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8/2/2019 SURGICAL SITE INFECTIONS (by Naveed)
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WE L C O M E
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SURGICAL SITEWOUND INFECTIONS
BY:Rtr. DR. MAHAR NAVEED SARWARFCPS-II TRAINEE,WARD # 26,JPMC
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IMPORTANT TERMS:Normal flora
Various bacteria and fungi that are thepermanent residents of the certain body partswithout causing harm
ColonizationPresence and multiplication of a new organism
that is not the part of normal flora
InfectionInvasion of normally sterile host tissue by a
virulent microorganism OR
Its invasion of organism into the body, followinga breach in the local or systemic host defenseleading to Systemic and local signs of
inflammation
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Lactobacilli
StreptococciLactobacilli
Enterobacteriac
eae
Aerobic+
Anaerobic
MicrobialPopulations
NORMAL FLORA OF THE GITRACT
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IMPORTANT TERMS:Bacterimia:
Invasion of blood by viable bacteria withoutcausing any systemic upset
Systemic inflammatory responsesyndrome SIRS:
It is bodys inflammatory response to bothinfective and non-infective cause i.e.pancreatitis,trauma,vasculitis
Defined by presence of any TWOof the
following:Temperature >38.0C or 90/m R/R > 20/minWBC >12000 or
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SURGICAL SITE
INFECTIONS(SSIs)3rd most common nosocomial infection (after
PNEUMONIA & UTI)
Most common nosocomial infection amongsurgery patients
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Criteria for defining SSIs
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CRITERIA FOR DEFININGSSI
Superficial surgical site infection (SSSI):
Occurs within 30 days after operation
Involves only skin and subcutaneous tissue
with any of the following
purulent discharge with or without laboratory confirmation;
bacteria isolated from culture of wound;
clinical signs (any one or more of following)
pain/tenderness
localized swelling
Redness
heat
diagnosis of superficial SSI by attending surgeon.
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Deep surgical site infections (DSSI)Occurs within 30 days after operation if no implant is
placed or within 1 year if implant is placed Involves deep soft tissue e.g.: fascia and muscles
with any of the following
Purulent discharge from deep incision but not fromorgan/space component of the surgical site
Deep incision dehisces spontaneously or deliberatelyopened by surgeon to evacuate pus
Clinical signs (one or more of following) fever > 38 C localized pain tenderness
Abscess/other evidence of deep infection Diagnosis by attending surgeon
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Organ/ Space infection:
Occurs within 30 days after operation if no implant is placed orwithin 1 year if implant is placed
Involves the body cavities and its organs e.g.. abdominal abscessafter anastomotic leak
And any of the following
purulent discharge from the organ or a drain in space;
organisms isolated from an aseptically obtained culture of fluid
or tissues in organ/space; abscess or other evidence of infection involving organ/space
found on :
direct examination
during reoperation or
by histopathological or radiological examination
diagnosis by attending surgeon..
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FURTHER CLASSIFICATION
SOURCE OF INFECTION
a)Primary /endogenous:
acquired from community or endogenous sourcesuch as following a perforated peptic ulcer)
b)Secondary / exogenous(HAI):
Infection arises following a complication that is notdirectly related to wound i.e. acquired from theater,
ward
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CONTNUED;TIME
a) Early
Infection presents within 30 days of procedure
b) Intermediate
Occurs between one and three months
c) Late
Presents more than three months after surgery
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CONTNUED;
SEVERITY a) Minor
when there is discharge without Cellulitis ordeep tissue destruction
With nil to mild systemic response
b) MajorWhen there is spontaneous discharge of
significant amount of pus orPartial or total dehiscence of the deep fascial
layers of wound or
if systemic illness is present.
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WOUND ASSESMENT
For surgical wound assessment severalscoring systems are employed especially
ASEPSIS scoring
Southampton wound assessment scale
These enable surgical wound healing to be gradedaccording to specific criteria, thus providing moreobjective assessment of wound.
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Class I wound (clean) Class I wounds are the simplesurgeries without violation ofthe hollow visceral structures ina non inflamed, atraumatic
wound. e.g. inguinal herniarepair.
No entry into GI, GU, Biliary, orrespiratory tract
These wounds rarely becomeinfected
Average infection rates are1.5%
CLASSIFICATION OF SURGICAL WOUND
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Class II Wound
(Clean-Contaminated) Class II wounds involve
controlled entry into a
hollow visceral structure.e.g.cholecystectomy andelective colon resections
Respiratory, GI, GU, orBiliary tract entered
under controlledconditions
Average infection ratesexpected are 7.5%
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Class III Wounds
(Contaminated)Traumatic wounds
Breaks in steriletechnique
Gross spillage from GItract
Acute, nonpurulentinflammation
Average anticipatedinfection rates are 15%
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Class IV Wounds (Dirty) Old traumatic wounds
Devitalized tissue
Clinical infection
present at the time ofoperation
Perforated hollowviscus
Average expectedinfection rates are 35%
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Microbiology
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NATURAL DEFENSEMECHANISMS OF HUMAN
BODYMechanical barriers:Intact epithelial surfaces
Chemical barriers:
Low gastric PHHumoral barriers:AntibodiesCompliment system
OpsoninsCellular barriers:Phagocytic activity by cells like
macrophages,neutrophils,NK cells
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During surgery
or trauma allof these
mechanismsmay be
compromised..!!!!!????
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PATHOGENESIS FOR
INFECTION
VirulenceBacterial dose
Impairedhost resistance
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RISK FACTORS FOR SSIs
Metabolic (Diabetes and Uremia)
Malnutrition (Obesity and starvation )
Nicotine use
Steroid useRadiotherapy
Chemotherapy
Disseminated cancers and AIDS
Poor perfusion (shock and ischemia)Foreign body material
Poor surgical technique(increased dead tissue andhaematoma formation)
Hospital stay
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Nicotineuse
Delays primary
wound healingIncrease the risk
of SSI
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PREVENTION OF SSIs
PROPHYLAXIS
PREOPERATIVE CARE AND PREPARATION
POSTOPERATIVE PRECAUTIONS
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PROPHYLAXIS
I/V administration of ABx within 30 minutes of induction
Single dose of prophylactic ABx is equivalent totherapeutic ABx
Repeat ABx 8 hourly and 16 hourly ifSurgery is prolonged (> 3 hours) Excessive blood loss in operative field(1500ml)
Prosthesis placement
Choice of ABx depends
Its empirical cover against the expected pathogen Cost
Local hospital policies (that are based on local trends ofresistance)
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ABX
Once the incision ismade,antibiotic delivery to thewound is impaired.Must give before incision!
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TIME OF ADMINSTRATIION PERCENT SSIs
Early (2-24 hours beforeincision)
3.8%
Preoperative (0-2 hours beforeincision)
0.6%
Perioperative (3 hours after
surgery)
1.4%
Postoperative (more than 3hours after surgery)
3.3%
TIMINGS OF PROPHYLACTIC ANTIBIOTIC ADMINSTRATION AND SUBSEQUENTRATES OF SSIs
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TYPE OF SURGERY ORGANISM ENCOUNTERD SUGGESTED
PROPHYLACTIC REGIMENVascular Staph epidermidis
Staph aureus
Aerobes gram ve bacilli
3 doses offlucloxacin,
Vancomycin or rifampcin ifMRCNS/MRSA
Orthopaedic Staph.A
Staph.E
1-3 doses of broadspectrum cephalosporin
Oesophago-gastric Enterobacteriaceae
Enterococci
1-3 doses of 2ndgeneration cephalosporin+ metronidazole
Biliary Enterobacteriaceae mainlyEcolab
Enterococci
1 dose of 2nd generationcephalosporin
Small bowel Enterobacteriaceae
Anaerobes (bacteroides)
1-3 doses of 2ndgeneration cephalosporinwith or withoutmetronidazole
Appendix/colorectal Enterobacteriaceae
Anaerobes (bacteroides)
1-3 doses of 2ndgeneration cephalosporin
with metronidazole
SUGGESTED PROPHYLACTIC REGIMENS FOR THE OPERATIONS AT RISK
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PRE-OPERATIVE
PREPARATIONShort hospital stayLowers the risk of MRSA/MRCNS and others HAIs
Medical staff should always wash their hands in betweenpatients
Strict aseptic care of intravenous lines; Isolation of infected cases.Preoperative shaving should be avoided, if necessary it
should be undertaken just before the surgery Because minor skin injuries promote bacterial colonization and
double the risk of SSIs)
Hair clipping is best with lowest infection rates
Attention to the theater technique & discipline Number of staff and their movement in & out of theater should
be kept to minimum Proper ventilation of theater
Proper instruments sterilization
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CONTINUEDProper Scrubbing & skin preparation
Thorough scrubbing including nails should be done beforefirst case in the morning
Subsequent cases merely involve washing up to elbow (asrepeated scrubbing releases more organisms)
Application of antiseptic over incision site decreases skinmicrobial colony counts
Avoidance of preoperative hypothermia andsupplementation of O2 in recovery room have proved toreduce the risk of SSIs
Drains: increase incisional SSI risk.
Increase in the incidence of SSIs is also noted with the useof silk as a suture for skin closure
If there is silk in the tissue the minimum number of organismneeded to start an infection is reduced logarthimatically
(bailey & love 25th edition vol:I,page #35)
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solutionsNAME PRESENTATION USES COMMENTS
Chlorhexidine (hibiscrub)Alcoholic 0.5%
Aqueous 4%
Skin preparation
Skin prep:, surgical scrubin dilute sol: in openwound
Effective againstgram+ve
Povione-iodine
(betadine)
Alcoholic 10%
Aqueous 7.5%
Skin preparation
Skin prep:, surgical scrub
in dilute sol: in openwound
Safe ,fast acting, broadspectrum with some
sporicidal activity
Citrimide (savlon) aqueous Hand washing
Instrument and surfacecleaning
Pseudomonas may growin stored contaminatedsolutions
Alcohols 70% ethyl, isopropyl Skin preparation should be reserved for
the use as disinfectant
hypochlorites Aqueouspreparations(eusol,milton,chloramine T)
Instrument and surfacecleaning
(debriding agent in openwound)
Toxic to tissue
Hexachlorophane Aqueous bisphenol Skin prep:
hand washing
Act against gram -ve
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POSTOPERATIVE
PRECAUTIONSPatients with established MRSA infectionsshould be
Nursed in a separate room
require specialist bacteriological advice about theantibiotic treatment needed.
All attending staff (medical and nursing) should wearprotective clothing (plastic apron and gloves) that isdiscarded in a designated container immediately the
patient is seen.This is followed by thorough disinfection of the hands.
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TREATMENT OF SSIs
Antibiotics are rarely used as the sole agentsto eradicate surgical infections;
usually they constitute adjuvant treatment to
surgery, e.g.excision of the infecting focus,
drainage of abscesses,
debridement,
lavage of infected serous cavities.
For established infections, the culture andsensitivity of the organisms to antibiotics isperformed
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CONTINUED..
Efflux of purulent material and pus
removal of sutures and clips if suppuration is evident
Fascia is intact:
debridement Irrigated with N/S and
packed to its base with saline-moistened gauze
Fascia separated:
drainage or reoperation
healing by secondary intention
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n Discharge planning
The intent of discharge planning:
maintain integrity of the healing incision,
educate the patient about the signs and symptoms
of infection, advise the patient about whom to contact to report
any problems.
Recommended