American College of Surgeons: Committee on Perioperative Care: Infection in the OR: Best Practices for the Next Millennium

Infection in the OR: Best Practices for the Next Millennium

San Francisco, CA
October 11, 1999
Moderator: Jonathan R. Hiatt, MD

New OR Pathogens for a New Century
David L. Dunn, MD, Professor and Chair, Department of Surgery, University of Minnesota

Asepsis in the OR: Reviewing the Discipline
Ronald L. Nichols, MD, Henderson Professor of Surgery, Professor of Microbiology and Immunology, Tulane University

Antimicrobial Prophylaxis in Surgery: An Evidence-Based Guide
Samuel E. Wilson, MD, Professor and Chair, Department of Surgery, University of California, Irvine

Blood-Borne Viral Infections: Protecting Your Patient and Yourself
Russell A. Williams, MD, Professor and Vice Chair, Department of Surgery, University of California, Irvine

Bacterial and Fungal Infections

At the end of the twentieth century, gram positives have re-emerged as significant pathogens, and increasing antibiotic resistance is a real problem. S. epidermidis is clearly a pathogen, seen with device-associated infections, bacteremias, and others. Staph aureus, Strep pyogenes, and enterococcus are other frequent pathogens.

Fungal infection is a common complication of critical illness, with increasing numbers of resistant species including Candida. The risk of developing fungal infection is limited by judicious use of antimicrobials.

Fever is an unreliable indicator of infection. Only half of patients with infection have fever, while treatment of fever without documented infection leads to antibiotic overuse.

Bacterial resistance may develop during therapy. Mortality of bacteremia doubles if due to resistant organisms. Antibiotic classes should be rotated during therapy to minimize development of resistance.

In recent years operative site infections have decreased significantly, while other nosocomial infections have increased; postoperative pneumonia is now the leader. Antibiotics, used properly, have played a key role, but one must remember that these drugs do have side effects, even in prophylactic doses, including allergic reactions, antimicrobial-related diarrhea, and enterocolitis.

There are two methods to classify risks of postoperative infections: A. Class I to IV (Cruse and Foord, Arch Surg 1973), still useful because it is based on the degree of contamination, and the surgeon to some extent can control this; and B. National Nosocomial Infection Survey method, which includes risk factors such as number of diagnoses, ASA class and length of operative procedure. Method B is now used by infection control nurses and also for comparison of rates, risk-adjusted for specific procedures. Infection rates are adversely affected by length of operation, diabetes mellitus, remote site of infection, hypothermia, blood transfusions, and surgeon “inexperience”.

Prophylactic antibiotics should be administered IV within 30 minutes of skin incision and discontinued within 24 hours. In penetrating trauma, 48 hours of therapy is as effective as five days. Antibiotic prophylaxis is indicated for all procedures except clean (Class I) operations and is used in these operations if a prosthesis will be implanted. Class IV (gross contamination) requires therapeutic regimens. First-generation cephalosporins (eg, cefazolin) are still the antibiotics of choice for all prosthetic procedures. Vancomycin should be avoided unless a specific MRSA or MRSE problem exists in the institution. Second-generation cephalosporins (eg, cefotetan) are used most commonly for GI surgical prophylaxis (biliary, gastroduodenal, small bowel and colorectal).

In the coming century, new classes of antibiotics will be available. Confidence in antimicrobials has led to some easing in antiseptic discipline, particularly in the ICU. To counter this trend, surgeons must exert the leadership they showed at the turn of the last century to minimize surgical infectious complications.

Protection from Blood-Borne Viruses (Hepatitis B, Hepatitis C, HIV)

Transmission occurs between patients and healthcare workers and also between healthcare workers and patients. The likelihood of transmission depends on the nature of the injury or the contact with patient or healthcare worker, “infectivity” of the virus, the frequency with which the injuries occur and the rates of infection among patient and healthcare worker groups.

The rate of infection with these viruses among orthopedic patients sampled in San Juan, Puerto Rico in 1998 was seven percent for HIV and 12 percent each for hepatitis B and C viruses. In the Johns Hopkins ER populations studied in 1992 the rate of HIV infection was six percent, HBV five percent, and HCV 18 percent. Among intravenous drug users in the methadone program in Geneva this rate was 38 percent for HIV and 81 and 92 percent for hepatitis B and hepatitis C viruses when studied in 1988. The rate in 1995 on a re-study was five percent, 20 percent and 30 percent respectively for each virus.

The risk of infection of the healthcare worker following a hollow needle stick injury is about 30 percent for hepatitis B, 10 percent for hepatitis C and 0.3 percent for HIV. For surgeon who operates on 350 cases annually over a 30-year period and who injuries herself once in 40 cases in a community with a prevalence of HIV of 1 in 100, the cumulated risk to a surgeon is one in 100. With HIV prevalence of 10 percent the cumulated risk to the surgeon is one in 5.

Of note, no cases of HIV transmission to members of the operating room team have been reported following solid bore needle punctures or contact with body fluids in the OR. In the case of hepatitis B transmission from the healthcare worker to the patient, there are 29 reported clusters since 1972. About five percent of patients operated on by a hepatitis B e-antigen positive surgeon are likely to become infected.

There are more than 5,000 healthcare workers infected each year with hepatitis B from patients they treat, and about 250 of these die from liver failure or cirrhosis and cancer. About 30 percent of mostly senior surgeons are not vaccinated against hepatitis B and therefore are susceptible to infection by this virus.

In the case of hepatitis C transmission from surgeon to patient, there are two reported clusters in the literature with a third recently reported in the English press. In each of the reported cases the surgeon was a cardiothoracic surgeon who was chronically infected with hepatitis C virus. The rate of transmission was 0.36 percent in the London outbreak and 2.25 percent in the Barcelona outbreak.

In a large prospective multicenter survey study done by the University of Pisa in Italy (39 hospitals, 15,375 operations ), 9.2 percent of healthcare workers were exposed to blood or body fluids. Two percent sustained a parenteral or needle exposure to blood.

One technique to reduce gloved punctures and blood exposure was studied at the University of Hull: a blunt needle was used to close the abdomen in the studied patients. The puncture rate was 14 out of 39 where cutting needles were used and three out of 46 where blunt tipped needles were used. Most of the punctures were through the gloves on the non-dominant hand. In a study of orthopedic operations where blunt needles were used in addition to double gloves, there was a 16 percent rate of penetration of the outer glove and six percent for the inner glove. Needle stick injuries occurred in six percent of the operations. The blunt needles eliminated these injuries.

The hand is the most common site of injury and blood contamination in OR personnel. Gloves prevent the transmission of pathogens from patient to surgeon, and there are many studies that measure glove leak rates and skin blood contact rates. At present there are no data which actually measure the protection afforded by gloves in terms of actual disease prevention.

Eye shields are also standard operating wear equipment. In 160 consecutive operations, eye shields were studied and it was found that 44 percent of them were positive when tested for blood, 16 percent had grossly visible blood, and surgeons were aware of the presence of blood on the shield in 8 percent. The surgeon was more likely to have the eye shields contaminated than was the assistant. There was an increased rate of contamination with increased length of operation.

At the University of Arkansas, a randomized study of surgeons and their assistants involved in joint surgery examined the effect of the surgeons’ wearing a total body exhaust hood and impermeable gown, hood and knee high covers. The instruments were also passed on trays. In addition to the operating uniform the surgeons had various glove combinations including latex and double latex, one and two gloves of latex, and a cloth glove. The combination of the latex, cloth and latex (triple gloves) reduced the glove perforation rate to 4.3 percent. There were no needle stick injuries, and one out of 267 operations resulted in body contamination of the operating surgeon with blood.

In the seven-year study of medical student blood exposures at UCSF, it was found that of 1919 accidental injuries that were reported, most of these were from needles. The investigators believed that 50 percent of cases were not reported. Of note, students if they are injured in the OR felt that they were discouraged by the senior staff from leaving the operating room to attend to the injury. Safety needles were introduced half way through this study in 1993. At that time there were 33 injuries reported in a year; in 1996 there were nine. One quarter of the injuries since the introduction of the safety needles occurred with the safety needles, and half of the injuries were in students who were on duty for more than 16 hours.

Guideline

Guideline for Prevention of Surgical Site Infection (SSI)

Guideline for Prevention of Surgical Site Infection (SSI), prepared by the CDC’s Hospital Infection Control Practice Advisory Committee, provides a summary of SSI and evidence-based recommendations for prevention of SSI. The Guideline is summarized in the following table. The entire document is available in Infection Control and Hospital Epidemiology 1999; 20:247-278, or online at http://www.cdc.gov/ncidod/hip/SSI/SSI.pdf

This file is in Adobe Acrobat format. To view Portable Document Files (PDF) download the free Adobe Acrobat Reader. Reminder: The Adobe Acrobat Reader ranges from 3.9 mb to 7.4 mb depending on the operating system your computer uses. Please allow for sufficient download time.

Ranking of Recommendations

Category IA: Strongly recommended for implementation and supported by well-designed experimental, clinical, or epidemiologic studies.

Category IB: Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and strong theoretical rationale.

Category II: Suggested for implementation and supported by suggestive clinical or epidemiological studies or theoretical rationale.

No Recommendation; unresolved issue: Practices for which insufficient evidence or no consensus regarding efficacy exists.

NOTE: Recommendations denoted with an asterisk (*) are mandated by U.S. Occupational Safety and Health Administration.

Recommendation	IA	IB	II	No Recommendation
1. Preoperative a. Perparation of the patient	1. Identify and treat remote site infections and postpone elective operation until infection resolved 2. Do not remove hair at incision site unless necessary for the operation 3. If hair is removed, remove immediately prior to operation, using electric clippers	4. Control blood glucose in diabetics, avoid preop hyperglycemia 5. Encourage tobacco cessation, at least 30 days before operation 6. Dr not withhold blood products to prevent SSI 7. Require patient to shower or bathe with antiseptic agent on night before operative day 8. Thoroughly wash and clean at and around the incision site to remove gross contamination before skin prep 9. Use an appropriate antiseptic agent for skin preparation 10. Apply preoperative antiseptic skin preparation in concentric circles moving toward the periphery	11. Minimize preoperative hospital stay	12. No recommendation to taper or discontinue steroids before operation 13. No recommendation to enhance nutritional support 14. No recommendation to apply mupirocin to nares to prevent SSI 15. No recommendation to provide measures that enhance wound space oxygenation
b. antisepsis for surgical team		1. Keep nails short and do not wear artificial nails 2. Surgical scrub at least 2-5 minutes (up to elbow) using appropriate antiseptic 3. Do not touch scrubbed arms on objects. Dry hands with a sterile towel and don a sterile gown and gloves	4. Clean underneath each fingernail prior to performing the first surgical scrub of the day 5. Do not wear hand or arm jewelry 6. Do not wear hand or arm jewelry	6. No recommendation on nail polish
c. management of infected surgical personnel		1. Educate personnel who have signs and symptoms of a transmissible infectious illness to report conditions to their supervisory personnel 2. Develop well-defined policies to govern (a) personnel responsibility to report illness; (b) work restrictions; and (c) clearance to resume work after an illness. Policies should identify persons who have authority to remove personnel from duty 3. Exclude from duty personnel who have draining skin lesions until infection has been ruled out or has been resolved 4. Do not routinely exclude personnel who are colonized with organisms, such as S aureus or group A streptococcus, unless personnel have been linked epidemiologically in the healthcare setting
d. antimicrobial prophylaxis	1. Administer prophylactic antimicrobial agent when indicated, based on its efficacy to prevent SSI for a specific operation and published recommendations s 2. Administer initial prophylactic antimicrobial agent IV, timed so that concentration is established when the incision is made 3. Before elective colon operations, use mechanical cleansing. Administer non-absorbable oral antimicrobial agents on the day before operation 4. For high-risk C-section, administer prophylactic antimicrobial agent immediately after umbilical cord is clamped	5. Do not routinely use vancomycin for antimicrobial prophylaxi
2. Intraoperative a. ventilation		1. Maintain positive-pressure ventilation in the ORs 2. Maintain at least 15 air changes per hour 3. Filter all air with appropriate filters 4. Introduce all air from ceiling with exhaust near floor 5. Do not use UV radiation in OR to prevent SSI 6. Keep OR doors closed when possible	7. Consider performing orthopaedic implant operations in ORs supplied with ultra clean air 8. Limit number of personnel entering the ORs
b. cleaning & disinfection of environmental surfaces		1. When blood or body fluid soiling occurs during an operation, clean with EPA approved hospital disinfectant before next operation * 2. Do not perform special cleaning or closing of ORs after class III-IV cases 3. Do not use tacky mats at OR suite entrance or individual rooms	4. Wet vacuum the OR floor after the last operation with EPA approved hospital disinfectant	5. No recommendation on disinfection of OR surfaces or equipment between operations when no visible soiling is observed
c. microbiologic sampling		1. Do not perform routine environmental sampling (do so only as part of an epidemiologic study)
d. sterilization of surgical instruments		1. Sterilize all instruments according to published guidelines 2. Flash sterilize only for patient care instruments needed immediately
e. surgical attire & drapes		1. Wear surgical mask that fully covers mouth and nose* 2. Wear a cap or hood to fully cover head and face hair * 3. Do not wear shoe covers for prevention of SSI * 4. Wear sterile gloves if a scrubbed surgical team member * 5. Use surgical gowns and drapes that are effective barriers when wet 6. Change scrub suits that are visibly soiled*		7. No recommendations on how or where to launder scrub suits, on restricting use of scrub suits to OR suite, or for covering scrub suits when out of OR suite
f. asepsis & surgical technique	1. Adhere to principles of asepsis when placing IV devices or dispensing IV drugs 2. Assemble sterile equipment and solutions immediately prior to use	3. Handle tissue gently, maintain effective hemostasis, minimize devitalized tissue, and eradicate dead spaces 4. Use delayed primary closure in heavily contaminated cases 5. If drainage is necessary, use a closed suction drain through a separate incision. Remove drain as soon as possible
3. Postoperative Incision Care		a. Protect with sterile dressing 24-48 hours postoperatively b. Wash hands before and after any contact with the surgical site	c. When dressing must be changed, use sterile technique d. Educate patient and family regarding proper incisional care, symptoms of SSI, and the need to report such symptoms	e. No recommendation to cover an incision closed primarily beyond 48 hours, nor on the appropriate time to shower or bathe with an uncovered incision
4. Surveillance		a. Use CDC definitions of SSI among surgical inpatients and outpatients b. For inpatient case-finding, use direct prospective observation, indirect prospective detection, or a combination of both d. For outpatient case-finding, use a method that accommodates resources and data needs f. For each patient undergoing an operation chosen for surveillance, record variables shown to be associated with increased SSI risk (e.g., surgical wound class, ASA class, and duration of operation) g. Periodically calculate operation-specific SSI rates stratified by variables shown to be associated with increased SSI risk h. Report appropriately stratified, operation specific SSI rates to surgical team members	c. When post discharge surveillance is performed for detecting SSI, use a method that accommodates resources and data needs e. Assign the surgical wound classification upon completion of an operation. A surgical team member should make the assignment	i. No recommendation to make available to the infection control committee coded surgeon-specific data

Revised July 31, 2002

Committee on Perioperative Care

Infection in the OR: Best Practices for the Next Millennium

This page and all contents are Copyright © 1996-2002 by the American College of Surgeons, Chicago, IL 60611-3211

This page and all contents are Copyright © 1996-2002
by the American College of Surgeons, Chicago, IL 60611-3211