SURGICAL ANTISEPSIS FOUNDATIONS 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
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SURGICAL ANTISEPSIS · SURGICAL ANTISEPSIS FOUNDATIONS OF OPTOMETRIC SURGERY Richard E. Castillo, OD, DO Consultative Ophthalmology and Procedural Optometry Professor & Assistant
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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
• 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
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.