Prevention and treatment of surgical infection

LEARNING OBJECTIVES The risk factors for developing a wound infection The classification of operative wounds The basic precautions to take to avoid surgically relevant health care-associated infections To learn the proper conduct in the Operating Room (OR) and the scientific basis for the procedures done in the OR to prevent infections. Microbial Factors of Importance in the Development of Infection The spectrum of commonly used antibiotics in surgery and the principles of therapy The indications for and choice of prophylactic antibiotics To learn the proper timing and duration of prophylactic antibiotics. The indications for and choice of antibiotic therapy Involvement of surgeons with HIV patients (universal precautions)

INTRODUCTION

Algorithm: The risk factors for developing a wound infection: the susceptibility of the host, the virulence of the invasive bacteria, and the environmental conditions in which the wound is made. Control of infection in the surgical patient should be considered in three components as indicated in Algorithm. The preoperative (prehospital) component consists of whatever medical conditions the patient brings to the hospital. Evaluation of this component dictates a careful review of the patients general health, so that appropriate antibiotics, when necessary, may be administered in a timely fashion. Other health conditions, such as smoking, should be stopped so that they have minimum effect during the surgical procedure. The second component is the operative environment. Care of the patient during this phase involves following appropriate conduct in the OR in order to minimize contamination and taking full advantage of the modern concepts regarding surgical infection. In this component, the timing of antibiotics and possible re-dosing of antibiotics need to be considered.

The third component is microbial factors. Here, the local hospital bacterial flora is important. The transmission of resistance organisms or the particular infestation of a highly virulent organism is the factor that determines whether a patient develops an infection. For this component, the surgeon needs to consider the antibiotic sensitivities so that proper antibiotics are given. The risk that any postoperative wound will get infected is based on the complexity and duration of the operation. Since clean operations do not violate bacterial-bearing organs, the infection rate is very low. A wound classification system identifies the infection risk following surgery. CLASSIFICATION OF SURGICAL WOUNDS Table National Research Council Classification of Operative Wounds

Surgical infection rates relating to wound contamination

Health care-associated infection (HAI) / Nosocomial Infections in Surgical Patients Evaluation of postoperative fever in surgical patients represents an important diagnostic undertaking in which the onus is on the surgeon to exclude the presence of a serious infection that may have profound detrimental effects on the patient." Potential sites of such nosocomial infections in surgical patients include UTIs, pneumonia, surgical site (wound) infections (SSIs), and bloodstream infection bacteremia; the last may occur with or without infection identified at a specific site, including that of an intravascular device.

PRINCIPLES OF PREVENTION TO INFECTION Preoperative Shower Over the past 20 years, there has been a revolution in the access of patients to the surgical environment. In 1980, 90% of surgical patients came to the hospital the day before surgery. Currently, 80% to 90% of patients stay at home the night prior to surgery. The preoperative management of these patients with respect to bathing, out of necessity, has been reevaluated. While a routine preoperative shower was standard in the 1970s, there is little evidence to indicate that this makes a difference in a patients risk of wound infection postoperatively. Remote-Site Infection and Shaving The presence of a remote-site infection, whether it is a pustule, an upper respiratory infection, or urinary tract infection, needs to be identified and treated prior to any surgical intervention. Similarly, the routine shave of the operating field done either in the OR immediately prior to surgery or the night before is not recommended. A patient whose surgical site has been shaved has an infection rate two to three times higher than patients who are not shaved. The reason for this increased risk of postoperative infection is based on numerous prospective trials, as well as on scanning electron microscopy showing small injuries to the skin of experimental animal models. These injuries show heavy bacterial colonization and inflammatory cells. The need for shaving a surgical site should be considered not for sanitary reasons but only for the convenience of the patients wound care. Hand Washing With respect to the surgeons handwashing, 30 years ago a 10-minute wash was considered the standard. However, increasingly shorter washes have been recommended by both the American College of Surgeons and the Centers for Disease Control. An initial wash of 5 minutes before the first surgery of the day is considered the standard, with subsequent preps of 2 minutes or less. One of the reasons for these decreasing skin prep times is the recognition that the soaps are harmful to the surgeons skin; a surgeon with a chronic skin condition can be a greater risk to the patient with respect to postoperative infection than the duration of the skin prep.

Three types of soaps currently are used: an iodophor-based soap, one with chlorhexidine and one with hexachlorophene. Alcohol-based skin preps, which are being used in Europe and have just been introduced in the U.S., offer the advantage that they require only topical application to clean skin, resulting in shorter skin prep times and less toxicity than soaps. In all of these considerations, it is important to recognize that the greater source of infection and contamination is the nail beds of the surgeon and the grossly evident contamination on the skin and arms. When scrubbing : Remove all jewellery and trim the nails Use soap, a brush (on the nails and finger tips) and running water to clean thoroughly around and underneath the nails Scrub your hands and arms up to the elbows After scrubbing, hold up your arms to allow water to drip off your elbows Turn off the tap with your elbow. Dry them with a sterile towel and make sure the towel does not become contaminated Hold your hands and forearms away from your body and higher than your elbows until you put on a sterile gown and sterile gloves.

Shoe Covers, Caps, Masks, Gowns, and Gloves Operating room (OR) conduct combines procedures that are ritualistic, with no scientific basis, and activities that have been studied extensively and are of paramount importance in preventing transmission of infection in the operating field. The use of shoe covers is a ritual from the era of flammable anesthetic gases. Because a spark from static electricity potentially could cause an explosion, specially designed nonconductive shoes that did not conduct an electric current were made for operating room personnel. For the visitor without special nonconductive shoes, shoe covers were available. Ether and cyclopropane especially were inflammable. Occasional explosions in the operating room were devastating events. By the mid-1970s, while explosive anesthetic agents were a thing of the past, shoe covers remained part of the accoutrements of the surgeon, along with caps and masks. However, current evidence suggests that the use of shoe covers actually may enhance the transmission of bacteria from the soles of ones shoes to the surgical wound. This is likely to occur especially if one does not wash ones hands after putting on the shoe covers.

With respect to barrier precaution, the use of cap, gown, mask, and OR gloves by the operating staff in the operating room to cover areas of their body that harbor a high density of potentially pathogenic bacteria is of paramount importance. However, data indicating the degree to which these barriers fail, resulting in infection, are seriously lacking. For example, the failure of gloves in the OR has been docu-mented; however, their failure has never been coordinated with the risk of postoperative infection, even though it has been estimated that a glove failure results in inoculation of 105 organisms per glove failure. This may have to do with the relative differences of bacterial density in different parts of the body. The scalp hair and face, especially around the nares, are areas of high bacterial density; bacteria easily can contaminate the wound, resulting in a wound infection. Adequate coverage of these areas is imperative to prevent infection in the surgical environment. Theatre technique and discipline also contribute to low infection rates. Numbers of staff in the theatre and movement in and out of theatre should be kept to a minimum. Careful and regular surveillance is needed to ensure the quality of theatre ventilation, instrument sterilisation and aseptic technique. Operator skill in gentle manipulation and dissection of tissues is much more difficult to audit, but dead spaces and haematomas should be avoided and the use of diathermy kept to a minimum. Core Body Temperature A recent, carefully controlled series of experiments clearly showed that the presence of the cold environment in the operating room reduces the patients core body temperature. This reduction in the patients core temperature significantly increases the risk of postoperative infection. This requires meticulous attention to keeping the patient warm while in the operating room and not allowing the patient to come into the OR and remain there for long periods of time prior to the initiation of surgery. Postoperative Care Causes of Postoperative Fever Postoperative fever is an important parameter to monitor after surgery since it can indicate that the patient has a serious postoperative infection. A temperature is abnormal if it is one degree Fahrenheit or one half of a degree centigrade above the normal core temperature. Depending on the patient population studied, the incidence of a postoperative fever in surgical patients may range from 15% to 75%. The decision of whether or not to evaluate a patient with expensive blood and radiographic tests needs to be made in the context of whether or not these tests are likely to yield helpful results. Since half of postoperative fevers do not have an infectious etiology, the timing, duration, and clinical setting of a fever are important clues in indicating whether or not further tests are necessary. A postoperative fever occurring in the first 2 days after surgery is very unlikely to have an infectious cause. After general anesthesia, pulmonary atelectasis causes activation of the pulmonary alveolar macrophage, resulting in endogenous pyrogen release. Early postoperative fever is believed to be due to this cytokine release. If, however, a fever occurs after postoperative day 3 or persists for more than 5 days, there is a high likelihood that an underlying infection is the cause. In this setting, before subjecting the patient to a battery of expensive laboratory tests, a careful clinical evaluation needs to be

done to look for a wound infection. The most common nosocomial infections are urinary tract infections (UTIs), wound infections, and pneumonia. The clinical setting is important, since most nosocomial UTIs follow instrumentation of the urinary tract. Similarly, nosocomial pneumonias frequently follow prolonged endotracheal intubation. Surgical Wound Management and Surgical Wound Infection Care What is the correct definition of a surgical wound infection? The rigid criterion of pus from a wound is only one sign of wound sepsis. The Centers for Disease Control and Prevention (CDC) expanded the definition in 1992 to include additional criteria. Organisms isolated aseptically from a wound, pain and tenderness, localized swelling, and redness in a wound that is deliberately opened by a surgeon all meet the criteria of a surgical site infection. In addition, the diagnosis of a superficial wound infection by the surgeon or attending physician meets the CDC criteria for a surgical site infection. Consequently, the intention to treat a wound with antibiotics meets the criteria of a wound infection. Postoperative management of a wound is dictated by the wound classification. Postoperative care of wounds Similar attention to standards is needed in the postoperative care of wounds. Secondary (exogenous) SSIs, as well as other health care-associated infection (HAIs), can be related to poor hospital standards. The presence of this organism in wounds, and the number of bacteraemias, can be a marker of inadequate postoperative wound care, and it can be very difficult and expensive to screen for, identify and eradicate. Primary intention healing occurs in closed wounds, which are wounds with the edges approximated (Fig. 9A). These wounds are usually closed in layers along tissue planes. Uncomplicated wounds healing with primary intention epithelialize within 24-48 h. At this point, water barrier function has been restored, and patients can be allowed to shower or wash. This has a psychological benefit during the postoperative recovery period. In addition, gentle cleansing removes old serum and blood, which reduces potential bacterial accumulation and infection risk. Secondary Intention Open wounds heal with the same basic processes of inflammation, proliferation, and remodeling as closed wounds. The major difference is that each sequence is much longer, especially the proliferative phase. There is much more granulation tissue formation and contraction. This type of healing process is referred to as secondary intention (Fig. 9B). Open wound edges are not approximated but are instead separated, which necessitates epithelial cell migration across a longer distance. Before epiboly can occur, a provisional matrix must be present. Granulation tissue must form. There are variable amounts of bacteria, tissue debris, and inflammation present depending on wound location and etiology. Infection, with high protein exudative losses and acute and chronic inflammation, can disregulate repair and transform the healing wound into a clinically nonhealing wound. When an open wound heals, which is generally defined as complete epithelialization, the dermal defect has been filled with collagen scar covered by epithelium. This scar has less tensile strength and is more susceptible to trauma than normal skin. Thus, after healing these scars more easily break down due to local trauma such as pressure. Topical Wound Treatment CLOSED WOUNDS Closed wounds healing by primary intention require much less care than open wounds. 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 6 weeks, 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). Therefore, if absorbable suture is used to close deep structures that are under significant tension, such as abdominal fascia, then the suture should retain significant

tensile strength for at least 6 weeks before absorption severely weakens the suture. In addition, heavy activity should be limited for a minimum of 6 weeks while healing of deep fascial structures occurs. OPEN WOUNDS Necrotic material should be removed from open wounds on initial presentation and subsequently as it accumulates. Necrotic tissue serves only as a culture source for bacteria and does not aid healing. The only exception to immediate debridement is a dry, chronic, arterial insufficiency eschar without evidence of infection. These types of wounds may be best treated by revascularization prior to debridement. Open wounds heal optimally in a moist, sterile environment. Although sterility is not possible to achieve clinically, numerous experimental and clinical studies have demonstrated that a moist environment speeds healing. This is thought to occur by preventing desiccation at the base of the wound. Desiccation causes necrosis at the base of the wound until an eschar forms, which may take several days. During this time, the wound is enlarging and initiation of the healing process is delayed. By keeping the wound covered and moist without infection, desiccation necrosis and healing delay are prevented.

Figure 9. A. Wound healing by primary intention. The edges are approximated. B. Wound healing with secondary intention. The wound is open, and the edges are not approximated. A potentially contaminated wound is best left open lightly packed with damp saline soaked gauze and the suture closed as delayed primary closure after 25 days. These wounds heal by contraction and epithelialization. DRAINS Drains are a very controversial issue with regard to infection. A recent study evaluating their effectiveness in draining elective colon resections shows no increased risk of infection or other complications with a drain as opposed to without one. Additionally, however, there is no clear advantage to placing a drain as opposed to not placing it. Routine use of drainage after axillary dissection has been subjected to prospective randomized trial. Again, no distinct advantage with respect to infection could be seen with the presence or absence of drains. The presence of drains resulted in fewer postoperative visits and a greater subjective evaluation of postoperative pain. In general, the use of drains should be restricted to those situations in which there is a specific indication, and the duration of drainage should be determined and limited as much as possible. Drainage of a wound or body cavity is indicated when there is risk of blood or serous fluid collection or when there is pus or gross wound contamination. Drains are not a substitute for good haemostasis or for good surgical technique and should not be left in place too long. They are usually left in place only until the situation which indicated insertion is resolved, there is no longer any fluid drainage or the drain is not functioning. Leaving a non-functioning drain in place unnecessarily exposes the patient to an increased risk of infection. MICROBIAL FACTORS OF IMPORTANCE IN THE DEVELOPMENT OF INFECTION One of the primary determinants of whether infection developsis the size of the initial microbial inoculum, whichfor bacteria is expressed in terms of colony-forming units(CFU). Even large numbers of

low-virulence microbes can overwhelm resident and recruited host defenses by direct toxicity or via subsequent division and proliferation, with the end result morbidity in the form of established infection, which can in tum be lethal. Two major reservoirs of microbes exist that can form the initial inoculums leading to infection in surgical patients: (1) host endogenous microflora and (2) microbes within the external milieu, which often represents the nosocomial environment for hospitalized individuals. As discussed, the presence of host microflora is normal in healthy individuals; these microbes as well as microbes in the environment are precluded from invading and proliferating within the body by a number of potent host defense. THE SPECTRUM OF COMMONLY USED ANTIBIOTICS IN SURGERY AND THE PRINCIPLES OF THERAPY The second half of the 20th century ushered in the antibiotics era. Since the introduction of antibiotics, it increasingly has become evident that most operative infections are caused by bacteria from the patients own body that reach the wound at the time of the surgery. Consequently, for antibiotics to work effectively, they have to be on board at the time of this inoculation in order to prevent the infection. Prophylactic antibiotics If antibiotics are given empirically, they should be used when local wound defences are not established (the decisive period). Ideally, maximal blood and tissue levels should be present at the time at which the first incision is made and before contamination occurs. Intravenous administration at induction of anaesthesia is optimal. In long operations, those involving the insertion of a prosthesis, when there is excessive blood loss or when unexpected contamination occurs, antibiotics may be repeated 8 and 16 hours later. The choice of an antibiotic depends on the expected spectrum of organisms likely to be encountered, the cost and local hospital policies, which are based on experience of local resistance trends. The use of the newer, broad-spectrum antibiotics for prophylaxis should be avoided. Patients with known valvular disease of the heart (or with any implanted vascular or orthopaedic prosthesis) should have prophylactic antibiotics during dental, urological or open viscus surgery. Single doses of broad-spectrum, for example amoxicillin, orally or intravenously administered, are sufficient for dental surgery. In urological instrumentation, a second-generation cephalosporin, such as cefuroxime, is sufficient, but in open viscus surgery, the addition of an imidazole such as metronidazole should be considered. Choice of antibiotics for prophylaxis Empirical cover against expected pathogens with local hospital guidelines Single-shot intravenous administration at induction of anaesthesia Repeat only in prosthetic surgery, long operations or if there is excessive blood loss Continue as therapy if there is unexpected contamination Benzylpenicillin should be used if Clostridium gas gangrene infection is a possibility Patients with heart valve disease or a prosthesis should be protected from bacteraemia caused by dental work, urethral instrumentation or visceral surgery Use antibiotic prophylaxis in cases where there are: Biomechanical considerations that increase the risk of infection: Implantation of a foreign body Known valvular heart disease Indwelling prosthesis

Medical considerations that compromise the healing capacity or increase the infection risk: Diabetes Peripheral vascular disease Possibility of gangrene or tetanus Immunocompromise 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. Consider using prophylaxis: For traumatic wounds which may not require surgical intervention When surgical intervention will be delayed for more than 6 hours. Active immunization with tetanus toxoid prevents tetanus. Examples of tetanus prone wounds include: Wounds contaminated with dirt or faeces Puncture wounds Burns Frostbite High velocity missile injuries Antibiotic Therapy The use of antibiotics for the treatment of established surgical infection ideally requires recognition and determination of the sensitivities of the causative organisms. Antibiotic therapy should not be held back if they are indicated, the choice being empirical and later modified depending on microbiological findings. Hospital and Formulary guidelines should be consulted for doses and monitoring of antibiotic therapy. However, once antibiotics have been administered, the clinical picture may become confused and, if a patients condition does not rapidly improve, the opportunity to make a precise diagnosis may have been lost. It is unusual to have to treat SSIs with antibiotics, unless there is evidence of spreading infection, bacteraemia or systemic complications (SIRS and MODS). The appropriate treatment of localised SSIs is interventional radiological drainage of pus or open drainage and debridement. There are two approaches to antibiotic treatment: A narrow-spectrum antibiotic may be used to treat a known sensitive infection; for example, MRSA (which may be isolated from pus) is usually sensitive to vancomycin or teicoplanin, but not flucloxacillin. Combinations of broad-spectrum antibiotics can be used when the organism is not known or when it is suspected that several bacteria, acting in synergy, may be responsible for the infection. For example, during and following emergency surgery requiring the opening of perforated or ischaemic bowel, any of the gut organisms may be responsible for subsequent peritoneal or bacteraemic infection. In this case, a triple-therapy combination of broad-spectrum penicillin, such as ampicillin or mezlocillin, with an aminoglycoside, such as gentamicin, and metronidazole, may be used per- and postoperatively to support

the patients own body defences. An alternative to the penicillins is a cephalosporin, e.g. cefuroxime. This has been a popular alternative as gentamicin toxicity and monitoring of levels are avoided, but the aminoglycosides remain inexpensive and effective. Other alternatives are piperocillin tazobactam or monotherapy using a carbapenem. In surgical units in which resistant Pseudomonas or other Gramnegative species (such as Klebsiella) have become resident opportunists, it may be necessary to rotate anti-pseudomonal and anti-Gram-negative antibiotic therapy. 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 Treatment of commensals that have become opportunist pathogens They are likely to have multiple antibiotic resistance It may be necessary to rotate antibiotics The use of these routines, subsequent wound infection and the alternation of combinations of chemotherapy should be monitored by the infection control team and local hospital protocols. In treating patients who have surgical infection with systemic signs (SIRS and MODS), a failure to respond to antibiotics may indicate that there has been a failure of infection source control. If response is poor after 34 days, there should be a re-evaluation with a review of charts and further investigations requested to exclude the development or persistence of infection such as a collection of pus. New antibiotics should be used with caution and, wherever possible, sensitivities should first be obtained. There are certain general rules on which the choice of antibiotics may be based. For example, it is unusual for Pseudomonas aeruginosa to be found as a primary infecting organism unless the patient has had surgical or hospital treatment. Local antibiotic sensitivity patterns vary from centre to centre and from country to country, and the sensitivity patterns of common pathogens should be known to the hospital microbiologist who should be involved. HIV, AIDS AND THE SURGEON The type I human immunodeficiency virus (HIV) is one of the viruses of surgical importance as it can be transmitted by body fluids, particularly blood. It is a retrovirus that has become increasingly prevalent through sexual transmission, both homo- and heterosexual, in intravenous drug addiction, through infected blood in treating haemophiliacs, in particular, and in sub-Saharan Africans. The risk in surgery is probably mostly through needlestick injury during operations. After exposure, the virus binds to CD4 receptors with a subsequent loss of CD4+ cells, T helper cells and other cells involved in cell-mediated immunity, antibody production and delayed hypersensitivity. Macrophages and gut-associated lymphoid tissue (GALT) are also affected. The risk of opportunistic infections (such as Pneumocystis carinii pneumonia, tuberculosis and cytomegalo virus) and neoplasms (such as Kaposis sarcoma and lymphoma) is thereby increased. In the early weeks after HIV infection, there may be a flu-like illness and, during the phase of seroconversion, patients present the greatest risk of HIV transmission. It is during these early phases that drug treatment, highly active anti-retroviral therapy (HAART), is most effective through the ability of these drugs to inhibit reverse transcriptase and protease synthesis, which are the principal mechanisms through which HIV can progress. Within 2 years, untreated HIV can progress to AIDS in 2535% of patients, which is considered to be fatal.

Involvement of surgeons with HIV patients (universal precautions) Patients may present to surgeons for operative treatment if they have a surgical disease and they are known to be infected or at risk, or because they need surgical intervention related to their illness for vascular access or a biopsy when they are known to have HIV infection or AIDS. Universal precautions have been drawn up by the CDC in the United States and largely adopted by the NHS in the UK (in summary): when there is a risk of splashing, particularly with power tools; 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 dropped sharps; double gloving needed (a larger size on the inside is more comfortable); 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 with minimised bleeding. After contamination Needle-stick injuries are commonest on the non-dominant index finger during operative surgery. Hollow needle injury carries the greatest risk of HIV transmission. The injured part should be washed under running water and the incident reported. Local policies dictate whether post-exposure HAART should be given. Occupational advice is required after high-risk exposure together with the need for HIV testing and the option for continuation in an operative specialty. SUMMARY Prevention of a surgical infection requires a thorough understanding of the three component parts (factors) that may contribute to a postoperative infection: the host, the environment, and the bacteria (see Algorithm). The severity and likelihood of an infection are dependent on the relative balance of these three factors. Since most infections come from the patients own body, knowing the infectious risk of an operation, using the appropriate antibiotics, and conducting a timely and efficient surgery are the most significant factors in preventing a postoperative infection. The success of treating an established infection requires an understanding of both the microbes involved and the spectrum of antibiotics to treat these microbes. Finally, the operating room environment may compromise the patients ability to resist infection in a variety of ways. The patients internal milieu is exposed to bacteria where the natural host defense mechanism is not effective. Keeping the patients core body temperature in a normal range is a significant factor in preventing infection. Finally, understanding the nature and types of resistant organisms present in the specific hospital, how they are spread, and what antibiotics are recommended to treat these organisms are important both for preventing the dissemination of these organisms and for curing the patient.