Jason T. Miller, BS; Scott Y. Rahimi, MD; Mark Lee, MD, PHD
Authors and Disclosures
Posted: 05/09/2005; Neurosurg Focus. 2005;18(4):1-5. © 2005 American Association of Neurological Surgeons
Modern Operating Room
Operating Room Layout / Personnel
The operating room provides a sterile
environment in which the operating team
can do surgery.
The operating team consists of the
following:
- Chief surgeon, who directs the surgery
- One or more assistant surgeons, who help
the chief surgeon
- Anesthesiologist, who controls the supply
of anesthetic and monitors the person
closely
- Scrub nurse, who passes instruments to
the surgeon
- Circulating nurse, who provides extra
equipment to the operating team
The operating room typically contains a monitor that displays vital signs, an instrument table, and an operating lamp.
Anesthetic gases are piped into the anesthetic machine. A catheter attached to a suction machine removes excess blood
and other fluids, which can prevent surgeons from seeing the tissues clearly. Fluids given by vein, started before the
person enters the operating room, are continued.
The Merck Manual
Aseptic Technique – Surgical Scrub
Aseptic Technique –
Gowning & Gloving
Hospital Acquired Infections
United States: The Centers for Disease Control and Prevention (CDC) estimates that
roughly 1.7 million hospital-acquired infections, from all types of bacteria combined,
cause or contribute to 99,000 deaths each year. Other estimates indicate that 10%, or
2 million, patients a year become infected, with the annual cost ranging from $4.5
billion to $11 billion.
In the USA the most frequent type of infection hospital-wide is urinary tract infection
(36%), followed by surgical site infection (20%), bloodstream infection (BSI), and
pneumonia (both 11%).
CDC
Device Related Infection
A device-associated infection is an infection in a patient with a device (i.e., central line,
ventilator, or indwelling urinary catheter) that was in use within the 48-hour period
before onset of infection. If the interval since discontinuation of the device is longer
than 48 hours, there must be compelling evidence that infection was associated with
device use.
Depending on the surgical procedure, approximately 1-6% of devices are infected.
The surgery was a success,
but the patient died.
Prevention of Surgical Site Infection
Patient Prep:
Patient Selection, Hand
washing, pre-op
shower, chlorhexidine,
iodine, antibiotics
Monitoring,
Education &
Modification
Post-op:
Wound care, drain
removal
OR Prep:
Airflow, aseptic tech
Surgical Technique:
Reduce time
Product Selection
Aseptic Technique
What Keeps a Surgeon up at Night?
Did the device I put in today get
contaminated during implant?
What if it was MRSA?
Methicillin-resistant
Staphylococcus aureus
Biofilm Formation
Biofilm Formation
Creating a Sterile Product From
Biologically-derived Tissue
Biologically-derived Device
Remodeling
Can you protect the device?
Optimal Characteristics of an
Antimicrobial Coating
1. Antimicrobial Efficacy Against Most Potential Pathogens
2. Antimicrobial Activity During Time Period at Highest Risk of Infection
3. Proven Zone of Inhibition in vitro correlated to in vivo results
4. No Toxicity to Human Tissues
Antimicrobial Products (on market)
Central Venous
Catheters3
R/M
Silver &
Chlorhex
Suture
Urinary
Catheters3
Triclosan2.
Bacitracin3
Nitrofurazone
Silver oxide
Silver alloy
Cefazolin3
Polymyxins3
Antimicrobial/
Antibiotic
Products
Hernia
Repair
Bone Cement
Tobramycin
Silver &
Chlorhex
gentamicin1
Wound
Care
Silver
PHMB, Iodine
Zinc, Honey
Penile
Implants
R/M
Hope is on the Horizon for our earlier
Patient
Do you think we will see Device
Related Infections in the Operating
Room of the Future?