SYNOPSIS
Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore
“POSTOPERATIVE WOUND SEPSIS AND PROPHYLACTIC ANTIBIOTICS”
Name of the candidate : Dr. Thejaswi N Marla
Guide : Dr. N Devidas Shetty
Course and Subject : M.S. (Gen.Surgery)
Department of Gen.Surgery
A J Institute of Medical Sciences,
Kuntikana, Mangalore.
2010
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE.
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / Name of the candidate and address (in block letters) / DR.THEJASWI N MARLAPOST GRADUATE RESIDENT,(MS)
DEPARTMENT OF GENERAL SURGERY,
A J INSTITUE OF MEDICAL SCIENCES,
MANGALORE.
2 / Name of the Institution / A J INSTITUTE OF MEDICAL SCIENCES MANGALORE.
3 / Course of study and Subject / MS SURGERY
4 / Date of admission to course / 11/05/2010
5 / Title of the Topic
POSTOPERATIVE WOUND SEPSIS AND PROPHYLACTIC ANTIBIOTICS
6 / BRIEF RESUME OF THE INTENDED WORK:
6.1 Need for the study
The aim of this work is to study the incidence of Post – operative wound infection in A.J. Institute of Medical Sciences, Mangalore taking only the clean and clean contaminated cases. To target most common pathogen responsible for sepsis,study their sensitivity and source of infection. To study the various factors such as host, environment and agent factors which are responsible for the increased incidence of wound infection.
To focus on the effect of antibiotic use and their contribution to the avoidance of wound sepsis.
Although significant advances have been made, there is still great divergence of opinion regarding best methods of preventing and controlling surgical infection. In principle it is simple to avoid surgical wound infection in elective surgery, all that is required is to prevent the access of bacteria to the operating area, in practice, this is relatively difficult to achieve with organisms infrequently encountered in our environment such as the spores of tetanus and gas gangrene. More difficult with hemolytic streptococci and the coliform organisms and indefinitely more difficult with pyogenic staphylococci. It is greatly surprising that the elimination of wound infection occurred in this order. Indeed it is doubtful whether it is possible to prevent completely the access of staphylococci to wounds even with present techniques.
6.2 Review of Literature
Throughout history infection has been one of the primary concerns of surgeons. Infections will probably always be with us. Infections have continued to be of primary interest to surgeons – both because they performed surgeries to treat infections and because operative procedures were complicated by infections.
Anaesthesia was introduced by Morton in 1846, even after anaesthesia was widely employed and surgeons could operate deliberately, infective operation remained an unacceptable risk for patients as all operative wounds became infected and almost half of patients who underwent a major surgery died as a result of infection.
Infection was so common, that, many thought it to be, a part of normal healing process. Many surgeons hoped for the development of ‘Laudable Pus’ in their wounds. In 1861 Louis Pasteur showed bacteria to be responsible for putrification and used carbolic acid to Prevent exogenous contamination. This discovery was the turning point for rapid advance of surgery. Joseph Lister has been recognized as the founder of the antibiotic principle in surgery and his paper ‘ ON THE ANTIBIOTIC PRINCIPLE IN THE PRACTICE OF SURGERY’ published in 1867 was instrumental in revolutoning the practice of surgery and, the infection rate in elective operations dropped from 90% to less with application of Listerian principles.
Asepsis and Antisepsis was followed by chemoprophylaxis, the introduction of sulfonamides in the 1930’s and penicillin in the 1940’s further reduced mortality and introduced an entirely new era in the treatment of infections, beginning with the discovery of penicillin in 1929 by Alexander Fleming. Florey in 1940 was able to successfully extract penicillin and demonstrate its use as an antibiotic.The first patient to be treated with systemic penicillin was Albert Alexander an Oxfordshire constable, who had cellulitis of the face.
DEFINITION AND CLASSIFICATION OF WOUND INFECTION
In 1992, US centre for disease control (CDC) published definition for wound infections, it renamed wound infection as surgical site infection which may reduce confusion associated with previously used term ‘Deep wound infection’. New CDC definition offers oneselves use in all types of Post-operative infection. Investigations increasing use allow them for proper assessment of problems as basis for therapeutic improvements.
CDC definition includes Superficial incisional, deep incisional and organ space surgical site infection.
Superficial surgical site infection must meet following criteria
1. Infection occurs within 30 days of the surgery
2. Infection involves only skin and subcutaneous tissue
3. The infection must meet at least one of the following
a. Purulent discharge from a superficial incision
b. Organisms isolated from a deseptically obtained culture of fluid
4. Incision must meet one of the following signs or symptoms of infection
a. Pain or tenderness c. Redness or Heat
b. Localized swelling d. superficial incision
6.3 Objectives of the study
1. To evaluate the incidence of Post – operative wound infection in clean and clean contaminated cases for the bacteriology of wound sepsis.
2. To study the organisms responsible for sepsis and their sensitivity patterns.
3. To determine the influence of various factors such as patient and environmental factors, pre – operative, intra – operative and post – operative factors in the pathogenesis of wound sepsis, inspite of prophylactic antibiotics.
4. To study the effect of prophylactic antibiotic in the incidence of wound sepsis.
7. / Material and methods:
7.1 Source of data.
100 cases of clean and clean contaminated cases operated at A.J.INSTITUTE OF MEDICAL SCIENCES are intended to be involved in the study.
7.2 Method of collection of data ( including sampling procedure, if any)
Oberving and recording of the information of 100 patients preoperatively, intraoperatively and postoperatively in a format attached, Serum albumin and haemoglobin of the patient is evaluated before and after surgery by aseptic precautions in vaccutainers. To assimilate all the data for analysis there by making a comparative study of the cases operated.
The results are processed further for interpretation. Before withdrawal of blood, an informed consent is taken which is duly enclosed.
Inclusion criteria:
1. In case of patients undergoing elective operative procedure without any features of infection or sepsis.
2. In clean contaminated case patients undergoing an operative procedure.
3. Cases operated within the study center dated post approval of the thesis synopsis
4. Patients of all age groups and both sexes are included.
Exclusion criteria:
1.Contaminated cases are not included in the study.
2.Outpatient cases are not taken into consideration and excluded from the study.
3.Patients who are discharged on day care basis are not included in the study.
Plan for data analysis:
Statistical Analysis to be done taking into consideration the overall numbers, then grouping the patients on the basis of preoperative biochemical parameters hampering the wound healing and documenting the benefits of prophylactic antibiotics. Having the afore said group a randomized control study is done.
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please describe briefly?
YES. After obtaining informed consent from the patients, under aseptic precautions, blood is collected in vacutainers for investigations like serum albumin and haemoglobin.
7.4 Has ethical clearance been obtained from your institution:
YES, obtained.
8 / LIST OF REFERENCES
1. Eric W. Taylor – Infection in surgical practice
2. Bailey and love – Short practice of surgery
3. David C Sobiston Jr. M. D. – Text book of surgery – the biological basis of modern surgical practice
4. Principles of surgery – by Schwartz
5. National academy of Science, National Research council division of Medical science Ad Hoccommittee of the committee on Trauma post O. P. wound infection. The influences of U. V. Irradiation of the op crating room and various other factors – Ann. Surg. 160
6. Elebute G. and Stoner, H. B (1983) the grading of sepsis, Br. J. Sugrg. 70, 29-31
7. Muller, J.C. Buzby, G.P. Waldman, M.T. etal, predication of operative morbidity and morality by pre operative nutritional assessment surg forum 30.80.1979
8. Surgical clinics of North America, Feb 1980, feb 1988, surgical infection
9. Fricschlag J. Busuttil-R the valve of post operative fever evaluation surgery 94.358.363.1983
10. Altemeir W.A. the surgical conscience A.M.A. Arch surg. 79. 167.1959
11. Chruch J and sanderson P. (1980), surgical glove puncturesJ. Hosp.infect. 1. 84
12. Howe, C. W (1966) Experiment studies on determination of wound infection, surg, bynecor. Obstet 123.507.14
9 / Signature of candidate
10 / Remarks of the guide
11 / Name & Designation of
(in block letters)
11.1 Guide
11.2 Signature / Dr. N DEVIDAS SHETTY M.B.B.S, MS., FRCS
PROFESSOR,
DEPARTMENT OF SURGERY,
A J INSTITUTE OF MEDICAL SCIENCES,
MANGALORE.
11.3 Head of Department
11.4 Signature / Dr. ASHOK HEGDE M.B.B.S, MS.,
DEPARTMENT OF SURGERY
PROFESSOR AND HOD,
A J INSTITUTE OF MEDICAL SCIENCES,
MANGALORE
12 / 12.1 Remarks of the
Chairman and Principal
12.2 Signature
PROFORMA
Name Age Sex DOA
IP.NO Economic Status Duration of disease a) < 1 month
b) 1 month – 1 year
c) > 1 year
Duration of stay in the Hospital prior to surgery;
a) < week
b) 1 week – 1 month
c) > 1 month
Duration of post op stay in the Hospital;
a) < 7 days
b) > - 12 days
c) > 12 days
PRE-OPERATIVE
1. Nutritional status:
Clinically Biochemically – S. Albumin
a) Well nourished a)> 3.5mg%
b) Moderately nourished b) 3 – 3.5%
c) Poorly Nourished c) < 3.0gm%
2. Haematological status:
Clinically Hemoglobin
a) No pallor a) > 11gm%
b) Mild pallor b) 9-11gm%
c) Severe pallor c) < 9gm%
3. History of any Drug Intake a) Yes b) No
4. If drug intake present nature of drugs
a) Steroids
b) Other immune suppressive agents
c) Antibiotics
d) Anti tuberculous therapy
e) Cyto toxic agents
f) Miscellaneous
5. Presence of any associated diseases
a) Diabetes mellitus
b) Peripheral vascular disease
c) Obesity
d) Distant source of infection
e) Associated infections
f) No detectable disease at the time of surgery
g) Miscellaneous
6. Preparation of the patient
a) Shaving the part 1. Yes
2. No
b) Bath in the morning on the day of surgery 1. Yes
2. No
c) If yes whether bath was taken
1. Before shaving the patient
2. After shaving the patient
7. Any prophylactic antibiotics used
a) Yes b) No
8. If used – type of antibiotics used
a) Ampicillin
b) Gentamicin
c) Metronidazole
d) Penicillin
e) Septran
f) Ampiclox
g) Ciprofloxacin
h) Cephalosporins – specify
i) Amikacin
j) Erthromycin
k) Tetracycline
l) Ofloxacin
m) Perloxacin
n) Norfloxacin
o) Cloxacillin
p) Miscellaneous
INTRA OPERATIVE
1. Skin Preparation a) loperp / spirit
b) Spirit only
c) Savion / Saline
2. Surgeons preparations: a) Routine Scrubbing with soap Yes / No
b) Loprep scrub Yes / No
c) Hibiscrub Yes / No
d) Spirit Yes / No
3. Type of surgery performed
4. Site of the surgery a) head and neck
b) Limb surgery
c) Abdomen
d) Thorax
e) External genitalia and perianal
5.First Assistant : Surgeon
PG Resident
Scrub Nurse
6. Whether part was isolated or not
Yes / No
7. Whether Hollow viscus was opened or not
Yes / No
8. Duration of the surgery a) < 1 hour
b) 1-3 hours
c) > 3 hours
9. Suture material used
A. Deep sutures B. Subcutaneous sutures C. Skin
1. Chronic catgut 1. Plain catgut 1. Linen
2. Plain catgut 2. Chromic catgut 2. Ethilon
3. Proline 3. Vicryl 3. Silk
4. Ethilon 4. No subcutaneous sutures applied 3. Proline
5. Vicryl
6. Skin
7. Linen
D. Sub-cuticular Yes / No
E. If yes what suture material used 1. Ethilon
2. Proline
3. Silk
4. Plain catgut
5. Chromic catgut
6. Vicryl
10. Whether drain used of not Yes / No
11. If yes – type of drain used a) Tube drain
b) Corrugated drain
c) Glove drain
d) Suction drain
12. Use of intra operative antibiotics Yes / No
13. If used – type of antibiotic used: a) Ampicillin
b) Penicillin
c) Gentamicin
d) Septran
e) Metronidazole
f) Ampiclox
g) Ciprofloxacin
h) Cephalosporins – specify
i) Amikacin
14. Whether cautery was used or not Yes / No
POST – OPERATIVE
1. Use of post – operative antibiotic Yes / No
2. If used type of antibiotic used a) Ampicillin
b) Penicillin
c) Gentamicin
d) Septran
e) Metronidazole
f) Amikacin
j) Norfloxacin
i) Miscellaneous
3. Whether wound was dressed or open
Dressed / open
4. Any post – op sym / sig of infection Yes / No
5. If yes – what are the symptoms / signs present?
a) Erythema around the wound margins
b) Induration around the wound margins
c) Tenderness
d) Fever
f) Discharge
g) Excessive pain at the wound site
6. Discharge from wound site Yes / No
7. Day of onset of discharge a. < 3 days
b. 3-30 days
c. > 30 days
8. If discharge present nature of the discharge
a. Serous
b. Serosanguinous
c. Purulent
d. Bloody
9. Culture and sensitivity report of discharge
Organisms Sensitivity Resistance
a) Commensals a) Ampicillin a) Ampicillin
b) Staphylococcus b) Penicillin b) Penicillin
c) Staphylococcus Species c) Gentamicin c) Gentamicin
d) E coli d) Septran d) Septran
e) Pseudomonas e) Metronidazole e) Metronidazole
f) Klebsiella f) Ampiclox f) Ampiclox
g) Anacrobes g) Ciprofloxacin g) Ciprofloxacin
h) No growth h) Cephalosporins h) Cephalosporins
specify specify
i) Miscellaneous i) Amikacin i) Amikacin
j) Erthromycin j) Erthromycin
k) Tetracycline k) Tetracycline
l) Pefloxacin l) Pefloxacin
m) Perfloxacin m) Perfloxacin
n) Norfloxcin n) Norfloxcin
o) Miscellaneous o) miscellaneous
10. Dressing of the wound a) Wound left open after removal of primary
dressing
b) Daily dressing
c) Primary dressing removed only on the
day of suture removal
11. Day of drain removal: a) < 24 hours
b) 24-48 days
c) > 48 days
12. Day of suture removal a) < 5 days
b) 5-10 days
c) > 10 days
13. Any associated infection a) UTI
b) Respiratory tract infection
c) Distant foci of infection
14. Post – operative follow up; was done in all cases who had post operative discharge was sent for culture sensitivity patterns on an OPD basis until discharge stopped and for any evidence of infection.
A.J.INSTITUTE OF MEDICAL SCIENCES
MANGALORE
INFORMED CONSENT FORM
I ……………………………………………. declare that I have been briefed and hereby consent to be included as a
subject in the following dissertation “POSTOPERATIVE WOUND SEPSIS AND PROPHYLACTIC ANTIBIOTICS”.
I have been informed by Dr. Thejaswi N Marla to my satisfaction, the purpose of the work done and also necessary laboratory investigation required.
This has been explained to me in the language I understand and I fully consent for the same.
SIGNATURE OF DOCTOR SIGNATURE OF PATIENT/RELATIVE
NAME OF THE DOCTOR NAME
DATE RELATIONSHIP
DATE
Consent for participation in research