SURGICAL SITE INFECTIONS (by Naveed)

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.

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SURGICAL SITE INFECTIONS (by Naveed)