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 1847
Realized that washing hand
with a chlorinated lime
solution decreased incidence
of newborn death from
“puerperal fever’.

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  1883-1897
 Britishsurgeon
 Used Carbolic Acid
(Phenol) to clean hands,
instruments and wipe on
surgical wounds drastically
decreased infections.

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Recognizing Infection

Soft Tissue Infections

Post-operative Infections
• Surgical Site Infection
• Hospital Acquired Infections
Antibiotic Prophylaxis

Blood Born Pathogens

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Infection is defined by:

1. Microorganisms in host tissue

or the bloodstream
2. Inflammatory response to
their presence.

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 CUCI TANGAN
Saat datang dan pulang dari tempat kerja

Sebelum dan setelah memeriksa klien

Sebelum dan setelah pakai sarung tangan

Setelah terpapar darah atau sekret tubuh

Setelah tersentuh material berbahaya/toksik

Sebelum dan setelah makan

Setelah menggunakan toilet/buang air

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 6-8
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 provider
Preparedness
Guidance
standardization

patient facilities

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 Systemic Inflammatory
Response Syndrome

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Duration of operation • Surgical technique
• Poor hemostasis
Duration of surgical scrub
• Failure to
Preoperative shaving,
skin preparation obliterate dead
Inadequate OR ventilation
space
• Tissue trauma
Inadequate sterilization of instruments
• Obesity
Skin antisepsis • Diabetes
Antimicrobial
prophylaxis

Surgical drains

Tissue kept moist with saline Tissue allowed to air dry

Mangram et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278
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INFLAMMATION GRANULATION REMODELLING

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Localized:
• Rubor, Calor, Dolor, Tumor,
and functio laesa (loss of
function)
Systemic:
• Systemic Inflammatory
Response Syndrome (SIRS)
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 Systemic Inflammatory
Response Syndrome

Any Two of the Following

Criteria

• Temperature: < 36.0, >38.0

• Heart Rate : >90
• Respiratory Rate: >20
• WBC: <4,000, >12,000
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Definition: SIRS plus evidence
of local or systemic infection.
Septic Shock
Definition: Sepsis plus end organ
hypoprofusion. Mortality of up to 40%

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Cellulitis

Abscess

Necrotizing Infections

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Definition: Diffuse infection with severe inflammation
of dermal and subcutaneous layers of the skin

Diagnosis: Pain, Warmth, Hyperesthesia

Treatment: Antibiotics.

Common Pathogens: Skin Flora

(Streptococcus/Staphylococcus)

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Definition: Infectious accumulation of
purulent material (Neutrophils) in a
closed cavity

Diagnosis: Fluctuant: Moveable and

compressible

Treatment: Drainage

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Definition: Deep infection of skin and soft tissue
that may spread rapidly along facial planes.

Diagnosis: Purely Clinical, dishwater discharge,

gray tissue, pain out of proportion to
examination, bulla, and dark, golden
discoloration.

Treatment: True Surgical Emergency, Antibiotics

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Common Pathogens
• Clostridium
• Group A streptococcus
• Polymicrobial
Toxic Shock Syndrome
• Streptococcus
• Staphylococcus
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Fever After Surgery

The “Five W’s”

• Wind: Atelectisis
• Water: UTI
• Walking: DVT
• Wonder Drug: Medication Induced
• Wound: Surgical Site Infection
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3rd most common hospital infection

Incisional
• Superficial
• Deep
Organ Space
• Generalized (peritonitis)
• Abscess

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There are 3 types of SSIs.

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Clean Hernia repair 1.5%
breast biopsy
Clean- Cholecystectomy 2-5%
Contaminated planned bowel resection
Contaminated Non-preped bowel 5-30%
resection
Dirty/infected perforation, abscess 5-30%

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Diabetes mellitus

Hypoxemia

Hypothermia

Leukopenia

Nicotine (tobacco smoking)

Immunosuppression

Malnutrition

Poor skin hygiene

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Operative site shaving

Breaks in operative sterile technique

Improper antimicrobial prophylaxis

Prolonged hypotension

Contaminated operating room

Poor wound care postoperatively

Hyperglycemia

Wound closure technique

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Jangan menggunakan pisau cukur pada area pembedahan

Pada area berambut, lakukan pengguntingan bila menghalangi lapangan

pandang operator

Tanyakan riwayat alergi antiseptik pada klien.

Bersihkan area operasi dengan sabun.

Usapkan larutan antiseptik pada area operasi secara secara melingkar

atau atas-bawah

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Incisional: open surgical
wound, antibiotics for
cellulitis or sepsis

Deep/Organ space:
Source control,
antibiotics for sepsis
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Decreases bacterial counts at surgical site

Given within 30 minutes prior to starting

surgery

Vancomycin 1-2 hours prior to surgery

Redose for longer surgery

Do not continue beyond 24 hours

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.

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Urinary Tract Infection

Indwelling Catheter Infection

Pneumonia
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Use only when indicated

Start with broad spectrum antibiotics designed

to cover likely pathogens

Take cultures when possible

Deescalate spectrum once pathogen is know

Have a plan for duration

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 HB HCV HIV
V
Risk from 30 2% 0.3%
Needle stick %
Chemoprophyla Yes No Yes
xis
Vaccine Yes No No
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  Operation Risk
Factors:
 skin preparation
 operating room
environment

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????????

6-40
 Dekontaminasi

Pencucian

Desinfektan
Sterilisasi
tingkat tinggi

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Autoklaf
106 kPa, 121°C, 20 menit & 30 menit (tanpa bungkus &
terbungkus)
Kimiawi Rendam dalam
Glutaraldehida selama 10
jam

Panas kering
170°C selama 60 menit
atau 160°C selama 120
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 REPETITIVE
ASSOCIATED TRAUMA
WITH
NEGATIVE BACTERIAL EXCESSIVE FOREIGN TATTOO
WOUND INFECTION TENSION BODIES VACCINATION
HEALING INJECTION
FACTORS :
BITES

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RCTs are needed to evaluate the
effectiveness of incisions made
with diathermy compared with
surgical knife in terms of
operating time, wound infection,
wound tensile strength, cosmetic
appearance and women’s
satisfaction with the experience
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  POINT OF
STICHING
 SIMETRICALLY
 APPROXIMATION
 SKIN TENSION
CONTROLED.
 ATRAUMATIC
TECHNIQUES

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Evidence-Based Perspective
on Wound Closure Technology
as a Risk-Reduction Strategy –
What is the Criteria?

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Utilizing Innovative Impregnated Technology to Reduce the
Risk of Surgical Site Infections

J Am Coll Surg 2006;203:481-489

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 Mean Microbial Recovery from Standard
Polyglactin 910 Sutures (V) and Triclosan-
Coated Polyglactin 910 Braided Sutures
(VT)
300
275
250 V
Mean colony forming units

225
200
175
VT
N=10
150
(cfu)/cm suture

125
100 p<0.
75
50
01
25
0
102 105 102 105 102 105
S. aureus S. epidermidis E. coli
(MRSA) RP62A

Exposure Time 2 Minutes

Edmiston et al, J Am Coll Surg 2006;203:481-

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• Like all foreign bodies, sutures can be colonized by
bacteria
• Implants provide nidus for attachment of bacteria
• Bacterial colonization can lead to biofilm formation
• Biofilm formation increases the difficulty of treating an
infection
On an implanted
device only 100
staphylococci per
Contamination Colonization Biofilm gram of tissue can
Formation cause an SSI
Ward KH et al. J Med Microbiol. 1992;36: 406-413.
Kathju S et al Surg infect. 2009;10:457-461
Mangram AJ et al. Infect Control Hosp Epidemiol.1999;27:97-134
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Adherence of Methicillin-Resistant
Staphylococcus aureus (MRSA) to Braided
Suture

Edmiston et al, Surgical Microbiology Research Laboratory, Milwaukee – APIC 2004

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Antimicrobial Activity Against MDRO
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1. Ford et al. Pediatric surgery- Surg Infect 2005;3:313
2. Rozzelle et al. Cerebro-spinal shunt surgery – J Neurosurg Pediatr 2008;2:111-1117.
3. Mingmalairak et al. Appendectomy – J Med Assoc Thai 2009;92:770-775.
4. Zhuang et al. Abdominal surgery – J Clin Rehab Tiss Eng Res 2009;13:4045-4048.
5. Zhang et al. Radical mastectomy – Chin Med J 2011;124:719-724.
6. Galal et al. General, GI surgery - Am J Surg 2011;202:133-138.
7. Rasic et al. Colorectal surgery – Colleg. Antropologicum 2011;35:439-443.
8. Williams et al. Breast CA surgery – Surg Infect 2011;12:469-474.
9. Barac et al. Colorectal surgery – Surg Infect 2011;12:483-489.
10. Isik et al. Cardiac surgery – Heart Surg Forum 2012;15:E40-E45.
11. Turtainen et al. Lower limb revascularization surgery – World J Surgery 2012; May 23
[Epub ahead of print].
12. Seim BE et al. Cardiac surgery – Interact Cardiovasc Thorac Surg 2012: June 12 [Epub
ahead of print].
13. Nakamura T, et al. Colorectal surgery – Surgery 2013 [Epub ahead of print].
14. Laas E, et al. Breast surgery – Int J Breast Cancer 2012 [Epub ahead of print].
15. Justinger et al. Abdominal wall closure – In Press 2013 Surgery

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The first intervention of updating the wound care policy will be
to discuss with the surgeons their preferred type of dressing, if
antiseptic should be used and type of technique to be used.

The second intervention would be to have all managers of each

surgical specialty review them.

The third intervention would be to get the information to the

Quality Assurance nurse to change the policy according to the
changes that were made.

The fourth intervention would be to have unit meetings on each

surgical specialty units informing them of the changes.

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Nursing management and surgeons will be
the main personnel involved with updating
the wound care policy.

To implement the changes involved with

the wound care policy, no additional
personnel would be needed, but additional
working hours may be necessary while
making changes to the wound care policy.

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Collaboration with
administration is essential
when dealing with a
problem that is significant
as SSIs.

Teamwork is more
imperative now than ever
before in dealing with SSIs.

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DURING WOUND HEALING PROCESS THE SURGEON AND THE
PATIENT SHOULD LOOK FOR AND EXPECT IMPROVEMENT.

TO INDENTIFY THE RISK AND PREDISPOSING FACTORS FOR

SSI.

SURGICAL PROCEDURES HAVE TO FOCUS ON THE QUALITY

OF HEALING

PREPARATION OF FACILITY

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.

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