Surgical Site Infections

Dr. Rahul AgarwalDNB General Surgery

Care Hospital

Why this topic?SSI is MOST COMMON hospital acquired infection in surgical patients.

3rd most common hospital acquired infection.

Preventable

Prolong the hospital stay (7.3 days)

Expenditure

Over one-third of postoperative deaths

Poor scar, persistent pain and itching, restriction of movement and a significant impact on emotional wellbeing

What is SSI?

Infections that occur in the wound created by an invasive

surgical procedure are generally referred to as surgical

site infections

Criteria for defining SSIs

Superficial incisional surgical site infections

Infection occur within 30 days of procedure

Involve skin or subcutaneous tissue • signs or symptoms of infection• purulent drainage +/-• organisms isolated• Diagnosis by experience

Stitch abscess, episiotomy, circumcision in infant, burn wound

Deep incisional surgical site infections

Infection occur within 30 days of procedure (or one year in the case of implants)

Involve deep soft tissues, such as the fascia and muscles.

• purulent drainage, signs of infection• spontaneously dehisces or opened by surgeon• an abscess or other evidence of infection

Involving both superficial and deep = DISSI

Space or organ ssi drain through Deep incision = DISSI

Organ or space Surgical site Infection

30 days no implant or 1 year with implant

Any part is involved which was opened or manipulated other than the incision• Purulent discharge from a drain• Isolated an organism• Abscess or other evidence of infection• Diagnosis by a surgeon

Early

• Infection presents within 30 days of procedure

Intermediate

• Occurs between one and three months

Late

• Presents more than three months after surgery

Minor• Wound infection is

described as minor when there is discharge without cellulitis or deep tissue destruction

Major

• When there is pus discharge with tissue breakdown , Partial or total dehiscence of the deep fascial layers of wound or if systemic illness is present.

Severity

Pathogenesis of surgical site infection

Contamination• Endogenous

infection• Exogenous

infection• Haematogenou

s spread• Staph aureus• Enterobacteri

aceae and anaerobes

Proliferation of bacteria

Induce inflammation –

signs appear

Identified or unidentified

Self resolving -> resolve by treatment ->

sepsis and death

Wound Assessment

ASEPSIS

• to assess wounds

Southampton Wound Assessment Scale

• categorized according to any complications and their extent

ASEPSIS wound scoring system

• Score 0-10-satisfactory healing• 11-20-disturbance of healing• 20-30-minor wound infection• 31-40-moderate wound infection• >41-severe wound infection

Southampton scoring system Grade Appearance

• 0 Normal

• I Normal healing with mild bruises and erythema A Some bruising B Considerable bruising C Mild erythema

Grade Appearance• II Erythema plus other signs of infection

A At one point B Around suturesC Along woundD Around wound

Grade Appearance• III Clean or haemoserous discharge

A At one point onlyB Along woundC Large volumeD Prolonged

Grade Appearance• IV Major wound complication like pus

A At one point onlyB Along wound

• V Deep or severe infection with or without breakdown

Types of Surgery / class of wound

Clean Hernia repairbreast biopsy

1.5%

Clean-Contaminated

Cholecystectomy planned bowel resection

2-5%

Contaminated Non-preped bowel resection

5-30%

Dirty/infected perforation, abscess 5-30%

Risk Factors for Development of

Surgical Site Infections

Patient factor

Local factor

Microbial factor

• Older age - linear trend• Immunosuppression • Obesity • Diabetes mellitus • Chronic inflammatory process • Malnutrition • Peripheral vascular disease • Smoking• Anemia • Radiation • Steroid use

Patient factors

• Poor skin preparation • Contamination of instruments • Inadequate antibiotic prophylaxis • Prolonged procedure• Site and complexity of procedure• Local tissue necrosis • Hypoxia • Hypothermia

Local factors

•Wound Class•Prolonged hospitalization (leading to nosocomial organisms)

•Resistance

Microbial factors

Treatment

• Incisional: open surgical wound, antibiotics for cellulitis or sepsis

• Deep/Organ space: Source control, antibiotics for sepsis

Management of Incisional surgical site infection

• Removal of sutures with drainage of pus• Debridement and open wound care• delayed primary or secondary suture• 15% of postoperative wounds are treated with

antibiotics -> inappropriate -> resistance• Wound bed preparation

Wound Dehiscence and Evisceration

• Separation of abdominal wound• Protrusion of abdominal content• Mean time - 8 to 10 days• c/f– Pink serosanguinous discharge from the wound

• t/t– Reclosure of the wound

Reclosure of the wound

• Early closure in early post operative period• If evesceration – cover OT resuturing• Retention suturing is not proven advantageous• Mesh and biological implants• In a small dehiscence – secondary suturing

PREVENTION OF

SURGICAL SITE

INFECTIONS

Ignaz Semmelweis

1846Realized that

washing hand with a chlorinated lime solution decreased mortality from “puerperal fever’.

Joseph Lister

• 1883-1897• British surgeon• Used Carbolic

Acid (Phenol) to clean hands, instruments and wipe on surgical wounds drastically decreased infections.

Guidelines for prevention of Surgical Site Infection• Information for patients and

carers• Preoperative phase• Intra operative phase• Post operative phase

Guidelines for prevention of SSI

• Explain in detail

Information for patients and carers

• Preoperative showering – none vs chlorhexidine/soap• Hair removal • Patient theatre wear• Staff theatre wear• Staff leaving the operating area• Nasal decontamination – mupirocin?• Mechanical bowel preparation• Hand jewellery, artificial nails and nail polish• Antibiotic prophylaxis

Preoperative phase

Operative Antibiotic Prophylaxis

1969

Decreases bacterial counts at surgical site

Given within 30 - 120 minutes prior to surgery - Cefazolin

MRSA - Vancomycin 1-2 hours prior to surgery

Allergic – vancomycin + clindamycin

Re-dose for longer surgery - twice the half life of drug

Single dose/ Do not continue beyond 24 hours

Do not - for clean non-prosthetic uncomplicated surgery

consider potential adverse effects

Give antibiotic treatment (in addition to prophylaxis)

Operative Antibiotic Prophylaxis

However….

• Prophylaxis not effective for– Lap cholecystectomy– Herniorraphy

• Insufficient evidence for– breast reconstruction with or without implants – abdominal hysterectomy (clean-contaminated) – uncomplicated appendicectomy in children

1

• Hand decontamination• Incise drapes• Use of sterile gowns• Gloves• Antiseptic skin preparation• Maintaining patient homeostasis – temp oxygen glucose• Diathermy• Wound irrigation and intra-cavity lavage• Antiseptic and antimicrobial agents before wound

closure• Wound dressings, Closure methods

Intra-operative phase

Guidelines for prevention of SSI

• Changing dressings• Postoperative cleansing• Use tap water for wound cleansing after

48 hours• No Topical antimicrobial agents - primary

intention• Dressings - secondary intention• Debridement• Antibiotic treatment

Postoperative phase

Guidelines for prevention of SSI

Practices to prevent SSI are therefore aimed at minimising the number of microorganisms introduced into the operative site, for example by:

• Removing microorganisms that normally colonise the skin.

• Preventing the multiplication of microorganisms.

• Enhancing the patient’s defences against infection.

• Preventing access of microorganisms into the incision postoperatively.

• Source– Schwartz’s Principles of surgery– Sabiston– Maingot’s Abdominal operations– Surgical site infection (prevention and treatment of surgical

site infection) 2008• National Collaborating Centre for Women’s and Children’s Health

– Commissioned by the National Institute for Health and Clinical Excellence

– Internet

THANK YOU