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Surgical Site Infections

Surgical Site Infections. Ignaz Semmelweis. 1847 Realized that washing hand with a chlorinated lime solution decreased incidence of newborn death from “puerperal fever’. Joseph Lister. 1883-1897 British surgeon

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Surgical Site Infections

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  1. Surgical Site Infections

  2. Ignaz Semmelweis 1847 Realized that washing hand with a chlorinated lime solution decreased incidence of newborn death from “puerperal fever’.

  3. Joseph Lister • 1883-1897 • British surgeon • Used Carbolic Acid (Phenol) to clean hands, instruments and wipe on surgical wounds drastically decreased infections.

  4. Outline : • Important Terms • Antiseptics • Surgical wounds • Post-operative Infections • Surgical Site Infection • Hospital Acquired Infections • Antibiotic Prophylaxis

  5. Definition : • Colonization • Bacteria present in a wound with no signs or symptoms of systemic inflammation • Usually less than 105 CFU/mL

  6. Contamination • Transient exposure of a wound to bacteria • Varying concentrations of bacteria possible • Time of exposure suggested to be < 6 hours

  7. DECONTAMINATION: is the process of removing or neutralizing infectious or injurious m.o. from inanimate objects • CLEANING: physically removes ALL visible blood, body fluid, or other foreign material as dust or soil from skin or intimate objects.

  8. ASEPSIS/ASEPTIC TECH.: is the practices performed just before or during clinical or surgical procedure to reduce the risk of infection that produce a state of asepsis . • ANTISEPSIS: is the prevention of infection by killing or inhibiting the growth of m.o. on skin or body tissues.

  9. DISINFECTION: is the elimination of most (but not all) disease causing m.o. from inanimate objects . • High level disinfection –by boiling or chemicals- eliminate ALL m.o. except some bacterial endospores.

  10. STERILIZATION: is the process that remove ALL m.o. including bacterial endospores form inanimate objects

  11. antiseptics • Antiseptics: • Kill m.o. on skin • Not strong enough to use on instruments • For surgical scrubs; preparations of pt. skin or mm before clinical procedures • DO NOT use for processing or storage of instruments • Disinfectants: • Kill m.o. on surfaces (counters; exam tables; floors…etc.) • DO NOT use on skin , may irritate skin • Acceptable antiseptics: As ( Alcohol; Chlorhexidine; Iodine preparations; Iodophor; Triclosan)

  12. Alcohol (60%-90% ethyl or isopropyl alcohol) Advantage: • Rapidlykill ALL fungi ; G+ve; G-ve; mycobacteria; Viruses (HBV,HIV) àethyl alcohol kill ALL viruses • Retard regrowth of organisms even under gloves for several hours • Are relatively inexpensive

  13. Disadvantage: • evaporate rapidly and cause skin dryness • Not appropriate for vaginal preparation • Can be inactivated by organic materials • Flammable • Do not penetrate organic material • None action on endospores Not for use on mm ; not good for physical cleaning of skin

  14. Chlorhexidine (2%-4%) (Hibitane; Hibiscrub) • 4% is the recommended concentration of chlorhexidine gluconate (CHG) • Either as pure CHG or 0.5% CHG in 60%-90% alcohol • Advantage: • Has persistent action on skin; stays chemically active for at least 6 hours • Repeated use increase the no. of inhibited mo • Minimally affected by organic material

  15. Disadvantage: • Expensive , and not always present • Action reduced or neutralized by natural soap or hard tap water • Must be used repeatedly for maximum effective and residual activity • Can cause dermatitis when used frequently for hand washing • Aqueous preparation is prone to contamination • None action against endospores; fair action on fungi and TB

  16. Iodine and iodophor solutions • 2 types: • 1-3% aqueous solution à Lugol • 70% alcoholic tincture • Iodophor are solutions of iodine mixed with carrier that release small amount of iodine • The most common iodophor is Betadine • Iodophor require up to 2 min. of contact time to release free iodine

  17. Advantage: • Inexpensive; effective and commonly available • Iodophor are non-irritating to skin and mm making them ideal for vaginal preparation before IUD insertion • Does not stain skin at 1:2500 concentration

  18. Disadvantage: • Little residual effect (30-60 minutes) • Inactivated by organic materials • Iodineà skin irritation ( need alcohol for removing it) . • May cause hypothyroidisms in neonates due to skin absorption Iodine not iodophor is the only antiseptic effective against endospores

  19. Surgical Wound Classification • Clean • Clean contaminated • Contaminated • Dirty

  20. Class I Wound (Clean) • Atraumatic wound without inflammation • Do not enter GI, GU, biliary, or respiratory tract • 1.5% infection rate

  21. Class II Wound(Clean-Contaminated) • Respiratory, GI, GU, or biliary tract entered under controlled conditions • 5% infection rate expected

  22. Class III Wounds(Contaminated) • Traumatic wounds • Breaks in sterile technique • Gross spillage from GI tract • Acute, nonpurulent inflammation • 10% anticipated infection rate

  23. Class IV Wounds (Dirty) • Old traumatic wounds • Devitalized tissue • Clinical infection present • Perforated viscus • 40% expected infection rate

  24. Prophylactic antibiotics indicated Therapeutic antibiotics SSI – Wound Classification • Class 1 = Clean • Class 2 = Clean contaminated • Class 3 = Contaminated • Class 4 = Dirty infected Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

  25. Infection Infection is defined by: • Microorganisms in host tissue or the bloodstream • Inflammatory response to their presence.

  26. Inflammatory Response Localized: • Rubor, Calor, Dolor, Tumor, and functio laesa (loss of function) Systemic: • Systemic Inflammatory Response Syndrome (SIRS)

  27. S.I.R.S. Any Two of the Following Criteria • Temperature: < 36.0, >38.0 • Heart Rate : >90 • Respiratory Rate: >20 • WBC: <4,000, >12,000

  28. Sepsis Definition: SIRS plus evidence of local or systemic infection. Septic Shock Definition: Sepsis plus end organ hypoprofusion. Mortality of up to 40%

  29. Soft Tissue Infections: • Cellulitis • Abscess • Necrotizing Infections

  30. Cellulitis

  31. Cellulitis Definition: Diffuse infection with severe inflammation of dermal and subcutaneous layers of the skin Diagnosis: Pain, Warmth, Hyperesthesia Treatment: Antibiotics. Common Pathogens: Skin Flora (Streptococcus/Staphylococcus)

  32. Abscess

  33. Abscess Definition: Infectious accumulation of purulent material (Neutrophils) in a closed cavity Diagnosis: Fluctuant: Moveable and compressible Treatment: Drainage

  34. Necrotizing Soft Tissue Infection

  35. Necrotizing Soft Tissue Infection Definition: Deep infection of skin and soft tissue that may spread rapidly along facial planes. Diagnosis: Purely Clinical, dishwater discharge, gray tissue, pain out of proportion to examination, bulla, and dark, golden discoloration. Treatment: True Surgical Emergency, Antibiotics

  36. Necrotizing Soft Tissue Infection • Common Pathogens • Clostridium • Group A streptococcus • Polymicrobial

  37. Post-Operative Infections • Fever After Surgery • The “Five W’s” • Wind: Atelectisis • Water: UTI • Walking: DVT • Wonder Drug: Medication Induced • Wound: Surgical Site Infection

  38. Surgical Site Infection(SSI) : • Infection at or near the site of surgery that occurs within 30 days of surgery if there is no implant (hardware, artificial graft, mesh, etc) OR occurs within 3 months of the surgery with an implant in place From CDC’s NNIS

  39. Why Prevent SSIs? • Approximately 500,000 surgical site infections (SSI) occur annually in the United States • Patients that develop SSI have twice the mortality and are: • 60% more likely to spend time in ICU • 5 times more likely to be readmitted

  40. Surgical Site Infections • 3rd most common hospital infection • Incisional • Superficial • Deep • Organ Space • Generalized (peritonitis) • Abscess

  41. Cross Section of Abdominal Wall Depicting CDC SSI Classifications

  42. Skin Superficial incisional SSI Subcutaneous tissue Superficial Incisional SSI Infection occurs within 30 days after the operation and involves only skin or subcutaneous tissue of the incision Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

  43. Deep soft tissue (fascia & muscle) Deep incisional SSI Deep Incisional SSI Infection occurs within 30 days after the operation if no implant is left in place or within 3 months if implant is in place and the infection appears to be related to the operation and the infection involves the deep soft tissue (e.g., fascia and muscle layers) Superficial incisional SSI Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

  44. Organ/space SSI Organ/space Organ/Space SSI Infection occurs within 30 days after the operation if no implant is left in place or within 3months if implant is in place and the infection appears to be related to the operation and the infection involves any part of the anatomy, other than the incision, which was opened or manipulated during the operation Superficial incisional SSI Deep incisional SSI Mangram AJ et al. Infect Control Hosp Epidemiol.1999;20:250-278.

  45. Risk factors • endogenous contamination (for example, procedures that involve parts of the body with a high concentration of normal flora such as the bowel) • exogenous contamination (for example, prolonged operations that increase the length of time that tissues are exposed)

  46. diminish the  general immune response (for example, diabetes, malnutrition, or immunosuppressive therapy with radiotherapy, chemotherapy or steroids) or local immune response (for example, foreign bodies, damaged tissue or formation of a haematoma).

  47. Host Risk Factors • Diabetes mellitus • Hypoxemia • Hypothermia • Leukopenia • Nicotine (tobacco smoking) • Immunosuppression • Malnutrition • Poor skin hygiene

  48. Perioperative Risk Factors • Operative site shaving • Breaks in operative sterile technique • Improper antimicrobial prophylaxis • Prolonged hypotension • Contaminated operating room • Poor wound care postoperatively • Hyperglycemia • Wound closure technique

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