Kharkiv National Medical University

Department of General Surgery №2

Asepsis and Antisepsis.

Antibiotic therapy in
surgery

Associate Professor Petiunin A.G.

Kharkiv 2019
Asepsis is complex of measurements,
used to prevent wound
contaminations (by bacteria, spores,
viruses, fungi and parasites).
REMEMBER!
2 main principles of asepsis are:
Everything that touch a wound should be
sterile;
All surgical patients just in admission
department should be separated on
“clean” and “dirty” groups
 The main routes of microbial contamination:
1. Exogenous route i.e. from environment into
organism
Airborne route Contact route Implantation route

Suture materials,
Cough, rhinitis, Contaminated
grafts and
sneezing, talking instruments,
operational linen, prostheses, other
etc.
dressing materials, trans- and
hands, operative implants (drainage,
field wound package
 2. Endogenous route i.e. chronic inflammatory
diseases which are localized out of surgical site or
in organs undergoing the surgery.
 Exogenous contact route

1. Surgical instruments sterilization

2. Dressing materials,
sterilization
operating linen, towels

3. Surgeon’s hands scrubbing

4. Operative field preparation

 Implantation spread
The main sources are:
. Suture material;
2. Catheters, drainages;
3. Stents, cava-filters;
4. Prostheses, grafts,
donor organs
 Exogenous airborne route
Prophylaxis:
• Ventilation;
• Medical clothes (gowns, uniforms, masks etc.);
• Disinfection of operating room, wards, dressing
rooms, manipulation rooms etc. ;
• Hygiene of personnel and patients;
• Regimens of surgical departments;
• UV-lamps
 Endogenous route
1. Direct contact
2. Haematogenous (with blood flow)
3. Lymphogenous (through lymphatic vessels)
The major sources of endogenous infections are:
chronic diseases out of the area of operation (e.g.
skin diseases, dental or tonsillar conditions etc.);
Infections of operated organs (e.g. appendicitis,
cholecystitis, osteomyelitis etc.)
Oral, intestinal, respiratory saprophytes

REMEMBER!
The patient’s own bacterial flora is the principle source of infection
in surgical wounds.
Disinfection is a process when mainly pathogenic
organisms (with exception of endospores and viruses) and
their transmitters (insects, rodents) on some object or
material are removed to minimize the risk of infectious
disease.
Sterilization is the complete elimination or destruction
of ALL forms of microbial life including bacteria, spores,
viruses and fungi.
Sterilization of instruments, operating linen, towels, dressing
materials involves the following stages:
1.Preparation of the material (disinfection + washing +
drying for instruments);
2. Control of preparation and preparing for sterilization
itself;
3. Sterilization;
4. Sterility control;
5. Safe-keeping of the sterilized material.
 Preparation for sterilization
Is aimed at thorough mechanical cleaning of instruments,
removing of organic debris and destruction of hepatitis
vireses and HIV.
REMEMBER!
The person responsible for this should
ALWAYS wear gloves.
Stage 1. Disinfection:
1. All surgical instruments, used during surgical operation
are placed into container with a disinfectant solution –
during 90 min. if 6% hydrogen peroxide is
used or during 60 min. if 3% chloromine is
used.
2. Washing and brushing in a warm running water during
5 min.
 Stage 2. Washing:

1. Soaking in warm (50-55°C) washing solution for

15-20 min:
- perhydrol 20g + washing detergent 5g + distilled
water 975ml
OR
- 2,5% hydrogen peroxide 200g + washing detergent
5g + distilled water 795ml
2. Brushing in the same solution for 1 min;
3. Rinsing in a warm water for 5 min;
4. Rinsing in distilled water for 1 min;
 Stage 3. Drying:

Drying the instruments by the dry-air sterilizer at

temperature 85°C
 Control of preparation for
sterilization
Use one of following reactants:
a) Benzidine;
b) Orthotholuidine;
c) Amidopyrine;
d) Phenolphthalaine
Put 2-3 drops of reactant on each prepared for
sterilization instrument. Pink colour for
Phenolphthalaine or dark blue-green for other
reactants indicates presence of residual
contamination (blood or detergent). Repeat
preparation up to negative result is obtained .
 The main methods of sterilization are
1. Physical methods:
• Thermal:
- Autoclaving (water steam and increased pressure);
- Dry air;
- Boiling;
- Burning
• Irradiation:
- γ-irradiation;
- accelerated electrons
2. Chemical methods (cold sterilization):
• Gas sterilization (Ethylene oxide; Formaldehyde)
• 2% Glutaraldehyde (Cidex);
• C-4 (Pervomur - formic acid + hydrogen peroxide);
• Alcohol solutions of chlorhexidine;
• Hydrogen peroxide gas plasma (cycle time is 28-52 min)
• Peracetic acid;
• Ozone
 Sterilization by steam (autoclaving)
Is used for materials which endure
temperature is less then 140°C, such as
iron, glass, rubber, porcelain, textile etc.
A combination of temperature, pressure
and hold-time is responsible for the
elimination of microbes.

The main regimens of autoclaving are:

1,1 atm - 120-122°C - 45 min

1,5 atm - 126-128°C - 30 min

2,0 atm - 132-134°C - 20 min

CONTROL OF STERILITY AFTER STERILIZATION
IN AUTOCLAVE
DIRECT METHOD – a swab from inner surface
of dressing box is taken and cultured or
bacterial test (ampula with microbes or
microbial spores) is used.
INDIRECT METHOD - chemical substances
with high melting point (more than 100 С) are
used: antipyrine, benzoic acid (melting point 110
С), sulfur (melting point 120 С). Material is
sterile, if present in dressing box antipyrine,
 Sterilization by dry heat
All micro-organisms are killed by dry heat of 160°C for 2h, or
of 180°C for 1 hour.
The method is advantageous when treating non-aqueous liquids, air tight
containers and non-stainless-steel instruments with fine cutting edges
where corrosion is to be avoided.
1. The materials are put into the sterilizer`s shelf and
the apparatus is switched on;

2. With open door the sterilizer is heated to 70-75°C to

dry its interior and the instruments for 30 min;

3. Then the door is closed and the temperature is

increased to 180°C for 1 h;

4. After switching off and cooling to 70-50°C the door is opened and the
container with instruments is covered with sterile lid;

5. Within the next 15-20 min the instruments can be removed

 Chemical sterilization (cold methods)
1. Gas sterilization
• Formaldehyde (12 – 24 hours)
• Ethylene oxide (18°C – 16h; 55°C – 6h)

2. 2% Glutaraldehyde (Cidex), instruments are kept for 8 hours

and then washed 3 times in sterile water or salt solution.

3. 2,4 - 4,8% Pervomur C4, (formic acid + hydrogen peroxide)

4. 6% Hydrogen peroxide ( 18°C – 6h, 50°C – 3h)

5. Alcohol solution of chlorhexidine
 Boiling
is the simplest and most reliable method of inactivating
most pathogenic microbes, including HIV, when
sterilization equipment is not available.
Boiling should be used only when
sterilization by steam of dry heat is not
available! by boiling for several
Hepatitis B virus is inactivated
minutes; HIV is also inactivated for several min. However,
in order to be sure, sterilization time should be
continued for 20 - 40 min from the onset of boiling.
20g of sodium hydrocarbonate per liter of water is also
added to destroy bacterial sheath.
Boiling do not destroy resistant bacterial spores or
certain viruses!!!
 Burning

In emergency, when it is not possible to use one of the

above-mentioned methods, sterilization can be achieved
by burning.
15-20 ml of ethyl alcohol are poured into a metallic pan,
several instruments are put inside and alcohol is burned.
Burning is used only in emergency cases !!!
 Irradiation
It is an industrial process used to sterilize
batches of single-use products such as
sutures, syringes and catheters. Irradiation by
gamma rays or accelerated electrons at a dose
of 25 kGy is accepted for adequate
sterilization.
 Surgeon hands scrubbing
Preoperative washing of hands is aimed at decreasing the
number of resident and transient flora on the hands. It
should also inhibit the growth of bacteria under the glove
during the procedure.
• Prior to entering the operating
room all jewelry should be
removed;

• Nails should be kept short and free

of nail polish with no false nails;

• A single-use disposable nail brush

should be used only on the
fingernails but not the skin to avoid
micro-trauma which increases
surface bacterial numbers
 Scrubbing with C4
Pervomur (C4) is a solution that contains formic acid and
hydrogen peroxide.
The “main solution” is prepared initially in the ratio of 81ml
of 85% formic acid and 171ml of 33% hydrogen peroxide which
are mixed in a glass container. From this amount of the main
solution 10 liters of “working solution” can be prepared via
diluting it with distilled water.

Technique of hands scrubbing:

1. Washing hands in warm running water
with soap 3 times for 1 min.;
2. Dry hands with sterile napkin;
3. Washing hands for another minute
in a bowl with C4;
4. Dry hands with sterile napkin.
 Scrubbing with 2 – 4% chlorhexidine gluconate (“Hibitane”,
“Hibiscrub”):
1. Wash hands with running water and soap 3 times for 1
min and drying with sterile napkin.;
2. Rubb hands with a gauze tampone soaked in the
solution of chlorhexidine for 90 seconds.
3. Repeat once.
Scrubbing with solution of degmicide:
1. Wash hands with running water and soap 3 times for 1 min
and drying with sterile napkin.;
2. Wash hands for another minute in a bowl with degmicide for 5
min.
AHD solution and Eurosept:
1. Wash hands with running water and soap 3 times for 1 min
and drying with sterile napkin.;
2. Rubb hands with a few milliliters of the solution for 1min.
3. Repeat twice.
 Scrubbing with “cerigel”:
Hands are washed with a soap for 2-3 min. A few
milliliters of the solution are poured onto the dry skin of
the hands and rubbed intensively for 8-10 sec. After drying
of the skin in 2-3 min there will be a thin membrane of
“cerigel”. This membrane has bactericidal effect and can
easily be cleaned off after the operation by ethyl alcohol.

Brun`s method:
Hands are washed with a soap for 2-3 min. After that they
are rubbed with 96% ethyl alcohol for 10 min or with 2%
alcohol solution of iodine for 3 min.
 Skin preparation to surgical procedures

STEP 1: If the hair from the operation place should

be removed, shaving should be done in the day of
operation (shaving increases the risk of infection);

STEP 2: Ask the patient about allergic reactions (e.g.,

to iodine preparations) before selecting an antiseptic
solution;

STEP 3: If the skin is visibly soiled, gently wash it

with soap and clean water and dry the area before
applying the antiseptic.
 Select the antiseptic solution for skin preparation
from the following recommended products:

• Alcohol-based solutions (tinctures) of iodine or chlorhexidine;

• Alcohols (60–90% ethyl, isopropyl or “methylated spirit”);

• Chlorhexidine gluconate (2–4%) (e.g., Hibitane, Hibiscrub®);

• Iodine (3%); aqueous iodine and alcohol-containing (tincture of

iodine) products;

• Iodophors (7.5–10%), various other concentrations (e.g., Betadine);

• Chloroxylenol (Para-chloro-metaxylenol or PCMX) (0.5–3.75%),

various other concentrations (e.g., Dettol)
 Preparation of operative field by Grossich-
Filonchikov`s method
1. Disinfect operative field twice by antiseptic solution
before draping;
2. Disinfect operative field by antiseptic solution after
draping (before the incision);
3. Disinfect operative field by
antiseptic solution before
cutaneous suturing;
4. Finally, disinfect operative
field by antiseptic solution
after cutaneous suturing.
Antisepsis is complex of
measurements to reduce or eliminate
pathogenic microorganisms already
present in a wound, skin, mucous
membrane or other body tissue.
The main types of antisepsis are:
1. Mechanical;
2. Physical;
3. Chemical;
4. Biological
 Mechanical antisepsis
is based on surgical wound debridement
Primary wound debridement (first 12h after
injury):
Secondary debridement
Incision;
(for purulent wounds):
Revision, removing of foreign bodies;
• Excision of necrosis and
Excision of infected tissues in limits of viable
devitalized tissue;
one (edges and floor of a wound);
• Wound irrigation;
Final hemorrhage arrest;
• Wound drainage
Surgical reconstruction of affected organs and
tissues (usually suturing)
 Physical antisepsis
Based on principles of capillarity, hygroscopicity,
osmosis, diffusion, siphoning etc.
• Hygroscopic dressing;
• Hypertonic dressing (e.g. 10% sodium chloride);
• Wound drainage
• Ultrasound
• Ultraviolet and laser (infrared) irradiation

Passive drainage Active drainage Flowing drainage

 Chemical antisepsis
Synthetic antibacterial agents are used to remove bacterial infection
from the wound or other body tissue
1. Haloids (1-5-10% Iodine, Iodopyron);
2. Alcohols (60-90% ethyl alcohol, isopropyl alcohol);
3. Oxidants (Hydrogen peroxide, Potassium permanganate);
4. Aldehydes (formaldehyde, formalin, glutaraldehyde);
5. Detergents (Chlorhexidine gluconate, Cerigel, Degmicide);
6. Alkali (Ammonium chloride);
7. Phenols (Carbolic acid, triple solution – 20g formalin + 10g carbolic
acid + 30g sodium chloride + water);
8. Acid groups (Salicylic acid, 2-3% Boric acid);
9. Derivatives of nitrofuran (furacilin, furagin);
10. Dyes (brilliant green, methylene blue);
11. Heavy metal salts (silver nitrate, streptocide, sulfadimethoxin);
12. 5-Nitro-Imidazol derivatives (Metronidazole);
13. Chinoxolin derivatives (Dioxydin);
14. 8-Oxychinolin derivatives (Nitroxolin, Intestopan, Enteroseptol)
 Biological antisepsis
This is of 2 types: specific (if specific causative agent
is identified – tetanus, gas gangrene, diphtheria etc.)
and nonspecific
1. Specific biological antisepsis include:
a) Substances for specific active immunization (vaccines,
anatoxins);
b) Substances for specific passive immunization (antitoxins, γ-
globulins, bacteriophages);

2. Nonspecific biological antisepsis include:

a) Antibiotics;
b) Proteolytic enzymes (Iruxol, Trypsin, Chymotrypsin);
c) Blood and blood products transfusion;
d) Substances stimulating unspecific immunity (vitamins,
interferon, interleukins, fractions isolated from the thymus;
 Antibiotics are organic substances that
are the products of habitability of fungi,
microorganisms, and also extracted from
vegetative and animal cells, or synthesized
compounds, which suppresses growth,
development and multiplication of
microbes.
 Antibiotics may have mainly bactericidal or
bacteriostatic activity.
Bactericidal drugs, which cause death and disruption
of the bacterial cell, include drugs that primarily act on
the cell wall (eg, β-lactams), cell membrane (eg,
daptomycin), or bacterial DNA (eg, fluoroquinolones).
Bacteriostatic agents inhibit bacterial replication
without killing the organism. Most bacteriostatic drugs,
including sulfonamides, tetracyclines, and macrolides,
act by inhibiting protein synthesis. The distinction is not
absolute, and some agents that are bactericidal against
certain organisms may only be bacteriostatic against
The antibiotics are of narrow and broad spectrum
activity.
Narrow spectrum antibiotics are active against mainly
Gram-positive (many cocci, agents of a anthrax,
erysipelas, listerosis, gas gangrene etc.), or Gram-
negative (various enterobacteria, blue pus bacillus,
cholera vibrio etc.) microbes. Examples of these are -
macrolides, lincomycine, ristomycine, polymyxines,
streptomycin, isonicotinic acid, rifamycin etc.
Broad spectrum antibiotics are active against both Gram-
positive and Gram-negative microbes, and sometimes,
there other types. This group includes chloramphenicol,
tetracyclines, ampicillin, carbenicillin, canamycin,
 Antibiotics
are the main part of biological antisepsis
1. Inhibitors of cellular membrane synthesis
• Beta-lactams
- Penicillins (Penicillin G, Methicillin, Ampicillin, Amoxicillin etc.)
- Cephalosporins (Cefotaxime, Ceftriaxone, Cefepime etc.)
- Monobactams (Aztreonam)
- Carbapenems (Imipenem, Meropenem, Faropenem etc.)
• Glycopeptides (Vancomycin, Teicoplanin)
• Fosfomycins

2. Inhibitors of protein synthesis

• Aminoglycosides (Gentamicin, Amikacin, Kanamycin, Streptomycin)
• MLSK (Macrolides, Lincosamides, Streptogramins, Ketolides)
• Tetracyclines (Tetracycline, Doxycycline)
• Glycylcyclines (Tigecycline)
• Phenicols (Chloramphenicol)
• Oxazolidinones (Linezolid)
• Ansamycins (Rifampin)
 Antibiotics (2)

3. Inhibitors of membrane function

• Lipopeptides ((Polymyxins (Colistin), Cyclic Lipopeptides
(Daptomicin))

4. Anti-metabolites (Folate Pathway Inhibitors)

• Sulfonamides
• Trimethoprim/Sulfamethoxazole

5. Inhibitors of nucleic acid synthesis

• Quinolones (Ciprofloxacin, Levofloxacin, Ofloxacin, Gatifloxacin)
• Furanes (Nitrofurantoin)
General Principles of Antimicrobial
Therapy
SELECTING AND INITIATING AN ANTIBIOTIC REGIMEN

Obtaining an Accurate Infectious Disease

Diagnosis i.e. infectious disease diagnosis is reached by
determining the site of infection, defining the host (eg,
immunocompromised, diabetic, of advanced age), and
establishing, when possible, a microbiological diagnosis.

b) Timing of Initiation of Antimicrobial Therapy

The timing of initial therapy should be guided by the
urgency of the situation. In critically ill patients, such as
those in septic shock, febrile neutropenic patients, and
patients with bacterial meningitis, empiric therapy
should be initiated immediately after or concurrently
c) Empiric vs Definitive Antimicrobial Therapy
Because microbiological results do not become
available for 24 to 72 hours, initial therapy for infection
is often empiric and guided by the clinical presentation.
Therefore, a common approach is to use broad-spectrum
antimicrobial agents as initial empiric therapy with the
intent to cover multiple possible pathogens commonly
associated with the specific clinical syndrome. Once
microbiology results have helped to identify the etiologic
pathogen and/or antimicrobial susceptibility data are
available, every attempt should be made to narrow the
antibiotic spectrum.
d) Interpretation of Antimicrobial Susceptibility
Testing Results
When a pathogenic microorganism is identified in
clinical cultures, the next step performed in most
microbiology laboratories is antimicrobial susceptibility
testing (AST) - measuring the ability of a specific
e) Bactericidal vs Bacteriostatic Therapy
Bactericidal agents are preferred in the case of
serious infections such as endocarditis and meningitis to
achieve rapid cure.

Use of Antimicrobial Combinations

Although single-agent antimicrobial therapy is

generally preferred, a combination of 2 or more
antimicrobial agents is recommended in a few scenarios:
when agents exhibit synergistic activity against a
microorganism;
when critically ill patients require empiric therapy
before microbiological etiology and/or antimicrobial
susceptibility can be determined;
to extend the antimicrobial spectrum beyond that
achieved by use of a single agent for treatment of
g) Host Factors to Be Considered in Selection of
Antimicrobial Agents (i.e. renal and hepatic function;
age; genetic variation; pregnancy and lactation; history
of allergy or intolerance; history of recent antimicrobial
use).
h) Oral vs Intravenous Therapy
Patients hospitalized with infections are often treated
with intravenous antimicrobial therapy because their
admission is often prompted by the severity of their
infection. However, patients with mild to moderate
infections who require hospitalization for other reasons
(eg, dehydration, pain control, cardiac arrhythmias) and
have normal gastrointestinal function are candidates for
treatment with well-absorbed oral antimicrobial agents.
i) Pharmacodynamic Characteristics
Along with host factors, the pharmacodynamic
properties of antimicrobial agents may also be important
in establishing a dosing regimen. Specifically, this relates
j) Efficacy at the Site of Infection
In addition to possessing in vitro antimicrobial
activity and achieving adequate serum levels, the
efficacy of antimicrobial agents depends on their
capacity to achieve a concentration equal to or greater
than the MIC (minimum inhibitory concentration) at the
site of infection and modification of activity at certain
sites - antimicrobial concentrations attained at some
sites (eg, ocular fluid, CSF, abscess cavity, prostate, and
bone) are often much lower than serum levels.
2. CONSIDERATIONS FOR CONTINUING ANTIBIOTIC
THERAPY
a) Duration of Antimicrobial Therapy
Treatment duration has to be carefully individualized
on the basis of clinical and radiologic response and may
require the guidance of an expert in infectious diseases.
b) Assessment of Response to Treatment
Response to treatment of an infection can be assessed
using both clinical and microbiological parameters.
Clinical parameters of improvement include symptoms
and signs (eg, a decrease in fever, tachycardia, or
confusion), laboratory values (eg, decreasing leukocyte
count), and radiologic findings (eg, decrease in the size of
an abscess). Although radiologic criteria are commonly
used in assessing response to infectious disease therapy,
radiologic improvement can frequently lag behind
clinical improvement, and routine radiographic follow-
c) Adverse Effects

Direct (antimicrobial allergy, nonallergic drug

toxicity, drug – drug interaction, therapeutic failure)
Indirect (effects on commensal flora, effects on
environment flora)
 Presurgical Antimicrobial Prophylaxis. 
Antimicrobial prophylaxis is used to reduce the
incidence of postoperative surgical site infections.
Patients undergoing procedures associated with high
infection rates, those involving implantation of
prosthetic material, and those in which the consequences
of infection are serious should receive perioperative
antibiotics.
The antibiotic(s) should cover the most likely
organisms and be present in the tissues when the initial
incision is made, and adequate serum concentrations
should be maintained during the procedure.
A single dose of a cephalosporin (such as cefazolin)
administered within 1 hour before the initial incision is
appropriate for most surgical procedures; this practice
targets the most likely organisms (ie, skin flora), while
avoiding unnecessary broad-spectrum antimicrobial
therapy. Duration of prophylaxis for surgical site
 Common Misuses of Antibiotics
In some settings, the use of antibiotics is
clearly inappropriate:
- prolonged empiric antimicrobial treatment
without clear evidence of infection;
- treatment of a positive clinical culture in the
absence of disease;
- failure to narrow antimicrobial therapy when a
causative organism is identified;
- prolonged prophylactic therapy; 
- excessive use of certain antimicrobial agents.