SURGICAL ANTISEPSIS. Overview FOUNDATIONS OF OPTOMETRIC SURGERY. Richard E. Castillo, OD, DO Consultative Ophthalmology and Procedural Optometry

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1 SURGICAL ANTISEPSIS FOUNDATIONS OF OPTOMETRIC SURGERY Richard E. Castillo, OD, DO Consultative Ophthalmology and Procedural Optometry Professor & Assistant Dean for Surgical Training and Education Director, The Center for Advanced Practice Optometry The Oklahoma College of Optometry Northeastern State University No financial interests or conflicts Overview Surgical site infections are relatively rare (<2%) in oculofacial surgery Most surgical site infections are the result of wound contamination at the time of surgery Five potential sources of infection are: Patient Surgical personnel Surgical environment Surgical instruments Implantable devices such as suture and alternate closure devices

2 Classification of surgical wounds Classification Class I: Clean Description of Wound Uninfected operative wound No acute inflammation Primary closure No break in aseptic technique Infection Risk <2% Class II: Clean-contaminated Class III: Contaminated Example: routine excision on non-inflamed eyelid skin under aseptic conditions Minor break in asepsis Elective entry into a mucosal region Examples: conjunctival biopsy; suture briefly touches non-sterile surface Inflammation without purelent drainage Penetrating traumatic wounds < 4 hours old Major break in aseptic technique Examples: excision of ulcerated, inflamed basal cell carcinoma <10% ~20% Class IV: Dirty-infected Purulent inflammation Devitalized or necrotic tissue Penetrating traumatic wounds >4 hours old. or with foreign bodies Example: excision of a suppurative hordeolum ~40% Surgical Site Infection (SSI) A surgical site infection (SSI) is defined as (at least 1 of the following) any surgical wound: That produces pus within 30 days of the procedure Where organisms are isolated from an aseptically obtained culture With at least one of the objective or subjective criteria in the table to the right AND incision is deliberately reopened by surgeon for any reason Objective criteria Purulent drainage Positive culture >10 5 organisms/gram of tissue Subjective criteria Erythema Induration Warmth Tenderness Dehisence of incision for any reason Infection as deemed by surgeon Normal postoperative sequelae Differential Diagnosis of Surgical Site Incisional discomfort Clinical Time Etiology Symptoms Course Swelling secondary to: Ecchymosis Hemporrhagic bullae Immediate to Hematoma Infiltrative anesthesia Progressive painfull swelling 48 hours Postoperative edema Chemical irritation or contact dermatitis from patient application of: Alcohol Hydrogen peroxide Seroma Irritant or allergic contact dermatitis Bacterial colonization Swelling Erythema Pruritus Erythema Papules, vesicles Erythema without purulence Non-purulent Exudate Delayed healing hours hours Days to weeks Topical antibiotics Suture reaction (Suture access) Sterile pustule Extruding suture material Weeks to months

3 Frequent causes of wound infection Not washing hands before and after each patient contact Failure to perform an adequate surgical hand scrub Failure to perform an adequate surgical site skin prep Poor surgical technique Inadequate cleanliness of the surgical environment Bacterial colonization of a member of the surgical team Two types: Normal or resident flora inhabit the skin surface and adnexal structures Not usually pathogenic but can be Embedded in adnexal structures and out of reach of the surgical scrub Transient flora are acquired through contact with people, objects or the environment The major cause of wound infection Loosely attached to skin surface and can be removed by washing the skin Flora Common Bacterial Skin Flora Resident flora Transient flora Coagulase-negative staph (>90% are S.epidermidis) Anaerobic diphtheroids (P. acnes) Gram-negative organisms (Enterobacter, Klebsiella, E. coli and Proteus spp.) Staphylococcus aureus Coagulase-negative staphylococci Enterococcus spp. Esherichia coli Group A streptococci Pseudomonas aeruginosa Enterobacteriaceae (Serratia spp., Klebsiella spp.) Staphylococcus aureus The most common cause of wound infections in oculofacial skin surgery

4 Comorbid risk factors for surgical site infection History of previous wound infection - may indicate chronic bacterial colonization Tobacco use within past 30 days - nicotine induced vasoconstriction Vascular insufficiency - reduced perfusion leads to necrosis, dehiscence, and wound infection Diabetes mellitus - increased risk of pseudomonas sp. colonization Malnutrition - considered immunocompromised state Alcohol abuse - considered immunocompromised state Intravenous drug abuse Chemotherapy Neutropenia (<1000/mm 3 ) Immunosuppression Organ transplant recipients HIV/AIDS (relative risk factor) Hands Surgeons hands are always washed before donning sterile gloves and after their removal Common antiseptic agents Agent Activity Onset Duration Comments Isopropyl and ethyl alcohol Chlorhexidine gluconate Povidone-iodine Para- Chlorometaxylenol (PCMX) Gram (+/-) Mycobacteria Fungi Enveloped viruses Gram (+/-) Fungi Enveloped viruses Gram (+/-) Mycobacteria Fungi Enveloped viruses Gram (+) Moderate Gram (-) Mycobacteria Fungi Enveloped viruses Very fast Minimal Flammable Poor cleanser Use liberally and allow to dry Irritating near much membranes Fast Prolonged Keratitis Ototoxicity Poor activity on spores & mycobacteria Fast Intermediate (minimal if wiped or blotted off) Potential risk of neonatal hypothyroidism Rapidly inactivated by blood or sputum Moderate Intermediate Poor pseudomonal coverage as a single agent Activity enhanced by adding EDTA as a chelator

5 Alcohol-based antiseptic skin preps Are flammable and must be allowed to dry completely before electrocautery, radio frequency coagulation, or lasers are used Povidone-iodine Has broad-spectrum activity but must be in contact with the skin 3 minutes prior to commencing procedure and then remain on the skin to have a prolonged effect Chlorhexadine gluconate Has sustained broad-spectrum activity but is toxic to the cornea and the middle/inner ear

6 Shaving hair at the surgical site Causes micro abrasions that increase the risk of infection Hair should be left in place or at most trimmed with scissors prior to establishing a sterile field Proper surgical technique Avoids compromising the environment of the surgical wound and decreases the risk of infection Proper technique includes: Establishing and maintaining a sterile field Atraumatic handling of tissue Effective hemostatic with minimal cautery Limiting the amount of implanted material such as suture There is debate Over the influence of surgical attire on wound infection rate Gown Mask Cap Shoe covers

7 Surgical Site Infections: Cellulitis A non-necrotizing inflammation of the skin and subcutaneous tissues. Which of the following conditions increases the risk for surgical site infection (SSI)? Diabetes? Cholecystitis Amyloidosis Alpha thalassemia Which of the following conditions increases the risk for surgical site infection? Diabetes Cholecystitis? Amyloidosis Alpha thalassemia

8 Which of the following conditions increases the risk for surgical site infection? Diabetes Cholecystitis Amyloidosis? Alpha thalassemia Which of the following conditions increases the risk for surgical site infection? Diabetes Cholecystitis Amyloidosis Alpha thalassemia? Which of the following conditions increases the risk for surgical site infection? Diabetes!

9 Which of the following is the most common site of cellulitis in general? Periorbital skin? Hand Leg Arm Which of the following is the most common site of cellulitis in general? Periorbital skin Hand? Leg Arm Which of the following is the most common site of cellulitis in general? Periorbital skin Hand Leg? Arm

10 Which of the following is the most common site of cellulitis in general? Periorbital skin Hand Leg Arm? Which of the following is the most common site of cellulitis in general? Leg! Less than 2% of surgical site infections involve the oculofacial tissues Which of the following pathogens is most likely responsible for a preseptal cellulitis with underlying drainage following surgical trauma? Vibrio vulnificus? Staphylococcus aureus Streptococcus pneumoniae Pseudomonas aeruginosa

11 Which of the following pathogens is most likely responsible for a preseptal cellulitis with underlying drainage following penetrating trauma? Vibrio vulnificus Staphylococcus aureus? Streptococcus pneumoniae Pseudomonas aeruginosa Which of the following pathogens is most likely responsible for a preseptal cellulitis with underlying drainage following penetrating trauma? Vibrio vulnificus Staphylococcus aureus Streptococcus pneumoniae? Pseudomonas aeruginosa Which of the following pathogens is most likely responsible for a preseptal cellulitis with underlying drainage following penetrating trauma? Vibrio vulnificus Staphylococcus aureus Streptococcus pneumoniae Pseudomonas aeruginosa?

12 Which of the following pathogens is most likely responsible for a preseptal cellulitis with underlying drainage following penetrating trauma? Staphylococcus aureus! A transient bacterium that is the most common pathogen isolated in oculofacial surgical site infections! Which of the following is an indication for emergent referral and systemic workup in a patient with suspected cellulitis? Regional lymphadenopathy? Preseptal cellulitis of the upper lid Tachypnea Infection site > 10 mm Which of the following is an indication for emergent referral and systemic workup in a patient with suspected cellulitis? Regional lymphadenopathy Preseptal cellulitis of the upper lid? Tachypnea Infection site > 10 mm

13 Which of the following is an indication for emergent referral and systemic workup in a patient with suspected cellulitis? Regional lymphadenopathy Preseptal cellulitis of the upper lid Tachypnea? Infection site > 10 mm Which of the following is an indication for emergent referral and systemic workup in a patient with suspected cellulitis? Regional lymphadenopathy Preseptal cellulitis of the upper lid Tachypnea Infection site > 10 mm? Which of the following is an indication for emergent referral and systemic workup in a patient with suspected cellulitis? Tachypnea! Defined as a respiratory rate > 20 breaths per minute May indicate sepsis When coupled with hypotension mandates Tissue and blood cultures CBC Serum creatinine, creatine phosphokinase, CRP, serum bicarbonate

14 Which of the following is the more appropriate choice for outpatient treatment of a non-preseptal cellulitis in which community acquired, CA- MRSA is NOT suspected? Cephalexin? Linezolid? Doxycycline? Terbinafine? Which of the following is the more appropriate choice for outpatient treatment of a non-preseptal cellulitis in which community acquired, CA- MRSA is NOT suspected? Cephalexin! Preseptal Cellulitis as an SSI Medications used in the treatment of preseptal cellulitis include the following: Amoxicillin/clavulanic acid or intramuscular ceftriaxone. Levofloxacin and azithromycin are also options. Dicloxacillin, first generation cephalosporins (cefalexin, cefazolin) If MSSA S aureus (NOT MRSA!) is suspected Exudate should be submitted for culture & sensitivity. CA-MRSA therapy is guided by C&S and may include trimethoprim-sulfamethoxazole, rifampin, clindamycin, and fluoroquinolones. Patients not responding to antibiotics with 48 hours or febrile children under 2 you should be admitted to the hospital. Nasal/Sinus cultures may be indicated. Consult ENT.

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