{"id":1333,"date":"2013-03-01T16:54:01","date_gmt":"2013-03-01T16:54:01","guid":{"rendered":"http:\/\/phosdev.com\/todaysveterinarypractice\/?p=1333"},"modified":"2022-02-17T19:18:26","modified_gmt":"2022-02-17T19:18:26","slug":"todays-technician-assisting-the-surgeon-practical-strategies-for-preventing-nosocomial-infections","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/infectious-disease\/todays-technician-assisting-the-surgeon-practical-strategies-for-preventing-nosocomial-infections\/","title":{"rendered":"Assisting the Surgeon: Practical Strategies for Preventing Nosocomial Infections"},"content":{"rendered":"<p class=\"p1\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2016\/09\/T1303C10.pdf\"><img decoding=\"async\" class=\"alignnone size-full wp-image-9886\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2011\/07\/pdf_button.png\" alt=\"pdf_button\" width=\"110\" height=\"27\" \/><\/a><\/p>\n<hr \/>\n<p class=\"p1\"><span class=\"s1\"><em>Noah Jones, RVT<\/em><\/span><\/p>\n<p class=\"p1\">Postoperative patients are among those at highest risk for nosocomial infection. Strategies for disinfecting personnel, equipment, and the surgical suite are meticulously outlined.<\/p>\n<hr \/>\n<p class=\"p1\"><span class=\"s1\">Nosocomial infections increase morbidity and mortality in patients as well as cost to clients. Antimicrobial resistance further complicates nosocomial infections by increasing morbidity, mortality, and cost.<\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>RISK FACTORS<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Postoperative patients are among those at highest risk for nosocomial infection because these patients:<\/span><span class=\"s2\"><sup>1<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Are frequently fasted<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Have ongoing disease processes<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Undergo procedures in which multiple medical devices are inserted into the body<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Receive drugs that alter the normal physiology of the patient. <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">All of these factors can modulate a patient&#8217;s immune system. Veterinary health care teams must take precautions to minimize the risk of transferring pathogens between patients and maximize their ability to fight infection.<\/span><\/p>\n<div class=\"orange-box\">\n<h2><span class=\"s1\"><b>POTENTIAL RISK FACTORS FOR NOSOCOMIAL INFECTION<\/b><\/span><span class=\"s3\"><b><sup>1<\/sup><\/b><\/span><\/h2>\n<h3><span class=\"s1\"><b>Patient Condition<\/b><\/span><\/h3>\n<ul>\n<li><span class=\"s1\">Immune deficiency (ie, neutropenia, diabetes mellitus, immunosuppresive drugs)<\/span><\/li>\n<li><span class=\"s1\">Malnutrition<\/span><\/li>\n<li><span class=\"s1\">Open wounds<\/span><\/li>\n<\/ul>\n<h3><span class=\"s1\"><b>Patient Environment<\/b><\/span><\/h3>\n<ul>\n<li><span class=\"s1\">Prolonged hospitalization, surgical preparation, or surgery\/anesthesia time<\/span><\/li>\n<\/ul>\n<h3><span class=\"s1\"><b>Medical Procedures<\/b><\/span><\/h3>\n<ul>\n<li><span class=\"s1\">Blood product administration<\/span><\/li>\n<li><span class=\"s1\">Central venous catheterization<\/span><\/li>\n<li><span class=\"s1\">Concurrent antibiotic therapy<\/span><\/li>\n<li><span class=\"s1\">Frequent bandage changes<\/span><\/li>\n<li><span class=\"s1\">Prolonged catheterization (of any type)<\/span><\/li>\n<\/ul>\n<h3><span class=\"s1\"><b>Inappropriate Care<\/b><\/span><\/h3>\n<ul>\n<li><span class=\"s1\">Improper aseptic\/sterile technique, care of catheters, and\/or tissue handling<\/span><\/li>\n<li><span class=\"s1\">Inexperienced surgeon<\/span><\/li>\n<\/ul>\n<\/div>\n<h2 class=\"p3\"><span class=\"s1\"><strong>SIGNS OF INFECTION<\/strong><\/span><\/h2>\n<p class=\"p3\"><span class=\"s1\">Patients at risk for nosocomial infections (see <strong>Potential Risk Factors for Nosocomial Infection<\/strong>) should be monitored closely for signs of infection, such as:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Increasing lethargy <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Edema, redness, pain, and\/or heat (or fever)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Discharge from wounds or surgical sites.<\/span><\/li>\n<\/ul>\n<h2 class=\"p3\"><span class=\"s1\"><b>NOSOCOMIAL OR RESISTANT?<\/b><\/span><\/h2>\n<h3 class=\"p5\"><span class=\"s1\"><b>Nosocomial Infections<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">A nosocomial infection is defined as <em>an infection that is acquired or occurs in a hospital<\/em>.<\/span><span class=\"s2\"><sup>1<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Extensive research has been performed in the human medical field due to the frequency of occurrence, increased costs, and large number of deaths associated with nosocomial infections: <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">In the U.S., annual costs related to nosocomial infections in human medicine are reported to be over $4 billion.<\/span><span class=\"s2\"><sup>1<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Over 2 million patients (5% to 10% of the total patient population) are affected, causing over 80,000 deaths each year.<\/span><span class=\"s2\"><sup>2<\/sup><\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Due to lack of uniform reporting and surveillance, veterinary nosocomial infection rates are unknown, though it has been found to be a common problem encountered in veterinary teaching hospitals.<\/span><span class=\"s2\"><sup>3<\/sup><\/span><span class=\"s1\"> Additional research is needed to determine the frequency of nosocomial infections in private veterinary practice as this data does not exist at this time.<\/span><\/p>\n<h3 class=\"p5\"><span class=\"s1\"><b>Antimicrobial Resistance<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Antimicrobial resistance (AMR) occurs when a pathogen develops resistance to 1 or more agents to which the pathogen was previously sensitive.<\/span><span class=\"s2\"><sup>1<\/sup><\/span><span class=\"s1\"> AMR is a growing problem in both human and veterinary medicine.<\/span><span class=\"s2\"><sup>1<\/sup><\/span><span class=\"s1\"> AMR has become more common in nosocomial infections, although the 2 are not synonymous.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">AMR often occurs due to inappropriate antimicrobial administration, causing selection for resistant organisms, but can also occur in the face of appropriate antibiotic administration.<\/span><span class=\"s2\"><sup>1<\/sup><\/span><span class=\"s1\"> In the latter case, the gastrointestinal tract is a reservoir for resistant organisms, which can then be transferred from patient to patient.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">The rate of AMR in veterinary medicine is largely unknown. In a recent study of 10 private veterinary hospitals,<\/span><span class=\"s2\"><sup>3<\/sup><\/span><span class=\"s1\"><em> Enterococcus<\/em> contamination was found at all 10 hospitals, with approximately 20% of the isolates having AMR. Of the AMR isolates:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">About 30% were found on stethoscopes, with 50% of personnel reporting that they almost never cleaned their stethoscopes. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">6% were found on thermometers, with 30% of hospitals reporting that thermometers were not cleaned between patients. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">60% were found on cage doors, with 30% of hospitals reporting that cage doors were not disinfected between patients.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Another study showed that 44% of dogs with pyoderma were infected with resistant isolates, mostly <em>Staphylococcus pseudintermedius<\/em>, which is the most frequently isolated <em>Staphylococcus<\/em> species in canine and feline patients.<\/span><span class=\"s2\"><sup>4<\/sup><\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>HAND HYGIENE<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Pathogen transmission in hospitals occurs most often via contaminated hands of health care workers.<\/span><span class=\"s2\"><sup>2<\/sup><\/span><span class=\"s1\"> Although our patients are handled differently than human patients, it is likely that pathogen transmission still occurs frequently via contaminated hands. Therefore, hand hygiene should be a high priority in any health care setting.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Proper hand hygiene consists of hand disinfection:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><b><\/b><span class=\"s1\"><b>Before<\/b><\/span>\n<ul class=\"ul2\">\n<li class=\"li1\"><span class=\"s1\">Direct contact with a patient or its environment<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Placement of any type of catheter<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Movement from a contaminated to a clean site on a patient<\/span><\/li>\n<\/ul>\n<\/li>\n<li class=\"li1\"><b><\/b><span class=\"s1\"><b>After<\/b><\/span>\n<ul class=\"ul2\">\n<li class=\"li1\"><span class=\"s1\">Direct contact with a patient or its environment<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Contact with patient bodily fluids<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Removal of gloves.<\/span><span class=\"s2\"><sup>2<\/sup><\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h3 class=\"p5\"><span class=\"s1\"><b>Disinfection<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Disinfection for visibly soiled hands is achieved by (<b>Figure 1<\/b>):<\/span><span class=\"s2\"><sup>2<\/sup><\/span><\/p>\n<ol class=\"ol1\">\n<li class=\"li1\"><span class=\"s1\">Washing hands in running warm water, with sufficient volume of antimicrobial soap to cover all surfaces of hands\/fingers in lather. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Rubbing for at least 15 seconds before rinsing. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Using paper towels or single-use cloth towels to dry hands.<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Turning the faucet off using the towel. <\/span><\/li>\n<\/ol>\n<div id=\"attachment_3280\" style=\"width: 310px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/Figure-1.jpg\"><img fetchpriority=\"high\" decoding=\"async\" aria-describedby=\"caption-attachment-3280\" class=\"wp-image-3280 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/Figure-1-300x223.jpg\" alt=\"Figure 1\" width=\"300\" height=\"223\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/Figure-1-300x223.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/Figure-1.jpg 403w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-3280\" class=\"wp-caption-text\">Figure 1. Proper hand hygiene is critical for prevention of nosocomial infection.<\/p><\/div>\n<p class=\"p1\"><span class=\"s1\">Alcohol-based sanitizers are the preferred method of hand hygiene in human medicine and have shown better bactericidal activity than that of soap and water.<\/span><span class=\"s2\"><sup>2<\/sup><\/span><span class=\"s1\"> Hands that require disinfection but are not visibly soiled can be effectively disinfected by:<\/span><span class=\"s2\"><sup>2<\/sup><\/span><\/p>\n<ol class=\"ol1\">\n<li class=\"li1\"><span class=\"s1\">Using a sufficient volume of alcohol-based hand sanitizer to cover all surfaces of hands\/fingers. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Rubbing for at least 15 seconds before hands are dry.<\/span><\/li>\n<\/ol>\n<h3 class=\"p5\"><span class=\"s1\"><b>Gloves<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Gloves can be used to prevent gross contamination of the hands, but are not an alternative to proper hand disinfection. Gloves should be worn while handling every patient and hand disinfection should be performed after carefully removing contaminated gloves. Even though clean gloves are used with each patient, hands can become contaminated during glove removal and hand disinfection prevents any transfer of pathogens from one patient to another.<\/span><\/p>\n<h3 class=\"p5\"><span class=\"s1\"><b>Education<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Despite health care workers acknowledging the importance of hand hygiene, compliance rates are very low.<\/span><span class=\"s2\"><sup>2,5,6<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Recent veterinary studies report hand hygiene compliance to be between 20% to 40%, with 85% of workers feeling they should be washing their hands more frequently.<\/span><span class=\"s2\"><sup>5<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">One veterinary study showed that implementing a comprehensive education program could increase compliance, which is consistent with human data on the same subject.<\/span><span class=\"s2\"><sup>6<\/sup><\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">The Institute for Healthcare Improvement (IHI) recommends implementing an intervention package consisting of 4 items to increase hand hygiene compliance:<\/span><\/p>\n<ol class=\"ol1\">\n<li class=\"li1\"><span class=\"s1\"><strong>Educate staff on the importance of proper hand hygiene:<\/strong> Staff should understand why hand hygiene is important and the implications of poor hand hygiene. In-service educational programs, posters, and other literature can be useful as educational tools.<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><strong>Verify appropriate hand hygiene technique:<\/strong> Proper technique should be demonstrated to all staff members. Reminders of proper technique may be posted at sinks and other hand hygiene stations (<b>Figure 2<\/b>). <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><strong>Ensure hand hygiene is available at point of care:<\/strong> Ideally, someone is assigned the task of refilling dispensers and ensuring availability of adequate supplies. Checklists may be especially useful for this purpose.<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><strong>Continually monitor compliance while providing feedback:<\/strong> Staff should be regularly evaluated on proper technique to ensure ongoing patient safety. Written examinations and direct observation are useful in monitoring compliance.<\/span><\/li>\n<\/ol>\n<div id=\"attachment_3281\" style=\"width: 310px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/Figure-2.jpg\"><img decoding=\"async\" aria-describedby=\"caption-attachment-3281\" class=\"wp-image-3281 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/Figure-2-300x225.jpg\" alt=\"Figure 2\" width=\"300\" height=\"225\" \/><\/a><p id=\"caption-attachment-3281\" class=\"wp-caption-text\">Figure 2. Various methods, such as posting reminders in patient care areas, are useful in promoting proper hand hygiene<\/p><\/div>\n<h2><span class=\"s1\"><b>SURFACE DISINFECTION<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Additional routes of transmission include contaminated environmental surfaces and equipment.<\/span><span class=\"s2\"><sup>3<\/sup><\/span><span class=\"s1\"> Proper environmental disinfection is challenging for veterinary teams as patients are not usually confined to a hospital bed.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">The appropriate disinfectant is dependent on the surface or device. Disinfectants are divided into 3 categories:<\/span><\/p>\n<ol class=\"ol1\">\n<li class=\"li1\"><span class=\"s1\">Low level<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Intermediate level<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">High level or sterilization.<\/span><\/li>\n<\/ol>\n<blockquote>\n<p align=\"LEFT\">Many disinfectants become unstable after dilution, and must be changed daily, while others may be stable for months.7,8 consultation with your disinfectant manufacturer for stabilityin-solution information is recommended.<\/p>\n<\/blockquote>\n<h3><span class=\"s1\"><b>Low-Level Disinfectants<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Low-level disinfectants are used for <strong>noncritical surfaces that touch intact skin or do not come in contact with the patient<\/strong>, such as floors, tables, food bowls, cages, and stethoscopes.<\/span><span class=\"s2\"><sup>7<\/sup><\/span><span class=\"s1\"> Examples include: <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">70% isopropyl alcohol<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Quaternary ammonium compounds<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Peroxygen compounds<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">0.05% chlorhexidine<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Sodium hypochlorite (1:100). <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">While very popular in the veterinary industry, quaternary ammonium compounds have been shown to have poor virucidal and sporucidal activity (despite label claims) and are not recommended for disinfection of contaminated or potentially contaminated surfaces, such as floors.<\/span><span class=\"s2\"><sup>7,8<\/sup><\/span><span class=\"s1\"> Additionally these compounds are bacteriostatic and can cause pathogens to become disinfectant-resistant.<\/span><span class=\"s2\"><sup>7<\/sup><\/span><\/p>\n<h3 class=\"p5\"><span class=\"s1\"><b>Intermediate-Level Disinfectants<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Intermediate-level disinfectants are used for <strong>semicritical surfaces that will contact mucous membranes or intact skin<\/strong>, such as laryngoscopes, thermometers, and endotracheal tubes.<\/span><span class=\"s2\"><sup>7<\/sup><\/span><span class=\"s1\"> Examples include: <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">70% ethanol<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Peroxygen compounds<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">0.5% chlorhexidine<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Sodium hypochlorite (1:10; contact time will be longer compared to low-level use<\/span><span class=\"s2\"><sup>7<\/sup><\/span><span class=\"s1\">).<\/span><\/li>\n<\/ul>\n<h3 class=\"p5\"><span class=\"s1\"><b>High-Level Disinfectants<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">High-level disinfectants or sterilizers are used for <strong>critical surfaces that enter the bloodstream or a body cavity<\/strong>, such as intravenous catheters, surgical instruments, and laparoscopes.<\/span><span class=\"s2\"><sup>7<\/sup><\/span><span class=\"s1\"> Examples include:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Ethylene oxide gas<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Hydrogen peroxide gas (low-temperature plasma)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">2% activated glutaraldehyde<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Steam (121\u00b0F). <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Two percent activated glutaraldehyde is often adequate for critical items that cannot be sterilized.<\/span><span class=\"s2\"><sup>7<\/sup><\/span><\/p>\n<div class=\"orange-box\">\n<p align=\"LEFT\"><strong>The Centers for Disease Control and Prevention<\/strong> have published guidelines outlining methods of disinfection and sterilization, available agents, concentrations, contact times, and special considerations. These guidelines are available at <strong>cdc.gov\/hicpac\/pdf\/guidelines\/Disinfection_Nov_2008.pdf<\/strong>.<\/p>\n<\/div>\n<h3 class=\"p5\"><span class=\"s1\"><b>Step-by-Step Disinfection<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Surface disinfection should be a 2-step process consisting of: <\/span><\/p>\n<ol class=\"ol1\">\n<li class=\"li1\"><span class=\"s1\">Organic debris removal <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Disinfection using appropriate contact time.<\/span><\/li>\n<\/ol>\n<div id=\"attachment_3282\" style=\"width: 310px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/Figure-31.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3282\" class=\"wp-image-3282 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/Figure-31-300x225.jpg\" alt=\"Figure 3\" width=\"300\" height=\"225\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/Figure-31-300x225.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/Figure-31.jpg 400w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-3282\" class=\"wp-caption-text\">Figure 3. Effective disinfection is ensured by proper disinfection protocols and care of disinfection equipment.<\/p><\/div>\n<p class=\"p1\"><span class=\"s1\">However, consideration of proper disinfectants, dilution, and contact times are not sufficient.<\/span><\/p>\n<ul>\n<li><span class=\"s1\"><strong>Prepared scrub gauze and items from cold sterile trays<\/strong> should be removed by tongs. Weekly sterilization of these items is necessary to prevent multidrug-resistant colonization.<\/span><span class=\"s2\"><sup>7<\/sup><\/span><\/li>\n<li><span class=\"s1\"><strong>Mop heads and solutions<\/strong> (<b>Figure 3<\/b>) should be changed at least twice daily, preferably at the beginning of the day and before final mopping at closing time; sooner if visible soil is present.<\/span><span class=\"s2\"><sup>7<\/sup><\/span>\n<ul>\n<li><span class=\"s1\">A separate mop bucket\/head should be used for the surgical suite to minimize potential for cross contamination. <\/span><\/li>\n<li><span class=\"s1\">Periodic scrubbing with an intermediate-level disinfectant should be performed on all mop buckets and handles. <\/span><\/li>\n<\/ul>\n<\/li>\n<li><span class=\"s1\"><strong>Floor drains<\/strong> should be disinfected weekly with a 1:50 bleach solution.<\/span><span class=\"s2\"><sup>7<\/sup><\/span><\/li>\n<li><span class=\"s1\"><strong>High-touch surfaces<\/strong>, such as computers, handsets, mobile phones, door handles, and cage handles, should receive low- or intermediate-level disinfection. <\/span><\/li>\n<li><span class=\"s1\"><strong>Stethoscopes, pulse oximetry probes, Doppler probes, blood pressure cuffs, and other monitoring equipment<\/strong> must be cleaned between patients and at least once daily. Isopropyl alcohol (70%) is reportedly most effective when proper contact times are observed.<\/span><span class=\"s2\"><sup>3,7<\/sup><\/span><\/li>\n<li><span class=\"s1\"><strong>Laundry<\/strong> should be collected in leak-proof containers and washed in hot water (&gt; 160\u00b0F) for at least 25 minutes.<\/span><span class=\"s2\"><sup>7<\/sup><\/span><span class=\"s1\"> A 1% bleach solution should be used for laundry disinfection, although polyester fabric may be resistant to this form of disinfection, with further disinfection necessary.<\/span><span class=\"s2\"><sup>7<\/sup><\/span><\/li>\n<\/ul>\n<h2 class=\"p3\"><span class=\"s1\"><b>SURGICAL SUITE<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Special precautions must be made in the surgical suite as these patients may be at high risk for nosocomial infection due to anesthetic-related immune suppression and exposure of tissues (<b>Figure 4<\/b>). The anesthesia work area can become contaminated, causing spread of resistant bacterial organisms between patients.<\/span><span class=\"s2\"><sup>9<\/sup><\/span><\/p>\n<div id=\"attachment_3283\" style=\"width: 310px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/Figure-4.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3283\" class=\"wp-image-3283 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/Figure-4-300x226.jpg\" alt=\"Figure 4\" width=\"300\" height=\"226\" \/><\/a><p id=\"caption-attachment-3283\" class=\"wp-caption-text\">Figure 4. Patients under anesthesia for surgical procedures are at higher risk for nosocomial infection.<\/p><\/div>\n<h3 class=\"p1\"><span class=\"s1\"><b>Area Designation<\/b><\/span><\/h3>\n<ul>\n<li><span class=\"s1\">A <em>clean<\/em> area should be used to store new items and drugs; a <em>dirty<\/em> area should be used to store items specific to the current patient, such as monitoring equipment and predrawn drugs. <\/span><\/li>\n<li><span class=\"s1\">A plastic bag or tub works well as a <em>dirty<\/em> area to isolate patient-specific items while maintaining portability throughout the hospital. <\/span><\/li>\n<li><span class=\"s1\">All surfaces and equipment should be disinfected between patients using an appropriate disinfectant and contact time.<\/span><\/li>\n<\/ul>\n<h3 class=\"p5\"><span class=\"s1\"><b>Personnel<\/b><\/span><\/h3>\n<ul>\n<li><span class=\"s1\">Surgical personnel should practice barrier precautions, such as gowns, gloves, masks, and face shields specific to that patient, when a known or suspected infectious patient, such as one with a positive culture or zoonotic disease, is in the surgical suite. <\/span><\/li>\n<li><span class=\"s1\">Street clothes should never be worn in the operating theatre. Research has shown that, when compared to street clothes, scrubs reduced airborne <em>S aureus<\/em> levels by 75%.<\/span><span class=\"s2\"><sup>10<\/sup><\/span><span class=\"s1\"> Therefore, scrubs should not be worn outside the hospital and surgical personnel should change into clean scrubs before entering the surgical suite. <\/span><\/li>\n<li><span class=\"s1\">The addition of masks and gowns only improved the reduction of <em>S aureus<\/em> levels to 82%, which emphasizes the importance of wearing clean scrubs in the surgical suite.<\/span><span class=\"s2\"><sup>10<\/sup><\/span><\/li>\n<\/ul>\n<h3 class=\"p5\"><span class=\"s1\"><b>Modifiable Risk Factors<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\"><strong>Perioperative hypothermia<\/strong> has been shown to suppress immune function and should, therefore, be avoided in patients.<\/span><span class=\"s2\"><sup>11<\/sup><\/span><\/p>\n<ul>\n<li><span class=\"s1\">Using forced-air blankets, heating pads, heat-moisture exchangers, low-flow oxygen, and minimizing surgical preparation time can all reduce the likelihood and severity of perioperative hypothermia. <\/span><\/li>\n<li><span class=\"s1\">Use of forced air blankets, however, should be delayed until final sterile draping of the patient to minimize the likelihood of foreign material or pathogens being blown into the surgical field.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\"><strong>Impaired tissue oxygenation<\/strong> has been shown to delay wound healing and increase infection rates; supplemental oxygen should be provided to all anesthetized patients.<\/span><span class=\"s2\"><sup>11<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><strong>Shaving patients<\/strong> with a razor has been shown to increase infection rates; patients should be clipped with clippers in the immediate preoperative period if hair removal is necessary.<\/span><span class=\"s2\"><sup>11<\/sup><\/span><\/p>\n<h3 class=\"p5\"><span class=\"s1\"><b>Protocols<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\"><strong>Prophylactic antibiotics<\/strong> must be present in sufficient concentration in the tissues at time of contamination in order to effectively prevent nosocomial infection.<\/span><span class=\"s2\"><sup>12<\/sup><\/span><span class=\"s1\"> The American Society of Health System Pharmacists recommends administration of cefazolin, 20 to 30 mg\/kg IV, at induction of anesthesia for most surgical procedures; however, specific veterinary data on the appropriate dosage and frequency of perioperative antibiotics is lacking.<\/span><span class=\"s2\"><sup>12,13<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><strong>Aseptic technique<\/strong> is essential, and any breach of the sterile field should be immediately brought to the surgeon&#8217;s attention. <\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><strong>Surgical instruments<\/strong> should be immediately processed after the procedure, including:<\/span><span class=\"s2\"><sup>14<\/sup><\/span><\/p>\n<ul>\n<li><span class=\"s1\">Manual scrubbing to remove gross contamination<\/span><\/li>\n<li><span class=\"s1\">Ultrasonic cleaning<\/span><\/li>\n<li><span class=\"s1\">Lubrication, if necessary<\/span><\/li>\n<li><span class=\"s1\">Appropriate sterilization<\/span><\/li>\n<li><span class=\"s1\">Careful inspection to ensure proper function and decontamination.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><strong><span class=\"s1\">Minimizing anesthesia and surgery time is likely the most important intervention in preventing nosocomial infections.<\/span><\/strong><span class=\"s2\"><sup>15<\/sup><\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>IN SUMMARY<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Nosocomial infections and AMR are life-threatening problems for veterinary patients, especially surgical patients. Proper hand hygiene, surface disinfection, and surgical etiquette are essential in minimizing risk and obtaining positive outcomes in veterinary patients. Further research is necessary to determine the rate of nosocomial infection, organisms responsible, risk factors, and recommended interventions for patients at risk.<\/span><\/p>\n<p class=\"p1\">AMR = antimicrobial resistance; IHI = Institute for Healthcare Improvement<\/p>\n<h3 class=\"p1\"><strong><span style=\"line-height: 1.5\">References<\/span><\/strong><\/h3>\n<ol>\n<li class=\"p1\"><span style=\"line-height: 1.5\">Ogeer-Gyles JS, Mathews KA, Boerlin P. Nosocomial infections and antimicrobial resistance in critical care medicine. <em>J Vet Emerg Crit Care<\/em> 2006; 16(1):1-18.<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Institute for Healthcare Improvement. <em>How-To Guide: Improving Hand Hygiene<\/em>. Available at shea-online.org\/assets\/files\/IHI_hand_hygiene.pdf, assessed June 16, 2012.<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">KuKanich KS, Ghosh A, Skarbek JV, et al. Surveillance of bacterial contamination in small animal veterinary hospitals with special focus on antimicrobial resistance and virulence traits of enterococci. <em>JAVMA<\/em> 2012; 240(4):437-445.<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Eckholm NG, Outerbridge CA, White SD, Sykes JE. Prevalence of and risk factors for isolation of methicillin-resistant <em>Staphylococcus<\/em> species from dogs with pyoderma in northern California, USA. <em>Vet Derm<\/em> 2013; 24(1):154-234.<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Nakamura RK, Tompkins E, Braasch EL, et al. Hand hygiene practices of veterinary support staff in small animal private practice. <em>J Small Anim Pract<\/em> 2012; 53(3):155-160.<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Shea A, Shaw S. Evaluation of an educational campaign to increase hand hygiene at a small animal veterinary teaching hospital. <em>JAVMA<\/em> 2012; 240(1):61-64.<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Portner JA, Johnson JA. Guidelines for reducing pathogens in veterinary hospitals: Disinfectant selection, cleaning protocols, and hand hygiene. <em>Compend Contin Educ Vet<\/em> 2010; 53(3):E1-E12.<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Eleraky NZ, Potgieter LN, Kennedy MA. Virucidal efficacy of four new disinfectants. <em>JAAHA<\/em> 2002; 38(3):231-234.<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Loftus RW, Koff MD, Burchman CC, et al. Transmission of pathogenic bacterial organisms in the anesthesia work area. <em>Anesthesiol<\/em> 2008; 109:399-407.<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Bischoff WE, Tucker BK, Wallis ML, et al. Preventing airborne spread of <em>Staphylococcus aureus<\/em> by persons with the common cold: Effects of surgical scrubs, gowns, and masks. <em>Infect Control Hosp Epidemiol<\/em> 2007; 28(10):1148-1154.<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Sessler DI. Non-pharmacological prevention of surgical wound infection. <em>Anesthesiol Clin<\/em> 2006; 24(2):279-297.<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">American Society of Health System Pharmacists. <em>ASHP Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery<\/em>. Available at ashp.org\/s_ashp\/docs\/files\/BP07\/TG_surgical.pdf, accessed January 31, 2013.<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Knights CB, Mateus A, Baines SJ. Current British veterinary attitudes to the use of perioperative antimicrobials in small animal surgery. <em>Vet Rec<\/em> 2012; 170(25):646.<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Crow S. Protecting patients, personnel, instruments in the OR. <em>J AORN<\/em> 1993; 58(4):771-774.<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Nicholson M, Beal M, Shofer F, Brown DC. Epidemiology evaluation of postoperative wound infection in clean-contaminated wounds: A retrospective study of 239 dogs and cats. <em>Vet Surg<\/em> 2012; 31:577-581.<\/span><\/li>\n<\/ol>\n<p class=\"p6\"><span class=\"author-bio\"><strong><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Noah-Jones.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-8989\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Noah-Jones-150x150.png\" alt=\"Noah Jones\" width=\"100\" height=\"114\" \/><\/a>Noah Jones<\/strong>, RVT, specializes in emergency and critical care practice. He has worked in private emergency\/referral practice as well as in academia at the University of California\u2013Davis Veterinary Medical Teaching Hospital. Mr. Jones has a strong interest in infectious disease prevention and critical care nursing of infectious patients.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Noah Jones, RVT Postoperative patients are among those at highest risk for nosocomial infection.<\/p>\n","protected":false},"author":1,"featured_media":2738,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":571,"footnotes":""},"categories":[375],"tags":[13],"class_list":["post-1333","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-march-april-2013","tag-peer-reviewed","clinical_topics-infectious-disease"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.7 (Yoast SEO v27.3) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Assisting the Surgeon: 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