Surgical site infection

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Surgical site infection

  1. 1. Surgical SiteInfection
  2. 2. Introduction Ignaz Semmelweis and Joseph Listerbecame the pioneers of infection controlby introducing antiseptic surgery in middleof 19thcentury. Since then a number of significantdevelopments, particularly in the field ofmicrobiology, have made surgery safer
  3. 3.  In 1992, the US Centers for DiseaseControl (CDC) revised its definition ofwound infection, creating the definitionsurgical site infection (SSI) to preventconfusion between the infection of asurgical incision and the infection of atraumatic wound
  4. 4. Classification Incisional organ, or other organs and spaces manipulatedduring an operation
  5. 5. Incisional infections are further classifiedinto- superficial (skin and subcutaneous tissue)and deep (deep soft tissue-muscle and fascia)
  6. 6. Microbiology of Surgical SiteInfections In clean surgical procedures, in which thegastrointestinal, gynecologic, andrespiratory tracts have not been entered,Staphylococcus aureus from theexogenous environment or the patient’sskin flora is the usual cause of infection
  7. 7. Factors influencing SSIs(Lancet2000)Surgical considerations Skin preparation Site, duration and complexity of the surgery. Presence of suture or foreign body Suturing quality. Pre-existing local or systemic infection Prophylactic atibiotic Haematoma Mechanical stress on wound
  8. 8. Anesthetic considerations Tissue perfusion Normovolaemia or hypovolaemia Concentration of the inspired oxygen Perioperative body temperature Pain Blood transfusion
  9. 9. Patient related factors Diabetes Alcoholism Smoking Poor nutrition Jaundice Obesity Advanced age Poor physical condition
  10. 10.  Surgical Factors- Decreased collagensynthesis Anesthetic factors- Vasoconstriction Patient factors -Immunosuppression
  11. 11. Decreased tissue perfusionDecreased PtO2Decreased collagen Decreased neutrophilDeposition Bactericidal activityDecreased wound Increased woundtensile strength InfectionWound break down
  12. 12. Classification for operative wounds Clean- Elective, not emergency, non-traumatic, primarily closed; no acuteinflammation; no break in technique;respiratory, gastrointestinal, biliary andgenitourinary tracts not entered. Clean contaminated- Urgent oremergency case that is otherwise clean;elective opening of respiratory,gastrointestinal, biliary or genitourinarytract with minimal spillage (e.g.appendectomy)
  13. 13.  Contaminated- Non-purulentinflammation; gross spillage fromgastrointestinal tract; entry into biliary orgenitourinary tract in the presence ofinfected bile or urine; major break intechnique; penetrating trauma <4 hoursold; chronic open wounds to be grafted orcovered. Dirty- Purulent inflammation (e.g.abscess); preoperative perforation ofrespiratory, gastrointestinal, biliary orgenitourinary tract; penetrating trauma >4hours old.(Ann Surgery 1964)
  14. 14. Rates of Infection clean 2.1%, clean-contaminated 3.3%, contaminated 6.4% and dirty 7.1%US National Nosocomial Infection Surveillance (NNIS)system
  15. 15. Prevention of SSI Appropriate use of antibiotics; Appropriate hair removal; Maintenance of postoperative glucosecontrol Maintenance of postoperativenormothermia
  16. 16. Antibiotics One dose of antibiotic to be givenpreoperatively It is generally recommended in electiveclean surgical procedures and cleancontaminated procedures that a singledose of cephalosporin to be administeredintravenously
  17. 17.  Involve pharmacy, infection control, andinfectious disease staff to ensureappropriate timing, selection, and durationof antibiotic
  18. 18. Hair removal Hairs to be removed in OT just beforesurgery. Use of clippers than razors reduces thechances of infection
  19. 19. Glucose control Implement a glucose control protocol. Develop one protocol to be used for allsurgical patients. Regularly check preoperative blood glucoselevels on all patients to identifyhyperglycemia; Assign responsibility and accountability forblood glucose monitoring and control.
  20. 20. CDC surgical site infectionsprevention guidelines, 1999 Category 1A- Strongly recommended forimplementation and supported by well-designed experimental, clinical, orepidemiologic studies Treat remote infection before electiveoperation; Postpone surgery until treated;
  21. 21.  Do not remove hair from operative siteunless necessary to facilitate surgery; Ifhair is removed, do immediately beforesurgery, preferably with electric clippers Select an antimicrobial agent withefficacy against expected pathogen; Intravenous route used to ascertainadequate serum levels during operationand for at most a few hours after incisionclosed
  22. 22.  Category 1B- Strongly recommended forimplementation and supported by someexperimental, clinical, or epidemiologicstudies and strong theoretical rationale Control serum blood glucose perioperatively; Cessation of tobacco use 30 days beforesurgery; Do not withhold necessary blood products toprevent SSIs
  23. 23.  Shower or bath on night before operativeprocedure; Wash incision site before performingantiseptic skin preparation with approvedagent Do not routinely use vancomycin forantimicrobial prophylaxis
  24. 24.  Category II- Suggested for implementationand supported by suggestive clinical orepidemiologic studies or theoreticalrationale Prepare skin in concentric circles fromincision site; Keep preoperative stay in hospital as shortas possible
  25. 25. Superficial incisional surgicalsite infections occur within 30 days of procedure involve only the skin or subcutaneous tissuearound the incision.
  26. 26.  purulent drainage from the incision organisms isolated from an asepticallyobtained culture of fluid or tissue from theincision at least one of the following signs orsymptoms of infection - pain ortenderness, localised swelling, redness orheat - and the incision is deliberatelyopened by a surgeon, unless the culture isnegative
  27. 27. Don’t considered superficial SSIs stitch abscesses infection of an episiotomy or neonatalcircumcision site infected burn wounds incisional SSIs that extend into the fascialand muscle layers
  28. 28. Deep incisional surgical siteinfections occur within 30 days of procedure (or oneyear in the case of implants) are related to the procedure involve deep soft tissues, such as thefascia and muscles.
  29. 29.  purulent drainage from the incision but notfrom the organ/space of the surgical site a deep incision spontaneously dehisces or isdeliberately opened by a surgeon when thepatient has at least one of the following signsor symptoms - fever (>38°C), localised painor tenderness - unless the culture is negative an abscess or other evidence of infectioninvolving the incision is found on directexamination or by histopathologic orradiological examination(CDC definitions of surgical wound infections )
  30. 30. Wound assessment ASEPSIS –to assess wounds resultingfrom cardiothoracic surgery Southampton Wound Assessment Scale –categorized according to any complicationsand their extent
  31. 31. ASEPSIS wound scoring system
  32. 32.  Score 0-10-satisfactory healing 11-20-disturbance of healing 20-30-minor wound infection 31-40-moderate wound infection >41-severe wound infection
  33. 33. Southampton scoring systemGrade Appearance 0 Normal I Normal healing with mildbruises and erythema A Some bruising B considerablebrusing C Mild erythema
  34. 34. Grade Appearance II Erythema plus other signsof infection A At one point B Around sutures C Along wound D Around wound
  35. 35. Grade Appearance III Clean or haemoserousdischarge A At one point only B Along wound C Large volume D Prolonged
  36. 36. Grade Appearance IV Major woundcomplication like pus A At one point only B Along wound V Deep or severeinfection with or withoutbreakdown
  37. 37. Treatment Surgical debridement of wound andantibiotics according to sensitivity
  38. 38. Thank you

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