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surgical site infection
1. Surgical Site InfectionsSurgical Site Infections
what an enigma?what an enigma?
Moderated by :Moderated by :
Dr Nasser Hammoud M.D ,FACSDr Nasser Hammoud M.D ,FACS
Presented byPresented by
Ali Haydar M.D PGY3 HHUMC GeneralAli Haydar M.D PGY3 HHUMC General
Surgery DepartmentSurgery Department
2. Infection
Infection is defined by:Infection is defined by:
1.1. Microorganisms in host tissue orMicroorganisms in host tissue or
the bloodstreamthe bloodstream
2.2. Inflammatory response to theirInflammatory response to their
presence.presence.
3. SSI – Definitions
• InfectionInfection
– Systemic and local signs of inflammationSystemic and local signs of inflammation
– Bacterial counts ≥ 10Bacterial counts ≥ 1055
cfu/mLcfu/mL
– Purulent versus nonpurulentPurulent versus nonpurulent
– LOS effectLOS effect
– Economic effectEconomic effect
• Surgical wound infection is SSISurgical wound infection is SSI
LOS=length of stay.
4. Surgical Site Infections (SSI)
• Third most common nosocomial infection (14%–Third most common nosocomial infection (14%–
16%)16%)
• Most common nosocomial infection amongMost common nosocomial infection among
surgical patients (38%)surgical patients (38%)
– 2/3 incisional2/3 incisional
– 1/3 organs or spaces accessed during surgery1/3 organs or spaces accessed during surgery
• 7.3 additional postoperative days at cost of7.3 additional postoperative days at cost of
$3,152 in extra charges$3,152 in extra charges
Mangram AJ et al. Infect Control Hosp Epidemiol.
5. Superficial Incisional SSI
Infection occurs within 30
days after the operation
and involves only skin or
subcutaneous tissue
of the incision
Mangram AJ et al. Infect Control Hosp Epidemiol.
SubcutaneousSubcutaneous
tissuetissue
SkinSkin
Superficial
incisional SSI
6. Deep Incisional SSI
Infection occurs within 30
days after the operation if
no implant is left in place
or within 1 year if implant
is in place and the
infection appears to be
related to the operation and
the infection involves the
deep soft tissue (e.g.,
fascia and muscle layers)
Deep soft tissueDeep soft tissue
(fascia & muscle)(fascia & muscle)
Deep incisional
SSI
Superficial
incisional SSI
Mangram AJ et al. Infect Control Hosp Epidemiol.
7. Organ/Space SSI
Infection occurs within 30
days after the operation if no
implant is left in place or
within 1 year if implant is in
place and the infection
appears to be related to the
operation and the infection
involves any part of the
anatomy, other than the
incision, which was opened
or manipulated during the
operation
Deep incisional
SSI
Superficial
incisional SSI
Organ/space SSIOrgan/spaceOrgan/space
Mangram AJ et al. Infect Control Hosp Epidemiol.
8. SSI – Risk Factors
Patient Characteristics
• Age
• Diabetes
– HbA1C and SSI
– Glucose > 200 mg/dL
postoperative period
(<48 hours)
• Nicotine use: delays primary
wound healing
• Steroid use: controversial
• Malnutrition
• Obesity: 20% over ideal body
weight
Mangram AJ et al. Infect Control Hosp Epidemiol.
1999;20:250-278.
• Prolonged preoperative stay:
Preoperative colonization with
Staphylococcus aureus:
significant association
• Perioperative transfusion:
controversial
• Coexistent infections at a remote
body site
• Altered immune response
9. SSI – Risk Factors
Operation Factors
• Duration of surgical scrub
• Maintain body temp
• Skin antisepsis
• Preoperative shaving
• Duration of operation
• Antimicrobial prophylaxis
• Operating room ventilation
• Inadequate sterilization of
instruments
Mangram AJ et al. Infect Control Hosp Epidemiol.
1999;20:250-278.
• Foreign material at
surgical site
• Surgical drains
• Surgical technique
– Poor hemostasis
– Failure to obliterate
dead space
– Tissue trauma
10.
11. Types of SurgeryTypes of Surgery
CleanClean Hernia repairHernia repair
breast biopsybreast biopsy
1.5%1.5%
Clean-Clean-
ContaminatedContaminated
CholecystectomyCholecystectomy
planned bowel resectionplanned bowel resection
2-5%2-5%
ContaminatedContaminated Non-preped bowelNon-preped bowel
resectionresection
5-30%5-30%
Dirty/infectedDirty/infected perforation, abscessperforation, abscess 5-30%5-30%
12. Preoperative phase
(hair removal)
– Do not routinely use hair removal
– Do not use razors for hair removal, as they
increase the risk of surgical site infection
– If hair has to be removed, use electric clippers
with a single-use head on the day of surgery
13.
14. Preoperative phase
(antibiotic prophylaxis)
–Give antibiotic prophylaxis before:Give antibiotic prophylaxis before:
- clean surgery for the placement of a prosthesis or implant- clean surgery for the placement of a prosthesis or implant
- clean-contaminated surgery- clean-contaminated surgery
- contaminated surgery- contaminated surgery
–Do not routinely use for clean non-prosthetic uncomplicatedDo not routinely use for clean non-prosthetic uncomplicated
surgerysurgery
–Use local antibiotic formulary and consider adverse effectsUse local antibiotic formulary and consider adverse effects
–Consider prophylaxis on starting anaesthesia, orConsider prophylaxis on starting anaesthesia, or
earlier for operations using a tourniquetearlier for operations using a tourniquet
15. SSI – Wound Classification
• Class 1 = Clean
• Class 2 = Clean contaminated
• Class 3 = Contaminated
• Class 4 = Dirty infected
m AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.
Prophylactic
antibiotics
indicated
Therapeutic antibiotics
16.
17. THE LENGTH AND
DIRECTION OF THE
INCISION
• The direction in which wounds naturally heal is from side-
to- side, not end-to-end.
• The arrangement of tissue fibers in the area to be dissected
will vary with tissue type.
• The best cosmetic results may be achieved when incisions
are made parallel to the direction of the tissue fibers.
18. DISSECTION TECHNIQUE
• When incising tissue, a clean incision should be
made through the skin with one stroke of evenly
applied pressure on the scalpel.
• Sharp dissection should be used to cut through
remaining tissues.
• The surgeon must preserve the integrity of as
many of the underlying nerves, blood vessels, and
muscles as possible.
19. TISSUE HANDLING
• Keeping tissue trauma to a minimum promotes faster
healing.
• Throughout the operative procedure, the surgeon must
handle all tissues very gently and as little as possible.
• Retractors should be placed with care to avoid excessive
pressure,
• since tension can cause serious complications: impaired
blood and lymph flow,
• altering of the local physiological state of the wound,
and predisposition to microbial colonization.
20. HEMOSTASIS
•Achieving complete hemostasis before wound closure will
prevent formation of postoperative hematomas.
•Collections of blood (hematomas) or fluid (seromas) in the incision
can prevent the direct apposition of tissue.
•These collections provide an ideal culture medium for microbial
growth and can lead to serious infection.
•When clamping or ligating avoid excessive tissue damage.
•Mass ligation that involves large areas of tissue may
produce necrosis.
21. MAINTAINING MOISTURE
IN TISSUES
• During long procedures, periodically irrigate the
wound with warm saline solution,
• or cover exposed surfaces with saline-moistened
sponges to prevent tissues from drying out.
22.
23.
24.
25. TreatmentTreatment
• Incisional: open surgical wound,Incisional: open surgical wound,
antibiotics for cellulitis or sepsisantibiotics for cellulitis or sepsis
• Deep/Organ space: Source control,Deep/Organ space: Source control,
antibiotics for sepsisantibiotics for sepsis
26.
27. Care of the wound
• Epithelialisation takes 48 hs.
• Dressing can be removed 3-4 days after operation.
• Wet dressing should be removed earlier and changed.
• Symptoms and signs of infection should be looked for, which if
present compression, removal of few stitches and daily
dressing with swab for C & S.
• Tensile strength of wound minimal during first 5 days, then rapid
between 5th
20th
day then slowly again (full strength takes 1-2
years).
• Good nutrition.
28. Management of drains
• To drain fluids accumulating after surgery, blood or pus.
• Open or closed system.
• Other types (Suction, sump, under water etc.)
• Should be removed as long as no function.
• Should come out throw separate incision to minimize risk of
wound infection.
• Inspection of contents and its amount.
• Soft drains e.g. Penrose should not be left more than 40 days
because they form a tract and acts as a plug.
29.
30. • Drain use after elective laparoscopic
cholecystectomy increases wound infection rates and delays hospital
discharge. We could not find evidence to support the use of drain
after laparoscopic cholecystectomy or open cholecystectomy.
• Many gastrointestinal operations can be performed safely without
prophylactic drainage
• There is insufficient evidence showing that routine drainage after
colorectal anastomoses prevents anastomotic and other
complications. Damage may be caused by mechanical pressure or
suction and drains may even induce an anastomotic leak.
• Drains are not a substitute for good surgical technique
31. Thank You
“The names of the patients whose lives we save can never be
known. Our contribution will be what did not happen to them”
Sources:
•Pubmed National library of medicine
•Loyola University Medical Center
•Memon MA, Memon MI, Donohue JH; Abdominal
drains: a brief historical review. Ir Med J. 2001
Jun;94(6):164-6
Editor's Notes
Surgical sites are considered infected when there are signs of systemic and local inflammation and bacterial counts are 105 cfu/mL or higher. Infections are also differentiated by purulence or nonpurulence.
The length of stay for the patient and economic effects of the hospital stay are important factors to consider in SSIs.
It is important to note is that a surgical wound infection is a surgical site infection.
Surgical site infections are the third most common type of nosocomial infection accounting for 14% to 16% of all infections.
Among surgical patients, however, SSIs are the most common nosocomial infection, observed in 38% of cases. Two-thirds of these infections are due to the incision, whereas one-third are due to infection of the organs or spaces during surgery.
Surgical site infections result in an additional 7.3 postoperative days at an added cost of $3,152.
The first type of surgical site infection is the superficial incisional surgical infection which occurs within 30 days post-op and involves only the skin or subcutaneous tissue.
A more serious SSI is a deep incisional surgical infection, which extends past the superficial layer. The infection occurs within 30 days post-op only if no implant is left in place or within 1 year if implant is in place and the infection appears to be related to the operation and the infection involves the deep soft tissue, which include the fascia and muscle layers.
The most extensive of these surgical infections involves the organs and the space surrounding the organs. These infections can occur within 30 days post-op if no implant is left in place or within 1 year if an implant is in place and the infection appears to be related to the operation and the infection involves any part of the anatomy, other than the incision, which was opened or manipulated during the operation.
This slide shows risk factors for patients who are considered to be at a higher risk for surgical site infection.
High-risk characteristics include advanced age, diabetes, smoking, poor nutritional status, obesity, coexisting infections at a particular body site, and altered immune response, among other factors.
Prolonged preoperative stay is also a risk, depending on the severity of illness and comorbid conditions. There is also a significant association between preoperative nares colonization with Staphylococcus aureus and surgical site infection. Perioperative transfusion remains a controversial issue.
Both operation factors and patient characteristics may influence the risk of surgical site infection.
Depending on the conditions of the operation a patient can be at an even greater risk of infection. These factors can include duration of surgical scrub, maintenance of body temperature, the use of skin antisepsis, preoperative shaving, duration of the operation, antimicrobial prophylaxis, ventilation of the operating room, inadequate sterilization of instruments, the presence of foreign material at the surgical site, surgical drains, and surgical technique. Poor surgical technique includes poor hemostasis, failure to obliterate dead space, and tissue trauma.
NOTES FOR PRESENTERS:
Key points to raise:
There is no evidence that hair removal in general influences the incidence of SSI, but it might be appropriate in some clinical circumstances.
Evidence showed that the use of electric clippers for preoperative hair removal was cost effective when compared with no hair removal, shaving using razors and depilatory cream. The use of electric clippers was not only found to generate more quality-adjusted life years but was also found to be less expensive (page 27 of full NICE guideline).
Recommendations in full:
Do not use hair removal routinely to reduce the risk of surgical site infection. (1.2.2)
If hair has to be removed, use electric clippers with a single-use head on the day of surgery. Do not use razors for hair removal, because they increase the risk of surgical site infection. (1.2.3)
NOTES FOR PRESENTERS:
Key points to raise:
Do not use the following routinely to reduce the risk of surgical site infections:
Nasal decontamination with topical antimicrobial agents targeting Staphylococcus aureus
Mechanical bowel preparation
Additional Information:
Inform patients before the operation, whenever possible, if they will need antibiotic prophylaxis, and afterwards if they have been given antibiotics during their operation. (1.2.17)
Definitions:
Clean: an incision in which no inflammation is encountered in a surgical procedure, without a break in sterile technique, and during which the respiratory, alimentary or genitourinary tracts are not entered.
Clean-contaminated: an incision through which the respiratory, alimentary, or genitourinary tract is entered under controlled conditions but with no contamination encountered.
Contaminated: an incision undertaken during an operation in which there is a major break in sterile technique or gross spillage from the gastrointestinal tract, or an incision in which acute, non-purulent inflammation is encountered. Open traumatic wounds that are more than 12–24 hours old also fall into this category.
Recommendations in full:
Give antibiotic prophylaxis to patients before; clean surgery involving the placement of a prosthesis or implant, clean-contaminated surgery and contaminated surgery. (1.2.11) Do not use prophylaxis routinely for clean non-prosthetic uncomplicated surgery. (1.2.12)
Use the local antibiotic formulary and always consider potential adverse effects when choosing specific antibiotics for prophylaxis. (1.2.13)
Consider giving a single dose of antibiotic prophylaxis intravenously on starting anaesthesia. However, give prophylaxis earlier for operations in which a tourniquet is used. (1.2.14)
Surgical site infections are categorized into four classes depending on wound type. Class 1 is a clean wound, class 2 is a clean contaminated wound, class 3 is a contaminated wound, and class 4 is a dirty infected wound.
