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  • Surgical Site Infection CDC defines • A surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial infections involving the skin only. Other surgical site infections are more serious and can involve tissues under the skin, organs, or implanted material. Dr.T.V.Rao MD 2
  • Surgical site infections • Surgical site infections have been shown to compose up to 20% of all of healthcare- associated infections. At least 5% of patients undergoing a surgical procedure develop a surgical site infection Dr.T.V.Rao MD 3 View slide
  • When the Infection occurs • Surgical site infection may range from a spontaneously limited wound discharge within 7–10 days of an operation to a life- threatening postoperative complication, such as a sternal infection after open heart surgery Dr.T.V.Rao MD 4 View slide
  • How Surgical Infections caused • Most surgical site infections are caused by contamination of an incision with microorganisms from the patient's own body during surgery. Infection caused by microorganisms from an outside source following surgery is less common. Dr.T.V.Rao MD 5
  • surgical site infections • 3rd most common nosocomial infection 14-16% Most common nosocomial infection among surgery patients 38% 2/3 incisional 1/3 organ Dr.T.V.Rao MD 6
  • SSIs: Magnitude of the Problem in USA SSIs occur in 2.6% of all surgeries = 1.5 million SSIs annually • SSIs are the second most common HAI • LOS in hospital increases by 7.5 days • Attributable cost: $25,546 (range $1783 to $134,602) • U.S. National Cost: $130-$845 million/year Dr.T.V.Rao MD 7
  • 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 national SSI surveillance programme Information on this slide updated June 2012 Dr.T.V.Rao MD 8
  • Risk Factors for SSI: The Patient • Age • Nutritional status • Diabetes • Nicotine use • Obesity • Coexistent infection • Colonization • Altered immune response • Long preoperative stay Dr.T.V.Rao MD 9
  • Risk Factors for SSI: Pre- and Intraoperative • 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 Dr.T.V.Rao MD 10
  • Pathogenesis Virulence Bacterial dose Impaired host resistance
  • Surgical Infection Prevention Project • Started in August 2002, by the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) • Based on 2 findings: –Estimates indicate that 40-60% of all SSIs are preventable – Overuse, underuse, improper timing, and misuse of antibiotics occurs in 25-50% of operations Dr.T.V.Rao MD 12
  • Selected Surgical Procedures Increases the Risk • Cardiac • Coronary Artery Bypass Graft (CABG) • Colon • Hip & Knee Arthroplasty • Abdominal & Vaginal Hysterectomy • Vascular Surgery: – Aneurysm repair – Thromboendarterectomy – Vein Bypass Dr.T.V.Rao MD
  • Important Definitions • Colonization – Bacteria present in a wound with no signs or symptoms of systemic inflammation – Usually less than 105 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 Dr.T.V.Rao MD 14
  • CDC on Skin Preparation • Require patients to shower or bathe with an antiseptic agent on at least the night before the operative day. Cat IB • Thoroughly wash and clean at and around the incision site to remove gross contamination before performing antiseptic skin preparation. Cat IB • Use an appropriate antiseptic agent for skin preparation. Cat IB • Apply preoperative antiseptic skin preparation in concentric circles moving toward the periphery. The prepared area must be large enough to extend the incision or create new incisions or drain sites, if necessary. Cat II Guideline for Prevention of Surgical Site Infection, 1999. HICPAC, Centers for Disease Control.
  • AORN on Skin Preparation • The surgical site and surrounding areas should be clean. – The skin around the surgical site should be free of soil and debris. Removal of superficial soil, debris, and transient microbes before applying antiseptic agent(s) reduces the risk of wound contamination by decreasing the organic debris on the skin. – Cleansing should be accomplished by any of the following methods before surgical skin preparation: • Patient showering and/or shampooing before arrival in the practice setting • Washing the surgical site before arrival in the practice setting, or • Washing the surgical site immediately before applying the antiseptic agent in the practice setting Standards, Recommended Practices, and Guidelines, 2005 Edition. AORN, Denver, CO.
  • AORN on Skin Preparation (cont’d) • When indicated, the surgical site and surrounding area should be prepared with an antiseptic agent – Antiseptic agents should be….used in accordance with the manufacturer’s written instructions. Antiseptic agent(s) should have a broad range of germicidal action.
  • Many Disinfectants Variance in protocols and practice
  • Contd; • Infection –Systemic and local signs of inflammation –Bacterial counts ≥ 105 cfu/mL –Purulent versus nonpurulent • Surgical wound infection is SSI Dr.T.V.Rao MD 19
  • 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 Dr.T.V.Rao MD 20
  • Criteria for defining SSIs Dr.T.V.Rao MD 21
  • Further Classification • Etiology a) Primary The wound is the primary site of infection b)Secondary Infection arises following a complication that is not directly related to wound Dr.T.V.Rao MD 22
  • Contd; • 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 Dr.T.V.Rao MD 23
  • Contd; •Severity a) Minor Wound infection is described as minor when there is discharge without cellulitis or deep tissue destruction b) 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. Dr.T.V.Rao MD 24
  • Microbiology Nature of the Isolates A major study Dr.T.V.Rao MD 25
  • Preoperative factors influences Preoperative antiseptic showering Preoperative hair removal Patient skin preparation in the operating room Preoperative hand/forearm antisepsis Antimicrobial prophylaxisDr.T.V.Rao MD 26
  •  Preoperative antiseptic showering  Decreases skin microbial colony counts  No 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 Dr.T.V.Rao MD 27
  • Symptoms include: • Redness and pain around the area where you had surgery • Drainage of cloudy fluid from your surgical wound • Fever Dr.T.V.Rao MD 28
  • Changing a dressing • Before you start, make sure you have gauze pads, a box of medical gloves, surgical tape, a plastic bag, and scissors. 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 29
  • 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. Dr.T.V.Rao MD 30
  • How to Deal with Problem • Remove the old dressing. • Remove the gloves. At this point, clean the incision if your doctor told you to do so. (See instructions below.) • Wash your hands, and put on another pair of medical gloves Dr.T.V.Rao MD 31
  • 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 the tissue and slow wound healing. • Air-dry the incision or pat it dry with a clean, fresh towel before reapplying the dressing. Dr.T.V.Rao MD 32
  • Do not • Don't expose your incision to direct sun for 3 to 9 months after surgery. As an incision heals, the new skin that is formed over the cut is very sensitive to sunlight and will burn more easily than normal skin. Bad scarring could occur if you get sunburn on this new skin. Dr.T.V.Rao MD 33
  • Preparing to Collecting the Swabs from Wounds • The person collecting specimens should decontaminate hands to reduce the risk of transfer of transient organisms on the healthcare workers hands to the patient. Apply gloves (remove dressing as appropriate) to protect the health care workers hands. Dr.T.V.Rao MD 34
  • Ideal way to Collect the Wound Swabs • The wound should be cleansed with sterile saline to irrigate any purulent debris (Stotts 2007) to achieve a clean culture site and to avoid obtaining a culture from the pus on the surface of the wound. Moisten the swab with sterile saline before taking sample. In dry wounds a moistened swab will attach bacteria more effectively. Dr.T.V.Rao MD 35
  • Collecting a SWABS for Bacterial Culturing • Always take a swab from a newly cleaned wound. • Cleanse with normal saline or sterile water • Take a swab by moving in a “Z” pattern over the wound and turning the swab at the same time • Punch biopsy (Physician only) • Do Not swab necrotic or slough tissue Dr.T.V.Rao MD 36
  • Collecting the Swab Dr.T.V.Rao MD 37
  • *When to order the Culturing wounds *Culture swab of a wound should only be taken if clinical infection is suspected. Or else the results are misleading Dr.T.V.Rao MD 38
  • Details of the Wound and Antibiotic Therapy should be included in the Requests to Laboratory • The details regarding the wound should be recorded on the request form- Document condition of wound and evidence of infection including clinical symptoms – any antibiotic treatment the patient on must be recorded, Clinical details will assist the microbiologist in making an accurate diagnosis. Dr.T.V.Rao MD 39
  • Collect the Specimens with Optimal care and Scientific Spirit • Properly collected specimens will give optimal benefit in proper identification of the causative organisms and appropriated Antibiotic suggestions. Dr.T.V.Rao MD 40
  • Wound Cleansing - Normal Saline or Sterile Water –Irrigate with 20- 30 ml syringe –Use 18 angiocath –4-6 inches above the wound – Dr.T.V.Rao MD 41
  • Prophylactic antibiotics • Class 1 = Clean • Class 2 = Clean contaminated • Class 3 = Contaminated • Class 4 = Dirty infected Prophylactic antibiotics indicated Therapeutic antibiotics Dr.T.V.Rao MD 42
  • ABX Once the incision is made, antibiotic delivery to the wound is impaired. Must give before incision! Do Remember Dr.T.V.Rao MD 43
  • 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 Dr.T.V.Rao MD 44
  • 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-prosthetic uncomplicated surgery – Use local antibiotic formulary and consider adverse effects – Consider prophylaxis on starting anaesthesia, or earlier for operations using a tourniquet Dr.T.V.Rao MD 45
  • Standardized infection ratio • The standardized infection ratio (SIR) is a summary measure used to track HAIs at a national, state, or facility level over time. The SIR adjusts for the fact that each healthcare facility treats different types of patients. For example, the experience with HAIs at a hospital with a large burn unit cannot be directly compared to a facility without a burn unit. Dr.T.V.Rao MD 46
  • Learn to Calculate the Infection Rates at you Hospitals • The SIR compares the actual number of HAIs in a facility or state with the baseline U.S. experience (i.e., standard population), adjusting for several risk factors that have been found to be most associated with differences in infection rates. Dr.T.V.Rao MD 47
  • Say Good Bye to Infections Just Wash your Hands Dr.T.V.Rao MD 48
  • Visit me for More Articles of Interest on FACEBOOK Rao’s Infection Care - Rao’s Microbiology Dr.T.V.Rao MD 49
  • • Programme Created by Dr.T.V.Rao MD for Medical and Health Care Professionals in the Developing World • Email • Dr.T.V.Rao MD 50