2. Overview of control measures to prevent surgical site infection

3. INTRODUCTION Surgical wound infections are the second most common healthcare-associated infection Although usually localized to the incision site, surgical wound infections can also extend into adjacent deeper structures; thus, the term surgical wound infection has now been replaced with the more suitable name, surgical site infection (SSI). CDC define SSIs as infections related to the operative procedure that occur at or near the surgical incision (incisional or organ/space) within 30 days of an operative procedure or within one year if an implant is left in place

4. GENERAL PRINCIPLES The most important factors in the prevention of surgical site infection (SSIs) are meticulous operative techniques and timely administration of effective preoperative antibiotics

5. A number of interventions have been used over the years to reduce the risk of SSIs, including : Preoperative showering with antimicrobial soaps Preoperative application of antiseptics to the skin of the patient Washing and gloving of the surgeon's hands Use of sterile drapes Use of gowns and masks by operating room personnel

6. Skin antisepsis Routine application of antiseptics to the skin should be performed to reduce the burden of skin flora, although bacteria in hair follicles and sebaceous glands cannot be sterilized by preoperative antiseptic agents. Preoperative skin cleansing with chlorhexidine -alcohol is superior to povidone-iodine; in a trial of 849 patients undergoing clean-contaminated surgery, the overall rate of SSI was significantly lower in the chlorhexidine- alcohol group than in the povidone-iodine group (9.5 versus 16 percent).chlorhexidine Chlorhexidine-alcohol may be superior to iodine- alcohol because chlorhexidine is not inactivated by blood or serum.

7. Interventions that do not appear to reduce the likelihood of SSI include skin preparation in concentric circles (rather than horizontal preparation) and use of surgical site markers. The benefit of bathing with an antiseptic preparation prior to surgery to reduce the risk of SSIs is uncertain. In a meta-analysis of six trials involving 10,007 participants, preoperative bathing with chlorhexidine conferred no benefit over preoperative bathing with other products for reduction of SSI. chlorhexidine

8. Barrier devices The primary role for barrier devices (masks, caps, gowns, drapes, and shoe covers) is to protect operating room personnel from exposure to infectious blood or body fluids. Their role in SSI prevention is not supported by rigorous study, but their routine use is universally accepted in hospitals where such equipment is available.

9. Gloves provide protection of personnel from exposure to infectious blood and body fluids and likely reduce the potential for transmission of bacteria to patients from the hands of surgical personnel. However, there is evidence for bacterial migration from undetected perforation of surgical gloves; the risk depends on the type of surgery performed and the duration of wear

10. Surgical hand hygiene Surgical hand hygiene consists of preoperative cleansing of hands and forearms with an antiseptic agent; this practice is universally accepted. Cleansing with aqueous alcoholic solution may be as effective as traditional hand scrubbing with antiseptic soap for prevention of SSIs. Either antimicrobial soap or an alcohol-based hand rub may be used The recommended duration of scrubbing with alcohol based hand rubs is shorter than with antimicrobial soap (varies by product) and scrub brushes are not required for preoperative hand cleaning by surgical staff.

11. Surgical technique There is general agreement that good surgical technique reduces the risk of SSIs. Such practices include gentle traction, effective hemostasis, removal of devitalized tissues, obliteration of dead space, irrigation of tissues with saline to avoid excessive drying, use of fine, non- absorbed monofilament suture material, judicious use of closed suction drains, and wound closure without tension. The precise role or proportional benefit of each of these techniques in SSI prevention has not been quantitated or proven by rigorous study.

12. ANTIMICROBIAL PROPHYLAXIS The goal of antimicrobial prophylaxis is to prevent surgical site infection (SSI) by reducing the burden of microorganisms at the surgical site during the operative procedure. The efficacy of antibiotic prophylaxis for reducing surgical SSI has been clearly established. Preoperative antibiotics are warranted if there is a high risk of infection or if there high risk of deleterious outcomes should infection develop at the surgical site (such in the setting of immune compromise, cardiac surgery,and/or implantation of a foreign device). Patients who receive prophylactic antibiotics within one to two hours before the initial incision have lower rates of SSI than patients who receive antibiotics sooner or later than this window.

13. Antimicrobial therapy administered in the setting of contaminated wounds is not considered prophylactic; in such cases, a therapeutic course of antimicrobial therapy is warranted. Errors in selection or dose of prophylactic antimicrobials are common. Among 34,133 patients undergoing surgery in centers around the United States, an antimicrobial was administered within one hour before incision to only 56 percent of patients, and antimicrobials were discontinued within 24 hours of surgery in only 41 percent of patients.

14. Antibiotic selection Cefazolin (1 to 2 g IV) is a first generation cephalosporin active against streptococci and methicillin susceptible staphylococci; it is generally appropriate for clean procedures. Cefazolin Cefuroxime (1.5 g IV) is a second generation cephalosporin with broader coverage against gram-negative organisms; it may be administered in place of cefazolin for thoracic (cardiac and noncardiac) and orthopedic procedures.Cefuroxime For procedures that may involve exposure to bowel anaerobes (including Bacteroides fragilis),cefoxitin (1 to 2 g IV) or cefotetan (second generation cephalosporins) have broader coverage including anaerobic activity than the above agents. However, some gram-negative bacilli such as E. coli have become resistant to cefoxitin; in such circumstances, reasonable alternatives includecefazolin plus metronidazole (500 mg IV) or monotherapy with ampicillin-sulbactam (3 g IV).cefoxitin cefotetan cefazolin metronidazole ampicillin-sulbactam

15. Patients with history of allergy to penicillin manifesting as an uncomplicated or minor skin rash may be treated with cephalosporins; allergic cross-reactions to cephalosporins are infrequent except in patients with severe IgE-mediated reactions to penicillin. If an IgE-mediated reaction against penicillin has occurred in the past, cephalosporins should be avoided Alternatives to cephalosporins include intravenous vancomycin (15 to 20 mg/kg) or clindamycin (600 to 900 mg) PLUS an agent with activity against gram-negative bacteria such as gentamicin,ciprofloxacin, levofloxacin, or aztreonam. This is particularly important in patients undergoing colorectal or vascular surgery involving a groin incision.vancomycin clindamycin gentamicin ciprofloxacin levofloxacin aztreonam Local resistance patterns should be considered. Vancomycin is preferable to cephalosporins in locations where methicillin-resistant Staphylococcus aureus or methicillin-resistant coagulase-negative staphylococci are a frequent cause of surgical site infections and in patients who are known to be colonized with methicillin-resistant S. aureus preoperatively.Vancomycin

16. Timing of prophylaxis Antimicrobial therapy should be administered within 60 minutes prior to the surgery to ensure adequate drug tissue levels at the time of initial incision (or within 120 minutes ifvancomycin or a fluoroquinolone is used). This practice also reduces the likelihood of antibiotic- associated reactions at the time of induction of anesthesia.vancomycin

17. This practice is supported by a prospective observational study of 2847 patients undergoing elective clean or clean-contaminated surgery in which the rate of SSI was lower among patients who received antimicrobial prophylaxis within 120 minutes before the incision than those who received prophylaxis more than two hours prior to incision (0.6 percent versus 1.4 to 3.8 percent) [ 25 ].25 If the 60-minute window for prophylaxis has past, administration of antimicrobial therapy 30 to 60 minutes prior to surgery appears to be more effective than administration immediately before surgery

18. Antimicrobial prophylaxis for gastrointestinal surgery Nature of operationCommon pathogens Recommended antimicrobials Adult dosage before surgery* Esophageal, gastroduodenal Enteric gram-negative bacilli, gram-positive cocci High risk only: cefazolin Δ <80 kg: 1 g IV ≥80 kg: 2 g IV Biliary tractEnteric gram-negative bacilli, enterococci, clostridia High risk ◊ only: cefazolin Δ§ <80 kg: 1 g IV ≥80 kg: 2 g IV ColorectalEnteric gram-negative bacilli, anaerobes, enterococci Oral: Neomycin PLUS erythromycin base ¥ or metronidazole ¥ ¥ Parenteral: Cefoxitin Δ or cefotetan Δ 1 to 2 g IV OR cefazolin Δ <80 kg: 1 g IV ≥80 kg: 2 g IV PLUS metronidazole500 mg IV OR ampicillin- sulbactam Δ������ 3 g IV Appendectomy, non- perforated ������ Same as for colorectalCefoxitin Δ or cefotetan Δ 1 to 2 g IV OR cefazolin Δ <80 kg: 1 g IV ≥80 kg: 2 g IV PLUS metronidazole500 mg IV

19. Antimicrobial prophylaxis for cardiac surgery Nature of operation Common pathogens Recommende d antimicrobials Usual adult dosage* Cardiac surgeryStaphylococcus aureus, S. epidermidis Cefazolin<80 kg: 1 g IV ≥80 kg: 2 g IV OR cefuroxime1.5 g IV OR vancomycin Δ 1 g IV

20. Antimicrobial prophylaxis for genitourinary surgery Nature of operation Common pathogens Recommended antimicrobials Usual adult dose* Cystoscopy alone Enteric gram- negative bacilli, enterococci High-risk only: ciprofloxacin Δ 500 mg orally or 400 mg IV OR trimethoprim - sulfamethoxazol e One 160/800 mg (double strength, DS) tablet orally Cystoscopy with manipulation or upper tract instrumentation ◊ Enteric gram- negative bacilli, enterococci Ciprofloxacin Δ 500 mg orally or 400 mg IV OR trimethoprim - sulfamethoxazol e One 160/800 mg (double strength, DS) tablet orally Open or laparoscopic surgery § Enteric gram- negative bacilli, enterococci Cefazolin ¥ <80 kg: 1 g IV ≥80 kg: 2 g IV

21. Antimicrobial prophylaxis for gynecologic and obstetric surgery ProcedurePreferred regimen DoseAlternative regimens Δ Dose Hysterectomy (abdominal, vaginal, laparoscopic, or robotic) Urogynecology procedures Cesarean section Cefazolin, Cefoxitin or Cefotetan <120 kg: 2 g IV ≥120 kg: 3 g IV 1. Ampicillin-sulbactam3 g IV 2. Clindamycin OR Vancomycin 600 mg IV 1 g IV PLUS one of the following: Gentamicin OR Aztreonam OR Quinolone 1.5 mg/kg IV 1g IV 400 mg IV Laparoscopy (diagnostic, tubal sterilization, operative except for hysterectomy) None Abortion, surgicalDoxycycline100 mg orally one hour before procedure and 200 mg orally after procedure Hysterosalpingogram or chromotubation Doxycycline ◊ 100 mg orally twice daily for five days Other transcervical procedures: Hysteroscopy (diagnostic or operative, including hysteroscopic sterilization) Intrauterine device insertion Endometrial biopsy None

22. Antimicrobial prophylaxis for head and neck surgery Nature of operation Common pathogens Recommended antimicrobials Usual adult dose* Incisions through oral or pharyngeal mucosa Anaerobes, enteric gram- negative bacilli, S. aureus Clindamycin600 to 900 mg IV OR cefazolin <80 kg: 1 g IV ≥80 kg: 2 g IV plus metronidazole 500 mg IV OR ampicillin- sulbactam 3 g IV

23. Antimicrobial prophylaxis for neurosurgery Common pathogens Recommended antimicrobials Usual adult dose* S. aureus, S. epidermidis Cefazolin<80 kg: 1 g ≥80 kg: 2 g OR vancomycin 1 g IV

24. Antimicrobial prophylaxis for ophthalmic surgery Common pathogensAntimicrobialsUsual adult dose S. epidermidis, S. aureus, streptococci, enteric gram-negative bacilli, Pseudomonas spp Gentamicin, tobramycin, ciprofloxacin, gatifloxacin, levofloxacin, moxifloxacin, ofloxacin or neomycin- gramicidin-polymyxin B Multiple drops topically over 2 to 24 hours OR cefazolin100 mg subconjunctivally

25. Antimicrobial prophylaxis for orthopedic surgery Common pathogens Recommended antimicrobials Usual adult dose* S. aureus, S. epidermidis Cefazolin <80 kg: 1 g IV ≥80 kg: 2 g IV OR vancomycinΔ 1 g IV

26. Antimicrobial prophylaxis for thoracic (noncardiac) surgery Common pathogens Recommended antimicrobials Usual adult dose* S. aureus, S. epidermidis, streptococci, enteric gram-negative bacilli Cefazolin<80 kg: 1 g IV ≥80 kg: 2 g IV OR ampicillin- sulbactam 3 g IV OR vancomycin Δ 1 g IV

27. Antimicrobial prophylaxis for vascular surgery Nature of operation Common pathogens Recommended antimicrobials Usual adult dose* Arterial surgery involving a prosthesis, the abdominal aorta, or a groin incision S. aureus, S. epidermidis, enteric gram- negative bacilli Cefazolin<80 kg: 1 g IV ≥80 kg: 2 g IV OR vancomycin1 g IV Lower extremity amputation for ischemia S. aureus, S. epidermidis, enteric gram- negative bacilli, clostridia Cefazolin<80 kg: 1 g IV ≥80 kg: 2 g IV OR vancomycin 1 g IV

28. HAIR REMOVAL Hair removal is commonly performed before many surgical procedures in order to provide the surgeon with a "clean" field and to prevent hair from falling into the surgical site. However, most studies have shown an increased risk for surgical site infections (SSIs) in patients undergoing preoperative hair removal. In one study, the rates of SSI were highest when shaving was performed compared with clipping the hair or use of depilatory creams (5.6 compared with 1.7 and 0.6 percent, respectively).

29. In another study, scanning electron micrographs showed that razors caused gross skin cuts, clippers caused less injury, and depilatory agents caused no injury to the skin surface. The timing of hair removal is also important. The lowest rates of SSI were reported when hair was removed just prior to the surgical incision

30. A meta-analysis that examined 11 randomized controlled trials concluded that there was no difference in rate of SSIs among patients who have had hair removed prior to surgery and those who have not. If hair needs to be removed, patients should be clipped rather than shaved, as patients who were shaved were more likely to develop SSI (three trials, 3193 patients, relative risk 2.02, 95% CI, 1.21-3.36)

31. S. AUREUS DECOLONIZATION Nasal carriage of S. aureus is a risk factor for surgical site infection (SSI). Nasopharyngeal decontamination may be effective for reducing the risk of postoperative infection in some situations. Agents include mupirocin nasal ointment and chlorhexidine soap mupirocin chlorhexidine

32. For circumstances in which the presence of nasal S. aureus carriage can be assessed via rapid screening, decolonization with mupirocin nasal ointment and chlorhexidine soap may reduce the risk of hospital-associated S. aureus infection.mupirocin chlorhexidine

33. it was suggested that S. aureus decolonization with intranasal mupirocin andchlorhexidine baths may be appropriate for surgical patients known to be nasal carriers of S. aureus with a high risk of deleterious outcomes should S. aureus infection develop at the surgical site.mupirocin chlorhexidine This includes patients who are immunocompromised, undergoing cardiac surgery, and/or undergoing implantation of a foreign device. There is no role for routine decolonization.

34. GLUCOSE CONTROL Hyperglycemia and diabetes have been identified as risk factors for deep sternal site infection after CABG. These studies have suggested that a preoperative blood glucose level of 200 mg/dL or more or postoperative hyperglycemia is associated with an increased risk of SSIs. each 50 mg/dL blood glucose increase may be associated with higher mortality and higher infection rate and longer postoperative hospital stay by 0.76 days and increased hospitalization cost

35. PERIOPERATIVE NORMOTHERMIA Mild perioperative hypothermia may promote surgical site infection (SSI) by triggering thermoregulatory vasoconstriction. However, hypothermia may protect tissue from ischemia by reducing oxygen consumption during surgery, an effect exploited during circulatory arrest in cardiac surgery. Despite this positive effect, most surgeons, anesthesiologists, and hospital epidemiologists acknowledge the benefit of perioperative normothermia in reducing the risk of SSI.

36. A similar advantage to perioperative warming has been shown in one study of clean surgical procedures. Wound infection was significantly more common among patients who were not warmed before surgery (14 versus 5 percent).

38. Prevention Of Nosocomial UTIs The most important measure is to avoid urinary catheters Keep the catheter closed and remove it as soon as possible Alternatives for urinary catheters include condom catheters and suprapubic catheters

39. Bladder irrigation Bladder irrigation — Antimicrobial irrigation of the bladder does not prevent or delay infection; Catheter replacement Catheter replacement — Urinary catheters should not be replaced routinely. Antimicrobial-coated catheters Antimicrobial-coated catheters : variable impact on infection rates. further studies are necessary before antimicrobial catheters can be recommended for routine use.

40. Suprapubic catheters Suprapubic catheters : not recommend Condom catheters Condom catheters : A reduction in urinary infections related to condom catheters is only seen when there is good cooperation with the use of the catheter and no unnecessary manipulation of the device.

41. Prophylactic antibiotics Prophylactic antibiotics : more studies are necessary before antibiotic prophylaxis can be recommended for patients in general or for specific subgroups of patients.

43. Prevention Of Intravenous Catheter related infections ASEPTIC TECHNIQUE : ASEPTIC TECHNIQUE : Strict adherence to hand washing and aseptic technique is crucial for reducing catether related infections. Peripheral catheters should be changed at least every 72-96 hr (after which the risk of infection rises significantly) Change as soon as possible (24-48 hr) any catheter inserted under less-than-sterile condition or in the emergency department Certainly use no cut-downs

44. CVP catheters should be inserted under sterile conditions _ sterile gloves, gowns, masks, head covering, and large sterile drapes reduce infection more than just sterile gloves and a drape Avoid using the jugular or the femoral route, both of which have higher risks of infection compared to the subclavian route Avoid multiple-lumen catheters, which receive multiple ( potentially contaminating) manipulations by health care workers

46. Risk factors and prevention of hospital-acquired, ventilator- associated, and healthcare- associated pneumonia in adults Dr.Bolandnazar Infectious diseases Specialist

47. INTRODUCTION  Hospital-acquired (or nosocomial) pneumonia (HAP), ventilator- associated pneumonia (VAP), and healthcare-associated pneumonia (HCAP) are important causes of morbidity and mortality despite improved antimicrobial therapy, supportive care, and prevention

48. PREVENTION  Decontamination of the digestive tract:  an attempt to reduce the incidence of pneumonia in critically ill patients by diminishing colonization of the upper respiratory tract.  The methods used include antiseptics in the oropharynx and nonabsorbable antibiotics taken orally with or without systemic antibiotics.

49. Decontamination of the oropharynx  Gingival and dental plaque  Gingival and dental plaque rapidly becomes colonized with aerobic pathogens in intensive care unit (ICU) patients due to poor oral hygiene and lack of mechanical elimination.

50.  Based upon the available data, we recommend performing regular oral care with an antiseptic solution in patients receiving mechanical ventilation.  Chlorhexidine has been best studied. Chlorhexidine  chlorhexidine 0.12% oral solution (15 mL twice daily until 24 hours after extubation).

51. Selective decontamination of the digestive tract  SDD is a strategy that aims to decrease the incidence of VAP by preventing oropharyngeal and gastric colonization with aerobic gram-negative bacilli and Candida spp, without disrupting the anaerobic flora.  A variety of regimens have been employed. Most use a combination of a locally administered nonabsorbable antibiotic (eg, polymyxin) and an aminoglycoside plus either amphotericin B or nystatin.amphotericin Bnystatin

52.  Despite the potential benefits described above, SDD has not found widespread favor in North America.  A major reason for this is concern about promoting the growth of resistant bacteria.  Compared with North America, SDD is used more commonly in some countries in Europe, such as the Netherlands, where rates of resistant bacteria in intensive care units are substantially lower.

53. Probiotics  Probiotics are defined as live microorganisms of human origin that are able to tolerate the hostile gastrointestinal environment such that they persist in the lower alimentary tract to confer a health benefit to the host.  In a randomized trial of 146 mechanically ventilated patients, the enteral administration of the probiotic Lactobacillus rhamnosus resulted in significantly lower rates of oropharyngeal and gastric bacterial colonization as well as subsequent VAP compared with placebo

54. Preventing aspiration  Aspiration is a major predisposing mechanism for both hospital-acquired pneumonia (HAP) and VAP.  Appropriate patient positioning and subglottic drainage in ventilated patients are two important modalities for the prevention of aspiration.

55. Patient positioning  Supine positioning appears to predispose to aspiration and the development of HAP.  Although no effect of positioning on mortality has been demonstrated, it seems prudent to preferentially place intubated patients in the semirecumbent position unless contraindicated.

56. Subglottic drainage  Drainage of subglottic secretions may lessen the risk of aspiration and thereby decrease the incidence of VAP.  Specially designed endotracheal tubes have been developed to provide continuous or intermittent aspiration of subglottic  The same devices can also be used for intermittent aspiration of subglottic secretions.

58.  The potential economic impact of widespread use of subglottic secretion drainage is unclear

59. Glucocorticoids  Stress-dose glucocorticoids have been proposed as a possible method for preventing HAP in critically ill patients.  Hydrocortisone (200 mg/day for five days followed by 100 mg on day six and 50 mg on day seven) was compared with placebo in a multicenter trial Hydrocortisone  patients who received hydrocortisone had a lower risk of HAP at 28 days compared with patients who received placebo

60.  Hydrocortisone use was also associated with a shorter duration of mechanical ventilation and a reduced risk of hyponatremia, but there was no difference in mortality compared with placebo.  Further studies are necessary to more clearly define the potential benefits and safety of glucocorticoid use in these populations