Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy

8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy

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Management of surgical site infectionsManagement of surgical site infections


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Surgical site infection (SSI)management of wound infectionsmanagement of wound infections

The strategy for wound infection management is toprevent or minimize the risk of infection.

An action or set of actions intentionally taken to reducethe risk of SSI.

Reducing opportunities for microbial contamination of the

patients tissues or sterile surgical environment. Applied to the patient preparation, Surgical team

members educated in aseptic technique, care of Theatreenvironment and instruments, optimize surgicaltechnique.

the Centers for Disease Control and Prevention (CDC)

and Healthcare Infection Control Practices AdvisoryCommittee (HICPAC) presents recommendations for theprevention of surgical site infections (SSIs), formerly

called surgical wound infections.


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CDC GUIDELINE: PREVENTION OF SSICDC GUIDELINE: PREVENTION OF SSI

Categorizing RecommendationsCategorizing Recommendations

IA Strongly recommended for implementationand supported by well-designedexperimental,clinical or epidemiological studies & should beadapted by all practices .

IB Strongly recommended for implementationand supported by some experimental, clinical, orepidemiological studies and strong theoreticalrationale.

II Suggested for implementation and supported

by suggestive clinical or epidemiological studies ortheoretical rationale.

No recommendation; unresolved issues, practices&evidence for which are insufficient.


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CDC GUIDELINE: PREVENTION OF SSICDC GUIDELINE: PREVENTION OF SSI

Preoperative circumstances:Preoperative circumstances:

Patient preparation.Patient preparation.

Antimicrobial prophylaxis.Antimicrobial prophylaxis.

Surgical team members.Surgical team members.

Management of infected or colonized surgicalManagement of infected or colonized surgicalpersonnelpersonnel (staff).(staff).

Intraoperative Recommendations:Intraoperative Recommendations:

Surgical drapes.Surgical drapes.

wound care.wound care.

Postoperative Recommendations:Postoperative Recommendations: Incision Care.Incision Care.


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Preoperative circumstancesPreoperative circumstances

Patient preparationPatient preparation CategoryIA criteria

Identify and treat all infections remote from the surgical site.

Do not remove hair unless it will interfere with the operation .

CategoryIB criteria

Adequately control serum blood glucose levels .

Encourage tobacco cessation

Do not withhold necessary blood products from surgical patients asa means to prevent SSI. .

Pre-operative shower or bathe with an antiseptic agent on at least

the night before the operative day Thoroughly wash and clean at and around the incision site &Use an

appropriate antiseptic agent .

CategoryIIcriteria:

Keep preoperative stay in hospital as short as possible while allowing foradequate preoperative preparation of the patient.

Apply preoperative antiseptic skin preparation in concentric circles&Theprepared area must be large enough to extend the incision or create newincisions or drain sites,

No recommendation

Taper or discontinue systemic steroid use before elective surgery .

enhance nutritional support .


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Hair RemovalHair Removal

PrePre--operative Shavingoperative Shaving

Shaving the surgical site with a razor

induces small skin lacerations:

Potential sites for infection.

Disturbs hair follicles which are oftencolonized with S. aureus

Risk greatest when done the night

before.


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Shaving of operative siteShaving of operative site

Shaving ProtocolShaving Protocol SSIRiskSSIRisk

Hair not removed 0,6%

Hair removed by razor night

before

5,6%

Razor < 24hrs before surgery 7,1%

Razor > 24hrs before surgery > 20%

Clippers right before surgery 1,8%

Clippers night before surgery 4,0%


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Antimicrobial prophylaxisAntimicrobial prophylaxis

To reduce the microbial burden of intra-operativecontamination to a level that cannot overwhelm hostdefences.

Category 1A Select an antimicrobial agent safe, inexpensive, and bactericidal

with efficacy against expected pathogen . Administer IV& timed to achieve adequate bactericidal serum

levels during operation and for few hours after incision closed .

Before colorectal elective operations, in addition to IVantimicrobial drugs, mechanically prepare the colon withenemas and cathartic agents; administer nonabsorbable oralantimicrobial agents in individual doses the day before surgery .

For cesarean sections in patients at high risk administer IV

antimicrobial agent immediately after cord is clamped. Category 1B

-Do not routinely use vancomycin for prophylaxis


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Prophylactic AntibioticsProphylactic AntibioticsQuestionsQuestions

Which cases benefit?Which cases benefit?

Which drug should you use?Which drug should you use?

When should you start?When should you start?

How much should you give?How much should you give?

How long should antibiotics be continued?How long should antibiotics be continued?


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Antibiotic ProphylaxisAntibiotic ProphylaxisDemonstrated BenefitDemonstrated Benefit

All clean-contaminated procedures; these include

penetration of the gastrointestinal tract, whether by

penetrating trauma or related to a pathological organ

event (e.g. ruptured appendix, perforated colonic

diverticulum) prior to the development of clinical

peritonitis.

Clean operations with foreign body implant(e.g.

vascular, cardiac and orthopaedic operations), and those

without foreign body implants especially hernia repair,

breast surgery, median sternotomy, vascular surgery

involving the aorta and the lower extremities, and

craniotomy.

For contaminated & dirty 0perations(e.g. acute

cholecystitis, empyema , ascending cholangitis or liver

abscess , perforated appendix with evidence of local or

generalised peritonitis and/or intraabdominal abscess,

antibiotic given as part of treatment (for a longer

duration ).


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Operation Expected Pathogens Recommended

Antibiotic

Orthopedic surgery,

neurosurgery , breast

surgery Cardiothoracicsurgery

S aureus, coagulase-negativestaphylococci

Cefazolin 1-2 g IV OR

Cefuroxime 1.5 g IV OR

Vancomycine

Gastroduodenal surgery Gram-negative bacilli andstreptococci , anaerobic

Cefazolin 1-2 g IV

Colorectal surgery Gram-negative bacilli andanaerobes

Cefoxitin 1-2 g plus oral Neomycin1 g and oral Eerythromycin 1 g(start preoperatively for 3 doses)

Appendectomy, biliary

procedures

Gram-negative bacilli andanaerobes

Cefazolin 1-2 g OR

Cefoxitin 2 g IV

Vascular surgery S aureus, Staphylococcus

epidermidis, gram-negative bacilliCefazolin 1-2 g

Head and neck surgery S aureus, streptococci, anaerobesand streptococci

Cefazolin 1-2 g

Amoxiclav 1.2 g IV

Obstetric and

gynecological

procedures

Gram-negative bacilli, enterococci,anaerobes, group B streptococci

Cefazolin 1-2 g

Urology procedures Gram-negative bacilli Cefazolin 1-2 g

Contaminated Surgery

Ruptured viscus &

traumatic wound

Enteric gram-negative

bacilli, anaerobes,

Enterococci & S. aureus, group Astrep, clostridia

Cefoxitin or Cefazolin / Gentamicin

OR Metronidazole plus Gentamicin

IV


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Antibiotic ProphylaxisAntibiotic ProphylaxisProper Timing of Antimicrobial AdministrationProper Timing of Antimicrobial Administration

The optimal concentration in the serum/tissueat the time of the incision.

It is important to maintain therapeutic level inthe serum/tissue throughout the operation.

If the surgical procedure is longer than the half-life of the drug, re-dosed during the procedure,(a second dose only given if the operation lastsfor longer than 2 - 3 hours ).

According to the most recent Medicalrecommendations the drug should be givenbetween 30 minutes and two hours before thetime of surgical incision.


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Antibiotic ProphylaxisAntibiotic Prophylaxis

Dose of Antibiotic for ProphylaxisDose of Antibiotic for Prophylaxis

Always give at least a full therapeutic dose of

antibiotic.

Consider the upper range of doses for large

patients and/or long operations.

Consider repeating doses for long operations.


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When should antibiotics be stopped?When should antibiotics be stopped?


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Prophylactic AntibioticsProphylactic AntibioticsLimiting the Duration of AntimicrobialLimiting the Duration of Antimicrobial

AdministrationAdministration

Discontinuation of the antibiotic within 24

hours after surgery is recommended for the

following reasons:

Use of the prophylaxic antimicrobial agent after

this period has not been shown to improvesurgical site infection rates and increases the cost

of care unnecessarily .

Indiscriminate & prolong use of antimicrobials

agents can lead to the development of antibiotic-

resistant microorganisms. Increased antibiotic-associated complications:

.Clostridium difficile Enterocolitis

.Colonization with MRSA


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Prolonged prophylaxis

Wound infectionwith

Resistant organismsMRSA, pseudomonas

Risk of nosocomial

Infections CDAD


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Surgical team membersSurgical team members

CategoryIB

Keep fingernails short.

Perform a preoperative surgical scrub for at least 2

to 5 minutes using an appropriate antiseptic.

After performing the surgical scrub, keep hands up

and away from the body.

use a sterile towel to dry the hands and put on asterile gown and gloves.

CategoryII Clean underneath each fingernail prior to performing

the first surgical scrub of the day.

Do not wear arm/hand jewelry.

No recommendation wearing nail polish.


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Management of infected or colonized surgicalManagement of infected or colonized surgical

personnelpersonnel (staff)(staff)

CategoryIB

Routine exclusion of personnel colonized by

organisms, such as Saureus or group A

streptococci, is not necessary unless they are

specifically linked to dissemination of such

organisms.

Personnel with skin lesions that are draining are to

be excluded from duty until treated and the infection

has resolved.

Educate and encourage surgical personnel regarding

reporting illness of transmissible nature to

supervisory and occupational health personnel.


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Intraoperative RecommendationsIntraoperative Recommendations

Surgical drapesSurgical drapes

CategoryIB Masks should cover the mouth and nose & worn in

the operating room if sterile instruments are exposedand throughout the surgical procedure.

The hair on the head and face is to be covered with a

hood or cap. Liquid-resistant sterile surgical gowns and sterile

gloves are to be worn by scrubbed surgical teammembers.

Visibly soiled gowns are to be changed.

Shoe covers are not necessary.

No recommendation Restriction of scrub suits to the operating theater.

Covering the scrub suits when outside the theater.


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Intraoperative RecommendationsIntraoperative Recommendations

wound carewound care

CategoryIA:

Asepsis is necessary in the insertion of indwellingcatheters, such as intravascular, spinal, or epiduralcatheters, and subsequent infusion of drugs.

CategoryIB

Handle tissues gently with good homeostasis,minimize foreign bodies, and minimize

devitalized tissue and dead space. For Class III and IV wounds, use delayed closure

or leave the wound incision open to heal bysecondary intention.

If draining of a wound is necessary, use a closedsuction drain the drain exit should be via

separate incision distant from the wound.Remove the drain as soon as possible.

CategoryII

Assemble sterile equipment and solutionsimmediately prior to use.


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Postoperative RecommendationsPostoperative Recommendations

Incision CareIncision Care

CategoryIB

Incisions should be protected with a sterile dressing for 24-

48 hours.

Wash hands before and after dressing changes and any

contact with the surgical site.

CategoryII

Use sterile technique for wound dressing change.

Educate the patient and relatives regarding wound care

symptoms of SSIs and the need to report such problems.


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Treatment of surgical site infectionsTreatment of surgical site infections

Treating wound infections depends on the nature of thewound, degree of infection, and the bacteria responsiblefor the infection.

Open the wound and allow it to drain:

Remove sutures and staples local to the site of infection.

Skin and subquatenous tissues in involved area opened& exam to assess its integrity and for a deep spaceinfection & to exclude the underlying fascial dehiscence.

Evacuate the pus.

Swab for c/s.

Cleansing the wound: by irrigating the wound withsterile (clean) water or normal saline &It may be doneusing high pressure with a needle or catheter and a largesyringe , Germ-killing solutions may also be used toclean the wound like Hydrogen peroxide.


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Treatment of surgical site infectionsTreatment of surgical site infections

Debridement: to clean and remove objects, dirt, or dead skinand necrotic tissues from the wound area.

Dressing the wound : to protect the wound from furtherinjury and infection. These may also help provide pressure todecrease swelling. Dressings may come in different forms.Dressing changes allow the tissues to granulate.

Close the wound.

Antibiotics to fight the infections, patient high risk fordissemination of infection (i.e. diabetics ; Immnuno-compromised, if prosthetics involved, if patient has signs ofsystemic toxicity or if surrounding area of soft tissue erythemaand edema.

A tetanus vaccine booster shot may be indicated to preventthe occurrence of tetanus.

Other treatment: Controlling or treating the medical conditionthat causes poor wound healing & treat complications.


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Choice of antibioticChoice of antibiotic

1-post operative wound infection without

sepsis (no GIT,FGT)

Cephalexin 500mg po q6 h

amoxiclav 500 mg po q8 h Dicloxacillin 500 mg po q6 h

+/-

Ciprofloxacin 500 mg po q12 h


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Choice of antibioticChoice of antibiotic

2) Post. Op. wound infection with sepsis

(surgery involving GIT,FGT)

Cefoxitin 1gm iv q6h or

Cefotaxime 1gm iv q 8 h, Ceftriaxone 1-2 gm iv q 24 h

+

metronidazole iv q8h or

imipenum 500 mg iv q6 h.


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Traumatic wound infectionIntroduction

Traumatic injuries have a potential for serious bacterialwound infections, including gas gangrene and tetanus,and these in turn may lead to long term disabilities,chronic wound or bone infection, and death.

Wound infection is particularly of concern wheninjured patients present late for definitive care, or indisasters where large numbers of injured survivorsexceed available trauma care capacity.

Appropriate management of injuries is important to

reduce the likelihood of wound infections.

The following core principles and protocols provideguidance for appropriate prevention and management

of infected wounds.


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Management of traumatic wound infection

Core Principles

1. Never close infected wounds:

Systematically perform wound toilet and surgical

debridement until the wound is completely clean.

2. Do not close contaminated wounds and clean

wounds that are more than six hours old:Surgical toilet, leave open and then close 48 hours later

(delayed primary closure).

3. Antibiotics:

They are necessary but not sufficient and need to be

combined with appropriate debridement and wound

toilet .

3. Use of topical antibiotics and washing wounds

with antibiotic solutions are not

recommended.


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Management of traumatic wound infection

Core Principles

5. To prevent wound infection: Restore breathing and blood circulation as soon as

possible after injury.

Warm the victim and at the earliest opportunity provide

high-energy nutrition and pain relief. Do not use tourniquets.

Perform wound toilet and debridement as soon as

possible (within 8 hours if possible).

Respect universal precautions to avoid transmission of

infection.

Give antibiotic prophylaxis to victims with deep wounds

and other indications.


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Protocols

Protocol 1: Wound toilet and surgical debridement

Protocol 2: Management of tetanus-prone wounds

Protocol 3: Antibiotic prophylaxis and treatment


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Protocols

Protocol 1: Wound toilet and surgical

debridement

1.1. Wash the woundWash the wound with large quantities of soap and

boiled water for 10 minutes, and then irrigate the

wound with saline.

2. DebridementDebridement: mechanically remove dirt particles

and other foreign matter from the wound and use

surgical techniques to cut away damaged and dead

tissue, Irrigate the wound again. If a local anesthetic

is needed, use 1% lidocaine withoutepinephrine.

3. Leave the wound openLeave the wound open. Pack it lightly with dampsaline disinfected or clean gauze and cover the

packed wound with dry dressing. Change the

packing and dressing at least daily.


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Protocol 2: Management of tetanus-prone

wounds

Wounds more than 6 hours before surgicaltreatment of the wound or show one or more of thefollowing: a puncture-type wound, a significantdegree of devitalized tissue, clinical evidence ofsepsis, contamination with soil/feces likely to

contain tetanus organisms, burns, frostbite, andhigh velocity missile injuries.

For patients with tetanus-prone injuries, WHOrecommends TT or Td and TIG.

When tetanus vaccine and tetanus immunoglobulinare administered at the same time, they should beadministered using separate syringes andseparates sites.


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Protocol 2: Management of tetanus-prone

wounds

Tetanus vaccine

ADULT and CHILDREN overADULT and CHILDREN over 1010 years:years:

Active immunization with tetanus toxoid (TT) or with tetanus and

diphtheria vaccine (Td)

1 dose (0.5 ml) by intramuscular or deep subcutaneous injection. Follow

up: 6weeks, 6 months.CHILDREN underCHILDREN under 1010 years:years:

Diphtheria and tetanus vaccine (DT)

0.5 ml by intramuscular or deep subcutaneous injection. Follow up at

least 4 weeks and 8 weeks.

Tetanus immune globulin

ADULT and CHI

LDADU

LT and CHI

LD Tetanus immunoglobulin (human) 500 units/vial

250 units by intramuscular injection, increased to 500 units if any of the

following conditions apply: wound older than 12 hours; presence, or risk

of, heavy contamination; or if patient weight more than 90 kg.


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Protocol 3: Antibiotic prophylaxis and

treatment

Antibiotic prophylaxisAntibiotic prophylaxis

Contaminated wounds, penetrating wounds, abdominal trauma,compound fractures, lacerations greater than 5 cm, wounds withdevitalized tissue, high risk anatomical sites such as hand or

foot.

Recommended prophylaxis consists of penicillinG andmetronidazole given once.

Penicillin G ADULT: IV8-12million IU once. CHILD: IV200,000IU/kg once.

Metronidazole ADULT: IV1,500 mg once (infused over 30min). CHILD: IV20 mg/kg once.


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Protocol 3: Antibiotic prophylaxis and

treatment

Antibiotic treatmentAntibiotic treatment

If infection is present or likely, administer antibiotics via

intravenous and not intramuscular route.

PenicillinG and metronidazole for 5-7 days provide good

coverage.

Penicillin G ADULT: IV1 - 5 MIU every 6 hours. After 2 days it is possible to use oral Penicillin: Penicillin V 2

tablets every 6 hours.

CHILD: IV100mg/kg daily divided doses (with higher doses in

severe infections),

In case of known allergy to penicillin use erythromycin

Metronidazole ADULT: IV500 mg every 8 hours (infusedover20 minutes).

CHILD: IV7.5 mg/kg every 8 hours.

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Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy