Infection Control in the OR:

Just how important is it?

Elsie Truter

Waiariki Institute of Technology

Rotorua

New Zealand

Challenges in the OR

Preventing Surgical Site Infections against a backdrop of;

Changes to perioperative nursing practice and surgical techniques

New equipment – is it safe to use? How do we sterilise or disinfect?

New infectious diseases

Antibiotic Resistance

Staff compliance with Infection Prevention and Control practice

Government Initiatives

• Health Quality and Safety Commission New

Zealand

• Current Infection Prevention and Control Foci;

• Hand Hygiene

• CLAB prevention

• Surgical Site Infection

• To come – Antibiotic Stewardship

Government Initiatives

• Australian Commission on Safety and Quality in

Health Care

• Australian College of Operating Room Nurses

(ACORN) 2014-2015 Standards for Perioperative

Nursing

• The common emphasis (from an IPC perspective) is

the reduction of Health Care Acquired Infections

This presentation

• Will look at;

• Antibiotic resistance

• Pre surgical skin preparation – showering with or

using Chlorhexidine impregnated cloths.

• The behaviour of the multidisciplinary team in the

OR

A (very) Brief History

Van Leeuwenhoek 1673

Semmelweis 1847

Louis Pasteur Lister

Anaesthesia 1847

Sir James Simpson

Surgical site

infections

Bacterial resistance

Antibiotic overuse

Estimated Annual Human Antibiotic Use (USA)

Site Amount Correct use

Hospital 190 million defined 25 - 55(%)

daily doses/year

Community 140 million courses/year 20- 50(%)

Complacency with aseptic

technique infection

Global microbial resistance

(WHO Global Report 2014)

• Prevention of the spread and control of Multi drug –

resistant organisms (MDRO’s) at a critical level.

• Availability of antibiotics to treat these infections

extremely limited

• Worldwide the most common MDRO’s are;

MDRO’s

• MRSA - Methicillin resistant Staphylococcus aureus

• ( prevalence 10% in Auckland NZ)

• VRE – Vancomycin resistant Enterococci ( rare in NZ)

• ESBL- Extended Spectrum b lactamase Gram –ve

organisms ( increasing in NZ 157/100000)

• CRE – Carbapenem resistant Enterobacteriaceae

• MRAB - multi resistant Acinetobacter baumannii

MDRO’s

• Understanding the current resistance pattern

influences both prophylactic and therapeutic a

antibiotic use

Antibiotic Stewardship in the OR

• Key to reducing MRDO’s and Healthcare associated

infections

• Therapeutic antibiotics- give narrow spectrum for

the shortest period of time, for 24hrs after incision

only. Cardiac surgery for 48 hrs only.

• Prophylactic antibiotics – within 1hr prior to skin

incision. Superior efficacy between 0-30 min prior

• ( Anderson, et.al., 2014)

• Exception:

• Vancomycin and fluroquinolones must be

administered 2 hrs before incision

Antibiotic stewardship in the OR

• ACORN - IPC Standard 11 - recommends; 2g

Cephazolin for all patients up to 80kg

• 3g for pts over 120kg. Paediatric dose 30 mg/kg

• Experts believe prophylactic antibiotics should be

administered prior to tourniquet inflation.

• Redose prophylactic antibiotics for long procedures

or excessive blood loss

( Anderson, et.al., 2014)

Antimicrobial-Resistant Pathogen

Antimicrobial Resistance

Antimicrobial Use

Infection

Prevent

Transmission

Prevent

Infection

Optimize Use Effective

Diagnosis

& Treatment

Susceptible Pathogen

Antimicrobial Resistance:

Key Prevention Strategies

Preventing Infection

CDC estimates that 5% of all patients acquire an

infection leading to 100.000 deaths per annum

(CDC, 2010)

Where do these pathogenic microbes come from?

Most come from endogenous microbes – skin,

intestines

Within hours of admission the

room will reflect the patient’s

microbiome . These microbes

will move to adjacent patients

and rooms. Visitors add to this

mix. (Arnold,2014)

Preventing Infection

• Patients become colonised with hospital microbes

within hours – they could be resistant strains.

• These can lead to infection once natural defence

barriers have been broken

Entry Points

______________________________________________________________________

Clinical infections

Colonised patients

Preventing Infection:

Minimising skin flora

• Using Chlorhexidine Gluconate (CHG)2-4% wipes or showering with CHG has been shown to reduce surgical site infections from 3.19% - 1.59% ( Eiselt,2009)

• Considered an adjunct risk reduction strategy to pre-operative skin prep with Chlorhexidine and alcohol or povidone-iodine and alcohol

• Broad spectrum (Gram –ve and Gram +ve bacteria) killing effect

Preventing infection

Minimising skin flora

• Higher concentrations of Chlorhexidine gluconate

are rapidly bactericidal

• Does not denature in the presence of serum and

blood and has a longer residual effect

• BUT cannot be used on periorbital sites – eyes and

ears. Use of Povidone-iodine recommended

• Patient compliance difficult to assess.

1

10

100

1000

10000

100000

1000000

Inguinal Axilla Inguinal Axilla

Baseline Postwash

One Wash

6 9 11

Three Washes

Mea

n S

kin

Bac

teri

al C

oun

t (l

ogar

ith

mic

sca

le)

8

128352

6622

17975 33808

NOTES:

• Lab detection limit = 10 CFU. Those n.d were given a count of 5 for analysis

• Postwash values for ‘three washes’ is after one wash. Mean counts remained below

10 after all three washes.

Chlorhexidine Gluconate 4%

pre-op washes. 2 cohorts

10/arm

Preventing Infection:

Pre-screening

• May be logistically complicated and is expensive

• Decide between vertical or horizontal surveillance

• Consensus seems to be that riskier patients with

complex surgery and co morbidities should be

screened.

• Each institution to set realistic policies

• ( Making Health Care Safer ll , 2013)

HAIs are SSI ( previously called SWI) Exogenous Sources of

Infection

To mask or not to mask?

ACORN

Infection Prevention

Standard Statement 6

• Wear a mask;

• where a sterile field is being prepared or used

• to protect the health care worker against blood and

body fluid spatters

• To decrease the dispersals of microbial droplets from

nose and mouth

ACORN

Perioperative Attire

• Shall replace all outer garments and shall be worn

correctly at all times when entering the operating

suite

• Do not wear perioperative attire outside the

healthcare facility

ACORN

Infection Prevention

Standard Statement 4

• The multi disciplinarary team shall comply with

infection control parameters related to the

environmental boundaries of the perioperative

setting i.e. zone conformity

Other Exogenous Sources

• Environment - air changes, temperature and

humidity

• Inadequately cleaned environment

In conclusion:

Infection prevention in the OR is

paramount

• This presentation has highlighted a few important

infection prevention methods in the OR

1. Antibiotic stewardship

2. The use of preoperative showering to decrease skin

colonisation

3. The behaviour of the multidisciplinary team in the

OR

Thank you!

Questions?

REFERENCES Australian College of Operating Room Nurses. Standards in Perioperative Nursing 2014-2015

Australian College of Operating Room Nurses: Adelaide, South Australia

Anderson,D.J.,Podgorney,K., Berrio-Torres,S.I.,Bratzler,D.W.,Dellinger.P.E…..(2014)

Stratergies to Prevent Surgical Site infections in Acute Hospitals. Infection Control

and Hospital Epidemiology www.medcape.com.

Arnold,C, (2014). Rethinking Sterile: The Hospital Microbiome Environmental health

Perspective 122(7) www.medscape.com.

Bishop,W.J. (1960). The Early History of Surgery Barnes & Noble: New York

Chlebicki,M.P.,Safdar,N.,O’Horo,J.C.,Maki,D.G. ( 2012). Preoperative chlorhexidine

shower or bath for prevention of surgical site infection: A meta-analysis.

American Journal of Infection Control 1-7

Coatsworth, N.R., Huntington,P.G., Giuffre,B.J.,Kotsiou,G. ( 2013). The Doctor and the

Mask: Iatrogenic septic arthritis caused by Streptococcus mitis. MJA 198 (5)285-

286.

Edmiston,C.E., Okoli,O., Graham, M.B., Sinski,S & Saebrook,G.R. ( 2010). Evidence for

using Chlorhexine Gluconate Preoperative Cleansing to Reduce the Risk of

Surgical Site infection AORN 92 (5) 509-518

REFERENCES Eislet, D. (2009). Presurgical Skin preparation With a Novel 2% Chlorhexidine Gluconate

Cloth Reduces Rates of Surgical Site Infection in Orthopaedic Surgical patients.

Orthopaedic Nursing 28 (3) 141-145

Grayling,P. (2013). Surgical Attire Compliance for Safe patients and Practitioners

AORN 97(4) 475-477

Grayling,P.R.& Vasaly,F.W. (2013). Effectiveness of2% Chlorhexidine Cloth Bathing for

Reducing Surgical Site Infections, AORN 97 (5) 547-551

Haung,S. & Platt,.(2003). Risk of methicillin-resistant Staphylococcus aureus infection after

previous Infection or colonization. Clinical Infectious Diseases.36(3): 281-285

Lee,G & Bishop,P. (2013) Microbiology and Infection Control for Healthcare Professionals (5th ed.).

Frenchs Forest: Pearson Australia

Making health Care Safer ll : An Updated Critical Analysis of the Evidence for Patient

Safety Practices Agency for Healthcare Research and Quality: USA

www.ahrq.gov

Mayhall, C.G. (Ed.) ( 2012). Hospital Epidemiology and Infection control (4th ed.).

Lippincott William and Wilkins: Philadelphia: United States of America

Zywiel,M.G., Daley,J.A. Delanois,R.E.,Nazir,Q., Johnson,A.J., Mont,M.A. (2011).

Advance pre-Operative chlorhexidine reduces the incidence of surgical site

infections in knee Arthroscopy. International Orthopaedics , 35 1001-1006