1 JOURNAL OF PUBLIC OF PUBLIC HEALTH, HEALTH, NURSING NURSING AND AND MEDICAL RESCUE RESCUE No.4/2013 No.4/2013 (16-21) 16 Surgical site infections in gynaecology (Zakażenia miejsca operowanego w ginekologii) B Stawarz 1 A,D,F, M Sulima 2 E, M Lewicka 2 E, I Brukwicka 1B 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 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 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.
2 JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE No.4/ 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 Correspondence to: Barbara Stawarz, MD, PhD, Ostrów 109, PL Radymno, Poland; N 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 5 th 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 hours after the patient was admitted to hospital or discharged from it . 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%) . 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), 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]. 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-
3 JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE No.4/ 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 . 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 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 . 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
4 JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE No.4/ 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 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 . 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
5 JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE No.4/ 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. VI. REFERENCES  Marchlik WD, Kurnatowski P. Grzyby jako czynniki etiologiczne zakażeń szpitalnych. Otolaryngologia; 2010, 9, 2:  Bulanda M, Tyski S, Ciuruś M. Zakażenia szpitalne w Polsce stan wiedzy na kwiecień Raport programu Stop Zakażeniom Szpitalnym. Program Promocji Higieny Szpitalnej.  Fiedotow M, Denys A. Wybrane aspekty zakażeń szpitalnych. Pol Merk Lek; 2006, XXI, 125:  Ustawa z dnia 5 grudnia 2008 r. o zapobieganiu oraz zwalczaniu zakażeń i chorób zakaźnych u ludzi. Dz. U nr 234 poz  Johnz-Różek K. Zakażenia Szpitalne raport opracowany dla Europejskiego Stowarzyszenia Promocji Zdrowia PRO-SALUTEM. Warszawa; 2009, 5:  Bulanda M. Zakażenia szpitalne na oddziałach zabiegowych. Kraków; Polskie Towarzystwo Zakażeń Szpitalnych,  Kowalewska M. Zakażenia szpitalne w chirurgii. W: Podstawy pielęgniarstwa chirurgicznego. Walewska E (red). Warszawa; Wyd. Lek. PZWL,  Bober-Greek B, Fleischer M. Podstawy pielęgniarstwa epidemiologicznego. Wrocław; Wyd. Urban & Partner,  Dalkowska A, Krzemiński M, Gaworska-Krzemińska A. Roszczenia pacjentów-konsekwencje cywilno prawne ran powikłanych. Zakażenia; 2007, 3:  Sajdak S, Witczak K. Zakażenia operacyjne w ginekologii i położnictwie. Sepsis; 2008, 1:  Krasnodębski I, Wójcik Z. Teoretyczne i praktyczne podstawy chirurgii narządów jamy brzusznej oraz chirurgii urazowej tkanek miękkich. Warszawa; Wydawnictwo Akademii Medycznej w Warszawie,  Schlegel HG. Mikrobiologia ogólna. Warszawa; Wyd. Nauk PWN,  Drews M, Marciniak R. Zakażenia chirurgiczne. Poznań; Wyd. Nauk. UM im. Karola Marcinkowskiego w Poznaniu,  Sierocka A, Cianciara M. Monitorowanie zakażeń szpitalnych. Probl Hig Epidemiol; 2010; 91, 2:  Bielecki K. Zakażenia chirurgiczne. Warszawa; Wyd. Borgis,  Gondek S. Nowa koncepcja terapeutyczna z uwzględnieniem procesów patofizjologicznych zachodzących w ranach przewlekle niegojących się. Zakażenia; 2006, 1:  Dulny G, Lejbrandt E. Higiena w placówkach opieki medycznej. Zakażenia; 2003, 8:  Nicklin J, Killington R. Mikrobiologia. Warszawa; Wyd. Nauk. PWN,  Drews M, Marciniak R. Postępy w zapobieganiu zakażeniom chirurgiczny w leczeniu w 2005 roku. Med Prakt; 2006; 6:  Heczko PB. Kontrola Zakażeń Szpitalnych. Warszawa; Wyd. Lek. PZWL,  Juraszczyk W, Szulc R. Postępowanie okołooperacyjne. Warszawa: Wyd. Lek. PZWL,  Wróblewska M, Kawecki D. Dezynfekcja skóry i obłożenie pola operacyjnego. Zakażenia; 2008, 4:  Szmit J. Podstawy chirurgii. Warszawa; Wyd. Medycyna Praktyczna,  Jaje E. Skuteczna dezynfekcja rąk u personelu medycznego oddziału zabiegowego. Zakażenia; 2008, 3:  Drews M, Marciniak R. Postępy w zapobieganiu zakażeniom chirurgicznym i ich leczenie-postępy w 2002 roku. Med Prakt; 2002, 5:  Gruca Z, Stefaniak T, Głowacki J. Zakażenia miejsca operowanego po zabiegach klasycznych i laparoskopowych w chirurgii jamy brzusznej. Zakażenia; 2006, 5:  Ciuruś M. Pielęgniarstwo operacyjne. Lublin; Wydawnictwo Makmed,  Adamska D, Wojciechowska M, Kopański Z. Ochrona brzegów rany przed zakażeniem przy użyciu retraktora ran operacyjnych Alexis. JPHNMR; 2012, 3:  Staszkiewicz W, Hryniewicz W, Grzesiowski P. Praktyczne zasady kontroli zakażeń szpitalnych. Zbiór rekomendacji. Warszawa, 2000.
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