New 1
This document was uploaded by user and they confirmed that they have the permission to share it. If you are author or own the copyright of this book, please report to us by using this DMCA report form. Report DMCA
Overview
Download & View New 1 as PDF for free.
More details
- Words: 1,935
- Pages: 23
Post operative infections
AIM
This project was done with the aim, to make awareness about the fact that even after undergoing surgery for the treatment, a patient’s life should not be considered as totally out of the danger, as there arises a possibilility of having a post operative or a surgical site infection. Cancer patients are prone to this danger due to the consumption of different chemotherapeutic drugs and thus becoming immunocompromised. Even after, the surgical procedure has been carried out in a very sophisticated hospital, the
Public Health Importance of SSIs Postoperative infection is a major cause of
Postoperative infection is a major cause of patient injury, mortality and health care cost: second most common nosocomial infection (24% of all nosocomial infections) An estimated 2.6 percent of nearly 30 million operations are complicated by surgical site infections (SSIs) each year. Each infection is estimated to increase a hospital stay by an average of 7 days and add over $3,000 in charges (1992 data). Appropriate preoperative administration of antibiotics is effective in preventing infection. According to the CDC’s National Nosocomial Infections Surveillance (NNIS) system : 38% of all nosocomial infections in surgical
What is Post operative infection?
A post operative or surgical site infection, is the infection that occurs after an operation or a surgery. Post Operative Infections (POIs) are also known as ‘Surgical Site Infections’(SSIs) or ‘Wound Infections’(WIs) . The CDC definition states that only infections occurring within 30 days of surgery (or within a year in the case of implants) should be classified as SSIs.
Occurrence
A surgical site infection can occur when the infectious agents from the skin, other parts of the body or the environment enter the surgical site and multiply in the tissues. As a result, there may be inflammation, pus, swelling, pain and fever. The infections acquired in the hospital cause anxiety & discomfort, complicate illness and delay the recovery process. Following three factors are the determinants of any infectious process: The infecting organism (in surgical patients, usually bacteria). The environment in which the infection takes
CDC Definition of Surgical Site Infections
Superficial incisional surgical site infections These involve only the skin and subcutaneous tissue around the incision. Symptoms of these infections include pain or tenderness, localised swelling, redness or heat . Deep-incisional surgical site infections These involve deep soft tissues, such as the fascia and muscles. Symptoms include an abscess , fever (>38°C), localised pain or tenderness . Organ / Space surgical site infections These involve any part of the anatomy (e.g. organs, spaces) other than the incision that was manipulated during the operative procedure.
Stratification of risk for SSIs
Class1 : Clean Non-traumatic, primarily closed; no acute inflammation ; no break in technique; respiratory, gastrointestinal, biliary and genitourinary tracts not entered.
Class3 : Contaminated-Non-
purulent inflammation; gross spillage from the gastrointestinal tract; entry into biliary or genitourinary tract in the presence of infected bile or urine; major break in technique.
Class 2 : Clean Contaminated- Elective opening of respiratory, gastrointestinal, biliary or genitourinary tract with minimal spillage (e.g. appendectomy) not encountering infected urine or bile; minor technique break.
Class 4 : Dirty-
Purulent inflammation (e.g. abscess); preoperative perforation ofrespiratory, gastrointestinal , biliary or genitourinary tract.
Rates of infections
Incidence varies from 1.5 to 13 / 100 operations. Infection rates in US National Nosocomial Infection Surveillance (NNIS) system hospitals were reported to be: 2.1 % (clean), 3.3 % (clean-contaminated), 6.4% (contaminated ) & 7.1% (dirty wounds) . Probability of SSI = x + a (bacteria) + b (environment: local factors) + c (host defense mechanisms: systemic factors) – omitted.
Nature, Diagnosis and Treatment of Surgical Infections Different kinds of SSIs, caused by different kinds of pathogens are as follows:
Soft tissue infections, Necrotizing soft tissue infections, Intra abdominal and retroperitoneal infections, Prosthetic (Catheter) device associated infections, Central nervous system infections, Oroesophageal infections, Blood stream infections (BSI) / Bacteremia.
Soft tissue infections Subcutaneous abscess - pus filled central portion surrounded by a vascularized zone. e.g. Superficial abscesses on trunk, head (S.aureus and Streptococci) .Cellulitis - intact blood supply & viable tissue, with inflammation & edema. Treatment done with antibiotic therapy.
Necrotizing Soft tissue infections
A layer of necrotic tissue, not surrounded by a clear boundary. e.g. Clostridial myonecrosis or. gas gangrene (C.perfringens, C.septicum). Treatment done by removing areas of necrotic tissue.
Intra abdominal and retroperitoneal infections These infections include Intra abdominal abscesses, sub hepatic abscesses, enteritis etc. Yield different aerobic and anaerobic pathogens. Symptoms include fever, abdominal pain, fluid shifts. Treatment done by operative intervention, drainage, and antibiotic therapy.
Central nervous system infections
Prosthetic device associated infections Usually caused by the exogenous & endogenous microflora of body e.g. endocarditis. (Staphylococcus aureus, Coag. negative staphylococci ,Candida), These infections results in complications of vascular grafts, cardiac valves, pacemakers and artificial joints. Treatment done by intensive antibiotic therapy & replacement with a new uninfected device.
Oroesophageal infections Infections of upper GI tract that occurs due to extensive use of cancer chemotherapy. As a consequence mucosal candidiasis (Candida spp.), substernal burning (C.esophagitis), ulcerations (Cytomegalovirus and Herpes virus) occur.
Blood stream infections (BSI) / Bacteremia Primary :- Isolation of bacterial blood pathogen in absence of infection at another site. Secondary : - When bacteria are isolated from the blood during an infection with the same organism at another site. i.e. UTI, LRI. Sources :- vascular catheters, multidose medication vials, autoinfection. Causative agents are gram positive bacteria and fungi.
Diagnosis and Treatment
S&S: -fever -swelling -erythema -localized pain -incision tenderness -leukocystosis variable Most infections are superficial anduncomplicated
Treatment:
skin and subq in involved area opened – underlying fascia examined for dehiscence -gram stain any purulent drainage -debridement necrotic tissue -antibiotics only for complicated infections or patient high risk for dissemination of infection (i.e. diabetics; immnunocompromised)
Pathogenesis of SSI
Relationship equation
Dose of bacterial contamination x Virulence Resistance of host SSI Risk
Pathogenesis of SSIs Pseudomonas aeruginosa Enterococcus Coag-neg staphylococcl E-coli Staphylococcus aureus Other
SSI Risk Factors
Age Obesity Diabetes Malnutrition Prolonged preoperative stay Infection at remote site Systemic steroid use Nicotine use
Hair removal/Shaving Duration of surgery Surgical technique Presence of drains Inappropriate use of antimicrobial prophylaxis
Prevention
Use prophylactic antibiotics appropriately (selection, timing, duration of AP) Engineering & architectural advances in modern operating rooms (UV, laminar flow ventilation systems) . Patients Preoperative Preparations : Avoid shaving operative site (hair removal technique) Maintain glucose control oxygen tension Thermoregulation Operating room team discipline Surgical Attire (Scrub suits, Cap/hoods, Shoe covers, Masks, Gloves , Gowns)
METHODS
Collection and Transport of Samples: Blood sample :- The elbow skin disinfected by spirit and 5% carbolic acid solution. A fixed vein located and venipuncture performed. Required amount of blood sample collected in special, anticoagulant (Sodium citrate) containing, clean and sterile, blood collecting glass vials. Urine sample :- The vulva or. penis, wiped with cotton swab soaked in normal saline and 5 -10 ml. urine sample collected in sterile and wide mouthed screw capped bottles. Pus sample :- Lesion first cleaned with a swab soaked in warm normal saline, then pus aspirated with syringe and carried in sterile container to the laboratory. Tip of Central Line as sample :- This is the part of a catheter, inserted during operation for monitoring fluid balance and infectious agents. It was also taken for detection of infection. This part of the catheter
Culture The clinical samples collected in the above manner were inoculated by simple streaking method on the nutrient agar medium plates and then incubated at 37 ˚C for 24 hrs. After incubation the bacterial growth was observed and then to further differentiate the bacterial colonies, these were inoculated on selective media, as Mac Conkey’s agar and Blood Agar medium and after incubation at 37 ˚C for 24 hours., bacterial growth was observed Isolation and characterization of the bacterial isolates Isolation :- The isolation was done on the nutrient agar medium, Mac Conkey’s Agar medium and Blood Agar media. The samples collected were inoculated on these media plates and colonial growth was observed. The isolated bacterial colonies were sub cultured and incubated .These plates were observed for growth of pure colonies.
Details of the patients, test samples and identification of the microorganisms.
S.No
Patient’s name
Age / Sex
Date of surgery
Date of sample collection
Sample type
Sheela Sharma
65/F
5.5.06
8.5.06
Purushottam Das
60/M
6.5.06
8.5.06
Urine
Sample was sterile after 48 hours of aerobic incubation at 37 ˚C.
Mahaveer Prasad
50/M
9.5.06
14.5.06
Pus
Pseudomonas species over 1 lac organisms/cc. cultured.
10.5.06
16.5.06
Urine
Sample was sterile after 72 hours of aerobic incubation at 37 ˚C.
Mr. Pala
56/M
Blood
Microorganisms identified
Sample was sterile after 72 hours of aerobic incubation at 37 ˚C.
Prem Kumar
45/M
15.5.06
19.5.06
Urine
Sample was sterile after 48 hours of aerobic incubation at 37 ˚C.
Ranjeet
50/M
16.5.06
18.5.06
Urine
Sample was sterile after 72 hours of aerobic incubation at 37 ˚C.
Nitesh Kumar
48/M
20.5.06
24.5.06
Pus
24.5.06
1.6.06
Tip of Central line
Mrs. Usha Singhal
39/F
E.coli over 1 lac organisms/cc. cultured. Sample was sterile after 72 hours of aerobic incubation at 37 ˚C.
Godawari devi
30/F
24.5.06
26.5.06
Urine
Sample was sterile after 72 hours of aerobic incubation at 48 ˚C.
Hetram
25/M
25.5.06
27.5.06
Urine
Sample was sterile after 72 hours of aerobic incubation at 37 ˚C.
Mr. Sardul.Singh
52/M
31.5.06
2.6.06
Pus
Mannu Ram
60/M
2.6.06
5.6.06
Urine
Sample was sterile after 72 hours of aerobic incubation at 37 ˚C.
Mast. Ajay Kumar
15/M
3.6.06
13.6.06
Pus
Sample was sterile after 72 hours of aerobic incubation at 37 ˚C.
Narayani devi
60/F
9.6.06
10.6.06
Pus
Pseudomonas species over 1 lac organisms/cc. cultured.
Mrs.Prabha
35/F
10.6.06
12.6.06
Urine
Sample was sterile after 48 hours of aerobic incubation at 37 ˚C.
Shyam Sunder Gupta
60/M
11.6.06
19.6.06
Urine
Sample was sterile after 48 hours of aerobic incubation at 37 ˚C.
Mohini devi
65/F
19.6.06
24.6.06
Pus
Fojer
55/M
19.6.06
22.6.06
20.6.06
23.6.06
21.6.06
23.6.06
Girdhari devi
Chagani devi
50/F
66/F
Urine Blood
Pseudomonas species over 1 lac organisms/cc. cultured.
Staphylococci coagulase positive, cultured. Sample was sterile after 72 hours of aerobic incubation at 37 ˚C. Sample was sterile after 48 hours of aerobic incubation at 37 ˚C.
Pus
E.coli over 1 lac organisms/cc. cultured.
SUMMARY
Twenty hospitalized surgical cancer patients with suspicion of having POI were studied. The selection of the patients for the present study was made on the basis of their certain clinical syndromes / effects e.g. Pain, swelling, inflammation, fever, pus formation, pneumonia, diarrhoea, UTI etc. Clinical samples from all those patients were collected and tested for the presence of any pathogenic microorganisms. Samples from 6 patients showed positive results e.g. significant bacterial growth (< 10 5 CFU / ml.) on nutrient agar medium. The isolation, identification, and confirmation of microorganisms was done by different morphological and biochemical tests. After screening, Pseudomonas, E.coli, Staphylococci were found to be the causative agents of SSIs / POIs. Pseudomonas aeruginosa was found to be the major causative agent of SSIs / POIs. Even after being a short term study, it has demonstrated that Pseudomonas aeruginosa is the predominant cause of SSIs / POIs.
AIM
This project was done with the aim, to make awareness about the fact that even after undergoing surgery for the treatment, a patient’s life should not be considered as totally out of the danger, as there arises a possibilility of having a post operative or a surgical site infection. Cancer patients are prone to this danger due to the consumption of different chemotherapeutic drugs and thus becoming immunocompromised. Even after, the surgical procedure has been carried out in a very sophisticated hospital, the
Public Health Importance of SSIs Postoperative infection is a major cause of
Postoperative infection is a major cause of patient injury, mortality and health care cost: second most common nosocomial infection (24% of all nosocomial infections) An estimated 2.6 percent of nearly 30 million operations are complicated by surgical site infections (SSIs) each year. Each infection is estimated to increase a hospital stay by an average of 7 days and add over $3,000 in charges (1992 data). Appropriate preoperative administration of antibiotics is effective in preventing infection. According to the CDC’s National Nosocomial Infections Surveillance (NNIS) system : 38% of all nosocomial infections in surgical
What is Post operative infection?
A post operative or surgical site infection, is the infection that occurs after an operation or a surgery. Post Operative Infections (POIs) are also known as ‘Surgical Site Infections’(SSIs) or ‘Wound Infections’(WIs) . The CDC definition states that only infections occurring within 30 days of surgery (or within a year in the case of implants) should be classified as SSIs.
Occurrence
A surgical site infection can occur when the infectious agents from the skin, other parts of the body or the environment enter the surgical site and multiply in the tissues. As a result, there may be inflammation, pus, swelling, pain and fever. The infections acquired in the hospital cause anxiety & discomfort, complicate illness and delay the recovery process. Following three factors are the determinants of any infectious process: The infecting organism (in surgical patients, usually bacteria). The environment in which the infection takes
CDC Definition of Surgical Site Infections
Superficial incisional surgical site infections These involve only the skin and subcutaneous tissue around the incision. Symptoms of these infections include pain or tenderness, localised swelling, redness or heat . Deep-incisional surgical site infections These involve deep soft tissues, such as the fascia and muscles. Symptoms include an abscess , fever (>38°C), localised pain or tenderness . Organ / Space surgical site infections These involve any part of the anatomy (e.g. organs, spaces) other than the incision that was manipulated during the operative procedure.
Stratification of risk for SSIs
Class1 : Clean Non-traumatic, primarily closed; no acute inflammation ; no break in technique; respiratory, gastrointestinal, biliary and genitourinary tracts not entered.
Class3 : Contaminated-Non-
purulent inflammation; gross spillage from the gastrointestinal tract; entry into biliary or genitourinary tract in the presence of infected bile or urine; major break in technique.
Class 2 : Clean Contaminated- Elective opening of respiratory, gastrointestinal, biliary or genitourinary tract with minimal spillage (e.g. appendectomy) not encountering infected urine or bile; minor technique break.
Class 4 : Dirty-
Purulent inflammation (e.g. abscess); preoperative perforation ofrespiratory, gastrointestinal , biliary or genitourinary tract.
Rates of infections
Incidence varies from 1.5 to 13 / 100 operations. Infection rates in US National Nosocomial Infection Surveillance (NNIS) system hospitals were reported to be: 2.1 % (clean), 3.3 % (clean-contaminated), 6.4% (contaminated ) & 7.1% (dirty wounds) . Probability of SSI = x + a (bacteria) + b (environment: local factors) + c (host defense mechanisms: systemic factors) – omitted.
Nature, Diagnosis and Treatment of Surgical Infections Different kinds of SSIs, caused by different kinds of pathogens are as follows:
Soft tissue infections, Necrotizing soft tissue infections, Intra abdominal and retroperitoneal infections, Prosthetic (Catheter) device associated infections, Central nervous system infections, Oroesophageal infections, Blood stream infections (BSI) / Bacteremia.
Soft tissue infections Subcutaneous abscess - pus filled central portion surrounded by a vascularized zone. e.g. Superficial abscesses on trunk, head (S.aureus and Streptococci) .Cellulitis - intact blood supply & viable tissue, with inflammation & edema. Treatment done with antibiotic therapy.
Necrotizing Soft tissue infections
A layer of necrotic tissue, not surrounded by a clear boundary. e.g. Clostridial myonecrosis or. gas gangrene (C.perfringens, C.septicum). Treatment done by removing areas of necrotic tissue.
Intra abdominal and retroperitoneal infections These infections include Intra abdominal abscesses, sub hepatic abscesses, enteritis etc. Yield different aerobic and anaerobic pathogens. Symptoms include fever, abdominal pain, fluid shifts. Treatment done by operative intervention, drainage, and antibiotic therapy.
Central nervous system infections
Prosthetic device associated infections Usually caused by the exogenous & endogenous microflora of body e.g. endocarditis. (Staphylococcus aureus, Coag. negative staphylococci ,Candida), These infections results in complications of vascular grafts, cardiac valves, pacemakers and artificial joints. Treatment done by intensive antibiotic therapy & replacement with a new uninfected device.
Oroesophageal infections Infections of upper GI tract that occurs due to extensive use of cancer chemotherapy. As a consequence mucosal candidiasis (Candida spp.), substernal burning (C.esophagitis), ulcerations (Cytomegalovirus and Herpes virus) occur.
Blood stream infections (BSI) / Bacteremia Primary :- Isolation of bacterial blood pathogen in absence of infection at another site. Secondary : - When bacteria are isolated from the blood during an infection with the same organism at another site. i.e. UTI, LRI. Sources :- vascular catheters, multidose medication vials, autoinfection. Causative agents are gram positive bacteria and fungi.
Diagnosis and Treatment
S&S: -fever -swelling -erythema -localized pain -incision tenderness -leukocystosis variable Most infections are superficial anduncomplicated
Treatment:
skin and subq in involved area opened – underlying fascia examined for dehiscence -gram stain any purulent drainage -debridement necrotic tissue -antibiotics only for complicated infections or patient high risk for dissemination of infection (i.e. diabetics; immnunocompromised)
Pathogenesis of SSI
Relationship equation
Dose of bacterial contamination x Virulence Resistance of host SSI Risk
Pathogenesis of SSIs Pseudomonas aeruginosa Enterococcus Coag-neg staphylococcl E-coli Staphylococcus aureus Other
SSI Risk Factors
Age Obesity Diabetes Malnutrition Prolonged preoperative stay Infection at remote site Systemic steroid use Nicotine use
Hair removal/Shaving Duration of surgery Surgical technique Presence of drains Inappropriate use of antimicrobial prophylaxis
Prevention
Use prophylactic antibiotics appropriately (selection, timing, duration of AP) Engineering & architectural advances in modern operating rooms (UV, laminar flow ventilation systems) . Patients Preoperative Preparations : Avoid shaving operative site (hair removal technique) Maintain glucose control oxygen tension Thermoregulation Operating room team discipline Surgical Attire (Scrub suits, Cap/hoods, Shoe covers, Masks, Gloves , Gowns)
METHODS
Collection and Transport of Samples: Blood sample :- The elbow skin disinfected by spirit and 5% carbolic acid solution. A fixed vein located and venipuncture performed. Required amount of blood sample collected in special, anticoagulant (Sodium citrate) containing, clean and sterile, blood collecting glass vials. Urine sample :- The vulva or. penis, wiped with cotton swab soaked in normal saline and 5 -10 ml. urine sample collected in sterile and wide mouthed screw capped bottles. Pus sample :- Lesion first cleaned with a swab soaked in warm normal saline, then pus aspirated with syringe and carried in sterile container to the laboratory. Tip of Central Line as sample :- This is the part of a catheter, inserted during operation for monitoring fluid balance and infectious agents. It was also taken for detection of infection. This part of the catheter
Culture The clinical samples collected in the above manner were inoculated by simple streaking method on the nutrient agar medium plates and then incubated at 37 ˚C for 24 hrs. After incubation the bacterial growth was observed and then to further differentiate the bacterial colonies, these were inoculated on selective media, as Mac Conkey’s agar and Blood Agar medium and after incubation at 37 ˚C for 24 hours., bacterial growth was observed Isolation and characterization of the bacterial isolates Isolation :- The isolation was done on the nutrient agar medium, Mac Conkey’s Agar medium and Blood Agar media. The samples collected were inoculated on these media plates and colonial growth was observed. The isolated bacterial colonies were sub cultured and incubated .These plates were observed for growth of pure colonies.
Details of the patients, test samples and identification of the microorganisms.
S.No
Patient’s name
Age / Sex
Date of surgery
Date of sample collection
Sample type
Sheela Sharma
65/F
5.5.06
8.5.06
Purushottam Das
60/M
6.5.06
8.5.06
Urine
Sample was sterile after 48 hours of aerobic incubation at 37 ˚C.
Mahaveer Prasad
50/M
9.5.06
14.5.06
Pus
Pseudomonas species over 1 lac organisms/cc. cultured.
10.5.06
16.5.06
Urine
Sample was sterile after 72 hours of aerobic incubation at 37 ˚C.
Mr. Pala
56/M
Blood
Microorganisms identified
Sample was sterile after 72 hours of aerobic incubation at 37 ˚C.
Prem Kumar
45/M
15.5.06
19.5.06
Urine
Sample was sterile after 48 hours of aerobic incubation at 37 ˚C.
Ranjeet
50/M
16.5.06
18.5.06
Urine
Sample was sterile after 72 hours of aerobic incubation at 37 ˚C.
Nitesh Kumar
48/M
20.5.06
24.5.06
Pus
24.5.06
1.6.06
Tip of Central line
Mrs. Usha Singhal
39/F
E.coli over 1 lac organisms/cc. cultured. Sample was sterile after 72 hours of aerobic incubation at 37 ˚C.
Godawari devi
30/F
24.5.06
26.5.06
Urine
Sample was sterile after 72 hours of aerobic incubation at 48 ˚C.
Hetram
25/M
25.5.06
27.5.06
Urine
Sample was sterile after 72 hours of aerobic incubation at 37 ˚C.
Mr. Sardul.Singh
52/M
31.5.06
2.6.06
Pus
Mannu Ram
60/M
2.6.06
5.6.06
Urine
Sample was sterile after 72 hours of aerobic incubation at 37 ˚C.
Mast. Ajay Kumar
15/M
3.6.06
13.6.06
Pus
Sample was sterile after 72 hours of aerobic incubation at 37 ˚C.
Narayani devi
60/F
9.6.06
10.6.06
Pus
Pseudomonas species over 1 lac organisms/cc. cultured.
Mrs.Prabha
35/F
10.6.06
12.6.06
Urine
Sample was sterile after 48 hours of aerobic incubation at 37 ˚C.
Shyam Sunder Gupta
60/M
11.6.06
19.6.06
Urine
Sample was sterile after 48 hours of aerobic incubation at 37 ˚C.
Mohini devi
65/F
19.6.06
24.6.06
Pus
Fojer
55/M
19.6.06
22.6.06
20.6.06
23.6.06
21.6.06
23.6.06
Girdhari devi
Chagani devi
50/F
66/F
Urine Blood
Pseudomonas species over 1 lac organisms/cc. cultured.
Staphylococci coagulase positive, cultured. Sample was sterile after 72 hours of aerobic incubation at 37 ˚C. Sample was sterile after 48 hours of aerobic incubation at 37 ˚C.
Pus
E.coli over 1 lac organisms/cc. cultured.
SUMMARY
Twenty hospitalized surgical cancer patients with suspicion of having POI were studied. The selection of the patients for the present study was made on the basis of their certain clinical syndromes / effects e.g. Pain, swelling, inflammation, fever, pus formation, pneumonia, diarrhoea, UTI etc. Clinical samples from all those patients were collected and tested for the presence of any pathogenic microorganisms. Samples from 6 patients showed positive results e.g. significant bacterial growth (< 10 5 CFU / ml.) on nutrient agar medium. The isolation, identification, and confirmation of microorganisms was done by different morphological and biochemical tests. After screening, Pseudomonas, E.coli, Staphylococci were found to be the causative agents of SSIs / POIs. Pseudomonas aeruginosa was found to be the major causative agent of SSIs / POIs. Even after being a short term study, it has demonstrated that Pseudomonas aeruginosa is the predominant cause of SSIs / POIs.
