DR. BAMBANG ARIANTO Sp. B.

KOMITE PPI RSU HAJI SURABAYA

Manajemen Infeksi Luka Operasi

Antibiotik oral/iv Kultur bakteri, bakteri resisten?

Reeksplorasi luka insisi, drenase

pus? Evakuasi hematoma? Plate/screw, bila infeksi berat, perlu dilepas Terapi suportif, cairan/medikasi Masuk rumah sakit? Lapor PPI/Surveilance

Alur Monitoring Infeksi

Surveilance Laporan Infeksi paska operasi

PPI
KLB

Reaksi Cepat

Non KLB

Konsep manajemen infeksi paska operasi

Pengendalian Infeksi Paska Operasi

Pasien SDM AB Profilaksis Prosedur operasi Sterilisasi alat/linen

Ruang Operasi Prosedur Tetap Patient savety

Pasien? SDM? AB Profilaksis? Prosedur operasi? Sterilisasi alat/linen? Ruang Operasi? Prosedur Tetap? Infeksi Paska Operasi

Epidemiology of Postoperative Infection

18 million surgical procedures yearly
486,000 nosocomial infections

20% in intensive care unit, with SICU highest risk

Patients have longer and costlier hospitalization

Twice as likely to die

Mortality rate up to 44% in ICU patients

60% more likely to spend time in ICU Five times more likely to be re-admitted

Excess direct cost $5,038/infected patient

Kirkland et al. Infect Control Hosp Epidemiol 1999;20:725-730 Wallace et al. Am Surg 1999;65:987-989

Transmission cycle in OT

Strategi mencegah SSI

Objektif
Menurunkan jumlah bakteri pada tempat insisi Surgical Site Preparation Antibiotik Profilaksis Optimmalisasi lingkungan mikro area operasi Meningkatkan fisiologi pertahanan tubuh

Berkaitan dengan faktor resiko, bisa

dikelompokkan :

Faktor intrinsik pasien Pre-operative Operative

Faktor Pasien
- Age - Nutritional status - Diabetes - Smoking - Obesity - Coexistent infections at a remote body site - Colonization with microorganisms - Altered immune response - Length of preoperative stay

Faktor prosedur operasi

Hair removal technique Preoperative infections Surgical scrub Skin preparation Antimicrobial prophylaxis Surgeon skill/technique Asepsis Operative time Operating room characteristics

Traditional Classification of Operative Procedures and Risk of Surgical Site Infection (SSI)
Type of Procedure Clean Clean-Contaminated Contaminated Dirty* Risk of SSI <2% 5 -15 % 15 - 30 % > 30 %

* Dirty wounds infection - antibiotics indicated as therapy

Nichols RL. Am J Surg 1996;172: 68-74.

Risk Factors Surgical Site Infection NNIS Study-CDC

Wound classification

(Contaminated/dirty) ASA Class > 3 Prolonged operative time (> 75th percentile)

Surgical Site Infections Stratified By Patient Risk-CDC 1991

14 12 10 8 6 4 2 0
0 Risk Factors 1 Risk Factor 2 Risk Factors 3 Risk Factors

SSI/ 100 Operations

Major Pathogens in Surgical Site Infection

20%
% of infections

Elective colon surgery (plus anaerobic coverage)

15% 10% 5% 0%
S En te ro co cc i au re us ae ru gi no En sa te ro ba ct er sp p.
NNIS, 1990-1996.

S.

E.

For the VAST majority of procedures, antibiotic prophylaxis should be directed here

P.

co li

Relative Distribution of Bacteria from Superficial to Deep Infections

Superficial infection

Staphylococcus Streptococcus Gramnegative bacilli

Deep infection

Anaerobes

Antibiotik Profilaksis
1.

Antibiotik profilaksis diberikan dalam satu jam sebelum insisi operasi

Tujuannya agar antibiotik telah mencapai level bakteriosid di jaringan dan serum ketika dilakukan insisi. Dasar pemikirannya adalah menurunkan jumlah kontaminasi mikroorganisme intraoperasi pada level tidak melebihi kemampuan pertahananan tubuh.

2.

Antibiotik profilaksis selektif pada setiap pasien operasi.

Pasien operasi yang mendapatkan antibiotik profilaksis harus konsisten dengan paduan antibiotik yang dibuat untuk menurunkan infeksi luka operasi. (spesifik pada tiap prosedur operasi).

*CDC Guideline for Prevention of Surgical Site Infections, 1999

Antibiotik Profilaksis
3. Antibiotik profilaksis maksimal digunakan dalam 24 jam paskaoperasi.
Dasar pemikirannya : penggunaan antibiotik yang pendek efektif mencegah infeksi dibanding penggunaan antibiotik yang lama. Penggunaan antibiotik yang lama sering menyebabkan berkembangnya bakteri resisten.

4. Antibiotik profilaksis tidak boleh sebagai antibiotik terapi

Relation Between Timing and Surgical Wound Rate

6% 5%

Infection Rate (%)

4% 3% 2% 1% 0%
>2 2 1 1 2 3 4 5 6 7 8 9 10 >10

Hours before

Hours after incision Incision

Classen et al. N Engl J Med1992;326:281-285.

Days of Antibiotics and Risk of MRSA-Pooled Odds Ratios

Asensio et al. ICHE 1996;17:20-28
12 10 8 6 4 2 0 0 1 to 2 3 to 7 8 to 14 15 or more Odds Ratios

Days of Antibiotic Administration

Infeksi Luka Operasi

Perioperative Hypothermia and the Risk of SSI

Kurz et al. N Engl J Med 1996;334:1209-1215.
200 patients-colorectal surgery Standardized anesthesia and antibiotics Randomized to routine care (34.7oC) or active

warming (36.6oC) during surgery SSI: Culture-positive drainage of pus Hypothermia group:
More infections (19 vs. 6%, p<0.01)

Hospitalization longer (2.6 days) (p<0.01)

Perioperative Supplemental Oxygen and the Risk of SSI

Greif et al. N Engl J Med 2000;342:161-167.
500 patients-colorectal surgery Standardized anesthesia and antibiotics Randomized 30% vs. 80% O2 during surgery and for 2 hours afterward SSI: Culture-positive drainage of pus Hypothermia group: More infections (11.2 vs. 5.2%, p=0.01)

Early Enteral Nutrition in Trauma Meta-Analysis

Marik and Zaloga. Crit Care Med 2001;29:2264-2270

15 randomized trials All postoperative, trauma, or burn studies Reduced infections RR 0.45 (0.30-0.66) Reduced hospital stay Mean, 2.2 days (0.81-3.63 days) No effect on mortality
No effect on non-infectious complications

Early Postoperative Glucose Control Predicts Nosocomial Infection Rate in Diabetic Patients

Pomposelli et al. JPEN 1998;22:77-81

100 consecutive diabetic patients initially free of

infection All patients received antibiotic prophylaxis Glucose control per attending surgeon
+ 220 mg/dL POD 1

Poor glucose control and infection All infections: RR 2.7 (31.3% vs 11.5%) Non-UTI: RR 5.7

Diabetes Control and Surgical Site InfectionsCardiac Surgery

Latham et al. Infect Control Hosp Epidemiol 2001;22:604-606.

1000 consecutive patients, 7.2%

infections Risk factors for infection:

Odds ratio Diabetes 2.76 Postoperative hyperglycemia 2.02
Chronic poor glycemic control was not a risk factor

Regulate the Operating Room Environment

Ventilation = positive pressure.
Variable air systems (positive

pressure only) Air introduced at the ceiling and exhausted near the floor Humidity <68% Temperature control

Regulate the Operating Room Environment

Minimize personnel traffic during

operations

Cleaning and Disinfecting

Environmental Surfaces
Medical equipment surfaces

knobs, handles on equipment such as xray machines, instrument carts

Housekeeping surfaces

floors, walls, chairs, and tabletops

Design of operation room with zonal ventilation

Sterilisasi

Tem PPI

SURVEILLANCE

Tem PPI

Surveillance

Ongoing, systematic collection,analysis interpretation

Planning, Implementation, Evaluation of practice

Timely dissemination of data

Costi P

Infection Control and Quality Healthcare in the New Millenium

Multidisciplinary team approach

1847
1863 1958 1970 1980 1990 2000
Pittet D, Am J Infect Control 2005, 33:258

WHO Patient Safety WHO Collaborating Centres

Country campaigns & activities Facility campaigns & activities including

evaluation and feedback

SAVE LIVES

TERIMA KASIH