1.Prevention and Treatment of Surgical Infection Edit

8/4/2019 1.Prevention and Treatment of Surgical Infection Edit

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PRINCIPLES OF SURGICAL

INFECTION:

PREVENTION AND TREATMENT

Besut Daryanto SpB,SpU

Department of UrologySaiful Anwar Hospital Malang


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INTRODUCTION


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The risk factors for developing a

wound infection

The preoperative (prehospital) component

The operative environment

The microbial factors


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CLASSIFICATION OF SURGICAL WOUNDS


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CLASSIFICATION OF SURGICAL WOUNDS


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Classification of Operative Wounds

and Surgical infection rates


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Health care-associated infection (HAI) /

Nosocomial Infections in Surgical Patients

Potential sites:

UTIs

Pneumonia

surgical site (wound) infections (SSIs)

bloodstream infection bacteremia


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Principles Of Prevention To Infection

Preoperative Shower

Remote-Site Infection and Shaving

Hand Washing

Shoe Covers, Caps, Masks, Gowns, and Gloves

Core Body Temperature

Postoperative Care

Surgical Wound Management and Surgical

Wound Infection Care


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Remote-Site Infection and Shaving

The presence of a remote-site infection,whether it is a pustule, an upper respiratoryinfection, or urinary tract infection, needs to beidentified and treatedprior to any surgical

intervention A patient whose surgical site has been shaved

has an infection rate two to three times higherthan patients who are not shaved

The need for shaving a surgical site should beconsidered not for sanitary reasons but only forthe convenience of the patients wound care.


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Hand Washing


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Shoe Covers, Caps, Masks, Gowns,

and Gloves


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Core Body Temperature

The presence of the cold environment in the

operating room reduces the patients core body

temperature

This reduction in the patients core temperaturesignificantly increases the risk of postoperative

infection

This requires meticulous attention to keeping the

patient warm


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Postoperative Care

Supportive therapy

Monitoring Postoperative Fever

Blood and radiographic tests Surgical Wound Management


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Surgical Wound Management and

Surgical Wound Infection Care

Topical Wound Treatment

CLOSED WOUNDS

OPEN WOUNDS


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Closed wound

Healing by primary intention Closed wounds should be kept sterile for 24-48 h until

epithelialization is complete

Tensile strength is only 200/0 of normal skin at 3 weeks

when collagen cross-linking is becoming significant. At 6weeks, wounds are at 70% of the tensile strength of normal

skin, which is nearly the maximal tensile strength achieved

by scar (75%-80% of normal).


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Open Wound

Necrotic material should be removed Open wounds heal optimally in a moist, sterile environment

The wound is open, and the edges are not approximated

The suture closed as delayed primary closure after 25 days

These wounds heal by contraction and epithelialization.


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Secondary closure of wound

The wound is open, and the edges are not approximated. A

potentially contaminated wound is best left open lightly packedwith damp saline soaked gauze and the suture closed as delayed

primary closure after 25 days


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MICROBIAL FACTORS OF IMPORTANCE IN

THE DEVELOPMENT OF INFECTION

Two major reservoirs:

(1) host endogenous microflora

(2) microbes within the external milieu, which

often represents the nosocomial

environment for hospitalized individuals


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ANTIBIOTICS IN SURGERY

Prophylactic antibiotics

Antibiotic Therapy


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Empirical cover against expected pathogens with localhospital guidelines

Single-shot intravenous administration at induction ofanaesthesia

Repeat only in prosthetic surgery, long operations or ifthere is excessive blood loss

Continue as therapy if there is unexpectedcontamination

Patients with heart valve disease or a prosthesis shouldbe protected from bacteraemia caused by dental work,urethral instrumentation or visceral surgery


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Medical considerations that compromise the

healing capacity or increase the infection risk:

Diabetes

Peripheral vascular disease

Possibility of gangrene or tetanus

Immunocompromise


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High-risk wounds or situations:

Penetrating wounds

Abdominal trauma

Compound fractures

Wounds with devitalized tissue

Lacerations greater than 5 cm or stellate lacerations

Contaminated wounds

High risk anatomical sites such as hand or foot

Biliary and bowel surgery.


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Antibiotic Therapy

A narrow-spectrum antibiotic may be used to

treat a known sensitive infection

Combinations of broad-spectrum antibiotics

can be used when the organism is not known


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Principles for the use of antibiotic

therapy

Antibiotics do not replace surgical drainage of

infection

Only spreading infection or signs of systemic

infection justifies the use of antibiotics Whenever possible, the organism and sensitivity

should be Determined


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Treatment of commensals that have become

opportunist pathogens

They are likely to have multiple antibiotic resistance

It may be necessary to rotate antibiotics


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HIV, AIDS AND THE SURGEON

Involvement of surgeons with HIV patients

(universal precautions):

use of a full face mask ideally, or protective spectacles;

use of fully waterproof, disposable gowns and drapes,particularly during seroconversion;

boots to be worn, not clogs, to avoid injury from droppedsharps;

double gloving needed

allow only essential personnel in theatre; avoid unnecessary movement in theatre;

respect is required for sharps, with passage in a kidney dish;

a slow meticulous operative technique is needed withminimised bleeding.


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Thank You


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NOSOCOMIAL INFECTIONS

Besut Daryanto

Departement of UrologySaiful Anwar Hospital


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Hospital-acquired infection(HAI) = health care-associated infection

An infection acquired in hospital by a patient whowas admitted for a reason other than that

infection Infection is a new infection that develops in a

patient during hospitalization

Result of treatment in a hospital/health careservice unit

First appear 48 hous or more after hospitaladmission or within 30 days after discharge

Definition


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WHO in 55 hospitals of 14 countries 4

regions ( Europe, Eastern Mediterranean,

South-East Asia and Western Pacific) : average

6.7%

Highest : EM & SE11.8&10.0%

Europe 7.7%

Western Pacifik 9.0%

Frequency of infection


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US,CDC: 1.7 million9.000 deaths/year

10% or 2 million ps become infected cost

4.5-11 billion USD

UK: 10% infection rate

Italy:6.7% infection rate

Finland: 8.5 infection rate

Incidence


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Leading causes of death

Increased lenght of stay economic cost

Impact of nosocomial infections


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Contact : direct and indirect

Droplet

Airborne

Common vehicle

Vector borne

Transmission


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Direct body to body surface contact & physicaltransfer of microorganisms

Patients : source of infectious microorganisms

susceptible host

Route of transmission


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Poor state of health : premature birth,

immunodefisiency, chronic pulmonary disease

Invasive devices : intubation tube, catheter,

surgical drain and tracheostomy

Treatment : immunosuppression,

antimicrobial and blood tranfusion

Risk factor


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Isolation

Handwashing and gloving

Surface sanitation

Aprons

Prevention


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Limiting transmission of organism

Controling enviromental risk of infection

Prorecting patient

Limiting the risk of endogenous infections

Surveilance of infections

Prevention of infection in staff members

Enhancing staff patient care practices, and

continuing staff education

Prevention of nosocomial infection


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Risk stratification

Reducing person to person transmission

Preventing transmission from enviromental

Prevention of nosocomial infection


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Hand decontamination

Personal hygiene

Clothing

Masks

Gloves

Safe injection practice

Reducing p to p transmission


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Cleaning of the hospital enviroment

Use of hot/superheated water

Desinfection of patient equipment

Sterilization

Preneting transmission from the

enviromental


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Survey 110.709 pediatric ICU patient 6.290

HAI

3 major sites infection : 28% blood stream,

21% pneumonia, and 15% urinary tract

Blood stream : 38% staphylococci, 11%

enterococci, and 9% S aureus

Pneumonia : 22% P auroginosa, 17% Saureus,

and 10% Haemophilus influenza

UTI : 19% E.coli, 14% C.albicans, and 13%

P.auero inosa

Causes


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The microbial agent

Patient susceptibility

Enviromental factors

Bacterial resistence

Factors influencing the development

of N I


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Surgical site infection

Urinary infection

Respiratory infection

Vascular catheter infection

Septicaemia

Type of nosocomial infections


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UTI : the most common; 80% of infections are

associated with the use of an indwelling

bladder catheter

SSI : 0.5 to 15%

Nococomial pneumonia

Nosocomial infection sites


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National or regional programmes

Hospital programmes : infection control

commitee and infection control professional

(infection control team), infection control

manual

Infection control responsibility

Infection control programmes


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Role of hospital management The physician

The microbiologist

The hospital pharmacist

The nursing staff

The central sterilization service

The food service

The laundry service

The housekeeping service

Role of maintenance, hospital hygiene service

Infection control responsibility

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1.Prevention and Treatment of Surgical Infection Edit

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