Surgical site infections in gynaecology

● JOURNAL
OF PUBLIC
HEALTH,
NURSING
AND
MEDICAL
RESCUE
● No.4/2013
(16-21)
● JOURNAL
OF PUBLIC
HEALTH,
NURSING
AND
MEDICAL
RESCUE
● No.4/2013
● ●
16
Surgical site infections in gynaecology
(Zakażenia miejsca operowanego w ginekologii)
B Stawarz1 A,D,F, M Sulima2 E, M Lewicka2 E, I Brukwicka1B
Abstract – Despite advances in prevention and treatment, modern
medicine is faced with increased risk of infections. Nosocomial infections are infections contracted while a patient was receiving health
benefits as long as the disease was not in the incubation period at the
time of healthcare provision or occurred after the healthcare provision, but no longer than the longest possible incubation period. Frequently an infection is considered nosocomial if it was contracted 4872 hours after admission or discharge of a patient to/from hospital.
Nosocomial infections occur most often in the form of urinary tract
infections (35%), surgical site infections (25%), blood infections
(10%), pneumonia (10%) and others (20%).
In gynaecology departments, one of the most common infections is
the surgical site infection, i.e. infection to the location of surgical
incision. The percentage of infections in gynaecological departments
ranges from 0.89% to 1.6%, and the duration of the treating patients
with infections is twice as long as treating patients without intercurrent infections. The risk of surgical site infections is influenced by
factors associated with a patient, procedures and medical care as well
as hospital environment. Risk factors for surgical site infections include the degree of cleanliness of the operating field, the duration of
treatment and the patient's condition. The risk of contracting a surgical site infection also occurs in connection with the mode of operation. Emergency operations are exposed to the greatest risk, as there
is usually not enough time to eliminate the source of infection.
Prevention of surgical site infections in gynaecology departments
should be based on modern organization of the department, the appropriate preparation of patients for surgery, the use of perioperative
antibiotic prophylaxis, appropriate post-operative care, monitoring
the development of infections by medical personnel and the implementation of appropriate procedures in the event of infection detection. Prevention of nosocomial infections, including surgical site
infections, contributes to an optimal treatment effect, shortens the
hospital stay, reduces the costs of treatment and decreases the intensity of complications among patients.
Key words - infections, gynaecology, operating site, prevention.
Streszczenie – Współczesna medycyna pomimo osiągnięć w dziedzinie profilaktyki i leczenia, zmaga się ze zwiększonym ryzykiem występowania zakażeń. Zakażenie szpitalne to zakażenie, które wystąpiło w związku z udzieleniem świadczeń zdrowotnych, w przypadku,
gdy choroba nie pozostawała w momencie udzielania świadczeń
zdrowotnych w okresie wylęgania albo wystąpiła po udzieleniu
świadczeń, w okresie nie dłuższym niż najdłuższy okres jej wylęgania. Najczęściej zakażenie uznaje się za szpitalne, jeżeli wystąpiło
48-72 godziny od przyjęcia lub wypisania ze szpitala. Zakażenia
wewnątrzszpitalne występują najczęściej pod postacią zakażenia dróg
moczowych (35%), miejsca operowanego (25%), zakażeń krwi
(10%), zapaleń płuc (10%) i innych (20%).
W oddziałach ginekologii do jednych z najczęściej występujących
zakażeń zalicza się zakażenie miejsca operowanego, oznaczającego
infekcję miejsca, które zostało nacięte podczas operacji ginekologicznej. Odsetek zakażeń w oddziałach ginekologicznych wynosi od
0,89% do 1,6%, a czas leczenia pacjentek z zakażeniami jest dwukrotnie dłuższy aniżeli czas leczenia chorych bez współistniejących
zakażeń. Na ryzyko wystąpienia zakażenia miejsca operowanego mają
wpływ czynniki związane z chorą, procedury pielęgnacyjne i lecznicze
oraz środowisko szpitala. Do czynników ryzyka wystąpienia zakażenia
miejsca operowanego zaliczają się stopień czystości pola operacyjnego, czas trwania zabiegu oraz stan zdrowia pacjentki. Ryzyko rozwoju
zakażenia miejsca operowanego występuje również w związku z trybem zabiegu operacyjnego. Największym ryzykiem obarczone są operacje ze wskazań nagłych, przy których jest zbyt mało czasu na wyeliminowanie źródła zakażenia.Zapobieganie zakażeniom miejsca operowanego w oddziałach ginekologii powinno polegać na nowoczesnej
organizacji oddziału, właściwym przygotowaniu pacjentki do zabiegu,
zastosowaniu antybiotykowej profilaktyki okołooperacyjnej, odpowiednio prowadzonej opiece pooperacyjnej, monitorowaniu rozwoju
zakażeń przez personel medyczny oraz odpowiednim postępowaniu w
sytuacji wykrycia zakażenia. Zapobieganie zakażeniom szpitalnym, w
tym zakażeniom miejsca operowanego, przyczynia się do uzyskania
optymalnego efektu leczenia, skrócenia czasu hospitalizacji, redukcji
kosztów leczenia oraz zmniejszenia powikłań wśród chorych.
Słowa kluczowe - zakażenia, ginekologia, miejsce operowane, profilaktyka.
Author Affiliations:
1. Institute of Health Protection, The Bronisław Markiewicz State
Higher School of Technology and Economics in Jarosław
2. Department of Obstetrics, Gynaecology and Obstetrical - Gynaecological Nursing, Faculty of Nursing and Health Sciences, Medical University of Lublin.
● JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE ● No.4/2013 ●
Authors’ contributions to the article:
A. The idea and the planning of the study
B. Gathering and listing data
C. The data analysis and interpretation
D. Writing the article
E. Critical review of the article
F. Final approval of the article
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 late infections - developing after day 7 at the hospital
(day 3 for neonates).
3. form and location:
 local infections (skin infections, mucosa infections, superficial operating site infections),
 Systemic infections (urinary tract infections, pneumonia)
 Disseminated (general) infections (sepsis, septic shock)
[2,6,7].
Correspondence to:
Barbara Stawarz, MD, PhD, Ostrów 109, PL-37-550 Radymno, Poland; e-mail [email protected]
I. INTRODUCTION
osocomial infections are one of the modern medicine’s
largest problems. Acknowledging the existence of infections and their consequences as well as knowledge on
their causes, etiological factors and clinical symptoms may
lead co controlling and fighting infections in a proper way
[1,2,3].
In Poland, issues related to nosocomial infections have legal
responsibilities and rights imposed upon them. The main regulation on this matter is the Act of 5th December 2008 on prevention and treatment of human infectious diseases (Dziennik
Ustaw 2008, No 234, item 1570), according to which a nosocomial infection is the one that is contracted while a patient
was receiving health benefits as long as the disease was not in
the incubation period at the time of healthcare provision or
occurred after the healthcare provision, but no longer than the
longest possible incubation period. Most of the time, an infection is deemed nosocomial if it was contracted with the period
of 48-72 hours after the patient was admitted to hospital or
discharged from it [4].
According to the report for the European Society for Health
Promotion "PRO-SALUTEM", nosocomial infections are most
common in the form of urinary tract infections (35%), postoperative wound infections (25%), blood infections (10%),
pneumonia (10%) and others (20%) [5].
Infections can be divided into groups on the basis of:
1. The mechanism and the etiological factor:
 endogenous – a patient’s internal flora causes the infection,
 exogenous – the infection is caused by microorganisms
acquired from the hospital environment,
 ungraded (e.g. intrauterine and perinatal infections).
2. The time of occurrence:
 early infections – developing before day 5-7 at the hospital (day 3 for neonates),
N
II. RISK FACTORS OF NOSOCOMIAL
INFECTIONS
The risk factors of nosocomial infections are defined as
likelihood ratios of infections stemming from the difference in
the frequency of infections, be the predisposing factor present
or absent.
Accordingly, three types of risk factors are distinguished:
1. Factors dependent on the microorganism – i.e. the type
of bacteria and the degree of infectiousness, virulence and susceptibility to antibiotics. This group of features impact the
infected person’s immunity.
2. Factors dependent on the biological condition of the infected person – they are, among others, immunological deficiencies related mainly to age, underlying pathologies (e.g.
diabetes, cancer, burns, congenital defects, compound fractures, polytrauma, proliferative haematological disorders, also
nutritional status (obesity, malnutrition), addictions and concomitant diseases.
3.
Factors related to diagnostics, treatment and care –
mainly invasive diagnostic and treatment techniques such as
breaking the continuity of tissues – catheterising blood vessels,
haemodialysis as well as catheterising urinary bladder, intubation, implants or mechanical lung ventilation. These treatments
potentially clear the way for an infection and cause the microorganisms in the patient’s natural flora to move [6,7].
III. SURGICAL SITE INFECTIONS IN
GYNAECOLOGICAL DEPARTMENTS
One of the most common infections at gynaecology departments is surgical site infection – i.e. infection to the operative
incision location. A relevant element of the surgical site infection is the time that has passed after the surgery [8,9]. The
most frequently distinguished etiological factors are: E. coli,
Enterobacter, Klebsiella, Gardnerella, Bacteroides fragilis,
Ureaplasma and Enterococcus [2,10].
The risk of contracting a surgical site infection is related to
the mode of surgery. The highest risk is present during emer-
● JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE ● No.4/2013 ●
gency operations as there is too little time to eliminate the
sources of infection. The technique used determines the postoperative condition of the wound. After the surgery is over, the
surgical wound is closed using stitches, special strips or clips.
Studies have shown that strips are more successful at protecting the wound from infections during the first days after the
surgery [11].
Clinical forms of operating site infections include: superficial infections of the surgical site (incision location) and
deep/organic infection of the surgical site, including lesser
pelvis infections. Superficial infections show at the incision
location and involve the skin and subcutaneous tissue. What is
more, at least one of the following conditions is fulfilled: pus
leak from the incision, positive results of a microbiological test
of the wound drainage, at least one clinical symptom of inflammation or a diagnosis of infection by a doctor. Deep infections are visible at the surgical site within 30 days after the
surgery. That pertains to the tissues above the fascia and at
least one of the following conditions is fulfilled: pus leaks
from the incision, the wound opens by itself or a doctor opens
it when there’s a symptom of inflammation, an abscess or
some other symptom visible during a direct examination or a
diagnosis of infection by a doctor. The infections of organs or
cavities show at the surgical site within 30 days after the surgery. That pertains to each organ or area violated during the
surgery apart from skin and subcutaneous tissue, fascia and
muscles near the incision location and when one of the following conditions is fulfilled: pus leak from a drainage tube inserted in an organ or cavity, positive results of a microbiological test of the organ or cavity, an abscess or some other symptom of infection visible either at the direct examination during
another surgery or in histopathology or radiology a diagnosis
of infection by a doctor [11,12,13].
The risk of surgical site infection may be:
I. determined by surgical techniques: the depth of surgical
site, tissue necrosis and ischemia, the size of the incision,
haemorrhages, hematomas, drainage tubes inserted, duration
(with surgeries that last over 2 hours, the exposure is highest),
the degree of operative field contamination, skin infections of
the operating theatre personnel, improper equipment sterilization, surgeries related to the application of chemotherapy,
immunosuppressive drugs, steroids, excessive movement of
the personnel in the operating room, improper ventilation of
the operating field;
II. caused by the patient’s condition: concomitant diseases
(diabetes, malnutrition, decreased serum albumin, cardiac failure), age, nutritional status (malnutrition, obesity), carrier state
(viral hepatitis, staphylococcus in nasopharynx), skin diseases
(mainly infections), smoking, tooth decay, chronic nidi;
III. dependent on the perioperative care provided: too few
sanitary facilities for the number of patients, wrong antibiotics
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policy, prolonged preoperative hospitalisation, removing hair
in the operating field, wrong skin disinfection in the operating
field, improper bandage change, improper sterilisation and
disinfection of the medical equipment, failure to observe aseptic and antiseptic rules and mistakes in training medical staff
[3,7,14].
The symptoms of surgical site infections can be divided into
local and general ones. Local infections are the infections of
skin and subcutaneous tissue and their symptoms are: pain
(dolor), the reddening of wound edges (rubor), increased tension, oedema and dehiscence of the wound edges (tumor),
drainage (usually pus), increased temperature (calor) as well
as fever occurring between 4 and 8 days after the surgery
(6,9,15). Fever is one of the first symptoms of a surgical site
infection. It usually appears from 5 to 10 days after the surgery. If so, it is an indication to re-examine the surgical
wound. The pain in the wound is a proper reaction of the organism to the trauma, which decreases with time after the surgery. If pain lingers for a prolonged period of time or it is limited to one spot, the wound infection can be suspected. Strong
pain is especially characteristic of anaerobic bacteria. Insignificant reddening is a normal symptom after surgeries; it is related to counter-irritation caused by the surgical trauma (it is
gone 2 or 3 days after the operation). If the reddening does not
disappear in that time, a surgical site infection might have been
contracted. The edges of a wound that is healing correctly are
usually soft; if they are hard, an infection can be suspected.
Often, there is a slight drainage from the post-surgical wound
during the first days after the surgery (the liquid is thin and
straw-yellow and contains some blood, it is the so-called serosanguinous drainage). If the drainage goes on for too long or
the colour or thickness changes, an infection has been contracted [11,16].
General infections that penetrate into deeper tissues
and organs may cause a systemic inflammatory response syndrome (SIRS), the formation of remote metastatic foci, abscesses or meningitis. Surgical site infections may lead to tenatus, gas gangrene and necrotizing fasciitis [9].
IV. THE PREVENTION OF SURGICAL SITE
INFECTIONS AT GYNAECOLOGICAL
DEPARTMENTS
Surgical site prophylaxis is threefold: preoperative, perioperative (preparing the patient for the surgery) and postoperative [17,18,19].
The preoperative prophylaxis includes identifying risk
group patients and decreasing the duration of hospitalisation
before the surgery by as much as possible. The condition of
the patients who are to undergo gynaecological surgeries is
● JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE ● No.4/2013 ●
subject to a thorough analysis of the existing risk factors of
surgical wound infection. One of the preventive methods is to
shorten the preoperative hospitalisation time. This method
prevents from colonisation by multiresistant hospital strains.
These strains inhabit digestive tract, upper respiratory tract and
skin during the first 5 days of hospitalisation [17,19].
The perioperative prophylaxis also involves preparing the
patient for a surgery, the preparations of the surgical team and
the theatre as well as implementing the procedure according to
specified standards. With the current intensity of infections,
preventive measures applied before the surgery are of crucial
significance. It is recommended to apply hygienic skin preparation (a bath and a proper disinfection directly before the incision). Agents used to clean the whole body should be chemically consistent and biocidal. The use of chemicals containing
chlorhexidine during the bath decreases the skin bacteria level
by nine times. Currently, a shower or a bath with an antiseptic
agent applied is recommended 6 to 12 hours before the surgery
and in the morning on the day of the surgery [20,21,22].
Sometimes it is necessary to remove the hair from the operating field before the surgery. The best equipment to do so is a
surgical clipper. Shaving with a clipper should be performed
on the day of the surgery. The risk of incision site infection is
the lowest when the hair is removed 1 to 2 hours before the
surgery [9,22].
Preparing the incision location and the area in its proximity
aseptically before the surgery has crucial significance in the
surgical site infection prevention. The aim of the disinfection
is to remove the microorganisms from the skin. A right chemical should be characterized by: a wide range of antimicrobial
activity, a prolonged biocidal effect, short drying time, no
smell, no skin irritation effect and no reactivity with drainage
and blood from the wound [22,23]. The effectiveness of the
disinfection is dependent on the concentration, the application
method and the activity time (the longer the time, the lower the
effectiveness) as well as the type of skin and the characteristics
of the patient’s physiological flora. The disinfection of the
operating field performed in accordance with the standards
guarantees the removal of the entire permanent flora and most
of the temporary flora. Of special significance is also the disinfection of medical staff’s hands and using sterile personal protective equipment – gloves, masks and gown [7,22,24].
Another element of perioperative infection prevention is
draping the surgical site. A material commonly used to place
around the site were reusable cotton cloths. Because of their
drawbacks (they could be penetrated by microorganisms) they
were replaced by disposable synthetic foil. This material clings
tightly to a patient’s skin and prevents from microorganism
migration. Also, it minimises the number of clamps used,
which is beneficial as clamps often violate the skin and break
the securing material. Yet another modern surgical site draping
19
method is a fluid microbiological barrier, which, as a result of
polymerisation, creates a protective layer. Thanks to that the
pathogen is immobilised and it retains the biocidal effect of the
disinfection chemicals used previously [22,24,25,26,27].
Among the preventive measures that decrease the risk of
surgical wound infection, mechanical protection is of greatest
significance. That role is performed effectively by the Alexis
wound retractor. This method is successfully used in surgical
practice, especially in the cases of high-risk patients, in which
group one has to include patients undergoing gynaecological
surgeries. According to some authors, mechanical protection
of surgical wounds should be one of the basic elements of
preventive measures applied in order to decrease the number
of surgical wound infections [28].
Another great impact on the surgical site infection prevention is the preparation of the surgical team and theatre. The
possibility of microorganism transportation is reduced by surgical hand washing and using sterile medical gloves. Any
members of staff with skin lesions of hands and face should be
excluded from the procedure. The same applies to any carriers
of methicillin-resistant Staphylococcus aureus (MRSA) and
the Staphylococcus aureus strains causing TSS (Toxic Shock
Syndrome). It is also necessary to minimise the number of
people remaining in the room and their movement – the prohibition form leaving or entering the room needlessly should be
rigorously observed [9,29].
Proper sterilisation of surgical equipment, ventilation system that lets clean air into the operating theatre (with 20-grade
filtration) as well as proper cleaning of the theatre (washing
and disinfection) prevent infections triggered by environment
from occurring. Gynaecological surgeries often require the use
of drainage tubes. The benefit of that is the facilitation of fluid
removal, as a result of which the wound is cleaned. Nevertheless, if the tubes are improperly inserted, the insertion point is
not cared for appropriately or the containers are not emptied, it
clears the way for microorganisms to enter [9,13,22,30,31].
Antibiotic perioperative prophylaxis consists in applying an
antibiotic shortly before the surgery or upon the inoculation of
the bacteria. The purpose of the treatment is to decrease the
probability of post-operative wound infections as well as remote infections. The essence of antibiotic prophylaxis is also
maintaining the proper concentration of antibiotic during the
whole surgery. The dosing method is based on the doubled
biologic half-life of the antibiotic. One dose before the surgery
is enough to ensure that the antibiotic level is appropriate
throughout the operation. In case of haemorrhages or duration
longer than expected that dose should be applied again. It has
to be remembered that during an underlying pathology the
physiological flora is disrupted and microorganisms that are
more immune and virulent can colonise the organism. Therefore, choosing the antibiotic one should take into account the
● JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE ● No.4/2013 ●
specifics of the department as well as the epidemiological situation [8,28,32,33].
The prophylaxis in the postoperative period consists mainly
in caring for the surgical site. It should be properly secured
with a sterile bandage, which should be changed in aseptic
conditions (in a treatment room) whenever needed. While
changing, sterile materials and equipment should be used and
there should be no contact with the hand skin of the staff. One
should also observe the infection prevention standards. Failure
to comply with these rules by medical staff is a source of potential infection to the surgical site. The risk is even higher is
the wound is open or a drainage tube has been inserted
[7,11,15].
V. CONCLUSIONS
Surgical site infections are a significant problem at gynaecological departments. The prevention of such infections at gynaecology departments should consist in the modern organisation of the department, proper preparation of the patient for
surgery, the application of antibiotic perioperative prophylaxis,
appropriate postoperative care, monitoring the development of
infections by medical staff and the implementation of the appropriate procedures should an infection be detected. These
measures contribute to the optimal effect of the treatment as
well as the reduction of the duration of hospitalisation, the
costs of the treatment and the complications experienced by
the patient.
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