SURGICAL SITE INFECTION.- prevention and Care

7/27/2019 SURGICAL SITE INFECTION.- prevention and Care

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SURGICAL SITE INFECTIONS

PREVENTION AND CARE

Dr.T.V.Rao MD

Dr.T.V.Rao MD 1


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Surgical Site InfectionCDC defines

A surgical site infection is an infectionthat occurs after surgery in the part of

the body where the surgery took place.Surgical site infections can sometimes besuperficial infections involving the skin

only. Other surgical site infections aremore serious and can involve tissuesunder the skin, organs, or implanted

material. Dr.T.V.Rao MD 2


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Definition of CDC Wound infection is most commonly

characterized by the classic signs of redness (rubor), pain (dolor), swelling(tumor), elevated incisional tissuetemperature (calor ) and systemic fever.Ultimately, the wound is filled withnecrotic tissue, neutrophils, bacteria andProteinaceous fluid that togetherconstitute pus.

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Surgical site infections Surgical site infections

have been shown tocompose up to 20% of

all of healthcare-associated infections .At least 5% of patients undergoing asurgical proceduredevelop a surgical siteinfection

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When the Infection occurs Surgical site infection

may range from aspontaneously limitedwound discharge within7 10 days of anoperation to a life-threateningpostoperativecomplication, such as asternal infection afteropen heart surgery

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How Surgical Infections caused

Most surgical site infections arecaused by contamination of an

incision with microorganisms fromthe patient's own body duringsurgery. Infection caused bymicroorganisms from an outsidesource following surgery is less

common. Dr.T.V.Rao MD 6


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surgical site infections 3 rd most common nosocomial infection

14-16%

Most common nosocomialinfection among surgerypatients 38%

2/3 incisional1/3 organ

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Epidemiology:SSI data 2006-2011

Surgical site infections: are the third most prevalent HCAI in hospital

inpatients are present in 1% of hospital inpatients surveyed

(2011) account for 1.4% of overall HCAI incidence in

England

developed in 10% of large bowel operation cases* are largely preventable *this figure applies to procedures tracked under the nationalSSI surveillance programme

Information on this slide updated June 2012

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Risk Factors for SSI: The Patient Age Nutritional status Diabetes Nicotine use Obesity Coexistent infection Colonization Altered immune response Long preoperative stay

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Risk Factors for SSI: Pre- andIntraoperative

Inappropriate use of antimicrobial prophylaxis Infection at remote site not treated prior to surgery Shaving the site vs. clipping Long duration of surgery Improper skin preparation Improper surgical team hand antisepsis

Environment of the room (ventilation, sterilization) Surgical attire and drapes Asepsis Surgical technique: hemostasis, sterile field

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Pathogenesis

VirulenceBacterial dose

Impairedhost resistance


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Surgical Infection PreventionProject

Started in August 2002, by the Centers for Medicare& Medicaid Services (CMS) and the Centers forDisease Control and Prevention (CDC)

Based on 2 findings: Estimates indicate that 40-60% of

all SSIs are preventable

Overuse, underuse, improper timing, and misuseof antibiotics occurs in 25-50% of operations

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Selected Surgical ProceduresIncreases the Risk

Cardiac Coronary Artery Bypass Graft (CABG) Colon Hip & Knee Arthroplasty Abdominal & Vaginal Hysterectomy Vascular Surgery:

Aneurysm repair Thromboendarterectomy Vein Bypass

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Important Definitions Colonization

Bacteria present in a wound with no signs orsymptoms of systemic inflammation

Usually less than 10 5 cfu/mL Contamination

Transient exposure of a wound to bacteria

Varying concentrations of bacteria possible Time of exposure suggested to be < 6 hours SSI prophylaxis best strategy

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CDC on Skin Preparation

Require patients to shower or bathe with an antiseptic agent onat least the night before the

operative day. Thoroughly washand clean at and around theincision site to remove gross

contamination before performing antiseptic skin preparation .

Guideline for Prevention of Surgical Site Infection, 1999. HICPAC, Centers for Disease Control.


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Use Appropriate Antiseptic

Use an appropriate antiseptic agentfor skin preparation. Apply

preoperative antiseptic skinpreparation in concentric circlesmoving toward the periphery. Theprepared area must be large enoughto extend the incision or create new

incisions or drain sites, if necessary.Dr.T.V.Rao MD 16


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Antiseptic skin preparation in concentriccircles moving toward the periphery

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On Skin PreparationMany present with open wonds

The surgical site and surrounding areasshould be clean.

The skin around the surgical siteshould be free of soil and debris.Removal of superficial soil, debris, andtransient microbes before applying

antiseptic agent(s) reduces the risk of wound contamination by decreasingthe organic debris on the skin.

Standards, Recommended Practices, and Guidelines, 2005 Edition. AORN, Denver, CO.


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Cleaning Carries Greater Importance

Cleansing should be accomplished by any of thefollowing methods before surgical skinpreparation:

Patient showering and/or shampooing beforearrival in the practice setting

Washing the surgical site before arrival in thepractice setting, or

Washing the surgical site immediately beforeapplying the antiseptic agent in the practicesetting

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Instruction on Skin Preparation (contd)

When indicated, thesurgical site andsurrounding area should beprepared with an antisepticagent

Antiseptic agents shouldbe.used in accordance withthe manufacturers writteninstructions. Antisepticagent(s) should have a broadrange of germicidal action.


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Many Disinfectants

Variance in protocols and practice


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Contd; Infection

Systemic and local signs of

inflammation Bacterial counts 10 5 cfu/mL Purulent versus nonpurulent

Surgical wound infection is SSI

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Preoperative phase(hair removal)

Do not routinely use hair removal

Do not use razors for hair removal, as theyincrease the risk of surgical site infection If hair has to be removed, use electric

clipperswith a single-use head on the day of surgery

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Criteria for defining SSIs

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Classification of surgical site infections

Superficial incisional infection: this isdefined as a surgical site infection

that occurs within 30 days of surgeryand involves only the skin orsubcutaneous tissue of the incision,and meets at least one of thefollowing criteria

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Nurses must have minimal Knowledgeon Superficial Infection

Criterion 1: Purulent drainage from thesuperficial incision

Criterion 2: The superficial incision yieldsorganisms from the culture of asepticallyaspirated fluid or tissue, or from a swab andpus cells are present

b. the clinician diagnoses a superficialincisional infection

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What is Stich Infection Stitch abscesses are

defined as minimalinflammation anddischarge confined tothe points of suturepenetration, andlocalised infectionaround a stab wound.They are not classifiedas surgical siteinfections

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Supporting Evidence Criterion 3: At least two of the following

symptoms and signs: - pain or tenderness - localised swelling - redness - heat

and a. the superficial incision is deliberatelyopened by a surgeon to manage the infection,unless the incision is culture-negative

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Symptoms include:

Redness and painaround the area

where you hadsurgery

Drainage of cloudy

fluid from yoursurgical wound Fever

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Further Classification Etiology

a) PrimaryThe wound is the

primary site of infectionb)Secondary

Infection arises

following acomplication that is notdirectly related towound

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Who are at Risk In general the risk of SSI increased in the older

age group (65 years) except in cardiac, bileduct/liver/pancreatic, cholecystectomy, gastric,

limb amputation and vascular surgery where thereverse was observed with the risk being higherin younger patients (


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Contd; Time

a EarlyInfection presents within 30 days of

procedureb Intermediate

Occurs between one and three monthsc) Late

Presents more than three months after

surgery Dr.T.V.Rao MD 32


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Contd; Severity

a MinorWound infection is described as minor when

there is discharge without cellulitis or deep tissuedestructionb major

When there is pus discharge with tissue

breakdown , Partial or total dehiscence of thedeep fascial layers of wound or if systemic illnessis present.

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Mi bi l g


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MicrobiologyNature of the Isolates

A major study

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Preoperative factorsinfluences

Preoperative antiseptic showeringPreoperative hair removal

Patient skin preparation in theoperating room

Preoperative hand/forearmantisepsis

Antimicrobial prophylaxisDr.T.V.Rao MD 35


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Preoperative antiseptic showering Decreases skin microbial colony countsNo evidence of benefit to reduce SSI rates

Preoperative hair removal

Shaving:@ immediately before the operation: SSI rates 3.1%

@ shaving within 24 hours preoperatively: 7.1%@ having performed >24 hours: SSI rate > 20%.

Depilatories:@ lower SSI risk than shaving or clipping

@ hypersensitivity reactions

How to Prepare the Patients

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Preoperative phase(hair removal)

Do not routinely use hair removal Do not use razors for hair removal, as they

increase the risk of surgical siteinfection

If hair has to be removed, use electric

clipperswith a single-use head on the day of

surgery


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Preoperative phase

(antibiotic prophylaxis) Give antibiotic prophylaxis before:- clean surgery for the placement of a prosthesis or

implant

- clean-contaminated surgery- contaminated surgery Do not routinely use for clean non-prostheticuncomplicated

surgery Use local antibiotic formulary and consider adverseeffects Consider prophylaxis on starting anaesthesia, or

earlier for operations using a tourniquet


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Intraoperative phase

Prepare the skin immediately beforeincision using an (aqueous or alcohol-based) antiseptic preparation -povidone-iodine or chlorhexidine aremost suitable

Cover surgical incisions with anappropriate interactive dressing at theend of the operation


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Changing a dressing Before you start, make sure you have

gauze pads, a box of medical gloves,surgical tape, a plastic bag, andscissors. Then:

Prepare supplies by opening the gauze

packages and cutting new tape strips. Put on medical gloves.

Loosen the tape around the old dressing.Dr.T.V.Rao MD 40


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How to Deal with Problem Inspect the incision for signs of infection. Hold a clean, sterile gauze pad by the corner

and place over the incision. Tape all four sides of the gauze pad. Put all trash, including gloves, in a plastic bag.

Seal plastic bag and throw it away. Wash your hands.

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How to Deal with Problem Remove the old dressing. Remove the gloves. At this point,

clean the incision if your doctor toldyou to do so.(See instructions below.)

Wash your hands, and put onanother pair of medical gloves

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Cleaning an incision

To clean the incision: Gently wash it with soap and water to remove

the crust. Do not scrub or soak the wound. Do not use rubbing alcohol, hydrogen

peroxide, or iodine, which can harm thetissue and slow wound healing.

Air-dry the incision or pat it dry with a clean,fresh towel before reapplying the dressing.

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Do not Don't expose your

incision to direct sun for 3to 9 months after surgery.As an incision heals, thenew skin that is formedover the cut is verysensitive to sunlight andwill burn more easily thannormal skin. Bad scarringcould occur if you getsunburn on this new skin.

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l d h


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Have a policy on Sending theSpecimens for Culturing

Develop clearguidance for staff onwhen a wound swabshould be taken:there should besome signs of

infection, e.g.discharging pus,redness, swelling,heat, pain.

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Preparing to Collecting the Swabs fromWounds

The person collectingspecimens shoulddecontaminate hands toreduce the risk of transferof transient organisms onthe healthcare workershands to the patient.Apply gloves (removedressing as appropriate)to protect the health careworkers hands.

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Ideal way to Collect the Wound Swabs

The wound should be cleansed withsterile saline to irrigate any purulentdebris (Stotts 2007) to achieve a cleanculture site and to avoid obtaining aculture from the pus on the surface of the wound. Moisten the swab withsterile saline before taking sample. In drywounds a moistened swab will attach

bacteria more effectively.Dr.T.V.Rao MD 47


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Collecting a SWABS for BacterialCulturing

Always take a swab from a newly cleanedwound.

Cleanse with normal saline or sterilewater

Take a swab by moving in a Z pattern overthe wound and turning the swab at the sametime

Punch biopsy (Physician only)

Do Not swab necrotic or slough tissueDr.T.V.Rao MD 48


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Collecting the Swab

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Collecting the Specimen

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A case of Sternal Infection

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*When to order the Culturing wounds

*Culture swab of awound should

only be taken if clinical infection issuspected.Or else the resultsare misleading

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Interpretation of Microbiology Results

Microbiology results should be interpreted inconjunction with clinical information. Advicefrom a Medical Microbiologist should be

sought if there is doubt about theinterpretation of a result. A positivemicrobiology report is not a clearindication of infection. The result mustalso indicate the presence of pus cells or thereshould be other clinical signs of an infection

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Details of the Wound and Antibiotic Therapy shouldbe included in the Requests to Laboratory

The details regarding the wound shouldbe recorded on the request form-Document condition of wound andevidence of infection including clinicalsymptoms any antibiotic treatment thepatient on must be recorded, Clinicaldetails will assist the microbiologist inmaking an accurate diagnosis.

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Request for Improvement of Requests

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C ll h S i i h O i l


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Collect the Specimens with Optimalcare and Scientific Spirit

Properly collectedspecimens will giveoptimal benefit in

proper identificationof the causativeorganisms and

appropriatedAntibioticsuggestions.

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Wound Cleansing

- Normal Saline orSterile Water

Irrigate with 20-30 ml syringe

Use 18 angiocath 4-6 inches above

the wound

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Prophylactic antibiotics Class 1 = Clean Class 2 = Clean contaminated Class 3 = Contaminated Class 4 = Dirty infected

Prophylacticantibioticsindicated

Therapeutic antibiotics

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ABX

Once the incision is made,antibiotic delivery to thewound is impaired.Must give before incision!

Do Remember

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Use/Choice of Antibiotics Use only when indicated Start with broad spectrum antibiotics

designed to cover likely pathogens Take cultures when possible Deescalate spectrum once pathogen is

know Have a plan for duration

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Preoperative phase


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Preoperative phase(antibiotic prophylaxis)

Give antibiotic prophylaxis before:- clean surgery for the placement of a prosthesis or

implant- clean-contaminated surgery- contaminated surgery

Do not routinely use for clean non-prostheticuncomplicated

surgery

Use local antibiotic formulary and consider adverseeffects

Consider prophylaxis on starting anaesthesia, orearlier for operations using a tourniquet

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Standardized infection ratio The standardized infection ratio (SIR) is a

summary measure used to track HAIs at anational, state, or facility level over time. The

SIR adjusts for the fact that each healthcarefacility treats different types of patients. Forexample, the experience with HAIs at a

hospital with a large burn unit cannot bedirectly compared to a facility without a burnunit.

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L t C l l t th I f ti R t t


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Learn to Calculate the Infection Rates atyou Hospitals

The SIR compares the actual numberof HAIs in a facility or state with the

baseline U.S. experience (i.e.,standard population), adjusting forseveral risk factors that have been

found to be most associated withdifferences in infection rates.

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Surgeons should be Role Models


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Surgeons should be Role ModelsNever forget to wear the Mask

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Infection is every bodys concern, it is not justNursing staff, but Doctors have a great Role.

Infections can make or break the future of Hospitals including the career of the

Surgeons I wish every body is partner in Prevention of

Hospital acquired infections.

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Say Good Bye to Infections


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Say Good Bye to InfectionsJust Wash your Hands

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SURGICAL SITE INFECTION.- prevention and Care