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@ The strategy for wound infection management is to
prevent or minimize the risk of infection.
@ An action or set of actions intentionally taken to reduce
the risk of SSI.
@ Reducing opportunities for microbial contamination of the
patient¶s tissues or sterile surgical environment.
@ Applied to the patient preparation, Surgical team
members educated in aseptic technique, care of Theatre
environment and instruments, optimize surgical
technique.
@ the Centers for Disease Control and Prevention (CDC)
and Healthcare Infection Control Practices Advisory
Committee (HICPAC) presents recommendations for the
prevention of surgical site infections (SSIs), formerly
called surgical wound infections.
x x 
    
x

 x


º IA Strongly recommended for implementation


and supported by   experimental,
clinical or epidemiological studies & should be
adapted by all practices .

º IB Strongly recommended for implementation


and supported by  experimental, clinical, or
epidemiological studies and strong theoretical
rationale.

º II Suggested for implementation and supported


by
   clinical or epidemiological studies or
theoretical rationale.

º Go recommendation; unresolved issues, practices&


evidence for which are 
  .
x x 
    
º Preoperative circumstances:
@ ¦     
@       
@ 
   
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º 

@ 
   
@ 
 
º 

@   
Preoperative circumstances

º     
@ Identify and treat all infections remote from the surgical site.
@ Do not remove hair unless it will interfere with the operation .

º     
@ Adequately control serum blood glucose levels .
@ Encourage tobacco cessation
@ Do not withhold necessary blood products from surgical patients as
a means to prevent SSI. .
@ Pre-operative shower or bathe with an antiseptic agent on at least
the night before the operative day
@ Thoroughly wash and clean at and around the incision site &Use an
appropriate antiseptic agent .

º      
@ eep preoperative stay in hospital as short as possible while allowing for
adequate preoperative preparation of the patient.
@ Apply preoperative antiseptic skin preparation in concentric circles&The
prepared area must be large enough to extend the incision or create new
incisions or drain sites,

º G    
@ Taper or discontinue systemic steroid use before elective surgery .
@ enhance nutritional support .
½ 

    


º Shaving the surgical site with a razor
induces small skin lacerations:
@ Potential sites for infection.
@ Disturbs hair follicles which are often
colonized with  
@ Risk greatest when done the night
before.
     
  ¦     
Hair not removed 0,6%

Hair removed by razor night 5,6%


before
Razor < 24hrs before surgery 7,1%

Razor > 24hrs before surgery > 20%

Clippers right before surgery 1,8%

Clippers night before surgery 4,0%


Preoperative circumstances
Antimicrobial prophylaxis

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º   
@ Select an antimicrobial agent safe, inexpensive, and bactericidal
with efficacy against expected pathogen .
@ Administer IV& timed to achieve adequate bactericidal serum
levels during operation and for few hours after incision closed .
@ Before colorectal elective operations, in addition to IV
antimicrobial drugs, mechanically prepare the colon with
enemas and cathartic agents; administer nonabsorbable oral
antimicrobial agents in individual doses the day before surgery .
@ For cesarean sections in patients at high risk administer IV
antimicrobial agent immediately after cord is clamped.
º   
@ -Do not routinely use vancomycin for prophylaxis
Prophylactic Antibiotics
Î 

‡ Which cases benefit?


‡ Which drug should you use?
‡ When should you start?
‡ How much should you give?
‡ How long should antibiotics be continued?
Antibiotic Prophylaxis
  
@ î       ; these include
penetration of the gastrointestinal tract, whether by
penetrating trauma or related to a pathological organ
event (e.g. ruptured appendix, perforated colonic
diverticulum) prior to the development of clinical
peritonitis.
@ x       (e.g.
vascular, cardiac and orthopaedic operations), and those
without foreign body implants especially hernia repair,
breast surgery, median sternotomy, vascular surgery
involving the aorta and the lower extremities, and
craniotomy.
@ For contaminated & dirty 0perations(e.g. acute
cholecystitis, empyema , ascending cholangitis or liver
abscess , perforated appendix with evidence of local or
generalised peritonitis and/or intraabdominal abscess,
antibiotic given as part of treatment (for a longer
duration ).
Prophylactic Antibiotics
Î 

‡ Which cases benefit?


‡ Which drug should you use?
‡ When should you start?
‡ How much should you give?
‡ How long should antibiotics be continued?
Œ    ¦   
  
 '(  , coagulase-negative Cefazolin 1-2 g IV OR
'(! staphylococci Cefuroxime 1.5 g IV OR
'x  Vancomycine
'
"' ëram-negative bacilli and Cefazolin 1-2 g IV
streptococci , anaerobic
x""' ëram-negative bacilli and Cefoxitin 1-2 g plus oral Geomycin
anaerobes 1 g and oral Eerythromycin 1 g
(start preoperatively for 3 doses)
)'(!"' ëram-negative bacilli and Cefazolin 1-2 g OR
 anaerobes Cefoxitin 2 g IV
"'     Cefazolin 1-2 g
 , gram-negative bacilli
½*'  , streptococci, anaerobes Cefazolin 1-2 g
and streptococci Amoxiclav 1.2 g IV
! ëram-negative bacilli, enterococci, Cefazolin 1-2 g
'"" anaerobes, group B streptococci

"' ëram-negative bacilli Cefazolin 1-2 g

x' Enteric gram-negative Cefoxitin or Cefazolin / ëentamicin

+ bacilli, anaerobes, OR Metronidazole plus ëentamicin


% Enterococci &  , group A IV
strep, clostridia
Prophylactic Antibiotics
Î 

‡ Which cases benefit?


‡ Which drug should you use?
‡ When should you start?
‡ How much should you give?
‡ How long should antibiotics be continued?
Antibiotic Prophylaxis
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Prophylactic Antibiotics
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‡ Which cases benefit?


‡ Which drug should you use?
‡ When should you start?
‡ How much should you give?
‡ How long should antibiotics be continued?
Antibiotic Prophylaxis
Dose of Antibiotic for Prophylaxis

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Prophylactic Antibiotics
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‡ Which cases benefit?


‡ Which drug should you use?
‡ When should you start?
‡ How much should you give?
‡ When should antibiotics be stopped?
Prophylactic Antibiotics
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@ Use of the prophylaxic antimicrobial agent after
this period has not been shown to improve
surgical site infection rates and increases the cost
of care unnecessarily .
@ Indiscriminate & prolong use of antimicrobials
agents can lead to the development of antibiotic-
resistant microorganisms.
@ Increased antibiotic-associated complications:
@ x    Enterocolitis
@ .Colonization with MRSA
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 Risk of nosocomial
      Infections x 
    
Preoperative circumstances
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º    
@ Maintain positive pressure ventilation of the operating room.
@ eep operating room doors closed .
@ Maintain a minimum of 15 air changes per hour, with a
minimum of 3 being fresh air.
@ Appropriate filters should be used for filtration of all air
whether re circulated or fresh.
@ Air should enter through the ceiling and exit near the floor.
@ Prior to subsequent procedures, visibly soiled surfaces should
be cleaned with Environmental Protection Agency (EPA)±
approved disinfectants.
@ Following a contaminated or dirty procedure, special cleaning
or closure of the operating room is not necessary.
@ Sterile surgical instruments and solutes should be assembled
just prior to use.
@ Sterilize all surgical instruments according to published
guidelines.
@ Temperature should be maintained at 20°- 22°C with a
humidity of 30 ± 60 %.
º   
@ 0imit the number of personnel entering the operating room.
@ Orthopedic implant surgery should be performed in an ultra
clean air environment & achieved by laminar air flow (particle
free air move over the aseptic operating field at a uniform
velocity)


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º Treating wound infections depends on the nature of the
wound, degree of infection, and the bacteria responsible
for the infection.
@ Œ
    !
‡ Remove sutures and staples local to the site of infection.
‡ Skin and subquatenous tissues in involved area opened
& exam to assess its integrity and for a deep space
infection & to exclude the underlying fascial dehiscence.
‡ Evacuate the pus.
‡ Swab for c/s.
@   
!by irrigating the wound with
sterile (clean) water or normal saline &It may be done
using high pressure with a needle or catheter and a large
syringe , ëerm-killing solutions may also be used to
clean the wound like Hydrogen peroxide.
#"#
@  ! to clean and remove objects, dirt, or dead skin
and necrotic tissues from the wound area.
@   
! to protect the wound from further
injury and infection. These may also help provide pressure to
decrease swelling. Dressings may come in different forms.
Dressing changes allow the tissues to granulate.
@  

@    to fight the infections, patient high risk for
dissemination of infection (i.e. diabetics ; Immnuno-
compromised, if prosthetics involved, if patient has signs of
systemic toxicity or if surrounding area of soft tissue erythema
and edema.
@  
 booster shot may be indicated to prevent
the occurrence of tetanus.

@ Π  ! Controlling or treating the medical condition


that causes poor wound healing & treat complications.
x   
       
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@ Cephalexin 500mg po q6 h
@ amoxiclav 500 mg po q8 h
@ Dicloxacillin 500 mg po q6 h
+/-
@ Ciprofloxacin 500 mg po q12 h
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@ Cefoxitin 1gm iv q6h or
@ Cefotaxime 1gm iv q 8 h,
@ Ceftriaxone 1-2 gm iv q 24 h
+
@ metronidazole iv q8h or
@ imipenum 500 mg iv q6 h.
ü
 

º The choice of closure should be
determined by risk of subsequent infection.

@ Wounds which are clean or with minimal


contamination , may closed primarily with
minimum tension.

@ Delayed primary closure can be


perform after several days of dressing
approximately 3-5 days post-op, optimal
management of contaminated ( Class
III/IV )Wounds.
6
  
   
 
 
@ Traumatic injuries have a potential for serious bacterial
wound infections, including gas gangrene and tetanus,
and these in turn may lead to long term disabilities,
chronic wound or bone infection, and death.

@ Wound infection is particularly of concern when


injured patients present late for definitive care, or in
disasters where large numbers of injured survivors
exceed available trauma care capacity.

@ Appropriate management of injuries is important to


reduce the likelihood of wound infections.

@ The following core principles and protocols provide


guidance for appropriate prevention and management
of infected wounds.
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Systematically perform wound toilet and surgical
debridement until the wound is completely clean.
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!
Surgical toilet, leave open and then close 48 hours later
(delayed primary closure).
"    !
They are necessary but not sufficient and need to be
combined with appropriate debridement and wound
toilet .
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@ Restore breathing and blood circulation as soon as
possible after injury.
@ Warm the victim and at the earliest opportunity provide
high-energy nutrition and pain relief.
@ Do not use tourniquets.
@ Perform wound toilet and debridement as soon as
possible (within 8 hours if possible).
@ Respect universal precautions to avoid transmission of
infection.
@ ëive antibiotic prophylaxis to victims with deep wounds
and other indications.
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‡ Protocol 1: ü     

‡ Protocol 2& '      

‡ Protocol 3: î     (   


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Protocol 1: ü     

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Protocol 2& '      

@ Wounds more than 6 hours before surgical
treatment of the wound or show one or more of the
following: a puncture-type wound, a significant
degree of devitalized tissue, clinical evidence of
sepsis, contamination with soil/feces likely to
contain tetanus organisms, burns, frostbite, and
high velocity missile injuries.

@ For patients with tetanus-prone injuries, WHO


recommends TT or Td and TIë.

@ When tetanus vaccine and tetanus immunoglobulin


are administered at the same time, they should be
administered using separate syringes and
separates sites.
Protocol 2: '      

Tetanus vaccine
ADU0T and CHI0DREG over 10 years:
‡    
     
 66   
 
   6
‡ 1 dose (0.5 ml) by intramuscular or deep subcutaneous injection. Follow
up: 6weeks, 6 months.
CHI0DREG under 10 years:
‡     
 6
‡ 0.5 ml by intramuscular or deep subcutaneous injection. Follow up at
least 4 weeks and 8 weeks.
Tetanus immune globulin
ADU0T and CHI0D
‡ 6 
 

 
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‡ 250 units by intramuscular injection, increased to 500 units if any of the
following conditions apply: wound older than 12 hours; presence, or risk
of, heavy contamination; or if patient weight more than 90 kg.
Protocol 3: î     ( 
 
Antibiotic prophylaxis

‡ Contaminated wounds, penetrating wounds, abdominal trauma,


compound fractures, lacerations greater than 5 cm, wounds with
devitalized tissue, high risk anatomical sites such as hand or
foot.

‡ Recommended prophylaxis consists of penicillin ë and


metronidazole given once.

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Protocol 3: î     ( 
 
Antibiotic treatment
‡ If infection is present or likely, administer antibiotics via
intravenous and not intramuscular route.
‡ Penicillin ë and metronidazole for 5-7 days provide good
coverage.
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‡ After 2 days it is possible to use oral Penicillin: Penicillin V 2
tablets every 6 hours.
‡ * $! &&'     (with higher doses in
severe infections),
‡ In case of known allergy to penicillin use erythromycin
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