Proper aseptic technique and administration of antimicrobial prophylaxis are essential for preventing surgical site infections. The document discusses the history and evolution of aseptic techniques, including the use of sterile instruments and dressings. It provides detailed steps for surgical hand scrubbing and gloving using aseptic technique. The timing and appropriate selection of antimicrobial agents for prophylaxis is important to reduce infection risks according to several studies discussed.

1. Skin preparing and role of antibiotics

2. Under the guidance of
Dr. P.V. Buddha,(M.S)
Dr. Venkat Reddy(M.S)
Dr.Satyavani(M.S)
Dr.Sailaja Rani(M.S)
Dr.Satyanarayana(M.S)

3. Ignaz Semmelweis
Puerperal fever transmission

4. Joseph Lister
• Started using carbolic acid dressings and
spraying carbolic acid in OT.

5. In 1882 Trendelenburg constructed an apparatus
for sterilization of surgical material and instruments
with dry steam. In 1886 Bloodgood invented rubber
gloves for protection of a surgeon's hands from
infections. Since 1890 Holoted Y. and Isege (since
1897) became to use gloves for protection of a wound
from a surgeon's hands.
Bergman E. and Shimelbus K. constructed a
sterilizing machine for boiling the instruments; they
created metallic drums for sterilization of clothes and
dressing, perfected an autoclave.

6. Introduction to Sterile Technique
• Proper aseptic techniques is one of the most fundamental
and essential principles of infection control in the clinical and
surgical setting
• Aseptic Techniques are those which:
– Remove/reduce or kill microorganisms from hands and objects
– Employ sterile instruments
– Reduce patient risk of exposure to microorganisms that cannot be
removed

7. The measures to prevent an infection from entering a
wound are referred to as asepsis, while those to cause the
exclusion or destruction of harmful microbes are generally
called antisepsis.
The two principles represent the united whole in the
prophylaxis of surgical infections. They have to be
considered in terms of the interrelationship between the
source of infection and its mode of transmission and the
susceptibility of the body.

8. The major sources of endogenous infections
incorporate chronic infections outside the area of the
operation (e.g. skin diseases, dental or tonsillar
conditions) or of the organs operated on as is (e.g.
appendicitis, cholecystitis, osteomyelitis), as well as the
oral, intestinal and respiratory saprophytes.
Among the modes of transmission of endogenous
infections are direct contact, lympho- and
haematogenous spread.

9. Aseptic Technique
• Immediately before and during surgical procedures
to reduce post-operative infection:
– Surgical Attire
– Surgical scrub, sterile gowning & gloving
– Patients surgical skin prep
– Using surgical barriers (surgical drapes and PPE)
– Using safe operative technique

10. Asepsis
• Absence of microorganism that cause disease
• Freedom from infection
• Aspetic Technique = methods by which
contamination with microorganisms is prevented

11. Principles of Aseptic Technique
• Only sterile items are used within the sterile field
• Sterile persons are gowned and gloved
– Gowns are only sterile from waist to shoulder
– Gloved hand must be kept in sight at all times
• Only the top of a draped table is considered sterile
• Sterile persons touch only sterile items or areas

12. • Unsterile persons avoid reaching over the sterile field
• The edges of anything that encloses sterile contents
are considered unsterile
• Sterile field is created as close as possible to the time
of use
• Sterile areas are continuously kept in view

13. • Sterile persons keep well within the sterile area
• Sterile persons keep contact with sterile areas to a
minimum
• Unsterile persons avoid sterile areas
• Destruction of the integrity of microbial barriers
results in contamination

14. The Surgical Hand Antisepsis
• Process of removing as many microorganisms as
possible from the hands and arms by mechanical
washing and chemical antisepsis before participating
in a surgical procedure
– Despite the mechanical action and the chemical
antimicrobial component of the scrub process, skin is
never sterile

15. Surgical Hand Antisepsis
• 4 factors affecting the effectiveness of surgical hand
antisepsis:
– The preparation before cleansing
– The choice of antiseptic solution
– The cleansing method
– The duration for hand cleansing

16. Choice of Antiseptic Solution
• Antimicrobial soaps, aqueous scrubs (ex. biguanides),
alcohol rubs used as antiseptic solutions+
• Alcoholic chlorhexidine was found to have greater
residual antimicrobial activity
– Review by Tanner et al, reported that biguanides (ex
Chlorohexidine gluconate are more effective in removing
microorganism on hands than Iodophors (ex. Providone iodine)

17. The Methodology of the Scrub
• The time method:
– All surgical scrubs are 3-5 minutes in length
– All are performed using a surgical scrub brush and
an antimicrobial soap solution

18. Preparation Before Surgical Scrub
• Removal of finger rings/jewelry, nail polish and artificial
nails
– Finger rings and jewelry can harbor microorganism and
dead skin
– Dark nail polish obscures the subungual space and
likelihood of careful cleansing is reduced
– Artifical nail ↑ the microbial load on hands

19. Preparation Before Surgical Scrub
• Performa a preliminary hand washing with
antimicrobial soap
• Wash both of your hands and arms, lathering up well
– Rinse and dry
• Clean underneath your fingernails with a nail file

20. Surgical Scrub Procedure
• 1. Remove sterile disposable brush-sponge from its
wrapper and moisten the sponge
• 2. Lather fingertips with sponge side of brush, then
using brush side of brush scrub the spaces under the
fingernails of the right or left hand with 30 circular
strokes

21. Surgical Scrub Procedure
• 3. Lather digits; scrub 20 circular strokes on all four
sides of each finger
• 4. Lather palm, back of hand, heel of hand and space
between thumb and index finger (scrub 20 circular
strokes) on each surface

22. Surgical Scrub Procedure
• 5. Forearm scrub – divide the forearm into 3
inch increments (the brush is 3 inches
lengthwise)
– Use the sponge side of the brush lengthwise to
apply soap around the wrist
– Scrub 20 circular strokes on all four sides of wrist
– Then move up the forearm – lather, then scrub
ending 2 inches above the elbow

23. Surgical Scrub Procedure
• 6. Repeat the previous steps for the other
arm
• 7. Discard the brush
• 8. Rinse hands and arms without retracing or
contaminating; allow the water to drip from
the elbows

24. Surgical Scrub Procedure
• 8. After final rinse, turn water off and keep scrubbed
hands and arms in view to avoid contamination and
back into operating room
• 9. In the operating room, dry hands and arms with a
sterile towel before donning a sterile surgical gown
and gloves

25. Drying the Hands
• Step 1: Reach down to the opened sterile
package containing the gown, and pick up the
towel
– Be careful not to drip water onto the pack
• Step 2: Open the towel full-length, holding one
end away from the non-sterile scrub attire
– Bend slightly forward

26. Drying the Hands
• Step 3: Dry both hands thoroughly but independently
– To dry one arm, hold the towel in the opposite hand and,
using the oscillating motion of the arm, draw the towel up
to the elbow
• Step 4: Carefully reverse the towel, still holding it away
from the body
– Dry the opposite arm on the unused end of the towel

27. Gowning Technique
– The gown is pulled on, leaving the cuffs of the sleeves
extended over the hands
– The back of the gown is securely tied or fastened at
the neck and waist, touch the outside of the gown at
the line of ties or fasteners in the back only

28. Gowning Technique
• Summary Principles:
– Touch only the inside of the gown while donning it
– If touch the outside, the gown is considered contaminated
– Scrubbed hands and arms are considered contaminated if they
fall below the waist level or touch the body
– After donning the gown, the only parts of the gown that are
considered sterile are the sleeves and front from waist level to a
few inches below neck opening

29. Gloving by the Closed Glove Technique
• Preferred method over open-gloving technique
• Provides a bacterial barrier between patient and
surgeon
• Step1: Using the right hand and keeping it within the
cuff of the sleeve, pick up the left glove from the
inner wrap of the glove package by grasping the
folded cuff

30. Gloving by the Closed Glove Technique
• Step 2: Extend the left forearm with the palm
upward
– Place the palm of the glove against the palm of the
left hand, grasping in the left hand the top edge of the
cuff, above the palm
– In correct position, glove fingers are pointing toward
you and the thumb of the glove is down

31. Gloving by the Closed Glove Technique
• Step 3: Grasp the back of the cuff in the left hand
and turn it over the end of the left sleeve and hand
– The cuff of the glove is now over the stockinette cuff of the
gown, with the hand still inside the sleeve

32. Gloving by the Closed Glove Technique
• Step 4: Grasp the top of the left glove and underlying
gown sleeve with the covered right hand
– Pull the glove on over the extended right fingers until it
completely covers the stockinette cuff
• Step 5: Glove the right hand in the same manner
– Use the gloved left hand to pull on the right glove

34. • Proper aseptic technique is one of the most
fundamental and essential principles of
infection control
• This stepwise process of proper aspetic
technique should be performed every single
time in the OR

35. Modifiable Risk Factors
• Skin or site preparation ineffective
– Removal of hair with clipper than razors
• Colorectal procedures
– Inadequate bowel prep/antibiotics
– Improper intraoperative temperature regulation
• Antimicrobial prophylaxis
– Inappropriate choice (procedure specific)
– Improper timing (pre-incision dose)
– Inadequate dose based on body mass index, procedures
>3h, or increased blood loss

36. • Excessive OR traffic
• Inadequate wound dressing protocol
• Improper glucose control
• Colonization with preexisting microorganisms
• Inadequate intraoperative oxygen levels

37. Prevention Strategies
Administer antimicrobial prophylaxis in accordance
with evidence based standards and guidelines
– Administer within 1 hour prior to incision*
• 2hr for vancomycin and fluoroquinolones
– Select appropriate agents on basis of
• Surgical procedure
• Most common SSI pathogens for the procedure
• Published recommendations

38. • Remote infections-whenever possible:
– Identify and treat before elective operation
– Postpone operation until infection has resolved
• Do not remove hair at the operative site unless it
will interfere with the operation; do not use razors
– If necessary, remove by clipping or by use of a
depilatory agent
• Operating Room (OR) Traffic
– Keep OR doors closed during surgery except as
needed for passage of equipment, personnel, and
the patient

39. • Redose antibiotic at the 3 hr interval in procedures with
duration >3hrs (* See exceptions to this recommendation in*Engelman
R, et al. The Society of Thoracic Surgeons Practice Guideline
Series:Antibiotic Prophylaxis in Cardica Surgery, Part II:Antibiotic Choice.
Ann Thor Surg 2007;83:1569-76)
• Adjust antimicrobial prophylaxis dose for obese patients (body mass
index >30)*Anderson DJ, Kaye KS, Classen D, et al. Strategies to prevent
surgical site infections in acute care hospitals. Infect Control Hosp
Epidemiol 2008;29 (Suppl 1):S51-S61
• Use atleast 50% of inspired oxygen intraoperatively and immediately
postoperatively in select procedure()*Maragakis LL, Cosgrove SE,
Martinez EA, et al. Intraoperative fraction of inspired oxygen is a
modifiable risk factor for surgical site infection after spinal surgery.
Anesthesiology 2009;110:556-562.

40. • Aqueous-based iodophors, such as povidone-iodine, contain
iodine complexed with a solubilizing agent, allowing for the
release of free iodine when in a solution. Iodine acts in an
antiseptic manner by destroying microbial proteins and DNA.
Iodophor-containing products enjoy widespread use because
of their broad-spectrum antimicrobial properties, efficacy, and
safety on nearly all skin surfaces regardless of the patient’s
age.
• Alcohol-based solutions are quick, sustained, and durable,
with broader spectrum antimicrobial activity. These agents
seem ideal for longer open surgeries with the potential for
irrigation or surgical spillage.

41. • Ethyl and isopropyl alcohol are 2 of the most effective
antiseptic agents available. When used alone, alcohol is fast
and short acting, has broad-spectrum antimicrobial activity,
and is relatively inexpensive. Flammability can be avoided by
allowing skin to completely dry and by avoiding preparation of
areas with excessive body hair that can delay alcohol
vaporization.
• Recent studies suggest that alcohol-based solutions may have
greater efficacy, easier application, improved durability, and a
superior cost profile when compared with traditional
aqueous-based solutions.

42. • DuraPrep solution, an antiseptic skin solution that contains
iodine povacrylex in isopropyl alcohol, shows durability in the
surgical/procedural environment and enhances adhesion
between surgical drapes and the prepared skin surface,
theoretically limiting the spread of organisms onto the
surgical field.

44. • Effects of Preoperative Skin Preparation on
Postoperative Wound Infection Rates: A
Prospective Study of 3 Skin Preparation
Protocols.
• Authors swenson etal
• In 2009
• OBJECTIVE
To compare the effects of different skin
preparation solutions on surgical-site infection
rates.

45. DESIGN
Three skin preparations were compared by means of a sequential
implementation design.
Period 1 used a povidone-iodine scrub-paint combination (Betadine)
with an isopropyl alcohol application between these steps.
Period 2 used 2% chlorhexidine and 70% isopropyl alcohol
(ChloraPrep).
Period 3 used iodine povacrylex in isopropyl alcohol (DuraPrep).
Surgical-site infections were tracked for 30 days .

46. CONCLUSIONS
• Skin preparation solution is an important
factor in the prevention of surgical-site
infections. Iodophor-based compounds may
be superior to chlorhexidine for this purpose
in general surgery patients.

47. • Perioperative antibiotic prophylaxis: improved
compliance and impact on infection rates
• By E. PROSPERO, P. BARBADORO, A.
MARIGLIANO, E. MARTINI and M. M. D'ERRICO
• In Cambridge journals in 2010

48. • Aim- of this study were to determine
adherence to the perioperative antibiotic
prophylaxis (PAP) protocol used at a large
Italian teaching hospital during a 6-year
period, to assess the variables associated with
inappropriate administration, and to measure
the impact on surgical site infection (SSI) rates
• Results - 28 621 patients surveyed of which
74·6% received PAP. An improvement in
adherence to the PAP protocol was registered
for 58·8% of patients.
• During the study period, a significant
reduction in SSIs rates was detected

49. • Conclusion - global reduction of inadequate
PAP administration signifies the efficacy of a
multidisciplinary quality improvement
initiative on antimicrobial utilization, and this
is supported by the observed reduction of the
SSI rate.

50. • Timing of Surgical Antibiotic Prophylaxis and
the Risk of Surgical Site Infection
• By Mary T. Hawn, MD, MPH etal
• In JAMA Surg. 2013
• Objective - To determine whether
prophylactic antibiotic timing is associated
with SSI occurrence
• Design - Retrospective cohort study

51. • Results
• Of the 32 459 operations, prophylactic
antibiotics were administered at a median of
28 minutes (interquartile range, 17-39
minutes) prior to surgical incision, and 1497
cases (4.6%) developed an SSI
• Compared with procedures with antibiotic
administration within 60 minutes prior to
incision, higher SSI rates were observed for
timing more than 60 minutes prior to incision

52. • Conclusions and Relevance - The SSI risk
varies by patient and procedure factors as well
as antibiotic properties but is not significantly
associated with prophylactic antibiotic timing.
While adherence to the timely prophylactic
antibiotic measure is not bad care, there is
little evidence to suggest that it is better care.

53. • A systematic review of the ASEPSIS scoring
system used in non-cardiac-related surgery
• By C J Shia et al
• In Journal of wound care in Aug 2013

54. • Objective: To assess the validity, reliability and
sensitivity of the ASEPSIS scoring system, used to
assess non-cardiac related surgery for surgical
wound infection.
• Method: Five studies were included in this
review. One study discussed the development of
the ASEPSIS scoring system; two studies were on
its reliability, one study on the sensitivity and the
final compared the ASEPSIS scoring system
against other surgical wound infection criteria
and definitions. Due to variation in study designs,
the findings were summarised and presented in a
narrative format.

55. • Results: Validity and reliability were not
established in assessing non-cardiac surgical
sites. Sensitivity level was reported for non-cardiac
surgical sites, but its reliability level
declined as the severity of infection worsened.
• Conclusion: This review revealed that there
are limited choices of scoring systems to
assess different surgical sites for surgical
wound infection. Currently, only the ASEPSIS
scoring system is available, but it is not
validated for use with sternal wounds.
Therefore, it should be used cautiously when
assessing non-cardiac surgical wound
infection.