Surgical Site Infection

1. Surgical Site Infections
Dr. Rahul Agarwal
DNB General Surgery
Care Hospital

2. 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

3. What is SSI?
Infections that occur
in the wound created
by an invasive surgical
procedure are
generally referred to
as surgical site
infections

4. Criteria for defining SSIs

5. 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

6. 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

7. 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

8. Early
• Infection
presents
within 30 days
of procedure
Intermediate
• Occurs
between one
and three
months
Late
• Presents more
than three
months after
surgery

9. 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.

10. Pathogenesis of surgical site infection
Contaminati
on
•Endogenous
infection
•Exogenous
infection
•Haematogeno
us spread
•Staph
aureus
•Enterobacte
riaceae and
anaerobes
Proliferation
of bacteria
Induce
inflammation
– signs
appear
Identified or
unidentified
Self resolving
-> resolve by
treatment ->
sepsis and
death

11. Wound Assessment
ASEPSIS
• to assess wounds
Southampton Wound
Assessment Scale
• categorized
according to any
complications and
their extent

12. ASEPSIS wound scoring system

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

15. Southampton scoring system
Grade Appearance
• 0 Normal
• I Normal healing with mild
bruises and erythema
 A Some bruising
 B Considerable bruising
 C Mild erythema

16. Grade Appearance
• II Erythema plus other signs
of infection
A At one point
B Around sutures
C Along wound
D Around wound

17. Grade Appearance
• III Clean or haemoserous discharge
A At one point only
B Along wound
C Large volume
D Prolonged

18. Grade Appearance
• IV Major wound complication like pus
A At one point only
B Along wound
• V Deep or severe infection with or
without breakdown

20. Types of Surgery / class of wound
Clean Hernia repair
breast biopsy
1.5%
Clean-
Contaminated
Cholecystectomy
planned bowel resection
2-5%
Contaminated Non-preped bowel
resection
5-30%
Dirty/infected perforation, abscess 5-30%

21. Risk Factors for
Development of
Surgical Site Infections
Patient factor
Local factor
Microbial factor

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

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

24. •Wound Class
•Prolonged hospitalization
(leading to nosocomial
organisms)
•Resistance
Microbial factors

25. Treatment
• Incisional: open surgical wound,
antibiotics for cellulitis or sepsis
• Deep/Organ space: Source control,
antibiotics for sepsis

26. 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

27. 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

28. 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

29. PREVENTION
OF
SURGICAL
SITE
INFECTIONS

30. Ignaz Semmelweis
1846
Realized that washing
hand with a chlorinated
lime solution decreased
mortality from
“puerperal fever’.

31. Joseph Lister
• 1883-1897
• British surgeon
• Used Carbolic Acid
(Phenol) to clean
hands, instruments
and wipe on surgical
wounds drastically
decreased infections.

32. Guidelines for prevention of
Surgical Site Infection
•Information for patients and
carers
•Preoperative phase
•Intra operative phase
•Post operative phase

33. 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

34. 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

35. 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

36. 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

37. 1

38. • 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

39. • 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

40. 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.

41. • 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