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Innovations in patient care: infection control found similar results, with a lower rate of infection in those wounds closed primarily (relative risk 0.64, 95% confidence interval 0.46 to 0.91) 21 . The one exception in which DPC might be advisable is in the management of traumatic wounds. For DPC of traumatic wounds, the same general principles for DPC of surgical wounds apply: no wound should be closed if grossly contaminated, and any devitalized tissue should first be debrided. The management of neglected or chronic wounds by DPC is more complicated. The International Committee of the Red Cross provides a good overview of DPC in traumatic, neglected, and contaminated wounds 22 . Decisions surrounding placement of a surgical drain is beyond the scope of this review. However, in most cases the routine use of surgical drains should be discouraged, as is discussed in an excellent review by Schein 23 . Schein does note that select situations may be appropriate for drain placement, including noncollapsible abscesses (rare), high prediction of fluid leakage (bile, pancreatic juice, or urine), or drainage for a short duration of an “oozy” surface. One study compared the use of post-mastectomy drains for 4 days or 10 days, and found a significantly higher rate of infection among those drains left in place for 10 days (9.5% versus 2.2%) 24 , lending support to Schein’s recommendation of a short duration of drainage. Treatment of surgical site infections The following section outlines the diagnosis and surgical treatment of SSIs. Use of antibiotics is discussed in section 6, and is secondary to adequate drainage, discussed below. Diagnostic criteria An SSI is defined by both clinical and microbiological examinations. The isolation of bacteria from the wound alone is not diagnostic for an SSI without at least clinical evidence of infection (redness, localised swelling, pain or tenderness, purulent discharge, relative warmth to the touch). Often, SSIs are diagnosed and treated based on a constellation of signs and symptoms. However, samples from the wound can also be taken for culture. Pus or, if appropriate, a tissue biopsy is preferred over simple wound swabs. In patients where bacteraemia or sepsis is suspected, blood cultures should also be taken. Drainage “Never let the sun set on an abscess.” This frequently quoted surgical adage emphasizes the critical importance of timely diagnosis and treatment of SSIs. Though some SSIs may be limited to cellulitis, one should have a low threshold for incision and drainage, or reopening, either a portion or all of the incision, to drain pus if examination suggests the infection is more then cellulitis. Special note must also be made of necrotizing fasciitis, which can occur as a SSI. Signs that suggest necrotizing fasciitis include: ✚ wounds with early drainage of clear brown fluid (“dishwater drainage”); ✚ wounds in which the subcutaneous fat has a dark brown discoloration; ✚ wounds in which normally adherent tissue planes separate easily; ✚ wounds in which subcutaneous vessel thrombosis is present. Any of these signs or the presence of systemic toxicity, suggest a serious infection, and immediate debridement of all infected tissue is the mainstay of treatment. This may require debridement of skin, subcutaneous fat, and possibly muscle. (See Surgery in Africa, October 2005: Soft-tissue infections) Antibiotics and SSIs The goals of antibiotic prophylaxis are to achieve inhibitory antibiotic levels at incision and throughout the procedure in an effort to decrease the likelihood of developing a SSI. Antibiotics can also play an important role in the treatment of SSIs. Antibiotics for prophylaxis of SSIs Animal studies have shown that antibiotic prophylaxis is most effective in preventing post-surgical infections when administered before the start of surgery, and pharmacokinetic data suggest administration as near the time of incision as possible. Classen et al., in a prospective observational study, monitored the timing of antibiotic prophylaxis in 2847 patients in “clean” or “clean contaminated” surgery. Using a step-wise logistic regression model, they found that preoperative antibiotics within two hours of incision had the lowest rate of infection as compared to antibiotics given after incision or earlier than two hours prior 25 . In addition to being given preoperatively, prophylactic antibiotics should not be continued postoperatively. A five-month prospective survey of surgical-site infections (SSI) conducted in the department of general surgery at Kilimanjaro Christian Medical Center, Tanzania by Eriksen et al., showed that 77 (19.4%) of the 397 patients studied developed SSI 2 . Twenty-eight (36.4%) of these infections were apparent only after discharge from hospital. A surprising eighty-seven percent of the patients who developed SSI had received antibiotics, the majority having received the antibiotics for several days. Such a practice is contrary to the current recommendation of a single preoperative dose, and prolonged inappropriate use of broad-spectrum antibiotics may contribute to increased emergence of resistance. The type of surgery (clean, clean/contaminated, contaminated, or dirty) (see Table 1) also impacts the role of antibiotic prophylaxis. An understanding of this classification, as well as knowledge of recommendations for specific procedures, is invaluable in making an appropriate choice regarding antibiotic prophylaxis. Antibiotic administration in dirty cases is not considered prophylactic as these cases represent treatment of infection rather than prophylaxis. Controversy exists regarding the use of antibiotic prophylaxis for clean cases. When antibiotic prophylaxis is given, the agent should target S. aureus, the most common organism causing SSIs in clean cases; cefazolin is a good choice 26 . When bone is incised, the use of prophylactic antibiotics is clearly recommended 27 . A good choice in this situation, or for cardiothoracic or vascular surgery, is cefazolin or cefuroxime (or clindamycin or vancomycin for penicillin allergic) 26 . For general surgical clean cases, the decision is less clear. A Cochrane Database of Systematic Reviews examined the use of prophylactic antibiotics prior to hernia surgery, and found that infection rates were lower with use of antibiotics (2.9% versus 3.9%) but concluded that “antibiotic prophylaxis for elective inguinal hernia repair cannot be universally Hospital and Healthcare Innovation Book 2009/2010 123
Innovations in patient care: infection control recommended” because of overall low infection rates, a high number needed to treat, and a lack of a large, randomized controlled trial to prove efficacy 28 . Similarly, Osuigwe et al. studied the use of prophylactic antibiotics for paediatric surgery in a prospective, randomized, double-blind study of 289 children at a teaching hospital in Nigeria 29 . Patients were randomly assigned to receive either doses of ampicillin/cloxacillin (Ampliclox) with vitamin B (Group A, treatment group), or vitamin B only (Group B, placebo group). The doses were begun at induction and continued for five days postoperatively. Patients were evaluated for wound infection at postoperative day 5, and then again at postoperative day 7 to 10 during suture removal. Wound infection was defined as the presence of erythema, induration, or discharge. Group A had a 4.3% infection rate compared to 5% in group B, a difference that was not statistically significant. For clean-contaminated and contaminated cases, antibiotic prophylaxis is recommended. Colorectal surgery is the most thoroughly studied type of procedure in this category, and as such most recommendations are based on studies involving colorectal surgery. The most commonly encountered organism in cleancontaminated and contaminated SSIs is still S. aureus, though other aerobic as well as anaerobic bacteria are also culprits 30 . As such, prophylaxis should be broader than that used for clean cases. Song et al. reviewed all randomized controlled trials of antibiotic prophylaxis in colorectal surgery 31 . Four of these studies compared antibiotic regimens to no antibiotics and showed a convincing benefit of prophylactic antibiotics (odds ratio 0.24, 95% confidence interval 0.13 to 0.43). Further analysis revealed that the most efficacious regimens include coverage against both aerobic and anaerobic organisms (such as a 2nd or 3rd generation cephalosporin, or gentamicin in combination with metronidazole), and cited certain regimens inadequate (metronidazole alone, doxycycline alone, piperacillin alone) 32 . Though data from Africa is limited, differences in efficacy between various 2nd and 3rd generation cephalosporins appear negligible 33 , and choice prophylaxis with a single-agent 2nd or 3rd generation cephalosporin can probably be dictated by availability or cost. For penicillin-allergic patients, clindamycin combined with gentamicin, aztreonam, or ciprofloxacin, or metronidazole combined with gentamicin or ciprofloxacin are adequate choices 26 . Antibiotics for treatment of SSIs Empiric treatment of an SSI after clean cases should be primarily directed against S. aureus. Clean-contaminated, contaminated, and dirty cases require broader empiric coverage to include both aerobic and anaerobic bacteria. Choices of empiric therapy, against SSIs suspected of being caused by S. aureus, such as SSIs after clean cases, include cloxacillin or in penicillin-allergic patients, clindamycin. For SSIs after clean-contaminated, contaminated or dirty cases, a second- or third-generation Cephalosporin (such as cefuroxime or ceftriaxone), metronidazole with gentamicin, or amoxicillin/clavulanate, are all reasonable choices that will provide aerobic and anaerobic coverage. It is also important to take note that in many surgical operations, patients will have previously received antibiotic prophylaxis. Prophylaxis can affect the flora and thus the cause of any subsequent infection. One study of antibiotic prophylaxis for cardiac surgery compared vancomycin to cefazolin, and found that SSIs in those receiving cefazolin were more likely to be Table 2: Possible regimens for post-exposure prophylaxis against HIV 40 DRUG CLASS Two nucleotide reverse transcriptase inhibitors (NRTIs) AND One protease inhibitor (PI) EXAMPLES lamivudine and zidovudine (Combivir) tenofovir and emtricitabine (Truvada) tenofovir and lamivudine stavudine and lamivudine lopinavir saquinavir fosamprenavir ritonavir caused by methicillin-susceptible S. aureus compared to SSIs in those receiving vancomycin (3.7% versus 1.3%) 34 . As such it is important to determine the nature of any prior antibiotic therapy; a prudent approach is to choose a different regimen that the one used for prophylaxis at the time of surgery. Lastly, it should be re-emphasized that antibiotic administration for SSIs is secondary to the cornerstone of treatment—which is adequate drainage of the infection. Additionally, if antibiotic sensitivities are identified, it may be necessary to tailor antibiotics to the specific strains. Many surgeons use topical agents such as hydrogen peroxide, 2% acetic acid, or Dakin’s solution (0.5% sodium hypochlorite), but evidence in support of this is scant. A review of the evidence regarding Dakin’s solution, for example, found only three small prospective studies and concluded that there was no benefit to its use 35 . More important is the frequency of dressing changes when managing SSIs; dressings should be changed if they appear soiled or are foul-smelling, and must be changed no less frequently than once daily. Lastly, one should not forget to emphasize the importance of hand hygiene to the guardian, or any others involved in the care of the patient, which minimizes cross-contamination. Universal precautions and post-exposure prophylaxis Universal precautions mandate that health care providers assume all patients carry a transmissible infectious disease (such as viral hepatitis or HIV), and maintain precautions against contracting such infections. The nature of personal protective equipment is situation-dependent, and may include gloves, eye protection, a protective gown and/or boots, or a mask. Bodily fluids, including blood and saliva, as well as airborne particles, are considered an exposure risk. Testing all patients to identify individuals infected with transmissible diseases is not feasible, and thus universal precautions are required 36 . In addition to universal precautions, pre-exposure vaccination against hepatitis B is recommended. All health care workers potentially coming in to contact with bodily fluids should be vaccinated against hepatitis B, which is given as a series of three intramuscular doses. Despite the importance of hepatitis B vaccination, many health care workers are not vaccinated due to either not being aware of the vaccine’s efficacy, or being unable to afford the series of vaccinations 37 . HIV and hepatitis C pose risks to health care providers, and to this date there are no vaccinations available for pre-exposure prophylaxis. Therefore prevention relies solely on universal precautions and safe practices, such as not recapping used needles, using sharps containers appropriately, and properly 124 Hospital and Healthcare Innovation Book 2009/2010
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International Hospital Federation I
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Introduction Sterile Barrier System
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Contents Healthcare transformation
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International Hospital Federation H
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Introduction Introduction ERIC DE R
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Innovation and strategy 14 Creativi
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Innovation and strategy: creativity
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Innovation and strategy: risk manag
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Innovation and stategy: Acceleratin
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Innovation and stategy: Acceleratin
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Innovation and clinical specialitie
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Innovation in clinical specialities
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Page 90 and 91: Company Profile: Shimadzu Europa Gm
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Page 119 and 120: Company Profile: Wipak Medical Wipa
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Page 133 and 134: IHF reference The International Hos
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Page 137 and 138: IHF reference IHF Governing Council
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Page 141 and 142: IHF reference JAPAN JAPAN HOSPITAL
Page 143 and 144: IHF reference KENYA THE NAIROBI HOS
Page 145 and 146: IHF Corporate Member Profiles GE He
Page 147: How Can Health Organizations Get th
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