Download PDF
Zentralbl Chir 2017; 142(05): 516-523
DOI: 10.1055/s-0043-120575
Übersicht
Georg Thieme Verlag KG Stuttgart · New York

Prävention von postoperativen Wundinfektionen – mit Fokus auf die Gefäßchirurgie

Prevention of Surgical Site Infections – with Special Focus on Vascular Surgery
Peter Bischoff
Institut für Hygiene und Umweltmedizin, Charité – Universitätsmedizin Berlin, Deutschland
,
Petra Gastmeier
Institut für Hygiene und Umweltmedizin, Charité – Universitätsmedizin Berlin, Deutschland
› Author Affiliations
Further Information

Publication History

Publication Date:
27 October 2017 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Einleitung Postoperative Wundinfektionen rangieren, je nach epidemiologischer Auswertung, zwischen den weltweit am häufigsten bzw. zweithäufigsten vorkommenden nosokomialen Infektionen. Erleidet ein Patient eine postoperative Wundinfektion, stellt dies für ihn, je nach Schwere, ein ernstzunehmendes Morbiditäts- und Mortalitätsrisiko dar. Die negativen Auswirkungen beschränken sich nicht nur auf den einzelnen Patienten, auch für die Angehörigen, das Krankenhaus und für das gesamte Gesundheitssystem bedeutet dies eine enorme Belastung. In der Gefäßchirurgie machen grampositive Hautkeime fast die Hälfte aller Infektionen aus, bei denen ein Erreger nachgewiesen werden konnte. Staphylococcus aureus allein ist mit einem Drittel dieser Infektionen assoziiert.

Präventionsmaßnahmen Neben generellen Maßnahmen zur Prävention von postoperativen Wundinfektionen lassen sich weitere, besonders für die Gefäßchirurgie relevante Interventionen ins Feld führen. Die im November 2016 veröffentlichte WHO Guideline zur Prävention von postoperativen Wundinfektionen ist die erste international gültige Leitlinie auf diesem Gebiet. Den Empfehlungen liegen ein systematischer Review und eine transparente und rigorose Beurteilung der Studienlage zugrunde. Dieser Beitrag beleuchtet den Stellenwert der Leitlinie und stellt prä-, intra-, und postoperative Maßnahmen mit einem speziellen Fokus auf die Studienlage in der Gefäßchirurgie vor.

Schlussfolgerung Es stehen eine Reihe von evidenzbasierten Maßnahmen zur Verfügung, die das Risiko für den chirurgischen Patienten, eine operationsassoziierte Wundinfektion zu erleiden, nachweislich senken können. Auf dem Gebiet der Gefäßchirurgie sollte ein besonderes Augenmerk auf jene Maßnahmen gelegt werden, die auf die Reduzierung der patienteneigenen Haut- und Schleimhautflora (Nase/Rachen) abzielen. Dazu gehören das präoperative Duschen/Waschen mit Seife, die Dekolonisation von nasalen Staphylococcus-aureus-Trägern mit Mupirocin und die chirurgische Hautantiseptik mit einem alkoholischen Kombinationspräparat. Chirurgen sollten in enger Zusammenarbeit mit Kollegen anderer Disziplinen sowie der Krankenhaushygiene und dem Krankenhausmanagement entsprechende Maßnahmen unter Berücksichtigung der lokalen Bedürfnisse und Besonderheiten Schritt für Schritt in die Praxis integrieren.

Abstract

Background Surgical site infections range between the most commonly and second most commonly reported health-care-associated infections worldwide, depending on the analysis. They are associated with increased morbidity and mortality. Not only for the individual patient, the negative consequences of acquiring a surgical site infection affect the patientʼs relatives, the hospital and health systems in general. In vascular surgery, gram-positive pathogens of the normal flora of the patientʼs skin and mucosa (nose/throat) represent the almost half of the number of pathogens detected at the infected surgical site. Staphylococcus aureus itself accounts for about one third of these positive samples.

Measures of infection prevention and control Several general and more specific infection prevention and control measures exist, which when applied consistently, reliably, and in a timely manner protects patients and health workers, strengthens the health systems, and optimizes financial resources. In 2016 the World Health Organization launched the first Global Guidelines for the Prevention of surgical site infections. This guideline provides a comprehensive range of evidence-based recommendations for interventions related to the prevention of surgical site infections during the pre-, intra-, and postoperative periods. This article points out the value of this guideline and highlights relevant infection prevention and control measures with a special focus on the evidence in vascular surgery.

Conclusion Among generally applicable recommendations and measures, in the field of vascular surgery, a special focus should be put on the interventions aiming at the reduction of the patientʼs flora on the skin and mucosa (nose/throat). This is relevant with regard to the relatively high percentage of pathogens being associated with surgical site infections in this field of surgery, and which are normally residing on these tissues. These measures compromise preoperative bathing or showering with soap, decolonization of Staphylococcus aureus in nasal carriers undergoing surgery with mupirocin ointment with or without CHG body wash or surgical skin preparation with an alcohol-based solution containing an antiseptic compound. Surgeons should closely cooperate with colleagues from other disciplines, the infection prevention and control team as well as with the hospital management in order to implement the infection prevention and control measures into the daily routine. Step-by-step implementation should be based upon the local needs and specifications.

Schlüsselwörter

postoperative Wundinfektion - Infektionsprävention - Chirurgie - Weltgesundheitsorganisation - Leitlinie

Key words

surgical site infection - infection prevention - surgery - World Health Organization - guideline
 

  • Literatur

  • 1 Behnke M, Hansen S, Leistner R. et al. Nosocomial infection and antibiotic use: a second national prevalence study in Germany. Dtsch Arztebl Int 2013; 110: 627-633
    PubMedGoogle Scholar
  • 2 Allegranzi B, Bagheri Nejad S, Combescure C. et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet 2011; 377: 228-241
    CrossrefPubMedGoogle Scholar
  • 3 Cassini A, Plachouras D, Eckmanns T. et al. Burden of six healthcare-associated infections on European population health: estimating incidence-based disability-adjusted life years through a population prevalence-based modelling study. PLoS Med 2016; 13: e1002150
    CrossrefPubMedGoogle Scholar
  • 4 Bundesministerium der Justiz und für Verbraucherschutz. Gesetz zur Verhütung von Infektionskrankheiten beim Menschen (Infektionsschutzgesetz – IfSG). § 23 Nosokomiale Infektionen; Resistenzen; Rechtsverordnungen durch die Länder. Im Internet: http://www.gesetze-im-internet.de/ifsg/__23.html Stand: 13.07.2017
    PubMedGoogle Scholar
  • 5 Nationales Referenzzentrum für Surveillance von nosokomialen Infektionen (NRZ). Modul OP-KISS (Surveillance System postoperative Wundinfektion. Im Internet: http://www.nrz-hygiene.de/surveillance/kiss/op-kiss/ Stand: 13.07.2017
    PubMedGoogle Scholar
  • 6 Geffers C, Gastmeier P. Nosocomial infections and multidrug-resistant organisms in Germany: epidemiological data from KISS (the Hospital Infection Surveillance System). Dtsch Arztebl Int 2011; 108: 87-93
    PubMedGoogle Scholar
  • 7 National Institute for Health and Care Excellence (NICE). A summary of selected new evidence relevant to NICE clinical guideline 74 ‘Prevention and treatment of surgical site infection’ (2008). Evidence Update 43. June 2013. Im Internet: http://www.nice.org.uk/guidance/cg74/evidence Stand: 13.07.2017
    PubMedGoogle Scholar
  • 8 Health Protection Scotland. Targeted literature review: What are the key infection prevention and control recommendations to inform a surgical site infection (SSI) prevention quality improvement tool? Version 3.0. Feb 2015. Im Internet: http://www.hps.scot.nhs.uk/resourcedocument.aspx?id=2805 Stand: 13.07.2017
    PubMedGoogle Scholar
  • 9 Royal College of Physicians of Ireland. Preventing Surgical Site Infections. Key Recommendations for Practice. Developed by the Joint Royal College of Surgeons in Ireland/Royal College of Physicians of Ireland Working Group on Prevention of Surgical Site Infection (2012). Im Internet: https://www.rcpi.ie/news/publication/preventing-surgical-site-infections-key-recommendations-for-practice/ Stand: 13.07.2017
    PubMedGoogle Scholar
  • 10 Anderson DJ, Podgorny K, Berríos-Torres SI. et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014; 35: 605-627
    CrossrefPubMedGoogle Scholar
  • 11 Berrios-Torres SI, Umscheid CA, Bratzler DW. et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg 2017; 152: 784-791 doi:10.1001/jamasurg.2017.0904
    CrossrefPubMedGoogle Scholar
  • 12 KRINKO. Prävention postoperativer Infektionen im Operationsgebiet. Empfehlungen der Kommission für Krankenhaushygiene und Infektionsprävention beim Robert Koch-Institut. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2007; 50: 377-393
    CrossrefPubMedGoogle Scholar
  • 13 World Health Organization. Global guidelines on the prevention of surgical site infection. Im Internet: http://www.who.int/gpsc/ssi-guidelines/en/ Stand: 13.07.2017
    PubMedGoogle Scholar
  • 14 Higgins JP, Altman DG, Gøtzsche PC. et al. The Cochrane Collaborationʼs tool for assessing risk of bias in randomised trials. BMJ 2011; 343: d5928
    CrossrefPubMedGoogle Scholar
  • 15 Wells GA, Shea B, OʼConnell D. et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality if nonrandomised studies in meta-analyses. Im Internet: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp Stand: 13.07.2017
    PubMedGoogle Scholar
  • 16 Guyatt G, Oxman AD, Akl EA. et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol 2011; 64: 383-394
    CrossrefPubMedGoogle Scholar
  • 17 Allegranzi B, Bischoff P, de Jonge S. et al. New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis 2016; 16: e276-e287
    PubMedGoogle Scholar
  • 18 Allegranzi B, Zayed B, Bischoff P. et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis 2016; 16: e288-e303
    CrossrefPubMedGoogle Scholar
  • 19 Graling PR, Vasaly FW. Effectiveness of 2 % CHG cloth bathing for reducing surgical site infections. AORN J 2013; 97: 547-551
    CrossrefPubMedGoogle Scholar
  • 20 Johnson AJ, Kapadia BH, Daley JA. et al. Chlorhexidine reduces infections in knee arthroplasty. J Knee Surg 2013; 26: 213-218
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Bode LG, Kluytmans JA, Wertheim HF. et al. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med 2010; 362: 9-17
    CrossrefPubMedGoogle Scholar
  • 22 Langenberg JC, Thomas AR, Donker JM. et al. Evaluation of Staphylococcus aureus eradication therapy in vascular surgery. PLoS One 2016; 11: e0161058
    CrossrefPubMedGoogle Scholar
  • 23 Bebko SP, Green DM, Awad SS. Effect of a preoperative decontamination protocol on surgical site infections in patients undergoing elective orthopedic surgery with hardware implantation. JAMA Surg 2015; 150: 390-395
    CrossrefPubMedGoogle Scholar
  • 24 Phillips M, Rosenberg A, Shopsin B. et al. Preventing surgical site infections: a randomized, open-label trial of nasal mupirocin ointment and nasal povidone-iodine solution. Infect Control Hosp Epidemiol 2014; 35: 826-832
    CrossrefPubMedGoogle Scholar
  • 25 Alexander JW, Fischer JE, Boyajian M. et al. The influence of hair-removal methods on wound infections. Arch Surg 1983; 118: 347-352
    CrossrefPubMedGoogle Scholar
  • 26 Deutsche Gesellschaft für Infektiologie e.V. (DGI). S-3-Leitlinie Strategien zur Sicherung rationaler Antibiotika-Anwendung im Krankenhaus. Im Internet: http://www.awmf.org/uploads/tx_szleitlinien/092-001l_S3_Antibiotika_Anwendung_im_Krankenhaus_2013-verlaengert.pdf Stand: 13.07.2017
    PubMedGoogle Scholar
  • 27 Wacha H, Hoyme U, Isenmann R. et al. Perioperative Antibiotika-Prophylaxe. Empfehlungen einer Expertenkommission der Paul-Ehrlich-Gesellschaft für chemotherapie e.V. Chemotherapie Journal 2010; 19: 70-84
    PubMedGoogle Scholar
  • 28 Dettenkofer M, Wilson C, Gratwohl A. et al. Skin disinfection with octenidine dihydrochloride for central venous catheter site care: a double-blind, randomized, controlled trial. Clin Microbiol Infect 2010; 16: 600-606
    CrossrefPubMedGoogle Scholar
  • 29 Vierhout BP, Ott A, Reijnen MM. et al. Cyanoacrylate skin microsealant for preventing surgical site infection after vascular surgery: a discontinued randomized clinical trial. Surg Infect (Larchmt) 2014; 15: 425-430
    CrossrefPubMedGoogle Scholar
  • 30 Melling AC, Ali B, Scott EM. et al. Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial. Lancet 2001; 358: 876-880
    CrossrefPubMedGoogle Scholar
  • 31 Silva jr. JM, de Oliveira AM, Nogueira FA. et al. The effect of excess fluid balance on the mortality rate of surgical patients: a multicenter prospective study. Crit Care 2013; 17: R288
    CrossrefPubMedGoogle Scholar
  • 32 Benes J, Chytra I, Altmann P. et al. Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Crit Care 2010; 14: R118
    CrossrefPubMedGoogle Scholar
  • 33 Pearse R, Dawson D, Fawcett J. et al. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445]. Crit Care 2005; 9: R687-693
    CrossrefPubMedGoogle Scholar
  • 34 Sandham JD, Hull RD, Brant RF. et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003; 348: 5-14
    CrossrefPubMedGoogle Scholar
  • 35 Mellin-Olsen J, McDougall RJ, Cheng D. WHO Guidelines to prevent surgical site infections. Lancet Infect Dis 2017; 17: 260-261
    PubMedGoogle Scholar
  • 36 Meyhoff CS, Fonnes S, Wetterslev J. et al. WHO Guidelines to prevent surgical site infections. Lancet Infect Dis 2017; 17: 261-262
    CrossrefPubMedGoogle Scholar
  • 37 Solomkin J, Gastmeier P, Bischoff P. et al. WHO Guidelines to prevent surgical site infections–Authorsʼ reply. Lancet Infect Dis 2017; 17: 262-264
    PubMedGoogle Scholar
  • 38 Sindelar WF, Mason GR. Irrigation of subcutaneous tissue with povidone-iodine solution for prevention of surgical wound infections. Surg Gynecol Obstet 1979; 148: 227-231
    PubMedGoogle Scholar
  • 39 Pitt HA, Postier RG, MacGowan AW. et al. Prophylactic antibiotics in vascular surgery. Topical, systemic, or both?. Ann Surg 1980; 192: 356-364
    CrossrefPubMedGoogle Scholar
  • 40 Turtiainen J, Saimanen EI, Makinen KT. et al. Effect of triclosan-coated sutures on the incidence of surgical wound infection after lower limb revascularization surgery: a randomized controlled trial. World J Surg 2012; 36: 2528-2534
    CrossrefPubMedGoogle Scholar
  • 41 Hall JC, Christiansen KJ, Goodman M. et al. Duration of antimicrobial prophylaxis in vascular surgery. Am J Surg 1998; 175: 87-90
    CrossrefPubMedGoogle Scholar