To: Dept. of Surgery Associates From: Gloria Karr, Dir. Infection Prevention Date: May, 2012 Re: Guidelines for Infection Control in In an effort to help reduce surgical site infections, Surgical Services associates will be expected to observe the following guidelines: HAND HYGIENE/GLOVES/SHARPS: Pre-op scrub must be done following the specific product manufacturer s directions Hand washing with soap must be performed whenever hands are visibly contaminated with blood or body fluids, or if the patient has suspected or known C.difficile Alcohol-based hand gels may be used for hand hygiene when there is no visible contamination, but not for C.difficile patients. Artificial nails and nail polish are not allowed in ; nails should be kept short. Subungual areas have the highest bacterial concentrations and are frequently colonized with coag-neg staph, gram-neg rods, Corynebacteria and yeasts the same organisms implicated in our SSIs. Gloves must be worn whenever any contact with blood, body fluids, mucous membranes, non-intact skin or other potentially infectious material is anticipated; double-gloving is recommended when puncture of first set of gloves is likely. Gloves must be changed before going to a clean area from one less clean ex. After starting IV, inserting foley catheter, etc. Gloves are intended for one-time use; discard and clean hands after removal. Gloves must be removed before touching equipment that will be used by others, or on other patients, such as the computer keyboard, or monitoring devices. In a case such as this, double gloves may be used; hands should be cleaned as quickly as possible once gloves are removed. Central and arterial lines must be placed using bundle recommendations, including mask, gown, gloves and sterile drape; chloraprep must be used to clean skin. Gloves should be worn and chloraprep used on skin when starting IVs. Clean hands before handling IVs and Scrub that hub recent evidence suggests that there is a direct correlation between contamination of environmental surfaces in the and positive cultures on the internal surface of intravenous stopcocks. Utilize protective safety features on needles and other sharps; dispose promptly after use JEWELRY,CAPS, MASKS AND OTHER ATTIRE: Jewelry is not to be worn, other than small post earrings, which should be covered by a cap, or a necklace which is able to be covered by the scrub top. Necklaces, watches, rings or bracelets risk contaminating the surgical attire and make effective scrubbing difficult. Bacteria are significantly higher on the skin of the finger and wrist than on the rings, watches or bracelets themselves. Hair on head and face, sideburns, and nape of neck, must be covered by a cap when in the room, semi-restricted and sterile areas; hoods may be required to cover facial hair. Only disposable caps will be worn, since home laundering of cloth caps or scrubs is no longer recommended under the new 2012 AN standards. Wear a surgical mask when open sterile items and equipment are present; masks must be changed between procedures. Efficacy is reduced beyond 15 min of use. Masks must be removed by only handling the ties, and hands cleaned once removed. Masks should not be worn hanging from the neck
Personal items such as books, handbags, backpacks, briefcases, food or drinks, etc. must not be brought into the ; surgeons on call will hand phone to associate at desk to obtain emergency messages. Change into clean scrubs on arrival in the ; change scrubs whenever visibly soiled, or contaminated. All attire worn in the must be removed and placed in trash or laundry when leaving for an outside location (walking or in cars). If scrubs come into contact with environments outside the building, they must be changed on return to the. Surgical attire must not include personal clothing that extends above the top neckline or below the sleeve; undergarments such as T-shirts with a V-neck, which can be contained underneath the scrub top, may be worn. All non-scrubbed personnel must wear a freshly laundered or single-use long-sleeved cover jacket snapped closed, with the cuffs down to the wrists; long-sleeved attire helps containing any shedding from bare arms, including skin squamous and hair. Perioperative nurses must wear a long-sleeved gown or jacket before prepping a patient, taking care that the sleeves do not come into contact with the sterile field. Scrubbed persons who are considered part of the sterile field shall wear sterile gowns and gloves; gowns are considered sterile in front from the chest to the level of the sterile field and on the sleeves up to two inches above the elbow. Surgical attire must be changed daily and must not be worn if it becomes wet or contaminated. If cover gowns are used to cover scrubs when outside the department, they must be changed daily if cloth, or discarded if disposable material. If shoe covers are used (when splashing, dripping of blood, fluids is anticipated), they must be removed when leaving the department. Perioperative personnel should wear clean shoes with closed toes and backs, low heels and non-slip soles. Shoes made of cloth or that have holes or perforations are not recommended (by AN or OSHA) due to the risk of sustaining a sharps injury from a dropped instrument/exposure to blood or body fluids. Recommendations for Antimicrobial Prophylaxis An important problem in selecting alternative agents for prophylaxis where there is possible allergy is the need, in all settings, for Gram-positive coverage for streptococci and methicillin-susceptible staphylococci. Untreated, these organisms have a high likelihood of causing infection due to a variety of virulence factors. If cephalosporins or penicillin derivatives cannot be used, clindamycin remains the best alternative. In addition, so called community acquired MRSA (CA-MRSA) are commonly susceptible to clindamycin, especially the USA300 strain that now predominates in the United States. This organism is replacing other strains of methicillin resistant staphylococci as the predominant pathogen in surgical site infections. Systemic aminoglycosides do not provide effective coverage for these organisms and quinolones have little activity against CA-MRSA. For this reason, where prophylaxis is needed for Gram-negative facultative and aerobic organisms, clindamycin should be added. In penicillin allergic patients undergoing procedures where Bacteroides fragilis and other anaerobes must be covered (colorectal surgery, appendectomy), gentamicin or a quinolone is recommended with the addition of clindamycin. There has been a continuing increase in Bacteroides fragilis resistance to clindamycin but this agent seems to retain sufficient activity to continue on as an effective prophylactic agent. The difficulty with replacing it with metronidazole, a more active anaerobic agent, is the loss of activity against Gram-positive organisms. The use of prophylactic vancomycin is becoming increasingly common, and we now recommend this for operative procedures in which prosthetic materials are placed. It is also recommended for patients undergoing median sternotomy or craniotomy. This is, however, a recommendation without a large body of data on effective dosing. Vancomycin has been used extensively as a therapeutic agent for MRSA. This drug has an unusual distribution and does not behave as single compartment beta-lactams do. Steady state is not reached until the fourth dose on a q12 hourly dosing regimen. PLEASE REMEMBER THAT ANTIBIOTIC DOSE SHOULD BE WEIGHT-BASED AND REPEATED F LENGTHY SURGERIES. SEE FOLLOWING CHARTS:
Surgical Service Routine Pre-op Antibiotic Penicillin or Cephalosporin Allergy Burns Cefazolin Clindamycin CABG, Other Cardiac or Vascular Colon Cefazolin, Cefuroxime, or Vancomycin 1 If B-Lactam allergy: Vancomycin 2 or Clindamycin 2 Cefotetan, Cefoxitin, Ampicillin/Sulbactam or Ertapenem 3 Cefazolin or Cefuroxime + Metronidazole If B-lactam allergy: Clindamycin + Aminoglycoside or Quinolone or Aztreonam Metronidazole with Aminoglycoside or Metronidazole + Quinolone Otolaryngology Cefazolin Plus or Minus Metronidazole Clindamycin Plus or Minus Ciprofloxacin General Surgery/Endocrine Cefazolin Clindamycin Plus or Minus Gentamicin GU Cefazolin Ciprofloxacin Plus or Minus Vancomycin Hepatobiliary (complicated) Neurosurgery Oncology Cefazolin Cefazolin Plus Vancomycin (craniotomy or implantation of a device) Cefazolin Plus Metronidazole (GI and pelvic cases only) Tobramycin Plus Vancomycin Vancomycin Oral/Maxillofacial Cefazolin Clindamycin Hip/Knee Arthroplasty Cefazolin, Cefuroxime or Vancomycin 1 Clindamycin (clean surgeries) Gentamicin Plus Clindamycin (GI and pelvic) Vancomycin (clean surgeries) Ciprofloxacin (GI and pelvic) If B-Lactam allergy: Vancomycin 2 or Clindamycin 2 Orthopedic Cefazolin Plus Vancomycin (Arthroplasties only) Vancomycin Clindamycin Orthopedic-Spine Cefazolin Vancomycin Clindamycin Obstetrics Cefazolin Clindamycin Vancomycin (if allergic to Clindamycin) Hysterectomy Plastics, Reconstructive & Hand Surgery Cefotetan, Cefazolin, Cefoxitin, Cefuroxime, or Ampicillin/Sulbactam Cefazolin If B-lactam allergy: Clindamycin + Aminoglycoside or Quinolone or Aztreonam Metronidazole + Aminoglycoside or Metronidazole + Quinolone Clindamycin Vancomycin Vascular Cefazolin Plus Vancomycin (synthetic graft only) Vancomycin Special considerations 1 Vancomycin is acceptable with a physician/apn/pa/ pharmacist documented justification for its use. 2 For Cardiac, orthopedic, and vascular surgery, if the patient is allergic to B- lactam antibiotics, Vancomycin or Clindamycin are acceptable substitutes. 3 A single dose of ertapenem is
recommended for colon procedures. Cefazolin and cefuroxime may be interchanged. 80 kg ( 176 lbs) 81 160 kg (177 352 lbs) 160 kg (>352 lbs) *Round to nearest 20 mg. Round to nearest 250 mg. Cefazolin 1 gram 2 grams 3 grams Cefuroxime 1.5 grams 3 grams 3 grams Ciprofloxacin 400 mg 600 mg 800 mg Clindamycin 600 mg 900 mg 1200 mg Gentamicin* 4 mg/kg 4 mg/kg (max 420 mg) 540 mg Metronidazole 500 mg 1000 mg 1500 mg Vancomycin 20 mg/kg 20 mg/kg (max 2500 mg) 3000 mg Therapeutic efficacy correlates most closely with a complex variable termed area under the curve. This is a variable determined by the height of the peak level and the trough level. In therapeutic settings, doses of 15 to 20 mg/kg (as actual body weight) given every 8 to 12 hour are recommended for most patients with normal renal function to achieve the suggested serum concentrations. In seriously ill patients, a loading dose of 25 to 30 mg/kg (based on actual body weight) can be used to facilitate rapid attainment of target trough serum vancomycin concentration. Prophylactic therapy is based on having effective levels of the antimicrobial present throughout the operative period from skin incision to closure, and in some settings, one or two postoperative doses. It is not known, however, if dosing vancomycin at levels below 20 mg/kg will achieve these levels quickly. The primary problem is that dosing on an actual body weight basis will mean, for a 100 kg patient, 2 grams of vancomycin, infused at a maximal rate of 1 gm/hour. This will take 2 hours preoperatively, an excessive time that consumes substantial hospital resources. We, therefore, recommend beginning the infusion 1 hour before scheduled incision and continue the infusion intraoperatively until completed. Redosing Many operations extend past the half life of the commonly used antibiotics. Current recommendations for redosing interval are given in Table 3, based upon renal function. Table 3. Intraoperative Dosing Intervals (hours) for Selected Antibiotics Based on Renal Function Antibiotic CrCl > 50 CrCl 20 50 CrCl < 20 Cefazolin 3 4 8 16 Cefuroxime 3 6 12 Ciprofloxacin 8 12 None Ampicillin/sulbactam (Unasyn) 3 6 12
Interpretation Clindamycin 6 6 6 Gentamicin 5 Call Pharmacy None Metronidazole (Flagyl) 8 8 8 Vancomycin 8 16 None The administration of systemic prophylactic perioperative antibiotics is among the most important of the currently available methods to prevent wound infection. Except for vancomycin and the fluorquinolones, the most effective time for administration is within the first 30 minutes before the incision is made. The cephalosporins provide good early penetration into the wounds. Longer acting antibiotics like vancomycin and fluorquinolones should be given between 1 and 2 hours before the incision. Redosing of antibiotics is important for short-acting antibiotics and should be given approximately 3 hours after the incision is made. Dosage should be adjusted for large body size. The combined evidence shows no benefit of administration of an antibiotic after the wound is closed in the vast majority of cases where there is not massive contamination. The practice of routine administration of 3 doses of antibiotics should be abandoned. Adjustments for redosing should be made for renal function and rate of drug elimination. Additional recommendations: Identify and treat remote infection Pre-operative smoking cessation Pre-admission chlorhexidine-alcohol skin preparation Pre-operative chlorhexidine- alcohol skin preparation Intraoperative wound edge protection Intraoperative glycemic and temperature control Gown and glove change prior to skin closure Avoid hair removal when possible, or use clippers only Select suture material which resists infection Limit use of electrocautery as much as possible Minimize trauma by gentle handling of wound Do not use drains through a working incision Prophylactic topic antibiotic solution used to irrigate wound during operation and before closure Inspired oxygen given at sufficient concentrations to maintain subcutaneous oxygen concentration of approximately 100 mm Hg and pulse ox readings above 96 Transfusion of blood products has been limited References: Updated Recommendations for Control of Surgical Site Infections. Annals of Surgery. 2011;253(6):1082-1093. 2011 Lippincott Williams & Wilkins Journal of Surgical Research, October 26, 2011