AIOC 2026 IC499 End of endophthalmitis – Hot topics in Hospital infection control

Introduction to Post-Operative Infection Prevention

Overview of the Discussion

• The session features Dr. Himanti Chadri and other experts discussing strategies to prevent post-operative infections, particularly endophthalmitis.

• Emphasis is placed on understanding both preventive measures and management strategies for complications if they arise.

Key Factors in Preventing Endophthalmitis

• Dr. Satang Shumatur highlights five critical factors contributing to endophthalmitis: patient hygiene, contaminated surgical supplies, faulty sterilization procedures, inadvertent touch, and environmental conditions. Proper management of these can significantly reduce infection rates.

• Common risk factors include conjunctivitis, lacrimal obstruction, recent immunosuppressive treatment, and diabetes; special care should be taken with diabetic patients due to their higher risk of complications.

Preoperative Patient Instructions

Guidelines for Patients

• Patients are advised to use broad-spectrum antibiotics one day before surgery and maintain proper hygiene by washing their face and hair prior to entering the operating room (OR). Clean clothing is also essential.

Staff Preparation Protocol

• Staff must ensure that biometric measurements are done correctly using immersion methods or optical biometries on diabetic patients first due to their increased infection risk. The OR should be thoroughly cleaned with antiseptic solutions before surgery begins.

Surgical Scrubbing Techniques

Importance of Scrubbing

• Effective scrubbing techniques are crucial; staff should scrub for at least five minutes using chlorhexidine soap up to the elbows while ensuring all areas are covered properly during the procedure preparation phase. A monitoring system has been implemented to ensure compliance with scrubbing times among staff members.

Surgical Supplies Management

Monitoring Supplies

• Regular checks on surgical supplies' expiration dates and packaging integrity are vital before use in surgeries; this includes changing irrigation bottles after a few cases rather than reusing them excessively which could lead to contamination risks.

Antibiotic Use During Surgery

Efficacy of Antibiotics

• Utilizing antibiotic irrigations during surgery has shown effectiveness in reducing endophthalmitis risks compared to previous practices where such measures were not routinely employed; intraoperative antibiotic injections have become standard practice now for better outcomes post-surgery.

Autoclaving Procedures

Sterilization Standards

• Autoclaving remains a preferred method for sterilizing instruments; it’s important that temperature (121°C), time duration, and steam contact are monitored closely during the process as improper autoclaving can lead to ineffective sterilization results which may contribute to infections later on.

Indicators for Sterilization Success

Types of Indicators

• Various indicators (physical, chemical, biological) help verify successful sterilization processes; physical indicators show temperature levels reached but do not confirm sustained exposure times necessary for effective sterilization while biological indicators provide more reliable confirmation through color changes indicating successful microbial kill rates post-autoclave cycles.

Environmental Cleaning Protocol

Daily Cleaning Practices

• Daily cleaning protocols involve wet mopping with appropriate disinfectants rather than dry dusting or sweeping which can spread contaminants; specific cleaning agents like D125 and D256 ammonium compounds are recommended for maintaining cleanliness in operation theaters (OT).

Waste Management in OTs

Biohazard Disposal

• Strict protocols must be followed regarding waste disposal within OTs including having designated bins away from clean areas; regular culture sensitivity tests from various surfaces within the OT environment help monitor contamination levels effectively over time.

Air Quality Control Measures

Ventilation Systems

• Central air conditioning systems equipped with HEPA filters are essential in maintaining air quality within OTs by filtering out microorganisms effectively while ensuring positive pressure is maintained inside the theater.

This structured summary provides an organized overview of key discussions surrounding infection prevention strategies in ophthalmic surgeries based on expert insights shared during the session.

Best Practices for Surgical Scrubbing and Operating Room Conduct

Surgical Preparation and Trolley Management

• When scrubbing for surgery, manage time effectively by preparing one trolley at a time rather than all at once. This ensures focus on the current case.

• Maintain a 6-foot distance when circulating sterile solutions and ensure a 1-foot clearance from the sterile area to prevent contamination.

Infection Control in the Operating Theatre

• Limit entry into the operating theatre (OT) if personnel show signs of infection to avoid outbreaks.

• Noise control is crucial; discussions should occur outside the OT to maintain a professional environment.

Surveillance and Monitoring in the OT

• Surveillance involves systematic monitoring to detect contamination sources, including patient profiles, surgical procedures, consumables, and sterilization techniques.

• Post-operative endophthalmitis rates are low but require regular surveillance protocols every month or more frequently during outbreaks.

Importance of Sterilization Procedures

Routine Cleaning Protocols

• For new setups, three non-significant reports are required before operations can commence. Daily cleaning and weekly fumigation are essential.

Causes of Sterilization Failure

• Common causes include inadequate cleaning, improper sterilization processes, pack failure, or contamination during handling/storage.

Key Areas for Surveillance

• Focus on air quality, water sources used for scrubbing, surfaces in the OT, AC filters, and autoclave indicators as part of routine checks.

Materials Needed for Effective Surveillance

Required Equipment

• Essential materials include sterile swabs, liquid media for cultures, solid media for testing bacteria levels, and biological monitors.

Air Sampling Techniques

• Use open petri dish methods placed strategically within the OT to monitor air quality; results indicate safety based on bacterial colony counts after exposure.

Monitoring Surgical Supplies

Inspection Criteria

• Regularly check expiry dates and particulate matter in surgical supplies; quantity discrepancies may indicate leaks even if not immediately visible.

Clinical Data Review

• In cases of infection outbreaks, clinical data must be reviewed alongside microbiology reports to inform treatment decisions effectively.

Introduction to Autoclaves: Selection Criteria

Importance of Sterilization

• The need for effective sterilization is paramount in minimizing contamination risks during surgeries. Steam sterilizers (autoclaves) are preferred due to their effectiveness against microorganisms.

Parameters for Effective Steam Sterilization

• Key parameters include steam pressure (15 psi), temperature (121°C), time duration (21 minutes), and maintaining an ideal dryness fraction of 97%.

Types of Autoclaves

Classification Based on Vacuum Creation

• Class N: No separate vacuum pump; suitable only for solid instruments.

• Class S: Includes a vacuum pump that operates twice; better suited for porous hollow instruments.

• Class B: Multiple vacuum cycles with steam pulses; ideal for all types of instruments including hollow ones.

Flash Autoclaving Techniques

Short Cycle Sterilization

• Flash autoclaves allow short cycle sterilizations without storage requirements but still necessitate proper cleaning protocols before use.

Managing Endophthalmitis with Intravitreal Antibiotics

Diagnosis Indicators

• Unusual inflammation post-cataract surgery within six weeks raises suspicion for endophthalmitis requiring immediate intervention.

Treatment Approaches

• Shift towards vitrectomy-focused management over traditional tap-and-inject methods due to advancements in technology and changing microbiological profiles.

Indications for Vitrectomy and Antibiotic Use

Overview of Recommendations

• The ABS recommends considering PP with intraocular antibiotics for patients with more than LP vision, especially those who are diabetic, regardless of their initial visual acuity.

Pre-Vitrectomy Considerations

• Before starting vitrectomy, obtaining a good sample for Gram stain, KOH culture, and PCR is crucial. This helps in identifying the causative agent effectively.

Sample Collection Techniques

• Samples can be collected using a 26-gauge needle with aspiration or through a butterfly method during vitrectomy. It's essential to transport samples in appropriate media for accurate culture and sensitivity testing.

Management of Endophthalmitis

Treatment Approaches

• A complete early vitrectomy (CEV) is recommended for endophthalmitis cases post-cataract surgery when the fundus is obscured; otherwise, tap and inject may suffice if the fundus is visible.

Comparative Studies on Interventions

• An Indian study indicated that PPV leads to quicker recovery and better visual outcomes compared to tap and inject in post-cataract endophthalmitis cases.

Timing of Surgical Intervention

Urgency of Vitrectomy

• Early surgical intervention on day one may lead to poorer visual function; thus, it’s advisable to perform tap and inject first before referring for vitrectomy within one or two days.

Inflammatory Scoring System

• Dr. Das's group suggests calculating an inflammatory score: if above 10, proceed with vitrectomy; if below 10, opt for tap and inject.

Case Studies in Endophthalmitis Management

Patient Cases Overview

• Two patient cases illustrate the importance of systemic antibiotics following intravitreal injections. One case involved rapid vision decline after injection leading to surgical intervention.

Surgical Techniques Employed

• In cases involving central venous obstruction with macular edema, careful vitrectomy techniques were employed without inducing PVD while ensuring thorough removal of vitreous material.

Post-Surgical Protocol

Antibiotic Administration Strategies

• Intraoperative antibiotic administration can be combined with gas injection to avoid separate ports during surgery.

Follow-Up Care Importance

• Continuous monitoring post-surgery is critical as some patients may require multiple interventions over time due to persistent infections or complications.

Diagnostic Challenges in Endophthalmitis

Limitations of Testing Methods

• Next-generation sequencing (NGS), while useful, did not yield results in some cases; however, Gram stains provided valuable insights into potential gram-positive infections.

Key Takeaways from Case Studies

Summary Insights

• Early complete vitrectomy improves outcomes.

• Systemic antibiotics play a vital role alongside local treatments.

• Accurate organism diagnosis aids effective treatment strategies.

Preventive Measures Against Endophthalmitis

Best Practices

• Differentiate between TAP and endophthalmitis carefully.

• Administer intravitreal antibiotics promptly but defer urgent surgeries by one or two days when necessary.

NABH Guidelines on Infection Control

Responsibilities in Infection Prevention

• Clarification on accountability among surgeons, nurses, and sterilization processes regarding infection control protocols laid out by NABH guidelines.

Documentation Requirements

• Mandatory pre-operative assessments must include comprehensive patient histories relevant to infection risks such as MGD or uncontrolled diabetes.

Surgical Safety Checklist Implementation

• WHO's surgical safety checklist emphasizes confirming patient identity and procedure details at three critical phases: sign-in, timeout before incision, and sign-out after surgery completion.