You are on page 1of 9

Lecture two Antiseptics and aseptics Antiseptics is a system of measures aimed at decreasing the amount of microbes in the wound,

reducing the risk of their penetrating and developing in the wound. The notion of antiseptics was introduced by the English military surgeon Pringle in 1750 following his observation of antiseptic action of mineral acids. However, ways of fighting infection, suppuration and saprogenic processes in wounds had existed long before. The doctors of ancient India, Palestine and Greece are known to demand that the doctors hands and everything that comes in contact with the wound must be clean; they believed that the contact of dirty hands with the wound may lead to suppuration. Thus, Hippocrates used only boiled water for dressing and bathing wounds. They also used wine, alcohol, vinegar, pitch, turpentine, mercury preparations as antiseptic agents. Later these principles were forgotten. Wound abscess was regarded as inevitable; mortality due to suppurative complication amounted to 80 %. In early 40-s of XIXth century N.I. Pirogov used solutions of carbolic acid, silver nitrate, zinc sulphate, alcohol, iodine tincture in his practice of wound repair. The Hungarian doctor I. Zimmelweiss intuitively approached the antiseptics method using the solution of chloride lime for washing hands and treatment of instruments. His approach did not gain recognition as it was believed that it was air-borne infection rather than direct contact infection that caused suppurative complication. D. Lister proposed using 2.5 5% solution of carbolic acid which was a very effective method. Later his used the solution for disinfecting the air, spraying it in operation theatre. Thus the main thesis was formulated: Everything that comes in contact with the wound must be disinfected. The first Russian surgeon who published the findings of applying the antiseptic method was I.I. Burtsev. Thus, antiseptics combines all measures and methods that contribute to reducing the number of microbes of the injured and intact areas of the body (the skin and mucous membranes). This can be achieved by reducing the possibility of transmission of infecting agent, interrupting its reproduction cycle and debridement of wound. Types of antiseptics The following types of antiseptics or disinfection are distinguished: physical, chemical mechanical and biological. Physical antiseptics includes scalding, use of dry heat or steam, boiling, irradiation and creation of conditions for the passage of liquid from the wound into the dressing. Burning is a reliable way of destroying infecting agents. Dressing materials, drains and tubes can be destroyed in this way.

Disinfection with hot air (for 120, 150-180 minutes) kills off microorganisms reliably. It is used for treatment of metal instruments, glass objects etc. Water steam can be used as fluid steam at normal or high air pressure. It is used for treatment of soft objects and textiles. Boiling is a reliable disinfecting method. The material to be disinfected is placed into cold water and boiled for 15-30 minutes starting from the moment of boiling. Ultraviolet irradiation can be regarded as an auxiliary method of fighting airborne infection only. Evacuation of wound content is based on the absorbent and capillary properties of cotton or other materials. Besides, drainage tubes of rubber, latex and other materials are used. Chemical antiseptics and disinfection Substances used in this method should answer the following requirements: quick, reliable action against all pathogenic microorganisms, stability of solutions upon exposure to air and light, good tolerance by materials, the greatest effect at least concentrations; they should be readily soluble in water, harmless to man, without unpleasant odour. All disinfecting agents can be divided into the following groups: 1. Agents for gentle disinfection are used on the skin; 2. Agents for intensive disinfection are used on very dirty objects and materials which have a large amount of organic substances (bedpans, washbasins etc). 3. Agents for disinfection of enclosed premises and objects contained there. 4. Agents for air disinfection. Chemical disinfectants include: acids, alkaloids, heavy metals, oxidants, halogens, phenol and its derivatives, chlorhexidine, compounds of quaternary ammonia, surfactants, alcohols, aldehydes, colourants. There is no universal disinfecting agent. The use of this or that substance must be determined by the desired objective. Over recent years there have emerged disinfecting agents whose chemical structure enhances their disinfecting action and, simultaneously, reduce their irritating action on skin. One of them is iodopyrron, iodine compound with polyvinylpyrrolidon. Its range of action includes bacteria, spore-forming bacteria, viruses, fungi and protozoa. It is active in the presence of blood, plasma, proteins, fats and soap. Taurolin, a combination of taurin and formaldehyde, is successfully used nowadays. Upon contact with bacteria it releases formaldehyde. 2 % taurolin solution can be stored for up to three years. Nowadays they widely use disinfection with glutaric dialdehyde as well as sodium hypochlorite solution comprised in the preparation Sydex. Instrument disinfection can be done with the triple solution (2 % formalin, 0.3 % fenol, 15 % sodium bicarbonate), 0.5 % chloramine B solution, 3%

hydrogen peroxide solution, 0.1 % desozone-1solution, dichlor-1, 0.1 % sulfachlorantine. As for the range of action and application of iodine alcoholic solution, ethyl alcohol, hydrogen peroxide, potassium permanganate, mercuric chloride, mercury oxycyanide, formalin, furacilin, and sulfanilamide, this information can be found in the textbook and we will not dwell on it. Disinfection of surgeons hands is a separate aspect of chemical disinfection. They distinguish hygienic and surgical disinfection, fast disinfection of hands and fast disinfection of skin. Hygienic disinfection of hands means the usual washing of hands with soap or with preliminary sponging the skin with 70-80 % ethyl alcohol, 0.5 % hybitan, chlorhexidine. Surgical disinfection of hands. The objective of surgical disinfection is to free the hands from microorganisms reliably for a long time. Its underlying principle is mechanical cleaning followed by disinfection. The hands and forearms are first scrubbed with soap and brush for 3-5 minutes, and then disinfected with a solution. Preparations used for scrubbing should answer the following requirements: 1. Kill off pathogenic flora on the skin surface quickly 2. Kill off microorganisms in the glove liquid quickly and reliably, so that the hands are sterile during the whole surgery procedure 3. Have a cumulative effect: frequent use of one disinfecting agent should reduce the amount of bacteria so that the surgeons hands are bacteria free in the period between disinfection procedures 4. Non-irritant for the skin. The following disinfecting agents are recognized as appropriate: alcohol (70 % ethyl alcohol, 60% propanol, 70% isopropanol), mixed alcohol and iodophor (iodopyrron, iodonate), performic acid or pervomur, 0.5% chlorhexidine solution. The classical Furbringers or Spasokukotsky-Kochergin methods and others are not in wide use nowadays as they take a long time. In our clinic we use the scrubbing method developed by professor A.A.Polyantsev. For quick disinfection of hands iodopyrron, butadion, cerigel are used. In case of emergency the hands can be quickly disinfected with 70% ethyl alcohol, hebitan, performic acid for 1 minute. For skin preparation before surgery we sponge it twice with 70 % alcohol and then with 2% iodine alcoholic solution. The patient should be asked first if he is sensitive to iodine. For preparation of surgical field hebitan, Roccal, desoxone-1. Mechanical disinfection. The objective of mechanical disinfection is removal of necrotized unviable tissue, blood clots foreign bodies which can harbor microorganisms, from the wound. Excision of damaged or unviable tissue from the walls or bottom of the wound is called initial surgical debridement. It should be performed no later than 2 hours after the injury.

Biological disinfection. Biological disinfection makes use of chemotherapeutic preparations which are divided into several groups: antibiotics, sulfanilamides, nitrofuran derivatives, enzyme preparations, vaccines and serums, immunostimulators. Antibiotics A great many antibiotics used in surgery and other medical fields are known nowadays. According to their effect antibiotics are divided into bacteriostatic (they slow down and terminate bacterial growth or reproduction) and bactericidal (they destroy the microbe cell). Administering antimicrobial therapy one should comply with the following rules: 1. The therapy should be started early enough. A therapy begun too late or at the end of the disease is less effective. 2. One should take into consideration susceptibility of the infecting agent to the preparation. 3. The preparation should be administered in such a way that it contacts the infecting agent directly and creates therapeutic concentration in the focus of infection. 4. The therapy should not be interrupted until the infecting agent is destroyed. 5. The duration of therapy should be optimum. 6. One should take into consideration toxicity of the preparation, adverse affects and take measures to prevent or correct them. 7. The drugs administered together with the antibiotic should be chosen well. Administering antibiotics one should bacterial resistance to antibiotics. In almost all cases it comes as a result of incorrect use of antibiotics. CHARACTERISTICS OF DRUGS Penicillines They are quickly absorbed into the bloodstream and delivered to the fluids and tissues of the body, except the cerebrospinal fluid. Maximum concentration in the blood is achieved 30-60 minutes after intramuscular administration. It is excreted almost completely 3-4 hours after administration of a single dose, that is why administration should be repeated every 3-4 hours. In severe cases stream or drop-by-drop introduction of the drug is used. The drug has bactericidal effect on streptococci, staphylococci, pneumococci, spirochetes and other infecting agents. The penicilline group includes: benzylpenicilline as sodium, potassium or novocaine salt, ampicilline, oxacilline, aztreonam, bicilline-1,2,3 etc. The latter are drugs of durable action. Indicated in pneumonia, bronchitis, sepsis, wound and suppurative infections, peritonitis. Adverse effects: administration in insufficient doses or early termination of therapy results in emergence of resistant strains of the bacteria, can cause allergy.

Contraindications: contraindicated to patients with bronchial asthma, allergic diseases. Endolumbal introduction is contraindicated in epilepsy. Tetracycline group This drug has a bacteriostatic action suppressing biosynthesis of protein in the microbial cell. It is used in therapy of respiratory, gastrointestinal, urinary and other infections. Adverse effect: diarrhea, edema of mucous membranes, allergy, photosensitivity of skin, enamel defects, candidomycosis. Contraindications: hypersensitivity, renal diseases, leucopenia, pregnancy, children under 8. It should not be administered with iron or calcium preparations, with milk or diary products. It absorbs well upon oral administration. Vibramycine and minocycline belong to this group. Macrolide antibiotics This group has a bacteriostatic effect on gonococci, meningococci, rickettsia and large viruses. Indicated in bronchopulmonary diseases, infections of urinary and biliary tracts, osteomyelitis, meningitis, gonorrhea. Adverse effects: nausea, vomiting, diarrhea, allergy. Contraindications: individual intolerance, lesion of hepatic parenchyma. It is well absorbed upon internal administration, penetrates many organs and fluids except cerebrospinal fluid. It is desirable to combine it with tetracycline. This group includes: erythromycine, oleandomycine, azythromycine, clarythromycine, clindamine. Aminoglycosides The drug has a bactericidal effect on most grampositive and gramnegative microorganisms as well as acid-fast bacteria including tuberculosis mycobacteria. Indicated in the therapy of pneumonia, tuberculosis, lung abscesses, infections of urinary tract. Adverse effects: it has ototoxic effect, nephrotoxic effect, can depress respiration (canamycine), cause allergy. Contraindications: it cannot be used in impaired hearing, renal or hepatic pathology, in pregnant women and small children. This group includes: canamycine, sysomycine, monomycine, amicacine, gentamycine, neomycine, streptomycine, tobramycine. Cephalosporines It is a group of semisynthetic antibiotics administered only parenterally as they are poorly absorbed from gastrointestinal tract. They produce a bactericidal effect by damaging cellular membranes of bacteria. The drug is effective against

staphylococci, pneumococci, streptococci, gonococci, meningococci. It is not effective against tuberculosis mycobacteria, viruses, protozoa. Indicated in acute and chronic respiratory infections, infections of soft tissues, peritonitis, sepsis. Adverse effects: it can impair renal excretory function, cause allergy. Contraindications: it should not be administered in the first months of pregnancy, in hypersensitivity. Cephalosporines of the first generation are: cephaloridin (ceporin), cephasolin (cephzole), cephalotin. Second generation: cephamandol, cephuroxim, cephmetazole and others. Third generation: latamoxef, cephotaxim, cephixim and others. Fourth generation: cephepim, cephpyrom. Cephalosporines for internal administration: cephalexin, cephadroxil, cephradin, cephaclor and others. Sulfonamides This group of drugs has bacteriostatic action inhibiting synthesis of folic acid which is indispensable for bacterial reproduction. Drugs of this group are divided into those easily absorbed from the alimentary tract and those not absorbed. Besides, according to the duration of their effect, sulfonamides are divided into drugs of short-term action (sulfathiazole, sulfadimine), median-term action (sulfazin), durable action (sulfapiridazin, sulfadimetoxin) and superdurable action (sulfalen). Indicated in the therapy of pneumonia, bronchitis, genitourinary infections etc. Side effects: due to poor solubility renal stones formation is possible, nausea, vomiting, leucopenia, and allergy. Contraindications: pregnancy, gravely compromised liver and kidney function, individual intolerance. Nitrofuran derivatives 1. Furaciline in solutions 1:5000 2. Furagine as 0.1% solution Besides, surgery makes use of antifungal preparations nystatin, nisoral, levorin. To normalize microbial flora of the body the so-called eubiotics are used bactisubtil, hylak-forte, linex. Ways of administration of disinfecting agents. 1. Administration to the wound surface: sponging the walls of the wound or using dressings saturated with disinfecting solution. 2. Introducing the drug into body cavities: for prevention and treatment of suppurative processes the drug is introduced into the pleural and abdominal cavity, into the lumen of joints.

3. Parenteral, intravenous, intra-arterial and endolymphatic introduction (deep disinfection) Aseptics Aseptics is a method preventing microbial invasion into surgical wound by using physical factors, chemical agents and measures. In other words, aseptics includes measures that ensure sterile conditions of work and reduce the risk of microbial invasion into the sterile zone. It includes all methods of sterilization and maintenance of sterility of instruments, dressings and suture material. Sterilization is achieved with physical and chemical methods. Physical methods include thermal and irradiation sterilization, chemical methods include sterilization with ethylene oxide, peracetic acid, and also chemical and thermal treatment. Thermal methods, irradiation sterilization and sterilization with ethylene oxide are considered the most reliable sterilization methods. In the thermal method sterilization is performed by steam in the autoclave at temperatures 110-140 degrees; or dry heat is used in drying cabinets at temperatures 160-200 degrees. In high temperature sterilisation the following working stages are distinguished: 1. Heating time from the onset of heating until the specified temperature in the chamber is achieved. 2. Stabilisation time from the moment when the sterilization temperature is achieved till the temperature is equal in all of the sterilized materials. This time depends on the type of sterilizer, type and amount of sterilised objects and also on the specified temperature level. 3. Extermination time the time necessary to kill off the microbes; its duration is specified in the instruction manual depending on sterilization temperature. Reliable sterilization is achieved by increasing extermination time by 50 % (additional safety time). 4. Cooling time from the moment when heating stops until the temperature drops to 80C (in dry heat sterilization) or to 60C (in autoclave sterilizing). If sterilization was interrupted in one of its working stages, the whole process has to be repeated. Steam sterilisation. Hot steam acts as heat carrier. It acts more intensely than hot air as the high thermal capacity of the steam is transferred to the sterilised object upon condensation. All objects which cannot be damaged by steam temperature should be sterilised by autoclaving. These are dressing materials, rubber and synthetic objects, paper filters, closed ampoules and cans with water-based preparations. Dry heat sterilising. In dry heat sterilizing the heating of sterilised objects enables one to destroy all microbes found on them. The average sterilization time at the temperature 180C is 15 minutes. With this method one can treat

heat-stable, incombustible objects of glass, metal or porcelain, rubber, most kinds of paper, plastic, water and water-containing liquids. Irradiation sterilisation. In this method ionizing radiation of great radiation capacity is used, which penetrates sterilised material to various depths. Betaand gamma-radiation are used for practical purposes. For each particular process the irradiation dose is chosen experimentally. Chemical sterilisation. The use of numerous synthetic materials in medicine prompted the development of chemical (cold) sterilization. The term cold sterilization is applicable to all methods where the temperature does not exceed protein coagulation temperature (45-60C). Ethylene oxide sterilisation. Ethylene oxide has a bactericidal effect due to the alkylation of bacterial proteins; it is soluble in water, alcohol, ethers. Under normal atmospheric conditions it is a colourless gas with unpleasant ether-like odour. The boiling point of ethylene oxide is 10.7C. Sterilisation is performed in special devices at the temperature 55C and ethylene concentration 1000 mg/l. Ethylene oxide is used to sterilize catheters of synthetic materials, tubing, prosthetic appliances, pacemakers, some parts of heart-lung apparatus, endoscopes, anesthesia and respiratory apparatus. Sterilization with peracetic acid. Its bactericidal effect is due to a strong oxidising action. It is used as a 40% solution (wofasteril); in this country the preparation desoxone-1 is produced. The usual method is using 0.2% solution for 10 minutes. In this way plastic tubes, pacemakers, valve prostheses, suturing material can be sterilised. Objects of iron and other metals are subject to strong corrosion, so this method is good only for stainless steel objects only. The preparation is toxic. Upon contact with skin it should be washed away with running water and soap, upon contact with eyes one should wash them with water and then rinse with physiologic saline solution or 2% sodium bicarbonate solution; upon swallowing the preparation gastric lavage should be given, then some milk or milk with a raw egg should be given to drink. It is noteworthy that sterilisation with peracetic acid is not considered a reliable method so it should not be used when thermal methods are available. Control of sterilisation is performed with special indicators. Despite the sterility of surgical garb, each member of the surgical team exudes about 1500 microorganisms a minute. To reduce the contamination of air and wound in surgery that requires especially high sterility standards (grafting, valve prostheses implantation) the surgical team can use special suits and helmets that are like diving-dress where fresh sterile air is forced in and then actively eliminated. This outfit hampers free movement and most surgeons use it only when aseptics must be observed most stringently. To disinfect air in the operation theatre bactericidal ultraviolet lamps are used with short-wave radiation. To reduce the possibility of microbes penetrating into surgery unit sterile gate is used where ventilation is performed through special filters that trap microbes.

In this lecture we wont touch upon the questions of layout of surgical department and operation unit; there is no need to describe characteristics of surgical lights, suturing material etc. as these aspects described in detail in your textbook. Hospital infection Hospital infection or nosocomial infection or cross-infection means that the patient was infected by the flora existing in the medical establishment, this flora being virulent and resistant to most antibiotics. The most common types of hospital infection are: infection of the urinary tract (40 %), wound infection (25 %) and respiratory infection (16 %), septicemia (3.5 %). Microorganisms can be transferred into hospital in various ways. The patients, visitors and medical staff are a major source of microbes. Man releases microbes into the environment at the following rate: from 10 000 to 100 000 from airways and skin at rest, while moving hands up to 1 million, while sneezing, coughing or talking up to 7 million microorganisms a minute. Channels of infection: from patient to patient, from staff and visitors to the patient and the other way round. The longer the patient stays in hospital, the more infected he becomes. Unfortunately, hospital infection is a common phenomenon; there are, however, measures aimed at fighting hospital infection which should kill off microbes in the setting where the patients are. Preventive administration of antibiotics has proved totally senseless and harmful as it results in the emergence of highly resistant causative agents. That is why measures fighting hospital infection should be aimed at observing stringent hygienic standards in all divisions of hospital. To arrest cross infection as much as possible, disposable clothes, towels, caps and gloves should be widely used. Frequently repeated hygienic disinfection of hands is of great importance, too. Prevention of hospital infection is of primary importance in intensive care and operating units where hygiene can be observed only as a result of strict professional discipline. Resistance of young staff members who often regard hygienic requirements as excessive should be overcome with the help of persuasion or administrative punishment. People fond of long hair and beards can be a source of trouble as they harbour large amounts of staphylococci. Regular control should be exercised in hospitals and operating units as this is the only way to get the staff observe rules of aseptics, antiseptics and hospital hygiene automatically.

You might also like