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Innovations in patient care: infection control
passing sharp instruments in theatre (by a sharps container, or
using verbal communication between the surgeon and the scrub
nurse).
To this date, there are no known cases of transmission of HIV
from a patient to a health care provider in the operating room.
However there are at least 57 documented cases of transmission
to health care providers in settings outside of the operating room 38 .
Hepatitis C poses a more serious risk of transmission, which is
estimated to be 2% if the patient is infected with hepatitis C, and
the health care provider as been stuck with a hollow needle 39 .
After unintentional exposure, the site should be copiously
washed, and consideration must be given to post-exposure
prophylaxis against HIV. If possible, the patient should be tested
for HIV. Factors influencing the choice for or against HIV post
exposure prophylaxis include the type of exposure, whether the
status of the patient is known at the time of exposure, and the
availability of post exposure prophylaxis. The overall risk of
transmission from a needle stick when the patient is HIV positive
is estimated at 0.3%; high risk occupational exposure from an HIV
positive patient is defined as a deep puncture with a hollow
needle, a needle that is visibly contaminated, large bore needle,
needle that was place directly in an artery or vein, high viral load of
the patient, or a patient with end-stage disease 40 . Post-exposure
prophylaxis should continue for 28 days and include both a
nucleotide reverse transcriptase inhibitor (NRTI) and a protease
inhibitor (PI); in the United Kingdom, the recommended regimen is
now Combivir (lamivudine and zidovudine, both NRTIs) with
lopinavir and ritonavir (PIs; supplied in combination as Kaletra)
(Table 2).
Summary of recommendations
In conclusion, SSIs represent a major cause of morbidity in
surgical patients, affecting only around 2% of patients with clean
cases, but upwards of 15-20% of patients undergoing
contaminated cases.
1. To limit the chance of SSIs, one should treat any endocrine or
metabolic disorders in the patient, and optimize nutritional
status.
2. Preoperative antibiotics should be given for clean-contaminated
and contaminated cases (second or third generation
cephalosporin). For clean cases, the evidence is mixed, and if
given the best choice is a first generation cephalosporin. The
antibiotic should be given before incision, but no longer than 60
minutes before, and should not be continued for more than 24
hours postoperatively. Antibiotics for dirty cases represent
treatment of infection and thus are not considered prophylaxis.
3. Body hair need not be removed, and if the surgeon chooses to
remove hair, it should be done by use of clippers or a depilatory
agent; shaving causes an increased chance of wound infections
and must be avoided.
4. Chlorhexidine is the best skin preparation agent. Soap followed
by iodine, or 70% alcohol followed by iodone are the next best
alternatives.
5. Intraoperatively, patients should retain normothermia,
normoglycemia, and adequate perfusion and oxygenation. The
surgeon should minimize tissue devitalisation, adhere to sterile
technique, avoid hematoma formation, and close potential
spaces.
6. Evidence supports closing primarily all wounds, and avoiding
drain placement, or if used, such as in breast surgery, not
leaving drains in post-operatively any longer than necessary.
7. If one suspects an SSI (redness, localised swelling, pain or
tenderness, purulent discharge, relative warmth to the touch),
maintain a low threshold for opening the wound which is the
primary treatment. Antibiotics are secondary to adequate
drainage. There are a number of reasonable choices for treating
SSIs, and the choice of an agent should be dictated by culture
results when possible.
8. Surgeons should be familiar with the risks of transmission of
HIV, and the indications for and choices of post-exposure
prophylaxis. All surgeons should be vaccinated against hepatitis
B virus. ❏
Acknowledgement
Reprinted with kind permission from Surgery in Africa Monthly
Review – November 2008
Jonathan Samuel was born and raised in Santa Barbara, California.
He completed his bachelor’s degree at Harvard University, and his
Medical Degree from Northwestern University. He received a
Master’s Degree in Public Health from the University of Michigan,
prior to beginning his specialty training in general surgery at the
University of North Carolina. For the past two years he has worked
as a general surgeon and researcher at Kamuzu Central Hospital in
Lilongwe, Malawi, where he currently resides. At KCH he is Director
of Continuing Professional Development. He also lectures in
surgery at the Malawi College of Health Sciences. He is a candidate
member of the Association for Academic Surgery, and a resident
member of the American College of Surgeons.
Born in Chitipa, Malawi, and a fifth born in a family of eight, Dr
Mulwafu went to Iponjola Primary School and proceeded to
Chaminade secondary school. There he was selected to do further
studies at Chancellor College in Zomba, Malawi, where he
completed two years in the faculty of bachelor of science and then
joined College of Medicine where he obtained his MBBS. From
College of Medicine, Wakisa did his internship at Queen Elizabeth
Central Hospital for two years and transferred to Kamuzu Central
Hospital where he worked as a registrar in surgery for another two
years. He specialized as an ENT surgeon at the University of Cape
Town, where he completed one year of general surgery and four
years of specialist training in ENT.
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