Dr John Mahony MBBS FFMACCSCosmetic Physician, Paddington, NSW

Dr Mark Birch MBBS FRACP Infectious Disease Physician, John Hunter HospitalNewcastle, NSW

www.peachcosmeticmedicine.com/treatments-ACCS2009infectioncontrol.html

Infection control in cosmetic medicine and surgery

ACCS/CPSA 2009

Cosmetic medical and surgical treatments are very, even remarkably, safe. Medical complications of cosmetic treatments are rare

Then again, because most have a purely aesthetic rather than medical indication, they need to be extremely safe in order to deliver a positive cost/benefit dividend.

Amongst these albeit rare medical complications, infection is significant, and occasionally disastrous

Three approaches to infection prevention.

1) Review legislation and regulations pertaining to the performance of medical and surgical procedures.

2) Review currently medically advised strategies to prevent procedural infection, such as published opinions and reviews

3) Finally, canvas an (apparently) novel approach to preventing infection in tumescent liposuction

The idea is to raise standards and protect patients

Legislation and regulation review

1) In the Medical Practice Act (NSW) 1992 Part 4 Section 36 (page 12 of .pdf) a finding of unsatisfactory professional conduct can be found against a practitioner whose conduct contravenes the regulations associated with this Act

2) Medical Practice Regulation (NSW) 2008 is an 18 page document, six of which relate to infection control.

Some of the regulations are quite specific. For example:

“Invasive procedures(1) In cases where it is technically feasible, retractors must be used forexposure and access during an invasive procedure.(2) Fingers must not be used for the purposes of an invasive procedure toexpose or increase access for the passage of a suture.(3) Only one sharp at a time is to be placed in a puncture resistant tray thatis being used in connection with an invasive procedure.(4) Forceps or a needle holder must be used when carrying out suturingboth to pick up the suture needle and to draw it through tissue.”

All best practice, certainly…..

And enshrined in law in NSW..., under pain of a finding of unsatisfactory professional conduct, which, if of sufficient gravity, can be upgraded to “professional misconduct” and suspension.

(Download the Act and Regulations from my website)

www.peachcosmeticmedicine.com/treatments-ACCS2009infectioncontrol.html

“Sterilisation of instruments and equipment(1) Any instrument or equipment used to enter, or that is capable ofentering, tissue that would be sterile under normal circumstances, or thevascular system of a patient, must be sterilised before it is used.(2) The method of sterilisation must be:(a) compatible with the particular type of instrument or equipmentconcerned, and(b) consistent with AS/NZS 4187 or (in the case of an office-basedpractice) AS/NZS 4815.”

The document “Medical Practice Regulation (NSW) 2008”, furthermore, enshrines the authority of Standards Australia (SA) with respect to the sterilisation of instruments, etc, and makes repeated reference to this document, e.g.,

AS/NZS 4815 is relevant to most of us, pertaining as it does to office-based procedures. It is an 86-page document, covering in great minutae every aspect of cleaning sterilising packing and storing instruments.

Both AS/NZS 4187 and AS/NZS 4815 are downloadable at a price (about $80 for AS/NZS 4815)

It is copyrighted and SA appear to want to defend copyright vigorously. (Contents list available on my website)

www.peachcosmeticmedicine.com/treatments-ACCS2009infectioncontrol.html

In summary,

under the NSW Medical Practice Act 1992,

its associated Regulations

and thence Standards Australia

there is an abundance of advice on how to prevent infections.

And that's not all, folks...

The Federal Dept of Health and Ageing produced in 2004 a work entitled “Infection control guidelines for the prevention of transmission of infectious diseases in the health care setting”

Much of it would be common knowledge to any medical graduate or indeed any nurse who had spent more than a little time working in public hospitals.

Part 5, chapters 33 and 34, relate to procedures, and is useful to review. Download from my website:

www.peachcosmeticmedicine.com/treatments-ACCS2009infectioncontrol.html

Other State governments have produced their own documents, guidelines, working parties,

recommendations etc etc.

It runs, in total, to some 455 pages.

Recent medical papers and

reviews.

“Guideline for Prevention of Surgical Site Infection”, April 1999Infection Control and Hospital Epidemiology

Produced under the auspices of the US Dept of Health Centres for Disease Control and Prevention

A landmark paper widely referenced in the field

www.peachcosmeticmedicine.com/treatments-ACCS2009infectioncontrol.html

Cited over 1000 times in Google Scholar

Key recommendations (with some modification) are

1) Preoperative strategies

a) Patients

i) Postpone cosmetic invasive procedures if patient has a remote site infection.

ii) Do not remove hair unless hair will interfere with procedure

iii) If removing hair, remove immediately prior to procedure, with clippers NOT razors.

iv) Avoid perioperative hyperglycaemia in diabetics

v) Patient to cease tobacco 30 days prior to procedure

vii) Patients to shower/bathe in antiseptic on night prior to procedure

viii) Clean any gross skin contamination prior to applying antiseptic skin prep.

ix) Use an appropriate antiseptic (d'oh)

x) Apply antiseptic in concentric circles from centre to periphery. Prep enough area to allow for extra incisions, drain sites, etc, (?contact with liposuction cannulae?)

xi) Keep preoperative hospital stay short

xii) Question: should we taper or discontinue systemic steroids if medically permissable?

xiii) Should we enhance nutritional support?

xiv) Should we apply pre-operative mupirocin to nares?

xv) Do we try to enhance wound space oxygenation?

b) Surgeon hand/forearm antisepsis

i) Keep nails short. No artificial nails

ii) Pre-operative scrub for 2-5 minutes. Scrub up to elbows

iii) Then keep hands up and away from body until gloved/gowned

iv) Clean under each fingernail prior to first scrub of the day

v) No hand or arm jewelry

vi) Question: can we wear nail polish?

c) Management of infected or colonised surgical personnel

i) Watch for evidence of infection in self (d'oh)

ii) Larger institutions need policies developed to deal with workforce issues

iii) Culture and suspend surgery in presence of draining skin lesions until treated/cleared

iv) Staff colonisation with staph/strepA in nares etc doesn't warrant exclusion from operating unless epidemiologically linked to dissemination.

d) Antimicrobial prophylaxis

i) “Only when indicated..” (what are our thoughts?)

ii) Preferably IV, allowing time for tissue levels to rise prior to incision. Maintain therapeutic levels for duration of procedure.

(More about this later) iii), iv), v) not relevant to us

2) Intraoperativea) Ventilation

i) Positive pressure ventilation in the operating room relative to adjacent areas

ii) 15 air changes per hour, 3 of which should be fresh air

iii) All air should be filtered appropriately

iv) Introduce air at ceiling and exhaust at floor level

v) Don't use UV irradiation in the theatre to prevent SSIs.

vi) Keep operating room doors closed

vii) ?Ultraclean air for implant work? (as for orthopedic implants?)

viii) Limit the number of personnel entering the operating room

b) Cleaning and disinfection of environmental surfaces

i) Any visible soiling or contamination of equipment or surfaces in theatre should be cleaned with appropriate disinfectant prior to next case

ii) but “special” cleaning, or closing of theatre, not required after a “dirty” procedure

iii) Don't use tacky mats at entries to operative rooms.

iv) Wet vacuum the theatre floor at end of day with appropriate disinfectant

v) Question: how much cleaning is required between cases in absence of visible soiling?

c) Microbiological sampling: Routine environmental sampling of theatre room is unnecessary

d) Sterilisation of surgical instruments

i) Sterilise according to standards, obviously

ii) “Flash sterilisation” is only for emergency circumstances, not for routine employ or to save time or costs of buying more instruments

e) Surgical attire and drapes

i) Wear a mask when in active theatre or where sterile instruments are exposed (US regulation)

ii) Wear a cap or hood under same circumstances

iii) Shoe covers do not help for the prevention of SSIs

iv) Wear sterile gloves if part of surgical team (der)

v) Use gowns and drapes that are effective barriers when wet.

vi) Change scrub suits that are visibly soiled or contaminated, etc

vii) ?Details of laundering scrub suits? Can you wear them on the wards? If so, should you cover them?

f) Asepsis and surgical technique

i) Aseptic technique for IV drugs, intravascular devices, etc

ii) Assemble sterile equipment and solutions immediately prior to use

iii) “Handle tissue gently, maintain effective haemostasis, minimise de-vitalised tissue and foreign bodies e.g. sutures, charred tissues, necrotic debris, and eradicate dead space at the surgical site”

iv) If surgical site heavily contaminated (hopefully never one of our patients) use delayed primary closure or leave incision open to heal by secondary intention.

v) If drainage necessary, used a closed suction drain, place it through a separate incision distant to the operative incision and remove ASAP.

3) Postoperative incision care

i) Incisions > sterile dressing for 24-48 hours (when closing primarily)

ii) Wash hands before and after dressing changes and/or any contact with surgical site.

iii) Change dressings with sterile technique

iv) Educate patient and family about wound care, symptoms of SSI and action plan.

v) ?When can we shower with uncovered incisions??

4) Surveillance

i) Use CDC definitions of SSIii) (Other recommendations pertain to hospital settings re surveillance)

Clinical Infectious Diseases June 2004

Antibiotic Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project

A major consensus paper, (link here on website)

www.peachcosmeticmedicine.com/treatments-ACCS2009infectioncontrol.html

Most pertinent recommendations for us are:

Keflin confirmed as prophylactic agent of choice in absence of allergy etc

IV dose 1g if patient under 80kg, 2g if they are over 80kg

Must give IV dose within an hour prior to first incision (over a few minutes)

Repeat dose every 2-5 hours depending on renal function of patient. (Since most of our patents are medically well, repeating every 2-3 hours would be indicated)

Prophylactic antibiotics should be suspended at or within 24 hours of end of procedure.

Whilst applying mupirocin to patient nares reduces staph carriage rates, they found no evidence of this manouvre reducing SSIs.

And a new idea-

Why not put prophylactic Keflin in our tumescent local anaesthetic (TLA) fluid?

As opposed to administering antibiotics orally or intravenously, direct local infusion of antibiotic into the liposuction field can bring about higher and better sustained local tissue levels of antibiotic whilst minimising risk of allergy and gut effects such as pseudomembranous colitis.

Since fatty tissue is so poorly perfused, how certain can we be that systemic doses of prophylactic antibiotic adequately distribute into the liposuction field?

Placing antibiotic into the TLA fluid removes this doubt.

Assuming lignocaine and cephalothin diffuse through tissues roughly equally well, we could be certain that there is cephalothin in our liposuction field wherever we have anaesthesia

If TLA fluid is infused as a volume ratio 1:1 into target fat (i.e. one litre of TLA is infused in order to aspirate one litre of fat), then a dose of merely 1mg of Keflin per litre bag will produce a tissue level of keflin six times the MIC within that litre of fatty tissue.

For the same reasons that lignocaine persists in the subcutaneous fatty tissue after TLA infusion, we would expect cephalothin to do the same.

Therefore only single dose is required.

So: why not?

More comprehensive argument can be downloaded from my website

www.peachcosmeticmedicine.com/treatments-ACCS2009infectioncontrol.html

These papers, plus the Act plus the Regulations in NSW, can be downloaded via a page on my website that I have set up for the purpose of this presentation

www.peachcosmeticmedicine.com/treatments-ACCS2009infectioncontrol.html

The Australian Standard document is copyright and so there is no link to it on my website. (Perhaps the College could do a deal with Standards Australia to make this document available to us at a cut rate?)

This Powerpoint is also available at the above webpage