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These comments were prepared by the PDA ad hoc Task Force on USP <1116>. The members of the Task Force are listed at the end of the comments.
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A study was designed to evaluate the effectiveness of a preoperative vaginal and perineal scrub in reducing bacteria. An iodophore soap followed by an iodophore solution was used for the scrub. Cultures were taken from the vagina and endocervix of 50 patients before and after the scrub, and cultured for aerobes, anaerobes, and mycoplasma. An average of 5.62 bacterial species per patient was cultured from the vagina before the scrub and 3.9 from the endocervix. The corresponding numbers after the scrub were 0.08 species per patient from the vagina and 1.84 from the endocervix. The reduction of organisms from the vagina was unrelated to the reduction in the endocervix. The scrub was by far more effective in the vagina than in the endocervix. The vagina was bacteria free in 92% of cases while the endocervix was bacteria free in only 8% of cases. No organisms could be recovered from the cervix of 8 patients who had removal of the endocervix by hot conization followed by the iodophore scrub. There was an average of 4.25 species per patient from the 8 cultures of the endocervix prior to the cone and scrub.
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Current practices of operating room management and sterile technique are direct descendants of the elaborate principles of antisepsis and asepsis set down by Lister. The surgical face mask has become an integral part of the uniform for theatre personnel since its introduction in an attempt to reduce the rate of clinical wound infections (von Mikulicz 1897). The Medical Research Council's (1968) recommendations on aseptic procedure advise donning a new mask for each patient and changing the mask part-way through long procedures (four hours or more). In most hospitals no one is allowed to enter an operating room without wearing a face mask. Anecdotal evidence in the author's own area of practice suggests that surgeons and other theatre personnel consider wearing face masks a nuisance but feel it is the "thing to do". Increasing costs of medical services is now a real problem. In one major teaching hospital in 1990, 10,000 pounds was spent on masks for theatre use (Leyland and McCloy 1993). Although the available clinical data suggests that the present generation of masks does not protect staff either from airborne bacteria or Hepatitis B virus (Ransjo 1986, Reingold 1988), theatre personnel may adopt self-protection as a reason for wearing a mask. It is not the intention of this literature review to examine self protection as a reason for wearing a face mask in theatre but to investigate whether masks do reduce bacterial infections in the postoperative patient.
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The practice of using antibiotic prophylaxis before surgery has evolved greatly in the past 20 years and is regarded as the third cornerstone in the prevention of postoperative wound infections. In contrast to asepsis and antisepsis, which have been standard techniques for almost a century, perioperative antibiotic prophylaxis is all too frequently administered in a suboptimal fashion. During the last few years, improvements in the timing of initial administration, the appropriate choice of antibiotic agents in each clinical setting, and the limitation of the duration of administration have defined more clearly the value of this technique in reducing postoperative wound infections. Implementation of these guidelines must be regarded as major issues in improving the quality of care in surgery.
Over a one-year period (Nov. 1996-Nov. 1997), a total of 154 patients are admitted on an emergency basis, with deferred emergency and for routine treatment in the Clinic of Emergency Surgery. They are distributed in three groups, as follows: patients not requiring perioperative antibiotic prophylaxis and postoperative antibiotic therapy--27, patients subjected to perioperative parenteral antibiotic prophylaxis under adequate hospital conditions--121, and patients undergoing antibiotic prophylaxis in conditions inappropriate for its application--six. The drug schemes elaborated are in conformity with worldwide and Bulgarian experience along this line, and with the concrete hospital and economical conditions in this country. In all patient indicated for antibiotic prophylaxis the listed below antibacterial agents (presented as drug schemes) are administered i.v. a single time prior to anesthesia induction: in operations on the gastrointestinal tract except for interventions in acute appendicitis: cephalotin/cefazolin 2.0 g and metronidazole 0.5 g i.v.; in operations for acute appendicitis: amoxicillin/clavulanate 1.2 g and petronidazole 0.5 f i.v.; biliary surgery free of extrahepatic cholestasis: cephalotin/cefazolin 2.0 g i.v.; biliary surgery with present or preceding extrahepatic cholestasis: cefotetan 2 g i.v.; contaminated liver cysts (parasitic and nonparasitic): cefotetan 2 g i.v.; abdominal trauma without perforation of a hollow organ: cefotetan 2 g i.v.; in plastic repair of the anterior abdominal wall (congenital defects, postoperative eventration) and in poor risk patients (local and general status: cephalotin/cefazolin 2.0 g i.v. In 135 patients the postoperative period runs a course free of complications worthy of notice. Complications directly linked to introduction of the method proposed are recorded in ten cases: operative wound suppuration (4) and hospital infection (6). Complications not related directly to the procedure are observed in nine cases: urinary tract infection (4), bronchopneumonia (2), fever with unknown source of infection (including negative hemoculture) necessitating additional antibiotic therapy (2) and secondary infection (within a week of intervention) necessitating further therapy with antibiotics. The specific features of antibiotic prophylaxis used in the various types of operative interventions are discussed from microbiological, clinical and pharmacotherapeutic viewpoints. The obtained results are compared with pertinent literature data on the issue with a special reference to the clinical efficacy attained. They mirror the approach against the background of the concrete hospital conditions in this country. The method developed is fully consistent with the level of surgical expertise in Bulgaria. All efforts should be aimed at intrahospital environment improvement by means of meticulous asepsis and antisepsis.
There have been three major avenues by which control over infection has been increased: (1) Preservation of host defenses, (2) antisepsis and (3) asepsis. Despite the major successes we have had, infection remains the major limitor of surgical horizons. Asepsis, the newest but long the mainstay of infection control, has probably been developed to nearly its greatest capacity. Its forefronts lie in laminar flow ventilation, ultraviolet radiation and operating theater design, all expensive and relatively inefficient. Cost and the problem of endogenous bacteria limit further advances. Antisepsis, including preventive antibiotics, is also reaching its zenith. Resistant organisms, toxicity and cost limit further applications. We desperately need a "social contract" among surgeons to limit, by defined rules, the choice of agent, the total dose and the indications for use. Controlled studies of the effects of "preventive antibiotics" on hospital ecology and infection are needed. A return to antiseptics is being and should be explored. Preservation and enhancement of host defenses is the oldest but the most neglected of these ideas. It appears to be the most exploitable now. Enhancement by nutrition, maintenance of tissue perfusion, oxygenation and immune stimulation appear to have contributed to reduction of infection rates. More success in this area seems distinctly possible.
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At the time of the American Civil War (1861-1865), a great deal was known about closed head injury and gunshot wounds to the head. Compression was differentiated from concussion, but localization of lesions was not precise. Ether and especially chloroform were used to provide anesthesia. Failure to understand how to prevent infection discouraged physicians from aggressive surgery. Manuals written to educate inexperienced doctors at the onset of the war provide an overview of the advice given by senior surgeons. The Union experiences in the treatment of head injury in the Civil War were discussed in the three surgical volumes of The Medical and Surgical History of the War of the Rebellion. Wounds were divided into incised and puncture wounds, blunt injuries, and gunshot wounds, which were analyzed separately. Because the patients were not stratified by severity of injury and because there was no neuroimaging, it is difficult to understand the clinical problems and the effectiveness of surgery. Almost immediately after the war, increased knowledge about cerebral localization and the development of antisepsis (and then asepsis) permitted the development of modern neurosurgery.
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