Surgical Site Infection 1 Lecture - Alison Livesey OCTOBER 2024 - University of Surrey PDF

SURGICAL SITE INFECTION 1 ALISON LIVESEY OCTOBER 2024 LEARNING OBJECTIVES » Be able to: understand how to achieve surgical asepsis for elective surgery and put these principles into practice understand the contribution of aseptic products, the need and means of sterilis...

SURGICAL SITE INFECTION 1 ALISON LIVESEY OCTOBER 2024 LEARNING OBJECTIVES » Be able to: understand how to achieve surgical asepsis for elective surgery and put these principles into practice understand the contribution of aseptic products, the need and means of sterilising instruments and surgical materials understand how instruments should be sterilised and prepare understand and describe Halsted’s principles of surgical technique understand the importance of these principles and outline reasons for their importance and consequences of not doing this #universityofsurrey 2 PREVENTION OF SSI Hospital and theatre design Pre- Instrument preparation cleaning, disinfection, sterilisation operatively Surgeon preparation Patient preparation Peri- Prophylactic antibiotics Surgical decision-making/technical skills operatively Halsted’s principles Post- Post-op incisional care and advice operatively #universityofsurrey 3  SURGEON PREPARATION No hair exposed Theatre hat Mask Gloves No jewellery Aseptic hand prep Gown Scrubs Theatre shoes #universityofsurrey 4 SURGEON AND THEATRE PREPARATION Scrubs Decrease debris, bacteria carried into theatre by staff Comfortable, lint-free, durable, easy to launder 280-count better than 140-count Barrier properties lost after 75 laundry cycles Laundering doesn’t sterilise (kill bacteria) can periodically sterilise? Tuck tops in, to reduce shedding squames? #universityofsurrey 5 SURGEON THEATRE PREPARATION Theatre hat Reduces contamination of surgical wound with bacteria/hair Hair and beard should be fully covered Durable, comfortable, lint free All staff in theatre should wear hat #universityofsurrey 6 SURGEON THEATRE PREPARATION Theatre shoes/shoe covers Protect operating room from external bacteria Protect shoes from hospital bacteria Not shown to decrease theatre contamination Does help maintain mental barrier between clean/dirty areas #universityofsurrey 7 SURGEON THEATRE PREPARATION Masks Surgeon should wear Protect surgical wound from saliva droplets and micro organisms Not shown to achieve this or reduce infection rate Redirect airflow out the sides of the mask, away from incision This increases with talking, sneezing or prolonged procedures Filter large particles well, not as well for small particles Work up to 8 hours even when wet #universityofsurrey 8 SURGEON PREPARATION Aseptic hand prep Thorough scrub first procedure (4 min) Remove dirt and oil from hands, forearms and clean under SHORT nails (no jewellery) Kills transient bacteria Profound depressant effect on resident bacteria Scrub should not be prolonged or cause trauma to skin (2-5 minutes) Technique (scrub all areas) Brushes not necessary, cause trauma can use the sponge side Trend towards alcohol based preps and shorter times Antiseptics Chlorhexidine Povidone-Iodine 85% ethanol (Sterliium) #universityofsurrey 10 #universityofsurrey 11 ANTISEPTICS Antiseptic Chemical used on patient or surgeon that kills microbial organisms Asepsis The absence of microbial organism on living tissues #universityofsurrey 12 ANTISEPTICS » Iodophors » Chlorhexidine » Alcohol based Sterilium #universityofsurrey 13 ANTISEPTICS Antiseptic Mechanism of Activity Immediate Persistent Residual Toxicity action action action action Alcohol Denature Poor against Rapid and 3 hours None Necrosis in proteins and viruses and spores bactericidal open wounds affect Decreased by metabolism organic debris Iodophors Blocks cell Bacteria, fungi, Rapid and 4-6 hours None Contact membrane viruses and spores bactericidal dermatitis protein Most effective at Toxic to synthesis 0.1% fibroblasts Chlorhexidine Interferes with Bacteria, variable to Bacteriostatic at >6 hours 2 days Toxic to cell membrane fungi, viruses. Not low fibroblasts Coagulation of spores concentrations Neurotoxic cellular Improved with and bactericidal Ototoxic contents alcohol at high concentrations Rapid onset #universityofsurrey 14 ANTISEPTICS Immediate action Amount of micro organisms killed or mechanically removed within 3 minutes Persistent action Ability to prevent re-colonisation of skin up to 6 hours after application Residual action Cumulative antimicrobial effectiveness after used for at least 5 days #universityofsurrey 15 SURGEON PREPARATION » Gowning Disposable or reusable Once donned, only the front from lower shoulder level to table height and sleeves are considered sterile Type Advantage Disadvantages Disposable Water repellent Expensive Always new May be less conforming Decreased Large storage space for labour/laundering costs stock required Pre-sterilised Reusable (cloth) Cheaper Poor barrier properties Less waste and higher rate of strike through Increased labour and laundering costs Linting Decreased quality with #universityofsurrey washing 16 SURGEON PREPARATION Once donned, only the front from lower shoulder level to table height and sleeves are considered sterile #universityofsurrey 17 SURGEON PREPARATION Gloving Protect surgical wound from surgeon's resident flora Repopulated from hair follicles Protect surgeon form patient’s bacteria 1.5% have holes at the start of surgery 12-30% have holes at the end of surgery Can double glove; Lose sensitivity of fingers/tactility 11.5-44% outer glove perforated at end 3.8%-13% inner glove perforated at end #universityofsurrey 18 SURGEON PREPARATION » Open Gloving #universityofsurrey 19 SURGEON PREPARATION Closed Gloving #universityofsurrey 20 SURGEON PREPARATION Plunge Gloving – staff assisted #universityofsurrey 21 SURGEON PREPARATION #universityofsurrey 22 PATIENT PREPARATION » Remove transient organisms from skin » Reduce endogenous bacterial microflora Normally on skin and hair Within glands on skin » Bathing controversial May dry skin, cause inflammation and liberate bacteria from pores May be necessary if heavily soiled #universityofsurrey 23  PATIENT PREPARATION » Clipping and primary aseptic prep Wide clip Well maintained clipper blades No razors Immediately prior to surgery Vacuum +/- lint roller Clean and disinfect Alternating scrub-alcohol preps Chlorhexidine or povidine-iodine with alcohol Move to theatre without interfering with area Position for surgery Final aseptic skin prep #universityofsurrey 24 ASEPTIC SKIN PREPARATION Concentric circles Back and forth/friction #universityofsurrey 25 PATIENT PREPARATION Dermatitis at the surgical site Distant pathology #universityofsurrey 26  PATIENT PREPARATION Draping Type Advantage Disadvantages Impermeable to fluid Resistant to tearing Disposable Water repellent Expensive Always new May be less conforming Secured to patient Decreased labour/laundering Large storage space for stock Sterile working area costs required Between instruments, Pre-sterilised surgeon and surgical site Reusable Cheaper Poor barrier properties and (cloth) Less waste higher rate of strike through Increased labour and laundering Fenestrated costs Four-corner draping Linting Decreased quality with washing #universityofsurrey 28  PATIENT PREPARATION incision Cover hands #universityofsurrey 29  PATIENT PREPARATION Last Drape Furthest away First Drape Nearest you #universityofsurrey 30 Prevention of SSI Hospital and theatre design Pre- Instrument preparation cleaning, disinfection, sterilisation operatively Surgeon preparation Patient preparation Peri- Prophylactic antibiotics Surgical decision-making/technical skills operatively Halsted’s principles Post- Post-op incisional care and advice operatively #universityofsurrey 31 PERI-OPERATIVE PROPHYLACTIC ANTIBIOTICS Prophylactic antibiotics Protect against anticipated bacterial infection Risks? Anaphylaxis, antibiotic resistance, multi-resistance carriage Benefits Lower infection rates Costs » Therapeutic antibiotics Treat an established infection #universityofsurrey 32 PERI-OPERATIVE PROPHYLACTIC ANTIBIOTICS » Indications Risk of infection is high Development of SSI would be catastrophic » Suggested uses Clean-contaminated, contaminated and dirty procedures Clean orthopaedic procedures » Not a substitute for good asepsis and surgical technique #universityofsurrey 33 #universityofsurrey 34 #universityofsurrey 35 PERI-OPERATIVE PROPHYLACTIC ANTIBIOTICS » Intravenous » Broad spectrum Clean procedures Staphylococci Contaminated procedures Enterobacteriacae Cefuroxime or Co-amoxyclav – broad spectrum, wide safety margin 22mg/kg » ~30 minutes prior to incision Then every 1.5-2 hours for duration of surgery + post op dose Fibrin seal within 3-6 hours » If break in asepsis » Post-operatively? #universityofsurrey 36 PERI-OPERATIVE PROPHYLACTIC ANTIBIOTICS » Clean Surgery Not unless > 90 minutes implants used Break in asepsis » Clean-contaminated Yes » Contaminated Yes » Dirty Yes #universityofsurrey 37 HALSTED’S PRINCIPLES OF SURGERY 1. Gentle tissue handling 2. Meticulous haemostasis 3. Preservation of blood supply 4. Strict aseptic technique 5. Tension free closure 6. Accurate apposition of tissues 7. Eliminate dead space William Stuart Halstead 1852 - 1922 #universityofsurrey 38 SURGICAL TECHNIQUE AND DECISION MAKING Gentle tissue handling Uninjured tissue takes 106 bacteria per g for infection to be established Injured/crushed tissue takes 103 #universityofsurrey 39 SURGICAL TECHNIQUE AND DECISION MAKING Meticulous haemostasis Better perfusion = better healing Better visualisation for the surgeon Clots in surgical field Perfect medium for bact growth #universityofsurrey 40 SURGICAL TECHNIQUE AND DECISION MAKING Strict asepsis Introduce fewer bacteria into surgical wound Reduce contamination #universityofsurrey 41 SURGICAL TECHNIQUE AND DECISION MAKING Preservation of blood supply Big vessels supplying region Capillaries Perfusion= delivery of O2, leukocytes, inflammatory proteins to healing tissues Removes waste products #universityofsurrey 42 SURGICAL TECHNIQUE AND DECISION MAKING Elimination of dead space Reduce wound fluid accumulation Allows tissue sealing earlier Lower risk of seroma/abscessation Less tension on wound #universityofsurrey 43 SURGICAL TECHNIQUE AND DECISION MAKING Accurate tissue apposition Aids and speeds healing Particularly important where leak proofing necessary GIT, Urinary, reproductive tract Improved functional results #universityofsurrey 44 SURGICAL TECHNIQUE AND DECISION MAKING Minimise tension Tension on tissues cause capillary to collapse Reduces perfusion Prolongs inflammation/slower healing Tissue death Sutures more likely to pull through tissue (dehiscence) Particularly if placed in active healing zone – 2-3mm #universityofsurrey 45 PREVENTION OF SSI Hospital and theatre design Pre- Instrument preparation cleaning, disinfection, sterilisation operatively Surgeon preparation Patient preparation Peri- Prophylactic antibiotics Surgical decision-making/technical skills operatively Halsted’s principles Post- Post-op incisional care and advice operatively #universityofsurrey 46 POST OP WOUND CARE Weak fibrin seal ~ 6 hours Waterproof Easily disrupted Tension Movement Licking Handling of the patient Wound gains strength over time Remove sutures 10-14 days #universityofsurrey 47 POST OP WOUND CARE Disruption of wound allows bacteria to enter post- operatively Leads to infection With patient handling Sterile technique Barrier Direct contact between wound and floor/kennel/grass Licking wound #universityofsurrey 48 POST OP WOUND CARE Reduce wound contamination Apply barrier in aseptic manner, while in theatre Maintain barrier carefully in hospital Costs Contact dermatitis Staff awareness Limit handling Hand hygiene Hospital bacterial population Kennel hygiene Barriers Patient interference Buster collar, bandage, t-shirt/socks/stockings/suits #universityofsurrey 49 IS THE WOUND INFECTED? Distinguish between inflamed and infected wounds SSI when purulent wound discharge #universityofsurrey 50 CLASSIFICATION OF SSI Incisional (superficial) Incisional (Deep) Organ/Space SSI Timing Within 30 days Within 30 days or 1 year if implant Within 30 days or 1 year if implant Location Skin and Subcut Deep soft tissues (fascia, muscle) Any part of body manipulated Clinical Signs Superficial purulent discharge Purulent discharge from deep in Purulent discharge Positive culture incision Positive culture Pain, redness, swelling, open Dehiscence or opening of incision Abscess wound Abscess #universityofsurrey 51 NOSOCOMIAL INFECTIONS Lots of antibiotics used in hospital settings Antibiotics resistant bacteria selected Transmissible via direct contact Reduce transmission Horizontal Wound hygiene – keep covered Hand hygiene Before touching patient with wound Vertical Routine hospital cleaning Daily, weekly, monthly protocols Barrier nurse to protect hospital/staff from being colonised and vice versa Swab and culture infected wounds (not fresh contaminated wounds) to better treat patient #universityofsurrey 52 TREATING SSI If no systemic signs Treat as a traumatic infected wound Swab for culture and sensitivity Broad spectrum pending results Antibiotics alone Might work if superficial Encourage resolution with surgical treatment of tissues Open, explore, debride, lavage, repair Remove any implants if possible Close over drain or manage open Antibiotics If implant – 4-8 weeks If systemic signs – 5-7 days No need if neither If recurs attempt implant removal if possible #universityofsurrey 53 TREATING SSI If septic Aggressive treatment IVFT, antibiotics, analgesia Surgery once stable for GA #universityofsurrey 54 RESPONSIBLE ANTIBIOTIC USE Awareness of problem of antimicrobial resistance One health Cooperative between animal/human physicians #universityofsurrey 55 RESPONSIBLE ANTIBIOTIC USE #universityofsurrey 56 RESPONSIBLE ANTIBIOTIC USE #universityofsurrey 57 RESPONSIBLE ANTIBIOTIC USE Agreed protocols- PROTECT Narrow spectrum, first-line antibiotics Only use 2nd or 3rd line antibiotics based on culture and sensitivity Stick to surgical principles #universityofsurrey 58 TOP TIPS Many theatre practices are ‘traditional’ or ‘assumed’ with little veterinary evidence base A lot of things are useful to maintain a mental barrier Theatre scrubs may encourage theatre discipline Hand disinfection, wearing of sterile surgical gloves and surgical site disinfection should be mandatory Further research is required to evaluate other risk factors for SSIs All decisions are based on a risk/benefit analysis taking into account many factors Good surgical technique and principles always Responsible use of antibiotics #universityofsurrey 59 Wound Preparation Wound Clipping and Cleaning Aseptic Skin Preparation Questions? #universityofsurrey 60 61