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Infection Control in the OR:
Just how important is it?
Elsie Truter
Waiariki Institute of Technology
Rotorua
New Zealand
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Challenges in the OR
Preventing Surgical Site Infections against a backdrop of;
Changes to perioperative nursing practice and surgical techniques
New equipment – is it safe to use? How do we sterilise or disinfect?
New infectious diseases
Antibiotic Resistance
Staff compliance with Infection Prevention and Control practice
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Government Initiatives
• Health Quality and Safety Commission New
Zealand
• Current Infection Prevention and Control Foci;
• Hand Hygiene
• CLAB prevention
• Surgical Site Infection
• To come – Antibiotic Stewardship
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Government Initiatives
• Australian Commission on Safety and Quality in
Health Care
• Australian College of Operating Room Nurses
(ACORN) 2014-2015 Standards for Perioperative
Nursing
• The common emphasis (from an IPC perspective) is
the reduction of Health Care Acquired Infections
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This presentation
• Will look at;
• Antibiotic resistance
• Pre surgical skin preparation – showering with or
using Chlorhexidine impregnated cloths.
• The behaviour of the multidisciplinary team in the
OR
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A (very) Brief History
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Van Leeuwenhoek 1673
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Semmelweis 1847
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Louis Pasteur Lister
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Anaesthesia 1847
Sir James Simpson
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Surgical site
infections
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Bacterial resistance
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Antibiotic overuse
Estimated Annual Human Antibiotic Use (USA)
Site Amount Correct use
Hospital 190 million defined 25 - 55(%)
daily doses/year
Community 140 million courses/year 20- 50(%)
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Complacency with aseptic
technique infection
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Global microbial resistance
(WHO Global Report 2014)
• Prevention of the spread and control of Multi drug –
resistant organisms (MDRO’s) at a critical level.
• Availability of antibiotics to treat these infections
extremely limited
• Worldwide the most common MDRO’s are;
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MDRO’s
• MRSA - Methicillin resistant Staphylococcus aureus
• ( prevalence 10% in Auckland NZ)
• VRE – Vancomycin resistant Enterococci ( rare in NZ)
• ESBL- Extended Spectrum b lactamase Gram –ve
organisms ( increasing in NZ 157/100000)
• CRE – Carbapenem resistant Enterobacteriaceae
• MRAB - multi resistant Acinetobacter baumannii
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MDRO’s
• Understanding the current resistance pattern
influences both prophylactic and therapeutic a
antibiotic use
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Antibiotic Stewardship in the OR
• Key to reducing MRDO’s and Healthcare associated
infections
• Therapeutic antibiotics- give narrow spectrum for
the shortest period of time, for 24hrs after incision
only. Cardiac surgery for 48 hrs only.
• Prophylactic antibiotics – within 1hr prior to skin
incision. Superior efficacy between 0-30 min prior
• ( Anderson, et.al., 2014)
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• Exception:
• Vancomycin and fluroquinolones must be
administered 2 hrs before incision
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Antibiotic stewardship in the OR
• ACORN - IPC Standard 11 - recommends; 2g
Cephazolin for all patients up to 80kg
• 3g for pts over 120kg. Paediatric dose 30 mg/kg
• Experts believe prophylactic antibiotics should be
administered prior to tourniquet inflation.
• Redose prophylactic antibiotics for long procedures
or excessive blood loss
( Anderson, et.al., 2014)
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Antimicrobial-Resistant Pathogen
Antimicrobial Resistance
Antimicrobial Use
Infection
Prevent
Transmission
Prevent
Infection
Optimize Use Effective
Diagnosis
& Treatment
Susceptible Pathogen
Antimicrobial Resistance:
Key Prevention Strategies
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Preventing Infection
CDC estimates that 5% of all patients acquire an
infection leading to 100.000 deaths per annum
(CDC, 2010)
Where do these pathogenic microbes come from?
Most come from endogenous microbes – skin,
intestines
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Within hours of admission the
room will reflect the patient’s
microbiome . These microbes
will move to adjacent patients
and rooms. Visitors add to this
mix. (Arnold,2014)
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Preventing Infection
• Patients become colonised with hospital microbes
within hours – they could be resistant strains.
• These can lead to infection once natural defence
barriers have been broken
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Entry Points
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______________________________________________________________________
Clinical infections
Colonised patients
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Preventing Infection:
Minimising skin flora
• Using Chlorhexidine Gluconate (CHG)2-4% wipes or showering with CHG has been shown to reduce surgical site infections from 3.19% - 1.59% ( Eiselt,2009)
• Considered an adjunct risk reduction strategy to pre-operative skin prep with Chlorhexidine and alcohol or povidone-iodine and alcohol
• Broad spectrum (Gram –ve and Gram +ve bacteria) killing effect
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Preventing infection
Minimising skin flora
• Higher concentrations of Chlorhexidine gluconate
are rapidly bactericidal
• Does not denature in the presence of serum and
blood and has a longer residual effect
• BUT cannot be used on periorbital sites – eyes and
ears. Use of Povidone-iodine recommended
• Patient compliance difficult to assess.
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1
10
100
1000
10000
100000
1000000
Inguinal Axilla Inguinal Axilla
Baseline Postwash
One Wash
6 9 11
Three Washes
Mea
n S
kin
Bac
teri
al C
oun
t (l
ogar
ith
mic
sca
le)
8
128352
6622
17975 33808
NOTES:
• Lab detection limit = 10 CFU. Those n.d were given a count of 5 for analysis
• Postwash values for ‘three washes’ is after one wash. Mean counts remained below
10 after all three washes.
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Chlorhexidine Gluconate 4%
pre-op washes. 2 cohorts
10/arm
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Preventing Infection:
Pre-screening
• May be logistically complicated and is expensive
• Decide between vertical or horizontal surveillance
• Consensus seems to be that riskier patients with
complex surgery and co morbidities should be
screened.
• Each institution to set realistic policies
• ( Making Health Care Safer ll , 2013)
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HAIs are SSI ( previously called SWI) Exogenous Sources of
Infection
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To mask or not to mask?
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ACORN
Infection Prevention
Standard Statement 6
• Wear a mask;
• where a sterile field is being prepared or used
• to protect the health care worker against blood and
body fluid spatters
• To decrease the dispersals of microbial droplets from
nose and mouth
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ACORN
Perioperative Attire
• Shall replace all outer garments and shall be worn
correctly at all times when entering the operating
suite
• Do not wear perioperative attire outside the
healthcare facility
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ACORN
Infection Prevention
Standard Statement 4
• The multi disciplinarary team shall comply with
infection control parameters related to the
environmental boundaries of the perioperative
setting i.e. zone conformity
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Other Exogenous Sources
• Environment - air changes, temperature and
humidity
• Inadequately cleaned environment
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In conclusion:
Infection prevention in the OR is
paramount
• This presentation has highlighted a few important
infection prevention methods in the OR
1. Antibiotic stewardship
2. The use of preoperative showering to decrease skin
colonisation
3. The behaviour of the multidisciplinary team in the
OR
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Thank you!
Questions?
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