SURGICAL ANTISEPSISFOUNDATIONS OF OPTOMETRIC SURGERY

Richard E. Castillo, OD, DO Consultative Ophthalmology and Procedural Optometry

Professor & Assistant Dean for Surgical Training and Education Director, The Center for Advanced Practice Optometry

The Oklahoma College of Optometry Northeastern State University

No financial interests or conflicts

Overview• Surgical site infections are relatively rare (<2%)

in oculofacial surgery

• Most surgical site infections are the result of wound contamination at the time of surgery

• Five potential sources of infection are:

• Patient

• Surgical personnel

• Surgical environment

• Surgical instruments

• Implantable devices such as suture and alternate closure devices

Classification of surgical woundsClassification Description of Wound Infection

Risk

Class I: Clean

Uninfected operative woundNo acute inflammation

Primary closureNo break in aseptic technique

Example: routine excision on non-inflamed eyelid skin under aseptic conditions

<2%

Class II: Clean-contaminated

Minor break in asepsisElective entry into a mucosal region

Examples: conjunctival biopsy; suture briefly touches non-sterile surface

<10%

Class III: Contaminated

Inflammation without purelent drainagePenetrating traumatic wounds < 4 hours old

Major break in aseptic technique

Examples: excision of ulcerated, inflamed basal cell carcinoma

~20%

Class IV: Dirty-infected

Purulent inflammationDevitalized or necrotic tissue

Penetrating traumatic wounds >4 hours old. or with foreign bodies

Example: excision of a suppurative hordeolum

~40%

Surgical Site Infection (SSI)• A surgical site infection (SSI) is defined as

(at least 1 of the following) any surgical wound:

• That produces pus within 30 days of the procedure

• Where organisms are isolated from an aseptically obtained culture

• With at least one of the objective or subjective criteria in the table to the right AND incision is deliberately reopened by surgeon for any reason

Objective criteria Subjective criteria

Purulent drainage Erythema

Positive culture Induration

>105 organisms/gram of tissue Warmth

Tenderness

Dehisence of incision for any reason

Infection as deemed by surgeon

Normal postoperative sequelae• Incisional discomfort

• Swelling secondary to:

• Infiltrative anesthesia

• Postoperative edema

• Chemical irritation or contact dermatitis from patient application of:

• Alcohol

• Hydrogen peroxide

• Topical antibiotics

Differential Diagnosis of Surgical Site Etiology Clinical

SymptomsTime

Course

HematomaEcchymosis

Hemporrhagic bullaeProgressive painfull swelling

Immediate to 48 hours

SeromaSwellingErythema 12-72 hours

Irritant or allergic contact dermatitis

PruritusErythema

Papules, vesicles12-72 hours

Bacterial colonizationErythema without purulence

Non-purulent ExudateDelayed healing

Days to weeks

Suture reaction(Suture access)

Sterile pustuleExtruding suture material

Weeks to months

Frequent causes of wound infection• Not washing hands before and after each

patient contact

• Failure to perform an adequate surgical hand scrub

• Failure to perform an adequate surgical site skin prep

• Poor surgical technique

• Inadequate cleanliness of the surgical environment

• Bacterial colonization of a member of the surgical team

Flora• Two types:

• Normal or resident flora inhabit the skin surface and adnexal structures

• Not usually pathogenic but can be

• Embedded in adnexal structures and out of reach of the surgical scrub

• Transient flora are acquired through contact with people, objects or the environment

• The major cause of wound infection

• Loosely attached to skin surface and can be removed by washing the skin

Common Bacterial Skin FloraResident flora Transient flora

Coagulase-negative staph (>90% are S.epidermidis) Staphylococcus aureus

Anaerobic diphtheroids (P. acnes)

Coagulase-negative staphylococci

Gram-negative organisms (Enterobacter, Klebsiella, E. coli and Proteus spp.)

Enterococcus spp.

Esherichia coliGroup A streptococci

Pseudomonas aeruginosa

Enterobacteriaceae (Serratia spp., Klebsiella spp.)

Staphylococcus aureus

• The most common cause of wound infections in oculofacial skin surgery

Comorbid risk factors for surgical site infection

• History of previous wound infection - may indicate chronic bacterial colonization

• Tobacco use within past 30 days - nicotine induced vasoconstriction

• Vascular insufficiency - reduced perfusion leads to necrosis, dehiscence, and wound infection

• Diabetes mellitus - increased risk of pseudomonas sp. colonization

• Malnutrition - considered immunocompromised state

• Alcohol abuse - considered immunocompromised state

• Intravenous drug abuse

• Chemotherapy

• Neutropenia (<1000/mm3)

• Immunosuppression

• Organ transplant recipients

• HIV/AIDS (relative risk factor)

Hands

• Surgeons hands are always washed before donning sterile gloves and after their removal

Common antiseptic agentsAgent Activity Onset Duration Comments

Isopropyl and ethyl alcohol

Gram (+/-)Mycobacteria

FungiEnveloped viruses

Very fast Minimal FlammablePoor cleanser

Use liberally and allow to dryIrritating near much membranes

Chlorhexidine gluconate

Gram (+/-)Fungi

Enveloped viruses

Fast Prolonged KeratitisOtotoxicity

Poor activity on spores & mycobacteria

Povidone-iodine Gram (+/-)Mycobacteria

FungiEnveloped viruses

Fast Intermediate(minimal if wiped or

blotted off)

Potential risk of neonatal hypothyroidism

Rapidly inactivated by blood or sputumPara-

Chlorometaxylenol (PCMX)

Gram (+)Moderate Gram (-)

MycobacteriaFungi

Enveloped viruses

Moderate Intermediate Poor pseudomonal coverage as a single agent

Activity enhanced by adding EDTA as a chelator

Alcohol-based antiseptic skin preps

• Are flammable and must be allowed to dry completely before electrocautery, radio frequency coagulation, or lasers are used

Povidone-iodine

• Has broad-spectrum activity but must be in contact with the skin 3 minutes prior to commencing procedure and then remain on the skin to have a prolonged effect

Chlorhexadine gluconate

• Has sustained broad-spectrum activity but is toxic to the cornea and the middle/inner ear

Shaving hair at the surgical site…

• Causes micro abrasions that increase the risk of infection

• Hair should be left in place or at most trimmed with scissors prior to establishing a sterile field

Proper surgical technique• Avoids compromising the environment of

the surgical wound and decreases the risk of infection

• Proper technique includes:

• Establishing and maintaining a sterile field

• Atraumatic handling of tissue

• Effective hemostatic with minimal cautery

• Limiting the amount of implanted material such as suture

There is debate…

• Over the influence of surgical attire on wound infection rate

• Gown

• Mask

• Cap

• Shoe covers

Surgical Site Infections: CellulitisA non-necrotizing inflammation of the skin and subcutaneous tissues.

Which of the following conditions increases the risk for surgical site infection (SSI)?

• Diabetes ?

• Cholecystitis

• Amyloidosis

• Alpha thalassemia

Which of the following conditions increases the risk for surgical site infection?

• Diabetes

• Cholecystitis ?

• Amyloidosis

• Alpha thalassemia

Which of the following conditions increases the risk for surgical site infection?

• Diabetes

• Cholecystitis

• Amyloidosis ?

• Alpha thalassemia

Which of the following conditions increases the risk for surgical site infection?

• Diabetes

• Cholecystitis

• Amyloidosis

• Alpha thalassemia ?

Which of the following conditions increases the risk for surgical site infection?

•Diabetes!

Which of the following is the most common site of cellulitis in general?

• Periorbital skin ?

• Hand

• Leg

• Arm

Which of the following is the most common site of cellulitis in general?

• Periorbital skin

• Hand ?

• Leg

• Arm

Which of the following is the most common site of cellulitis in general?

• Periorbital skin

• Hand

• Leg ?

• Arm

Which of the following is the most common site of cellulitis in general?

• Periorbital skin

• Hand

• Leg

• Arm ?

Which of the following is the most common site of cellulitis in general?

•Leg!• Less than 2% of surgical site infections

involve the oculofacial tissues

Which of the following pathogens is most likely responsible for a preseptal cellulitis with underlying drainage following surgical trauma?

• Vibrio vulnificus ?

• Staphylococcus aureus

• Streptococcus pneumoniae

• Pseudomonas aeruginosa

Which of the following pathogens is most likely responsible for a preseptal cellulitis with underlying drainage following penetrating trauma?

• Vibrio vulnificus

• Staphylococcus aureus ?

• Streptococcus pneumoniae

• Pseudomonas aeruginosa

Which of the following pathogens is most likely responsible for a preseptal cellulitis with underlying drainage following penetrating trauma?

• Vibrio vulnificus

• Staphylococcus aureus

• Streptococcus pneumoniae ?

• Pseudomonas aeruginosa

Which of the following pathogens is most likely responsible for a preseptal cellulitis with underlying drainage following penetrating trauma?

• Vibrio vulnificus

• Staphylococcus aureus

• Streptococcus pneumoniae

• Pseudomonas aeruginosa ?

Which of the following pathogens is most likely responsible for a preseptal cellulitis with underlying drainage following penetrating trauma?

• Staphylococcus aureus!• A transient bacterium that is the most

common pathogen isolated in oculofacial surgical site infections!

Which of the following is an indication for emergent referral and systemic workup in a patient with suspected cellulitis?

• Regional lymphadenopathy ?

• Preseptal cellulitis of the upper lid

• Tachypnea

• Infection site > 10 mm

Which of the following is an indication for emergent referral and systemic workup in a patient with suspected cellulitis?

• Regional lymphadenopathy

• Preseptal cellulitis of the upper lid ?

• Tachypnea

• Infection site > 10 mm

Which of the following is an indication for emergent referral and systemic workup in a patient with suspected cellulitis?

• Regional lymphadenopathy

• Preseptal cellulitis of the upper lid

• Tachypnea ?

• Infection site > 10 mm

Which of the following is an indication for emergent referral and systemic workup in a patient with suspected cellulitis?

• Regional lymphadenopathy

• Preseptal cellulitis of the upper lid

• Tachypnea

• Infection site > 10 mm ?

Which of the following is an indication for emergent referral and systemic workup in a patient with suspected cellulitis?

• Tachypnea!• Defined as a respiratory rate > 20 breaths per minute

• May indicate sepsis

• When coupled with hypotension mandates

• Tissue and blood cultures

• CBC

• Serum creatinine, creatine phosphokinase, CRP, serum bicarbonate

Which of the following is the more appropriate choice for outpatient treatment of a non-preseptal cellulitis in which community acquired,

CA- MRSA is NOT suspected?

• Cephalexin ?

• Linezolid ?

• Doxycycline ?

• Terbinafine ?

Which of the following is the more appropriate choice for outpatient treatment of a non-preseptal cellulitis in which community acquired,

CA- MRSA is NOT suspected?

• Cephalexin!

Preseptal Cellulitis as an SSIMedications used in the treatment of preseptal cellulitis include the following:

• Amoxicillin/clavulanic acid or intramuscular ceftriaxone. Levofloxacin and azithromycin are also options.

• Dicloxacillin, first generation cephalosporins (cefalexin, cefazolin) If MSSA S aureus (NOT MRSA!) is suspected

• Exudate should be submitted for culture & sensitivity. CA-MRSA therapy is guided by C&S and may include trimethoprim-sulfamethoxazole, rifampin, clindamycin, and fluoroquinolones.

• Patients not responding to antibiotics with 48 hours or febrile children under 2 you should be admitted to the hospital.

• Nasal/Sinus cultures may be indicated. Consult ENT.

castillo@nsuok.edu

THANK YOU NCOS!