Surgical Site Infections-Review of Current

Knowledge Methods of Prevention

Nurul Fitriah La Sengka 20014101022

Melissa G. Tansil 210141010110

Nathanael Prasetio 210141010128

Alson Sambonu 16014101136

Supervisor Pembimbing :

dr. Herman Kereh, Sp.B

BAGIAN ILMU BEDAH

FAKULTAS KEDOKTERAN
UNIVERSITAS SAM RATULANGI
MANADO
2022
LEMBAR PENGESAHAN
 Jurnal Reading Stase IBS dengan Judul :
“Surgical Site Infections-Review of Current
Knowledge Methods of Prevention”

Oleh
Nurul Fitriah La Sengka 20014101022

Melissa G. Tansil 210141010110

Nathanael Prasetio 210141010128

Alson Sambonu 16014101136

Telah dikoreksi, disetujui dan dibacakan pada tanggal 18 Februari 2022

di Bagian Ilmu Bedah RSUP Prof. Dr. R. D. Kandou Manado.

Supervisor Pembimbing

dr. Herman Kereh, Sp.B

Surgical site infections – review of current knowledge, methods of prevention
Wojciech Kolasiński

Department of General and Oncologic Surgery with Urology Unit, Zgierz, Poland
Article history: Received: 07.08.2018 Accepted: 05.11.2018 Published: 07.11.2018

ABSTRACT: Introduction: Surgical site infections have accompanied humanity since the dawn of time.
Development of medicine has reduced their percentage, but still they are a huge problem to face with.
Surgical site infections cause a significant increase in a cost of hospitalization. This is the main
reason why the whole scientific world is looking for prevention of these complications.
Materials and methods: The aim of the paper is to present current views on the etiology and
methods of prevention of surgical site infection.
Results: Patients own pathogens are most often responsible for surgical site infections. In
hospitalizations over 5–7 days exogenous and hospital flora have the advantage. The most common
isolated pathogen is Staphylococcus aureus. The percentage of MRSA – resistant methicillin strains is
increasing. Pre-operative antibiotic therapy reduces the frequency of surgical site infection in many
surgical procedures. Time of administration, type and dose of antibiotic play an important role in
preventing post-operative infections. Pre-operative skin antiseptic is also important. The two most
commonly used ingredients are chlorhexidine gluconate and povidone iodine. Recent reports point
the chlorhexidine alcohol solution as an agent with a higher degree of efficacy.
Conclusions: In 2017 Centers for Disease Control and Prevention published the new guidelines for
prevention of surgical site infections. This practical tips and tricks should be implemented to every
surgical procedure.
KEYWORDS: chlorhexidine, perioperative antibiotic therapy, Staphylococcus aureus, surgical site infections

INTRODUCTION According to historical sources, even the early man

practiced wound treatment. It is evidenced by cave
Surgical site infection (SSI) is one of the most paintings found in Spain dated back to 2–30
common hospital- acquired infections, and thousand years BCE [2]. However, the first written
according to recent studies its incidence is sources trace back to Hammurabi’s reign (approx.
estimated to be 2–11% for all surgical 2000 BCE). In ancient Greece and Rome, wound
interventions [1]. SSIs are associated with healing was practiced by Hip- pocrates, Celsus and
increased treatment costs, prolonged hospi- tal Galen. The saying pus bonum et laudabile literally
stay and increased mortality. They can also cause translated as ‘good and praiseworthy pus’ was a
disfiguring scars, which can be problematic, surgi- cal dogma at the time. The presence of pus
especially for young women. was considered a sign of normal healing [3].
Hippocrates commented on wound heal- ing saying
DEFInITIOn, HISTORICAL BACKgROUnD, – ‘if the pus is white and not heinous, the health
CLASSIFICATIOn shall come; but if it is ichorous and muddy, the
death will ensue’ [4]. It was not until the 19th
Surgical site infection has replaced previously used century that a breakthrough took place that
term surgical wound infection. The name SSI was eradicated the term pus laudabile from the medical
introduced by the US Center for Diseases Control literature [2, 5]. It was then that a Hungarian
and Prevention (CDC) in 1992. obstetrician Ignaz Philipp Sem- melweis (1818–
1865) recommended that physicians wash their
hands in chlorinated water before examining
patients, which led to
a drastic decrease in mortality [6]. Nevertheless, if a foreign body was implanted and involve
it is the British surgeon Joseph Lister who would fascia and muscles;
spray phenol over surgical field, and is now
considered the father of modern asepsis [6]. 3. Organ or body cavity infection in close
Despite the passing of time and enormous proximity to the surgi- cal site – developing
advances in medical technology, the problem of within 30 days or one year if a foreign body was
surgical site infections is still valid and hard to implanted.
fight, although various methods are now used,
including e.g. air condi- tioning in operating RISK FACTORS
rooms, antibacterial foils and perioperative
antibiotic prophylaxis. Surgical wounds are traditionally classified into four
classes based on how clean or contaminated they
According to the CDC definition, SSIs can be are according to the CDC definition [7]:
divided as follows:
• Class I: clean wound: infection risk <2%, e.g.
laparotomy, breast resection, vascular
1. Superficial
– develop within 30 days since
interventions;
surgery and involve skin and subcutaneous
tissue; • Class II: clean/contaminated wound: infection
risk <10%,
2. Deep – develop after 30 days or within one year e.g. elective cholecystectomy, small bowel
resection, laryn- gectomy;
 REVIEW ARTICLE

• Class III: contaminated wound: risk infection of about 20%,

e.g. appendiceal phlegmon, gangrenous cholecystitis;
• Class IV: dirty/infected wound: risk infection >40%,
e.g. infected traumatic wounds, pus collections such as testicular abscess. The appropriate
evaluation for
surgical site infection risk is not based solely on wound classification. There is a number of other risk
factors (Tab. I.) contributing to SSI.
MICROORGANISM RESPONSIBLE FOR SSI

The skin is the largest human organ colonized by various micro- organisms, which in majority are
harmless or even beneficial to the host. It is estimated that 1 cm3 of skin contains up to three mil- lion
bacteria [8]. Skin colonization is highly variable and depends on topographic location, host’s endogenous as
well as exogenous environmental factors. Some skin areas are folded, e.g. armpit or groin. Those areas
have higher temperature and humidity, which promotes growth of bacteria that develop well in humid
environ- ment (e.g. Gram-negative bacilli, Corynobacterium spp., S. au- reus). The skin of the back and
chest contains a great number of sebaceous glands, which makes perfect conditions for lipophilic
microorganisms (Propionibacterium spp., Malassezia spp.) [9]. The major role of skin as a physical barrier
is to protect the body against potential attacks by harmful microorganisms or substances. Symbiotic
microorganisms residing on skin play a role in matura- tion of millions of T cells, thus preventing invasion of
other patho- genic organisms [9]. The most common skin pathogens and their disease-inducing potentials
are summarized in Tab. II.

Endogenous pathogens are the main culprits responsible for surgi- cal site infections. Those include
bacteria that normally reside on the skin or within the operated organ (e.g. gut bacteria in gastro-
intestinal surgery) [10]. The most commonly isolated pathogens responsible for SSI are listed in Tab. III.
According to studies by the European Center for Disease Prevention and Control (ECDC), Staphylococcus
aureus has become the most common cause of SSI in the recent years [11]. Almost half of the cases are
caused by methicillin-resistant S. aureus (MRSA) strains [12]. Upper airway colonization of surgical patients
with MRSA is associated with an increased risk of SSI [5]. In a study on 9006 patients, MRSA colo- nization
in the anterior nasal passages was found in 4.3%. In that group, MRSA was responsible for 1.86% of SSIs
compared to 0.20% in non-colonized patients [13].

Routine eradication with chlorhexidine or mupirocin poses a risk of inducing drug-resistant strains.
Therefore, it is recommended to conduct active screening and to decolonize nasal passages only in subjects
that test positive [14].

PREVEnTIng SURgICAL SITE InFECTIOnS

Preoperative phase
Surgical site shaving
A few randomized controlled trials were conducted to evaluate hair shaving around the surgical site. The
results are ambiguous. It has been established, however, that the use of safety razors causes epithelial
microinjuries and hence increases the area for potential infection [15]. Hair removal should be done only
using an electric razor with a single-use tip, optimally right before transferring the patient to the OR [16].

Nutrition
Malnutrition is a common problem in surgery and has a negative effect on patient’s condition and
surgical outcomes. According to the definition by ESPEN (European Society for Clinical Nutri- tion and
Metabolism), malnutrition is‚ a condition resulting from malabsorption or inappropriate supply of
nutrients, which leads to changes in body composition, impaired physical and mental function and has a
negative effect on treatment outcomes for the underlying disease’ [17]. Two tools can be used to evaluate
patient’s nutritional status, namely the Nutritional Risk Screening (NRS- 2002) or Nutritional Risk
 REVIEW ARTICLE

Index (NRI) questionnaires [17]. NRS 2002 was introduced by ESPEN and is calculated based on four
variables: percentage weight loss, BMI, general condition (severity of the underlying disease) and food
intake during the week prior to surgery. The end score is a sum of points (0–3) for nuritional impairment
and points for disease severity (0–3). There is also an additional point for patients aged over 70. The score
of three or more means that the patient is at high risk of malnutrition-induced complications. On the
other hand, the Nutritional Risk Index is based on serum albumin and a ratio of the actual to predicted
body weight, which can be expressed in the form of an equation: NRI
= (1.519 × albumin g/L) + (41.7 × actual/predicted body weight). The score of 97.5 or less denotes high-
risk patients [18].

Skeie et al. evaluated the nutritional status of 1194 patients un- dergoing colorectal surgery and showed
that malnutrition was an important risk factor for surgical site infections [19]. On the other hand,
Pacelli et al. analyzed the nutritional status of pa- tients undergoing gastric tumor resection and did not
find any correlation between malnutrition and surgical site infections [20]. Therefore, any evaluation of
the relationship between malnutri- tion and surgical site infection should include type and extent of
surgical intervention.

Obesity (BMI > 30) affects wound healing in many ways. Subcu- taneous vascular bed in obese individuals
is insufficient and can- not provide adequate oxygen supply. Healing tissues have a high metabolic demand
and an inadequate oxygen supply slows down the whole process. Immune cells also have a high oxygen
demand, which is used e.g. to synthesize anitmicrobial reactive oxygen spe- cies [21]. Sufficient antibiotic
concentration for perioperative pro- phylaxis is more difficult to achieve in obese patients compared to those
with normal BMI. It is caused by higher distribution volume, which necessitates higher drug doses to
obtain the same serum concentration as in non-obese patients [22]. All those factors have a negative
effect on postoperative wound healing in obese patients.

Immunosuppressive therapy
There are no uniform guidelines as to managing surgical patients on immunosuppressive therapy. In the
study by Berthold et al., it was established that immunosuppressive therapy impairs wound healing and
increases the risk of infections [23]. On the other hand, discontinuation of immunosuppression can lead
to exac- erbation of the primary disease. Guidelines published by SHEA (Society for Healthcare
Epidemiology of America) recommend stopping immunosuppressive treatment perioperatively as long
 REVIEW ARTICLE

as it is possible [24]. The risk associated with treatment cessation should be assessed individually for each
patient including his or her treating physician, surgeon and patient him- or herself. Side effects, as a result
of stopping therapy, can potentially overcome even an increased risk of surgical site infection. The risk of
adverse outcomes is particularly high in post-transplant patients as well as those treated for rheumatoid
arthritis, yet the risk is lower than in inflammatory bowel disease [25].

Antibiotic prophylaxis
Antibiotic prophylaxis is indicated for clean/contaminated wounds as well as clean wounds with implanted
foreign objects (e.g. vas- cular or joint prosthesis). For contaminated and dirty wounds, the patient should
be given not a prophylactic dose but rather a full course of antibiotics. A widely-used tool for assessing
the need for perioperative antibiotics is the NNIS (National Nosocomial Infections Surveillance) scale. It
includes three features. The first feature is wound classification regarding infection risk – for a con- taminated
or dirty wound the patient scores one point. The next stage is patient evaluation using ASA score
(American Associa- tion of Anesthesiologists). For ASA 3, 4 or 5, the patient is given one point. The third
feature is duration of surgery – when it ex- ceeds 75% of time estimated by NNIS, the patient receives 1
point. For instance, predicted duration of appendectomy is 1 hour, colorec- tal surgery – 3 hours, pancreatic
and liver surgeries – 4 hours. When the overall score is one or more points, the patient should be given
antibiotic prophylaxis. Although a single dose is preferred, next doses should be given depending on the
duration of surgery, drug’s half-life time or excessive blood loss. In most cases, the antibiotic should be
active against methicillin-sensitive Staphy- lococci, Gram-negative bacteria (community-acquired or
endog- enous pathogens) and anaerobes. For prophylaxis, the most widely used antibiotic is cefazolin, which
is active against the above-list- ed pathogens except for anaerobes. Types of antibiotics and their dosage are
summarized in Tab. IV.

In the meta-analysis, Liu et al. proved the effectiveness of preop- erative antibiotic administration versus
placebo for inguinal her- nia, breast cancer or colorectal surgery as well as Caesarean sec- tion [26].
Combined antibiotic prophylaxis (intravenous + oral) is more effective at preventing SSIs. Nelson et al.
conducted a meta- analysis, which showed that combined therapy is associated with 4.14–6.87% risk of
surgical site infection compared to intravenous (12.76%) or oral (7.95%) routes only, the differences being
statis- tically significant [27]. Perioperative antibiotic prophylaxis does not induce bacterial drug resistance
[28]. The antibiotic should be given 30-60 minutes before skin incision, ideally during anesthesia induction.
When vancomycin or fluoroquinolones have been cho- sen, the administration time should be expanded
to 60–120 mi- nutes before surgery [29]. The dose should be modified for GFR
< 60 mL/min/1.73 m2 [30].

INTRAOPERATIVE PHASE
Operating room architecture

The operating room is the heart of every surgical hospital. The ultimate goal of the operating room is to
maintain maximal sani- tary and hygienic regime. The proper microbiological regime is
 REVIEW ARTICLE

Tab. I. Risk factors of surgical site infections.

PATIEnT- SURgERY-
DEPEnDEnT DEPEnDEnT
Ag Skin
e disinfection
Nutritional status Hair shaving

Diabetes Perioperative antibiotics

Smoking Duration of surgery

Obesity Operating room air conditioning

Concomitant infections Improper instrument sterilization

Colonization with drug- Foreign body within

resistant pathogens wound
Impaired immunity Surgical site drainage
Duration of hospital stay before surgery Insufficient hemostasis
„Dead space”
Significant surgical trauma
Source: Mangram A.J., Horan T.C., Pearson M.L. et al.: Guideline for prevention of surgical site infection, 1999. Am J Infect Control 1999; 27: 105.

Tab. II. Skin pathogens.

MICROORgAnISM InCIDEnCE / VIRULEnCE

Staphylococcus epidermidis Common, sometimes pathogenic

Staphylococcus aureus Rare, pathogenic
Staphylococcus warneri Rare, sometimes pathogenic
Streptococcus pyogenes Rare, pathogenic
Streptococcus mitis Common, sometimes pathogenic
Propionibacterium acnes Common, sometimes pathogenic
Corynebacterium spp. Common, sometimes pathogenic
Acinetobacter johnsonii Common, sometimes pathogenic
Pseudomonas aeruginosa Rare, sometimes pathogenic
Source: Cogen A.L., Nizet V., Gallo R.L. (2008). Skin microbiota: a source of disease or defense?. Br J Dermatol 158 (3): 442–55.

founded on limiting contamination of all surfaces with patho- gens. It is commonly known that, for a
patient to go through the healing process without infectious complications, he or she must be kept in a
clean environment. The correctly designed operat- ing room should have zones of increasing sterility. The
personnel should walk through

scrubbing areas in order to minimize con- tamination of the OR environment with hospital pathogens.
The fundamental rule of OR organization is separation between ‚clean’ and ‚dirty’ parts. According to the
one direction rule, ‚clean’ and
‚dirty’ pathways cannot cross. Air conditioning in the OR should provide sufficient amount of fresh air
and appropriate exchange volume, usually 15–30 times room volume depending on the type of surgery. It
should also provide laminar air flow, which separates the clean zone around the operating field [31].

Surgical field asepsis

The goal is to reduce the number of potential pathogens natural- ly residing on the skin and to limit
 REVIEW ARTICLE

their growth potential during and after surgery. Two most commonly used substances for pre- operative
skin decontamination are alcohol solutions of chlorhexi- dine gluconate and povidone iodine.
Chlorhexidine is adsorbed by phosphorus-containing proteins of the bacterial cell wall. At bacteriostatic
concentration, it penetrates and damages the cell membrane causing leakage of cytoplasmic structures.
However, at bactericidal concentrations, it penetrates to the bacterial cell
Tab. III. The most common pathogens responsible for SSIs.
In the meta-analysis by Priviter et al. aimed at
comparing alco- hol solutions of chlorhexidine
PATOgEn InFECTIOn RATE and povidone iodine, it was estab- lished that
Staphylococcus aureus 30,4 chlorhexidine use resulted in lower rate of surgical
Koagulozoujemne gronkowce 11,7 site infections [39].
Enterococci 11,6
Hand disinfection
Pseudomonas aeruginosa 5,5
Escherichia coli 5 The bacteria on the hands of the medical staff can
Streptococci 4 be a source of hospital-acquired infections.
Enterobacter species 4 Staphylococcus aureus and Gram- negative bacilli
are the main components of the superficial skin
Proteus species 3 bacterial flora [40]. Chlorhexidine solution is used
Klebsiella pneumonia/oxytoca 4 to provide sur- gical sterility by reducing bacterial
Serratia species 3 count. The effectiveness of dis- infection is
Source: Sievert D.M., Ricks P., Edwards J.R. et al.: Antimicrobial- measured by logarithmic decrease in microbe
resistant pathogens associated with healthcare-associated infections: num- ber. A decrease by 1-log in the number of
summary of data reported to the National Healthcare Safety Network at bacteria means a 10-fold reduction (i.e. elimination
the Centers for Disease Control and Prevention, 2009–2010. Infect of 90% of population), while 2-log de- notes a 100-
Control Hosp Epidemiol 2013; 34 (1): 1–14. time reduction (i.e. eliminating 99%) [41].
According to the US Food and Drug Agency (FDA),
effective disinfectants are characterized by a 1-log
Tab. IV. Antibiotics used for perioperative prophylaxis. reduction in bacterial count within one minute
TYPE OF SURgERY 1ST LInE 2nD LInE
and a 2-log reduction over 5 minutes [42].
Chlorhexidine is characterized by a wide
spectrum and long-lasting antibacte- rial effect,
while alcohol rapidly starts to act. Products
containing
Clean wounds Cefazolin 1 g < 80 kg, 2 g Cefurox chlorhexidine and alcohol combine rapid start by
(e.g. cardiac when ime the alcohol with the long-lasting effect of
surgery, vascular > 80 kg. When allergic chlorhexidine, and therefore are consid- ered the
grafts, to penicillin most effective [43].
orthopedics, – cefuroxime 1.5 g, or for
craniotomy) Blood transfusion
high risk of MRSA
infection – vancomycin According to the American College of Surgeons
15 mg / kg (ACS), an exten- sive blood loss is defined as a
Clean / Cefazolin + Ampicillin
contaminated Metronidazole When + loss
wounds (e.g. allergic to penicillin: sulbactam
colorectal surgery, Levofloxacin + , cefotetan
hysterectomy, Metronidazole
appendectomy)
 REVIEW ARTICLE

Source: Wilson J.W., Estes L.L.: Mayo clinic antimicrobial therapy quick guide. 2012.

and irreversibly attaches to the ATP and nucleic acids [32]. Chlo- hexidine also shows fungistatic and
fungicidal properties and can neutralize some viruses. Minimal inhibitory concentration is lower for
Gram-positive than for Gram-negative bacteria be- cause chlorhexidine shows greater affinity to Gram-
positive cell wall [32, 33]. Povidone iodine is a solution containing 1% of free iodine. Iodine molecules
penetrate though the cell wall and cause cysteine oxygenation and iodination of other amino acids and
unsaturated fatty acids [34]. It leads to reduced protein synthesis and cell wall damage. Iodine is effective
against Gram-positive and Gram-negative bacteria, as well as some spore-forming bacteria,
Mycobacteria, viruses and fungi [34, 35]. Mixing chlorhexidine with povidone iodine or ethanol, or
isopropyl ethanol can widen the bactericidal spectrum. Alcohol denaturates proteins and pro- vokes
bacterial cell lysis. It is effective against methicillin-resistant Staphylococcus aureus, vancomycin-resistant
Enterococci and My- cobacterium tuberculosis [36].

Studies comparing chlorhexidine and povidone iodine proved that both substances show similar
antibacterial spectrum. However, chlorhexidine acts longer by covalently bonding to skin and mu- cous
membrane proteins. Contrary to povidone iodine, its action is unaffected by blood or other bodily fluids,
and hence it is com- monly used to protect vascular catheters [37]. There are contra- dictory reports on
the effectiveness of chlorhexidine and povidone iodine. In the meta-analysis by Lee et al. including 9
randomized controlled trials, the greater effectiveness of chlorhexidine was con- cluded [38]. However, the
quality of the analysis has been debated due to the fact that some studies compared alcohol chlorhexidine
solution with povidone iodine only, which distorted the analysis. volume (TBV). Perioperative blood
loss leads not only to circu- latory failure, but also to a significant loss of proteins, antibodies and
coagulation factors. On the other hand, blood transfusion leads to two types of immune response in
humans, namely im- munosuppression and immunization. Probably, it results from a reduced cell-
mediated immunity with simultaneous increase in humoral immunity. It was observed that blood
transfusion causes an increase in Th2 cell population compared to Th1 cells, as well as their reduced
cytotoxic activity and a shift in the CD4+/CD8+ cell ratio [4]. Hypoxia, deficiency of protein and
albumin, which act as drug carriers, as well as changes in immune response all predispose to impaired
wound healing and surgical site infections.

Maintaining patient’s homeostasis

According to the European Center for Disease Prevention and Control 2017 Guidelines, it is
recommended to maintain periop- erative glucose level at <200 mg/dL in both diabetic and non-di-
abetic patients (recommendation level IA). The guidelines, how- ever, do not state precisely when and
at what intervals glucose level should be measured. Glucose monitoring applies not only to diabetics
but to all surgical patients. Stress hyperglycemia is a condition in which glucose level rises in response
to a stress- ful factor e.g. surgical intervention. Hyperglycemia >180 mg/dL within 48 h after operation is
associated with an increased risk of complications including surgical site infections [45]. Body tem-
perature should be maintained within normal limits (recommen- dation level IA). Temperature drop by
1.6°C leads to coagulation disturbances, excessive intraoperative blood loss and impaired peripheral
circulation [46]. Hypothermia can also promote surgi- cal site infections [47]. Patients with normal
respiratory function, who undergo general or endotracheal anesthesia, should be given
increased FiO2 during surgery and after extubation avoiding touching wounds and dress- ings with bare
immediately after the procedure. In order to hands. Sterile saline should be used for rinsing the
optimize oxygen supply, periop- erative wound. After 48 h postoperatively, the patient
normothermia and adequate volume exchange should take a show- er and wash his or her body
should be provided (recommendation level IA). with soap. It is not recommended to use local
antimicrobial products to reduce the infection risk.
POSTOPERATIVE PHASE In the randomized study by Kamath et al., local use
of chlorampheni- col had no effect on risk reduction
After operation, wound hygiene is crucial. The of surgical site infection [48].
gold standard is ‘non-touch’ techniques, i.e.
 REVIEW ARTICLE

Clinical signs of infection traditionally include the skin in health and disease. Journal of Investigative
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Word count: 4880 Page count: 7 Tables: 4 Figures: – References: 52

DOI: 10.5604/01.3001.0012.7253 Table of content: https://ppch.pl/issue/12067

Copyright © 2019 Fundacja Polski Przegląd Chirurgiczny. Published by Index Copernicus Sp. z
Copyrig o. o. All rights reserved. The authors declare that they have no competing interests.
ht: Competing
interests:
The content of the journal „Polish Journal of Surgery” is circulated
on the basis of the Open Access which means free and limitless
access to scientific data.

Corresponding This material is available under the Creative Commons – Attribution 4.0 GB. The full terms of this
author: license are available on: http://creativecommons.org/licenses/by-nc-sa/4.0/legalcode

Cite this article as: Wojciech Kolasiński, MD; Department of General and Oncologic Surgery with Urology Unit,
ul. Parzęczewska 35, 95-100 Zgierz; Providencial Specialty Hospital, Zgierz; E-mail:
[email protected]

Kolasinski W.: Surgical site infections – review of current knowledge,

methods of prevention; Pol Przegl Chir 2019: 91 (4): 41–4
REVIEW ARTICLE
Infeksi Luka Operasi – tinjauan pengetahuan saat ini,
metode pencegahan

Wojciech Kolasiński
Departemen Bedah Umum dan Onkologi dengan Unit Urologi, Zgierz, Polandia

Abstrak:

Pengantar:Infeksi Luka Operasi telah menyertai umat manusia sejak awal waktu.
Perkembangan obat-obatan telah mengurangi persentase mereka, tetapi mereka masih
merupakan masalah besar yang harus dihadapi. Infeksi luka operasi menyebabkan
peningkatan biaya rawat inap yang signifikan. Inilah alasan utama mengapa seluruh
dunia ilmiah mencari pencegahan komplikasi ini.

Bahan dan metode:Tujuan dari makalah ini adalah untuk menyajikan pandangan
terkini tentang etiologi dan metode pencegahan infeksi luka operasi.

hasil:Patogen pasien sendiri paling sering bertanggung jawab atas infeksi luka
operasi. Di rawat inap selama 5-7 hari eksogen dan flora rumah sakit memiliki
keuntungan. Patogen terisolasi yang paling umum adalahStafilokokus aureus.
Persentase strain methicillin yang resisten MRSA meningkat. Terapi antibiotik
praoperasi mengurangi frekuensi infeksi luka operasi di banyak prosedur bedah.
Waktu pemberian, jenis dan dosis antibiotik berperan penting dalam pencegahan
infeksi pasca operasi. Antiseptik kulit sebelum operasi juga penting. Dua bahan yang
paling umum digunakan adalah chlorhexidine gluconate dan povidone iodine.
Laporan terbaru menunjukkan larutan alkohol klorheksidin sebagai agen dengan
tingkat kemanjuran yang lebih tinggi.

kesimpulan:Pada tahun 2017 Pusat Pengendalian dan Pencegahan Penyakit

menerbitkan pedoman baru untuk pencegahan infeksi luka operasi. Tips dan trik
praktis ini harus diterapkan pada setiap prosedur pembedahan.

Kata kunci: klorheksidin, terapi antibiotik perioperatif,Stafilokokus aureus, infeksi

tempat operasi

Pengantar

Infeksi luka operasi (ILO) adalah salah satu infeksi yang didapat di rumah sakit, dan
menurut penelitian terbaru, insidennya diperkirakan 2-11% untuk semua intervensi
bedah [1]. SSI dikaitkan dengan peningkatan biaya perawatan, lama tinggal di rumah
sakit dan peningkatan kematian. Mereka juga dapat menyebabkan bekas luka yang
merusak, yang bisa menjadi masalah, terutama bagi wanita muda.

Definisi, Dasar Sejarah, Klasifikasi

Infeksi luka operasi telah menggantikan istilah infeksi luka operasi yang sebelumnya
digunakan. Nama SSI diperkenalkan oleh Pusat Pengendalian dan Pencegahan
Penyakit AS (CDC) pada tahun 1992. Menurut sumber sejarah, bahkan manusia
purba mempraktekkan perawatan luka. Hal ini dibuktikan dengan lukisan gua yang
ditemukan di Spanyol yang berasal dari 2– 30 ribu tahun sebelum masehi [2].
Namun, sumber tertulis pertama melacak kembali ke pemerintahan Hammurabi
(sekitar 2000 SM). Di Yunani kuno dan Roma, penyembuhan luka dipraktekkan oleh
Hippocrates, Celsus dan Galen. Pepatah pus bonum et laudabile secara harfiah
diterjemahkan sebagai 'nanah yang baik dan terpuji' adalah dogma bedah pada saat
itu. Adanya nanah dianggap sebagai tanda penyembuhan normal [3]. Hippocrates
mengomentari penyembuhan luka dengan mengatakan – 'jika nanah berwarna putih
dan tidak keji, kesehatan akan datang; tetapi jika ichorous dan berlumpur, kematian
akan terjadi' [4]. Baru pada abad ke-19 terjadi terobosan yang menghapus istilah pus
laudabile dari literatur medis [2, 5].

penurunan kematian yang drastis [6]. Namun demikian, ahli bedah Inggris Joseph
Lister yang akan menyemprotkan fenol ke bidang bedah, dan sekarang dianggap
sebagai bapak asepsis modern [6]. Meskipun berlalunya waktu dan kemajuan besar
dalam teknologi medis, masalah infeksi luka operasi masih valid dan sulit untuk
dilawan, meskipun berbagai metode sekarang digunakan, termasuk misalnya AC di
ruang operasi, foil antibakteri dan profilaksis antibiotik perioperatif.

Menurut definisi CDC, SSI dapat dibagi sebagai berikut:

1. Superfisial – berkembang dalam waktu 30 hari sejak pembedahan dan melibatkan

kulit dan jaringan subkutan;

2. Dalam – berkembang setelah 30 hari atau dalam satu tahun jika benda asing
ditanamkan dan melibatkan fasia dan otot;

3. Infeksi organ atau rongga tubuh di dekat lokasi pembedahan – berkembang dalam
waktu 30 hari atau satu tahun jika benda asing ditanamkan.
Faktor risiko

Luka bedah secara tradisional diklasifikasikan menjadi empat kelas berdasarkan

seberapa bersih atau terkontaminasinya luka tersebut menurut definisi CDC [7]:

• Kelas I: luka bersih: risiko infeksi <2%, misalnya laparotomi, reseksi payudara,
intervensi vaskular;
• Kelas II: luka bersih/terkontaminasi: risiko infeksi <10%, misalnya kolesistektomi
elektif, reseksi usus halus, laringektomi;
 Kelas III: luka terkontaminasi: risiko infeksi sekitar 20%, contohnya
phlegmon apendiks, kolesistitis gangren;
 Kelas IV: luka kotor/terinfeksi: risiko infeksi >40%, misalnya luka traumatis
yang terinfeksi, kumpulan nanah seperti abses testis. Evaluasi yang tepat
untuk risiko infeksi situs bedah tidak hanya didasarkan pada klasifikasi luka.
Ada sejumlah faktor risiko lain yang dapat berkontribusi terhadap IDO.

Bakteri penyebab Infeksi Daerah Operasi (IDO)

Kulit merupakan organ terbesar manusia yang dapat dihuni oleh berbagai kelompok
mikroorganisme yang Sebagian besar tidak berbahaya bahkan bermanfaat bagi host.
Diperkirakan bahwa 1 cm kulit dapat ditemukan hingga tiga juta bakteri. Kelompok
bakteri sangatlah bervariasi dan dapat tergantung pada lokasi topografi, endogen host
serta faktor lingkungan eksogen. Pada beberapa area kulit yang terlipat, misalnya
ketiak atau selangkangan memiliki suhu dan kelembaban yang lebih tinggi sehingga
dapat mendorong pertumbuhan bakteri dapat berkembang dengan baik pada
lingkungan yang lembab contohnya basil gram negative, corynobacterium sp. , S.
aureus dll. Kulit punggung dan dada mengandung banyak kelenjar sebaceous, yang
merupakan tempat yang sempurna untuk mikroorganisme lipofilik
( Propionibacterium sp., Malassezia spp.). Peran utama kulit adalah untuk
melingdungi tubuh dari serangan potensial dari mikroorganisme ataupun zat
berbahaya lainnya. Mikroorganisme symbiosis yang berada di kulit juga berperan
dalam pematangan jutaan sel T, sehingga dapat mencegah invasi organisme pathogen
lainnya.

Patogen edogen adalah pathogen penyebab utama dalam infeksi daerah operasi .
Bakteri tersebut biasanya berada di kulit atau di dalam orfan yang dioperasi
( misalnya bakteri yang ada di usus dalam operasi gastrointestinal). Patogen yang
paling sering meninfeksi dan menyebabkan IDO adalah Stafilokokus aureus,
oagulozoujemne gronkowce, Enterokokus, Pseudomonas aeruginosa, Escherichia
coli, streptokokus, spesies Enterobacter, spesies Proteus, Klebsiella
pneumonia/oxytoca, dan Spesies serratia. Menurut studi oleh Pusat Pencegahan dan
Pengendalian Penyakit Eropa (ECDC), Stafilokokus aureus terlah menjadi penyebab
paling umum dari IDO dalam beberapa tahun terakhir. Hampir setengan dari kasus
disebabkan oleh resisten methicillin S.Aureus (MRSA) strain. Pada saluran napas
atas pasien bedan dengan MRSA dikaitkan dengan peningkatan risiko IDO. Dalam
sebuah penelitian pada 9006 pasien, MRSA di saluran hidung anterior ditemukan
pada 4,3%. Dalam kelompok itu, MRSA bertanggung jawab atas 1,86% IDO
dibandingkan dengan 0,20% pada pasien yang tidak terdapat kumpulan MRSA.
Penggunaan klorheksidin dan mipurosin rutin dapat menimbulkan risiko terinduksi
strain yang resisten terhadap obaT, oleh karena itu, dianjurkan untuk melakukan
skrining aktif dan dekolonisasi saluran hidung hanya pada subjek yang dites positif.

Prevensi infeksi situs bedah

Fase pra operasi
Pencukuran area bedah
Beberapa uji coba terkontrol secara acak dilakukan untuk mengevaluasi pencukuran
rambut di sekitar lokasi pembedahan dan hasilnya ambigu. Telah ditetapkam,
bagaimanapun, bahwa penggunaan pisau cukur yang aman dapat menyebabkan
cedera mikro epitel dan karena hal itu dapat meningkatkan area untuk potensi infeksi.
Pencabutan rambut harus dilakukan menggunakan pisau cukur listrik dengan ujung
yang sekali pakai dan optimalnya tepat sebelum pasien dipindahkan ke ruang operasi.

Nutrisi
Malnutrisi adalah masalah umum dalam operasi dan memiliki efek negative pada
kondisi pasien dan hasil operasi. Menurut ESPEN (European Society for Clinical
Nutrition and Metabolism), malnutrisi adalah suatu kondisi akibat malabsorpsi atau
suplai nitrisi yang tidak tepat, yang menyebabkan perubahan komposisi tubuh,
gangguan fungsi fisik dan mental, serta berdampak negatif pada pengobatan penyakit
yang mendasarinya. Dua alat yang dapat digunakan untuk mengevaluasi status gizi
pasien, yaitu kuesioner Nutritional Risk Screening (NRS-2002) atau Nutritional Risk
Index (NRI). NRS 2002 diperkenalkan oleh ESPEN dan dihitung berdasarkan empat
variabel: persentase penurunan berat badan, BMI, kondisi umum (keparahan penyakit
yang mendasarinya) dan asupan makanan selama seminggu sebelum operasi. Skor
akhir adalah jumlah poin (0–3) untuk gangguan gizi dan poin untuk keparahan
penyakit (0–3). Ada juga poin tambahan untuk pasien berusia di atas 70 tahun. Skor
tiga atau lebih berarti pasien berisiko tinggi mengalami komplikasi akibat malnutrisi.
Di sisi lain, Indeks Risiko Gizi didasarkan pada albumin serum dan rasio berat badan
aktual terhadap prediksi, yang dapat dinyatakan dalam bentuk persamaan: NRI =
(1,519 × albumin g/L) + (41,7 × berat badan aktual/prediksi). Skor 97,5 atau kurang
menunjukkan pasien berisiko tinggi. . Indeks Risiko Gizi didasarkan pada albumin
serum dan rasio berat badan aktual terhadap prediksi, yang dapat dinyatakan dalam
bentuk persamaan: NRI = (1,519 × albumin g/L) + (41,7 × berat badan
aktual/prediksi ). Skor 97,5 atau kurang menunjukkan pasien berisiko tinggi. . Indeks
Risiko Gizi didasarkan pada albumin serum dan rasio berat badan aktual terhadap
prediksi, yang dapat dinyatakan dalam bentuk persamaan: NRI = (1,519 × albumin
g/L) + (41,7 × berat badan aktual/prediksi ). Skor 97,5 atau kurang menunjukkan
pasien berisiko tinggi.
Obesitas (BMI> 30) mempengaruhi penyembuhan luka dalam banyak cara. vaskular
subkutan pada individu obesitas tidak mencukupi dan tidak dapat memberikan suplai
oksigen yang memadai. Jaringan penyembuhan memiliki kebutuhan metabolisme
yang tinggi dan suplai oksigen yang tidak memadai memperlambat seluruh proses.
Sel imun juga memiliki kebutuhan oksigen yang tinggi, yang digunakan misalnya
untuk mensintesis spesies oksigen reaktif anitmikroba. Konsentrasi antibiotik yang
cukup untuk profilaksis perioperatif lebih sulit dicapai pada pasien obesitas
dibandingkan dengan mereka dengan BMI normal. Hal ini disebabkan oleh volume
distribusi yang lebih tinggi, yang memerlukan dosis obat yang lebih tinggi untuk
mendapatkan konsentrasi serum yang sama seperti pada pasien non-obesitas , Semua
faktor tersebut memiliki efek negatif pada penyembuhan luka pasca operasi pada
pasien obesitas.

Terapi Imunosupresif
Tidak ada pedoman yang seragam untuk mengelola pasien bedah dengan terapi
imunosupresif. Dalam studi oleh Berthold et al., ditetapkan bahwa terapi
imunosupresif mengganggu penyembuhan luka dan meningkatkan risiko infeksi . Di
sisi lain, penghentian imunosupresi dapat menyebabkan eksaserbasi penyakit primer.
Pedoman yang diterbitkan oleh SHEA (Society for Healthcare Epidemiology of
America) merekomendasikan penghentian pengobatan imunosupresif secara
perioperatif selama mungkin. Risiko yang terkait dengan penghentian pengobatan
harus dinilai secara individual untuk setiap pasien termasuk dokter yang merawat,
ahli bedah dan pasien itu sendiri. Efek samping, akibat penghentian terapi, berpotensi
mengatasi bahkan peningkatan risiko infeksi tempat operasi. Risiko hasil yang
merugikan sangat tinggi pada pasien pasca transplantasi serta mereka yang dirawat
karena rheumatoid arthritis, namun risikonya lebih rendah daripada penyakit radang
usus.
Antibiotik Profilasis
Profilaksis antibiotik diindikasikan untuk luka bersih/terkontaminasi serta luka bersih
dengan benda asing yang ditanamkan . Untuk luka yang terkontaminasi dan kotor,
pasien tidak boleh diberikan dosis profilaksis melainkan antibiotik lengkap. Alat
yang banyak digunakan untuk menilai kebutuhan antibiotik perioperatif adalah skala
NNIS (National Nosocomial Infections Surveillance). Ini mencakup tiga fitur. Fitur
pertama adalah klasifikasi luka mengenai risiko infeksi – untuk luka yang
terkontaminasi atau kotor, pasien mendapat skor satu. Tahap selanjutnya adalah
evaluasi pasien menggunakan skor ASA (American Association of
Anesthesiologists). Untuk ASA 3, 4 atau 5, pasien diberikan satu poin. Fitur ketiga
adalah durasi operasi – bila melebihi 75% dari waktu yang diperkirakan oleh NNIS,
pasien menerima 1 poin. Misalnya, perkiraan durasi operasi usus buntu adalah 1 jam,
operasi kolorektal – 3 jam, operasi pankreas dan hati – 4 jam. Ketika skor
keseluruhan adalah satu atau lebih poin, pasien harus diberikan profilaksis antibiotik.
Meskipun dosis tunggal lebih disukai, dosis berikutnya harus diberikan tergantung
pada durasi operasi, waktu paruh obat atau kehilangan darah yang berlebihan. Dalam
kebanyakan kasus, antibiotik harus aktif terhadap methicillin-sensitifStafilokokus,
bakteri Gram-negatif(patogen yang didapat masyarakat atau endogen) dan anaerob.
Untuk profilaksis, antibiotik yang paling banyak digunakan adalah cefazolin, yang
aktif melawan patogen yang disebutkan di atas kecuali anaerob.

Fase Intraoperatif
Ruang operasi
Ruang operasi adalah jantung dari setiap rumah sakit bedah. Tujuan akhir dari kamar
operasi adalah untuk mempertahankan rezim sanitasi dan higienis yang maksimal.
Rezim mikrobiologi yang tepat adalah membatasi kontaminasi dari semua
permukaan dengan patogen. Sudah menjadi rahasia umum bahwa, agar pasien dapat
menjalani proses penyembuhan tanpa komplikasi infeksi, ia harus dijaga dalam
lingkungan yang bersih. Ruang operasi yang dirancang dengan benar harus memiliki
zona peningkatan sterilitas. Personil harus berjalan melalui area scrubbing untuk
meminimalkan kontaminasi lingkungan OR dengan patogen rumah sakit. Aturan
dasar organisasi OR adalah pemisahan antara bagian 'bersih' dan 'kotor'. Menurut
aturan satu arah, jalur 'bersih' dan 'kotor' tidak boleh bersilangan. Pendingin udara di
OR harus menyediakan udara segar dalam jumlah yang cukup dan volume pertukaran
yang sesuai, biasanya 15–30 kali volume ruangan tergantung pada jenis operasi. Itu
juga harus menyediakan aliran udara laminar, dimana memisahkan area bersih sekitar
ruang operasi.

Asepsis lapangan bedah

Tujuannya adalah untuk mengurangi jumlah patogen potensial yang secara alami
berada di kulit dan membatasi potensi pertumbuhannya selama dan setelah operasi.
Dua zat yang paling umum digunakan untuk dekontaminasi kulit sebelum operasi
adalah larutan alkohol klorheksidin glukonat dan povidon iodin. Klorheksidin
diadsorpsi oleh protein yang mengandung fosfor dari dinding sel bakteri. Pada
konsentrasi bakteriostatik, ia menembus dan merusak membran sel yang
menyebabkan kebocoran struktur sitoplasma. Namun, pada konsentrasi bakterisida,
ia menembus ke sel bakteri dan ireversibel menempel pada ATP dan asam nukleat

Patogen paling umum untuk SSI

Antibiotik yang digunakan untuk profilaksis

Chlohexidine juga menunjukkan sifat fungistatik dan fungisida dan dapat
menetralkan beberapa virus. Konsentrasi penghambatan minimal lebih rendah untuk
Gram-positif daripada bakteri Gram-negatif karena klorheksidin menunjukkan
afinitas yang lebih besar terhadap dinding sel Gram-positif. Povidone iodine adalah
larutan yang mengandung 1% yodium bebas. Molekul yodium menembus dinding sel
dan menyebabkan oksigenasi sistein dan iodinasi asam amino lain dan asam lemak
tak jenuh. Ini menyebabkan berkurangnya sintesis protein dan kerusakan dinding sel.
Yodium efektif melawan bakteri Gram-positif dan Gram-negatif, serta beberapa
bakteri pembentuk spora, Mycobacteria, virus dan jamur.Campuran klorheksidin
dengan povidone iodine atau etanol, atau isopropil etanol dapat memperluas
spektrum bakterisida. Alkohol mendenaturasi protein dan memicu lisis sel bakteri.
Ini efektif melawan methicillinresistant Stafilokokus aureus, tahan
vankomisinEnterokokusdan Mycobacterium tuberculosis.
Studi yang membandingkan chlorhexidine dan povidone iodine membuktikan bahwa
kedua zat tersebut menunjukkan spektrum antibakteri yang serupa. Namun,
klorheksidin bekerja lebih lama dengan mengikat secara kovalen pada kulit dan
protein membran mukosa. Berlawanan dengan povidone iodine, aksinya tidak
terpengaruh oleh darah atau cairan tubuh lainnya, dan karenanya biasanya digunakan
untuk melindungi kateter vaskular . Ada laporan yang bertentangan tentang
efektivitas chlorhexiine dan povidone iodine. Dalam meta-analisis oleh Lee et al.
termasuk 9 uji coba terkontrol secara acak, efektivitas yang lebih besar dari
klorheksidin disimpulkan. Namun, kualitas analisis telah diperdebatkan karena fakta
bahwa beberapa penelitian membandingkan larutan alkohol klorheksidin dengan
povidon iodin saja, yang mendistorsi analisis.

Menjaga kebersihan tangan

Bakteri di tangan staf medis dapat menjadi sumber infeksi yang didapat di rumah
sakit. Staphylococcus aureus dan basil Gram-negatif adalah komponen utama flora
bakteri kulit superfisial. Larutan klorheksidin digunakan untuk memberikan sterilitas
bedah dengan mengurangi jumlah bakteri. Efektivitas desinfeksi diukur dengan
penurunan logaritmik jumlah mikroba. Penurunan 1-log dalam jumlah bakteri berarti
pengurangan 10 kali lipat (yaitu penghapusan 90% dari
populasi), sedangkan 2-log menunjukkan pengurangan 100 kali (yaitu
menghilangkan 99%) . Menurut Badan Pengawas Obat dan Makanan AS (FDA),
disinfektan yang efektif ditandai dengan pengurangan 1-log dalam jumlah bakteri
dalam satu menit dan pengurangan 2-log selama 5 menit [42]. Klorheksidin memiliki
spektrum yang luas dan efek antibakteri yang tahan lama, sementara alkohol dengan
cepat mulai beraksi. Produk yang mengandung klorheksidin dan alkohol
menggabungkan awal yang cepat dengan alkohol dengan efek jangka panjang dari
klorheksidin, dan karena itu dianggap paling efektif

Transfusi darah
Menurut American College of Surgeons (ACS), kehilangan darah yang luas
didefinisikan sebagai kehilangan 30-40%
dari total volume darah (TBV). Kehilangan darah perioperatif tidak hanya
menyebabkan kegagalan sirkulasi, tetapi juga
kehilangan protein, antibodi, dan faktor koagulasi yang signifikan. Di sisi lain,
transfusi darah menyebabkan dua
jenis respon imun pada manusia, yaitu imunosupresi dan imunisasi. Mungkin, ini
hasil dari penurunan imunitas yang
diperantarai sel dengan peningkatan imunitas humoral secara simultan. Diamati
bahwa transfusi darah menyebabkan peningkatan populasi sel Th2 dibandingkan
dengan sel Th1, serta aktivitas sitotoksik berkurang danpergeseran rasio sel
CD4+/CD8+

Mempertahankan homeostasis pasien

Menurut Pedoman Pencegahan dan Pengendalian Penyakit Eropa 2017, dianjurkan
untuk mempertahankan kadar glukosa perioperatif pada <200 mg/dL pada pasien
diabetes dan non-diabetes (tingkat rekomendasi IA). Pedoman, bagaimanapun, tidak
menyatakan secara tepat kapan dan pada interval berapa kadar glukosa harus diukur.
Pemantauan glukosa berlaku tidak hanya untuk penderita diabetes tetapi untuk semua
pasien bedah. Stres hiperglikemia adalah suatu kondisi di mana kadar glukosa
meningkat sebagai respons terhadap faktor stres misalnya intervensi bedah.
Hiperglikemia >180 mg/dL
dalam 48 jam setelah operasi dikaitkan dengan peningkatan risiko komplikasi
termasuk infeksi tempat operasi [45]. Suhu tubuh harus dipertahankan dalam batas
normal (rekomendasi level IA). Penurunan suhu sebesar 1,6°C menyebabkan
gangguan koagulasi, kehilangan darah intraoperatif yang berlebihan dan gangguan
sirkulasi perifer. Hipotermia juga dapat meningkatkan infeksi situs bedah. Pasien
dengan fungsi pernapasan normal, yang menjalani anestesi umum atau
endotrakeal, harus diberikan peningkatan FIO2 selama operasi dan setelah ekstubasi
segera setelah prosesdur