Chapter 5: Aseptic Technique

INTRODUCTION

Surgical site infections (SSI) represent a leading cause of morbidity following inpatient surgical procedures, and constitute up to one-third of all nosocomial infections.^1,2 Fortunately, there is a much lower risk of infection following dermatologic procedures than there is with more invasive surgical procedures. Dermatologists perform over 3.9 million procedures each year and are estimated to have an infection rate of only 3.5%.^3–9 Although the risk of infection is low, SSI can lead to increased morbidity, expense, and distress for the patient during the postoperative period.¹⁰

Historically, surgical procedures were associated with high rates of infection and sepsis, as well as patient mortality. It was not until 1865 that Joseph Lister significantly improved patient outcomes after his experimentation with various antiseptic techniques.¹¹ Lister required the patient’s wounds to be cleansed with carbolic acid prior to surgery.¹¹ He also required the surgical staff to scrub their hands with the acid prior to procedures and to soak instruments and towels in carbolic acid before using them in surgery.^11,12 As a result, surgeries that had once been associated with a 50% mortality rate due to infection showed vast improvements in patient survival.^11,12 In the years that followed, other scientists and researchers continued to improve upon Lister’s techniques, which ultimately led to the strict standards of antisepsis in place today.

This chapter discusses the current recommendations for sterile technique with specific application to dermatologic procedures. It is important to recognize that the bacterial load on the patient’s skin strongly correlates with the risk of SSI; therefore, proper preoperative precautions and aseptic technique are imperative to decrease the patient’s bacterial load and the subsequent risk of infection.^13–15 This chapter will also provide information regarding the antiseptic agents available today, proper preoperative preparation of the patient and surgical staff, and proper outpatient sterilization and storage of surgical instruments.

DEFINITION OF SURGICAL SITE INFECTION

The Centers for Disease Control (CDC) have formally defined what constitutes an SSI to help ensure prompt recognition by healthcare professionals. As dermatologic procedures are mostly confined to the superficial tissues, the definition of a superficial SSI is provided here. A superficial SSI is defined as an infection confined to the epidermis, dermis, or subcutaneous tissues occurring within 30 days of the surgical procedure in the presence of at least one other sign of infection: purulent drainage from the incision site, aseptic isolation of microbes, the diagnosis of a SSI made by an attending physician, or other signs of infection such as erythema, edema, tenderness, or warmth at the incision site (Table 5-1) (Fig. 5-1).^16,17