SEPSIS AND

ANTISEPSIS

SEPSIS
Sepsis is defined as the development of a systemic
inflammatory response syndrome (SIRS) as a result
of an infective process. SIRS is characterized by two
or more of the following conditions:
temperature greater than 38.4C or below 35.6C;
heart rate greater than 90 beats per minute;
respiratory rate greater than 20 per minute or PaCO2
less than 32mmHg;
white cell count greater than 12 000 cells per ml, or
less than 4000 cells per ml or 10% immature (band)
forms.

ASEPSIS
Asepsis

is a process or procedure performed

under circumstances in which bacterial
contamination is minimized. An aseptic
technique is one in which all the instruments
used are sterilized, the operator does not
touch the patient, and spillage of
contaminated material does not occur

INFECTION
Infection is defined by identification of
microorganisms in host tissue or the blood stream,
plus an inflammatory response to their presence.
At the site of infection the classic findings of rubor,
calor, and dolor in areas such as the skin or
subcutaneous tissue are common. Most infections in
normal individuals with intact host defenses are
associated with these local manifestations, plus
systemic manifestations such as elevated
temperature, elevated white blood cell (WBC) count,
tachycardia, or tachypnea. The systemic
manifestations noted above comprise the systemic
inflammatory response syndrome (SIRS).

PREVENTION AND TREATMENT

OF SURGICAL INFECTIONS
General

Principles

Maneuvers to diminish the presence of exogenous

(surgeon and operating room environment) and
endogenous (patient) microbes are termed
prophylaxis, and consist of the use of mechanical,
chemical, and antimicrobial modalities or a
combination of these methods.

Antisepsis

This is the removal or destruction of those transient

microorganisms that can be isolated from the skin,
but are not consistently present in the normal
population (e.g. Staphylococcus aureus).

Resident flora are organisms that can be

persistently isolated from the skin of most people
(e.g. coagulase-negative staphylococci,
corynebacteria, propionibacteria, Acinetobacter
spp., and in some areas Enterobacteriaceae); in
certain procedures a reduction in resident flora is
desirable.

Activity of antiseptic agents against skin flora

Mode of
action

Gram
+ve
bacteria

Gram
ve
bacteria

Fungi

Viruses

Rapidity
of action

Residual
activity

Affected
by
organic
matter?

Alcohols

Denaturation
of proteins

+++

+++

++

++

+++

Minimal

Chlorhexidine

Cell wall
disruption

+++

++

++

++

+++

Minimal

Iodine/Iodoph
ores

Oxidation/
+++
substitution
of free iodine

++

++

++

++

Yes,
above pH
4

Chloroxylenol

Cell wall
disruption

++

++

++

Minimal

Triclosan

Cell wall
disruption

++

+/++

++

+++

Minimal

Antiseptic agents
Several factors need to be considered when buying
antiseptic agents for an institution:
properties of the agent (e.g. persistence, emollients,
spectrum of action, non- absorption, rapid reduction
of flora)
safety (changes in product data should be
monitored)
acceptability by staff- Products should be used in
accordance with the manufacturers instructions and
staff should have clear instructions for their safe and
effective use.

Alcohols

Activity alcohols have a good broad spectrum of activity including bactericidal

activity for vegetative Gram-positive and Gram-negative bacteria. They are also
fungicidal, virucidal (against respiratory syncytical virus, hepatitis B, HIV) and have
antituberculous activity, but they are not sporocidal. They work by denaturing
proteins.
Safety alcohols applied to the skin are among the safest of antiseptics, though
they are flammable.
Rapidity provided the skin is clean, alcohols act rapidly; a 1-minute alcohol rub
is equivalent to a 47-minute scrub and a 3-minute rub is equivalent to a 20minute scrub.
Persistence alcohols do not have a persistent action, but organisms continue to
die off after application, probably as a result of death subsequent to sub-fatal
damage.
Preparations available include ethyl (ethanol), normalpropyl (n-propyl) and
isopropyl alcohols. There are subtle differences in their activity. Concentrations of
6090% are the most effective; 70% alcohol is used most often because it is
effective with less drying of the skin than higher concentrations. Many
preparations have added emollients to reduce this problem. After application, the
alcohol should be allowed to evaporate completely, to be fully effective and to
reduce irritation.

Chlorhexidine

Activity chlorhexidine gluconate is a cationic bisbiguanide that disrupts the cell

membranes of organisms and causes precipitation of the cell contents. It has good
activity against Gram-positive organisms and is slightly less active against Gramnegative organisms. It is active against enveloped viruses (e.g. HIV,
cytomegalovirus, influenza, herpes simplex) but has only moderate activity against
fungi and minimal antituberculous activity. The activity of chlorhexidine may be
affected by pH and neutralization may occur in the presence of non-ionic
surfactants, which may be present in hard water, hand creams and other soaps.
Safety chlorhexidine is very safe, though use may result in contact dermatitis and
occasional allergic reactions have occurred, including anaphylaxis. In the eye, it
may result in corneal damage and in the middle ear ototoxicity has been reported.
Rapidity chlorhexidine is not as rapidly active as alcohol and adherence to 35minute scrub times is important. It is classified as intermediate in rapidity compared
with other agents.
Persistence chlorhexidine is persistent. It has good skin adherence and exerts an
antibacterial effect for over 6 hours after appropriate use. The use of chlorhexidine
as a surgical scrub agent, followed by hand rub with 0.5% chlorhexidine and 70%
alcohol is highly effective for surgical hand preparation.
Preparations available chlorhexidine is available as 0.5% in an alcohol-based
hand rub, 2% aqueous formulations and 4% in a detergent base.

Iodine and iodophors

Activity iodine and iodophors act by penetrating the cell wall and replacing the cell
contents with free iodine. Active against a wide range of microorganisms including
Gram-positive and Gram-negative bacteria, viruses, fungi and mycobacteria. They
also have some activity against spores. They are inactivated rapidly by organic
material such as blood.
Safety iodine and iodophors may cause skin drying and irritation. If an iodophor is
used for hand scrub, it must be rinsed from the hands after drying because of the risk
of irritation. Iodine and iodophors may sensitize some people so that severe allergy
results. Absorption may occur percutaneously or via the mucous membranes and may
result in hypothyroidism, as has been reported in newborn infants.
Rapidity the rapidity of action of iodine and iodophors lies between that of alcohols
and chlorhexidine.
Persistence iodine-containing agents do not show the persistence of chlorhexidine,
but there appears to be continued cell death, probably as a result of cell damage.
Preparations available iodophors are a complex of iodine plus a carrier such as
polyvinylpyrrolidone (povidone) which improves solubility. The major determinant of
microbiocidal activity is the free iodine (i.e. that which is not complexed to the carrier).
Levels of 12 mg/litre free iodine are recommended for antiseptics. The most
commonly used iodophor is povidone-iodine. A 7.5% concentration is available for
hand scrub.

Cleaning
Cleaning

is a process that physically removes

contamination but does not necessarily
destroy microorganisms. The reduction of
microbial contamination cannot be defined
and depends on many factors, including the
efficiency of the cleaning process and the
initial bioburden. Cleaning is an essential
prerequisite of equipment decontamination to
ensure effective disinfection or sterilization

DISINFECTION
Disinfection

is a process used to reduce the

number of viable microorganisms. It may not
achieve the same reduction in microbial
levels as sterilization and may not necessarily
inactivate some viruses and bacterial spores

STERILIZATION
Sterilization

is a process used to render an

object free from viable microorganisms,
including bacterial spores and viruses

DECONTAMINATION & DISINFECTION

Decontamination of medical devices

Autoclaves
Hot air ovens
Ethylene oxide
Low-temperature steam and formaldehyde
Sporicidal chemicals
Gas plasma
Irradiation

Disinfection

Low-temperature steam
Boiling water
Washer/disinfectors
Chemical disinfectants

Wound Class, Representative

Procedures, and Expected Infection
Rates
Wound
class
Examples of cases
Expected
infection rates
Clean (class I)

Hernia repair, breast

biopsy

1.05.4 percent

Clean/contaminated
(class II)

Cholecystectomy
elective
GI surgery

2.19.5 percent

Contaminated (class III)

Penetrating abdominal
trauma, large tissue
injury, enterotomy during
bowel obstruction

3.413.2 percent

Dirty (class IV)

Perforated diverticulitis,
necrotizing soft tissue
Infections

3.112.8 percent

Risk Factors for Development of

Surgical Site Infections Patient
factors

Older age
Immunosuppression
Obesity
Diabetes mellitus
Chronic inflammatory process
Malnutrition
Peripheral vascular disease
Anemia
Radiation
Chronic skin disease
Carrier state (e.g., chronic
Staphylococcus carriage)
Recent operation
Local factors

Poor skin preparation

Contamination of instruments
Inadequate antibiotic
prophylaxis
Prolonged procedure
Local tissue necrosis
Hypoxia, hypothermia
Microbial factors
Prolonged hospitalization
(leading to nosocomial
organisms)
Toxin secretion
Resistance to clearance (e.g.,
capsule formation)