International Federation of Infection Control
Education
Programme for Infection Control
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International Federation of Infection Control
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Education
Programme for Infection Control
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Post-operative wound infection delays recovery and often increases length of stay and may produce lasting sequelae and require extra resources for investigations, management and nursing care. Therefore, its prevention or reduction is relevant to quality patient care.
Studies support the concept that a reduction in post-operative wound infection is directly related to increased education and awareness of its causes; its prevention is greatly aided by critically evaluated infection control practice. Surveillance for wound infection is a useful tool to demonstrate the magnitude of the problem. Combined with a regular feed back to the surgeon it has been shown to decrease the infection rate. It is important to realise that surveillance alone cannot act as a substitute for action and prevention.
There are multiple reasons for post-operative wound infections, which have been validated and documented as risk factors. A risk factor is any recognised contribution to an increase in post-operative wound infection.
In case of concurrent disease, delay operation and treat.
Antibiotic prophylaxis for dirty or contaminated operations. These include operations on gastro-intestinal tract and biliary tract in high-risk patients. Prophylaxis is usually given for clean operations where an infection constitutes a catastrophe for the patient e.g. insertion of joint and cardiac prostheses, hysterectomy, caesarean section with prolonged rupture of membranes. Prophylaxis for other clean surgery is controversial.
Adequate surgical training.
Wound Drains It is generally accepted that wound drains provide access for bacterial entry via colonisation and hands. Drains should not be used as an alternative to good haemostasis. The closed system of wound drainage is preferred where drainage is essential. Open wound drains are not considered appropriate and may lead to an increase in wound infection.
Antibiotic prophylaxis. A relevant antibiotic should be given at correct time, i.e. at induction of anaesthesia. It should not be given for more than 24 hours, preferably one or two doses.
Skin care
Shaving is no longer recommended. Remove hair with clippers where necessary.
Shaving if thought necessary should be performed in the operating ward. Prolonged
shaving leaves the skin bruised and with contusions which could increase the
risk of colonisation and infection.
Skin disinfection. It is essential that the operating site is well disinfected
before incision. A rapid reduction of skin flora is required. 70% of ethanol
or isopropanol is an effective disinfectant. However, alcoholic solutions containing
long acting skin disinfectants, such as chlorhexidine or povidone iodine are
preferred. The use of such disinfectants with greater than 40% alcohol content
increases the risk of burns to the patient during diathermy. The area must be
allowed to dry before operating.
The antiseptic should be applied with friction well beyond the operation site
for 3-4 minutes.
Excessive presence and movement of staff contributes
to an increase in air-borne bacterial particles. In the case of bacterial skin
infections dispersal of pathogens (S.aureus, beta-hemolytic streptococci) may
be large. It is advisable to keep the Operating Theatre staff to the essential
minimum. Staff with a boil or septic lesion of the skin or eczema colonized
with S.aureus should not be allowed in the theatre.
Theatre clothing. To avoid transfer of pathogens into the operation suite
clothes intended for work in the suite should not be worn in patient care outside
the suite. The operating team should wear sterile gowns and gloves. For surgical
handwashing see chapter on hand decontamination.
Open containers of solutions or disinfectants must not be used. This
can result in contamination with airborne contaminants and growth of gram-negative
bacteria, which may then colonise the wound. Disinfectants may be inactivated.
Liquid should be stored in bottles until immediately before use. Water-baths
should be disinfected after use.
Operating theatre ventilation. To prevent contaminated air from reaching
the operating theatre, mechanical ventilation is recommended. If windows have
to be left open, it is advisable coverer them with fly or insect proof netting.
Air-conditioning systems should ensure that a minimum of 20 to 24 air changes
per hour of filtered air is delivered. With correct design and good control
of staff movement the level of airborne contamination would then be below 100
cfu (colony forming unit)/m3 during operations.
It is now accepted that Ultra Clean Air (<10 cfu/m3) reduces the risk of
infection in implant surgery. To achieve this, laminar flow systems (airflow
0.5m/s) which deliver about 300 air changes per hour or special ventilation
combined with bacteria impermeable clothing has to be used.
Regular maintenance and checking of the ventilation filters and airflows must
be ensured, and bacteriological testing during on going operations should be
undertaken by the IC Team before recommissioning the operating theatres. Routine
bacteriological testing of operating room air is unnecessary but may be useful
when investigating an outbreak.
Avoid preoperative stay in the ward.
If this is necessary for medical reasons keep the patient in a clean environment
to protect from colonization with bacteria from infected patients. Do not use
prophylactic antibiotics in the ward.
