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  • 2. Approx 20% of all hospital hospital-acquired infections occur in surgical wounds (Meers 1981; Haley 1985) Prospective surveillance shows an overall surgical wound infection rate of < 5% (Cruse and Foord 1973, 1980, 1992)
  • 3. Acute and Chronic Wounds Acute wounds are: - less heavily colonised with micro micro-organisms - produced on healthy tissue by a traumatic event e.g. surgery - heal well if the wound is well vascularised - infection delays normal healing and this may lead to an acute wound becoming chronic
  • 4. Acute and Chronic Wounds (2) Chronic wounds are: - rarely, if ever, sterile - may be heavily colonised with micro micro-organisms depending on: - length of time wound has been present - underlying patient risk factors e.g. vascularity metabolic impairment e.g. diabetes
  • 5. Post-surgical infection rates surgical 3 prospective studies by Cruse and Foord 1973 1980 1992 Clean 1.8 1.5 1.4 Clean-contaminated 8.9 7.7 6.3 Contaminated 21.5 15.2 13.3 Dirty 38.3 40.0 39.9 All Wounds 4.8 4.7 4.4
  • 6. Potentially pathogenic bacteria commonly found in wounds Staphylococcus aureus Escherichia coli Proteus species Enterococcus fuecalis Streptococcus pyogenes Bacteroids species Klebsiella species Acinetobacter anitratus Pseudomonas aeruginosa
  • 7. Wound Classification - Clean Operations Gastro-intestinal, genitourinary and respiratory intestinal, tracts intact. No inflammation encountered. Asepsis maintained - e.g. varicose vein surgery. - Clean-contaminated Operations contaminated Viscus opened but with minimal spillage e.g. elective cholecystectomy.
  • 8. Wound Classification(2) - Contaminated Operations Gross spillage from an opened viscus. Acute inflammation without pus. Traumatic wound < 4 hours old. Breach in asepsis. e.g. appendicitis - Dirty Operations Pus encountered or perforation. Traumatic wound > 4 hours old. e.g. perforated diverticulum (National Research Council 1964)
  • 9. Routes of spread of micro micro- organisms causing wound infection - hands Contact - equipment etc. - droplet nuclei Airborne - skin scales Blood-borne
  • 10. Prevention of Wound Infection - minimise pre-operative stay operative - reduce skin shaving - adequate skin preparation - high quality surgical technique - antibiotic prophylaxis - clean operating environment and air filtration - sterile equipment - protective clothing - closed vacuum drainage of wound - optimum wound dressing - aseptic technique - HAND WASHING
  • 11. Ignaz Semmelweis 1847 Hungarian Obstetrician Reduced puerperal fever death rate from 11% to 1% by introducing hand hand-washing
  • 12. Resident Hand Flora Characteristics: - micro-organisms protect skin organisms - survive and multiply on skin - not easily removed by scrubbing - inactivated by topical antimicrobial agents - can cause infection when enter through breaks in the skin - “invasiveness” - can rapidly become highly pathogenic
  • 13. Resident Micro Micro-organisms Staphylococcus epidermidis micrococci diphtherroids anaerobic cocci propionibacteria
  • 14. Transient hand flora Characteristics: - loosely attached to skin surface - usually removed with friction, soap and water - acquired by direct contact - most abundant around fingertips - an important cause of cross infection
  • 15. Transient micro micro-organisms Staphylococcus aureus Streptococci Gram-negative bacilli including negative Escherichia coli Pseudomonas Viruses
  • 16. All micro-organisms found on hands organisms are capable of colonising and infecting wounds. Microbial counts usually increase in warm and moist conditions: - under gloves - beneath rings
  • 17. Gram Negative Bacilli Colonising Skin under Wedding Rings Organisms No. of Staff CFU’s per swab Ent. cloacae 10 10 - 24,000 Kleb. pneumoniae 5 10 - 2,200,000 Acinet. calcoaceticus 3 110 - 560,000 Ps. aeruginosa 2 7,200 - 40,000 Serratia marcescens 1 48,000 Proteus mirabilis 1 50 Prov. stuartii 1 14,000 Hoffmann et al 1985
  • 18. Jewellery esp. rings - Total bacterial counts are higher - Handwashing still removes bacteria under rings - Difficulty donning gloves - Gloves may tear
  • 19. Nails, nail polish, artificial nails Nails should be kept short. Artificial nails may increase microbial load. Thorough, effective handwashing difficult. Theatre staff should not wear artificial nails. Clear nail polish only.
  • 20. Gloves Gloves are not a substitute for handwashing. Massive increase in use in recent years. Hand contamination remains possible. Handwashing after glove removal essential and before sterile glove use. Hypersensitivity to latex increasing. Gloves must be changed: - between clean and dirty procedures - between patients
  • 21. Gloves (2) Glove quality very variable Beware re-use of disposable gloves. use If absolutely necessary, latex gloves can be washed , and dried, powdered and re re-used where their availability is scarce.
  • 22. Handwashing Mechanical - removes soil and debris with abrasive action Chemical - uses antimicrobial chemical agents to destroy or suppress growth of micro-organisms organisms - chemical agents are: - cidal or - static
  • 23. Choice of Handwashing Agents Dependent on: - task to be undertaken - inherent characteristics - type and spectrum of activity
  • 24. Handwashing Agents Soap and Water Antiseptic handwashes and water Alcohol hand-rubs rubs
  • 25. Soap and Water “Should be used for handwashing unless otherwise indicated” Centers for Disease Control 1985
  • 26. Active Ingredients in Antimicrobial Agents - alcohols - iodophors - chlorhexidine gluconate - triclosan - chloroxylenol (pcmx) - hexachlorophene
  • 27. Alcohols (70% (70%-90%) - Inexpensive - Do not require water or facilities - but will not remove dirt or debris - Provide rapid and greatest reduction in microbial counts - but no residual activity - Dry and irritate skin - Irritation reduced by adding emollients - Standard scrub solution in some European countries - Volatile and flammable
  • 28. Iodophors e.g. povidone-iodine - used primarily for surgical scrubbing - wide range of microbial activity - rapidly neutralised in presence of organic material e.g. blood - cause skin irritation and hypersensitivity
  • 29. Chlorhexidine gluconate - wide range of microbial activity - initially slow acting - but persistent chemical activity (up to 6 hours) - less irritating than alcohols or iodophors - not significantly affected by organic material - available in combination with alcohol as a highly-effective hand-rub rub
  • 30. Triclosan - wide range of bacterial activity - excellent residual activity - minimally affected by organic material eg blood - commonly used in commercial soaps - more data needed
  • 31. Chloroxylenol (Para-chloro-meta meta-xylenol) - less active than chlorhexidine gluconate - reasonable residual activity - minimally affected by organic material
  • 32. Hexachlorophene - inferior microbial activity - potentially toxic - slow-acting - minimally affected by organic material - must not be used on broken skin
  • 33. Emollients (Hand lotion or cream) - highly effective in protecting skin from excessive drying or cracking - however, may reduce or neutralise effect of antimicrobial agents - container can become contaminated - essential to consider possible interactions before purchase
  • 34. Summary of Handwashing Agents Most widely used agents are: - chlorhexidine gluconate - alcohol - povidone iodine
  • 35. Reasons for Noncompliance with Handwashing - insufficient time available between tasks - inconvenience/lack of facilities - perceived lack of need - poor skin condition resulting from repeated handwashing or harsh products Also Cultural factors lack of education lack of role models
  • 36. Other Considerations Soap - bar soap keep dry (magnet, ring, string) - liquid soap dispensers ideally cartridge use otherwise clean nozzles regularly - antiseptic soap dispensers ideally wall-mounted and elbow mounted elbow-operated should be sterile and disposable with a measured dose
  • 37. Further Considerations - preferably use a separate sink for handwashing. - elbow operated taps if possible. - paper towels are best method of drying hands. - nail brushes should ideally be single use. - handwash dispensers should be wall wall-mounted with elbow-operated pump
  • 38. Limited/Restricted Resources In absence of running water: - clean bowl of water change water after each use - drum with a spout elevate to serve as running water - store water in large clean receptacles whenever a water supply is available - ensure water is pathogen--free e.g. cholera consider chlorination/filtration/boiling
  • 39. Limited Resources In absence of paper towels: - clean cloth (12” x 12”) single person use and use once only launder after use - air dryers preferably non-touch touch
  • 40. “Hand-washing using an appropriate washing technique covering all surfaces ... at the right time is more important than the agent used or the length of time of handwashing” Ayliffe 1992
  • 41. Optimum Handwashing Technique (social and hygienic wash) Remove jewellery if possible. Roll back sleeves. Wet hands under running water. Apply soap to all areas of hands. Rub hands together vigorously and cleanse all areas of hands and wrists. Keep hands lower than elbows and do not touch equipment. Rinse hands thoroughly under running water. Dry hands thoroughly.
  • 42. Surgical Scrub Technique Remove all jewellery. Wet hands under running water. Wash hands to remove soil and debris. Using antimicrobial agent and nail sponge/brush, clean under nails. Discard sponge/brush. Scrub all surfaces of hands, wrists and forearms up to elbows. Keep hands higher than elbows.
  • 43. Surgical Scrub Technique (2) If there is any contact with unclean surfaces during scrubbing, restart procedure with a fresh sponge/brush. Once an area has been cleaned, do not return to the cleaned area again. Rinse hands and arms thoroughly. Avoid wetting clothes. Dry all areas with sterile cloth or towels.
  • 44. Hand Drying Wet surfaces - encourage multiplication of micro micro-organisms transfer micro-organisms more effectively than dry organisms High risk of contamination: communal hand towels roller towels Warm air dryers: cycle time often inadequate can be a source of cross cross-infection research is scanty
  • 45. TYPES OF HAND CARE Type Objective Method Handwash Remove soil and transient Soap or detergent for micro-organisms at least 10-15 seconds Hand antisepsis Remove or destroy transient Antimicrobial soap/ micro-organisms detergent/alcohol-based hand rub for at least 10-15 seconds Surgical hand Remove or destroy transient Antimicrobial soap/detergent scrub micro-organisms and reduce with brush to achieve friction organisms resident flora for at least 2 minutes OR alcohol-based preparation for APIC Guidelines 1995 at least 20 seconds
  • 46. How do I know which procedure to use? Handwash Antisepsis Surgical Scrub * before and after routine * before performing invasive procedures * prior to any surgical patient contact * before care of susceptible patients (operative) * before and after contact with wounds procedure * before handling food or invasive devices (e.g. IV cannula) * after situations where contamination of * after using toilet hands with blood or body fluids is likely to occur * whenever hands are * after caring for patients with a known soiled infection or colonised with micro micro- organisms of significance (e.g. resistant strains) * between contact with different patients in high-dependency units dependency