Surgical Site Infection


Published on

Surgical site infection definition, Classification, risk factors,,Asepsis score, southampton scoring, colonization,bacteria causing SSI, Management of SSI

Published in: Health & Medicine, Business
No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Surgical Site Infection

  1. 1. By Doctor Saleem
  2. 2. surgical site infections <ul><li>3 rd most common nosocomial infection </li></ul><ul><li>14-16% </li></ul><ul><li>Most common nosocomial </li></ul><ul><li>infection among surgery </li></ul><ul><li>patients 38% </li></ul><ul><li>2/3 incisional </li></ul><ul><li>1/3 organ </li></ul>
  3. 3. Important Definitions <ul><li>Colonization </li></ul><ul><ul><li>Bacteria present in a wound with no signs or symptoms of systemic inflammation </li></ul></ul><ul><ul><li>Usually less than 10 5 cfu/mL </li></ul></ul><ul><li>Contamination </li></ul><ul><ul><li>Transient exposure of a wound to bacteria </li></ul></ul><ul><ul><li>Varying concentrations of bacteria possible </li></ul></ul><ul><ul><li>Time of exposure suggested to be < 6 hours </li></ul></ul><ul><ul><li>SSI prophylaxis best strategy </li></ul></ul>
  4. 4. Contd; <ul><li>Infection </li></ul><ul><ul><li>Systemic and local signs of inflammation </li></ul></ul><ul><ul><li>Bacterial counts ≥ 10 5 cfu/mL </li></ul></ul><ul><ul><li>Purulent versus nonpurulent </li></ul></ul><ul><li>Surgical wound infection is SSI </li></ul>
  5. 5. Criteria for defining SSIs
  6. 9. Further Classification <ul><li>Etiology </li></ul><ul><li>a) Primary </li></ul><ul><li>The wound is the primary site of infection </li></ul><ul><li>b)Secondary </li></ul><ul><li>Infection arises following a complication that is not directly related to wound </li></ul>
  7. 10. Contd; <ul><li>Time </li></ul><ul><li>a) Early </li></ul><ul><li>Infection presents within 30 days of procedure </li></ul><ul><li>b) Intermediate </li></ul><ul><li>Occurs between one and three months </li></ul><ul><li>c) Late </li></ul><ul><li>Presents more than three months after surgery </li></ul>
  8. 11. Contd; <ul><li>Severity </li></ul><ul><li>a) Minor </li></ul><ul><li>Wound infection is described as minor when there is discharge without cellulitis or deep tissue destruction </li></ul><ul><li>b) major </li></ul><ul><li>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. </li></ul>
  9. 13. Wound assesment <ul><li>For surgical wound assesment several scoring systems are employed especially </li></ul><ul><li>a) Asepsis scoring </li></ul><ul><li>b) Southampton wound assessment scale </li></ul><ul><li>These enable surgical wound healing to be graded according to specific criteria, usually giving a numerical value, thus providing more objective assessment of wound. </li></ul>
  10. 16. Microbiology
  11. 17. Lactobacilli Streptococci Lactobacilli Enterobacteriaceae Aerobic + Anaerobic Microbial Populations
  12. 18. Pathogenesis Virulence Bacterial dose Impaired host resistance
  13. 19. Risk factors <ul><li>Patient factors </li></ul><ul><li>Diabetes </li></ul><ul><li>Obesity </li></ul><ul><li>Nicotine use </li></ul><ul><li>Steroid use </li></ul><ul><li>Malnutrition </li></ul><ul><li>Hospital stay  </li></ul><ul><li>Nares colonization with S. aureus </li></ul><ul><li>Transfusion </li></ul>
  14. 20. <ul><li>Diabetes </li></ul><ul><ul><li> Controversial </li></ul></ul><ul><ul><li> Patients underwent CABG </li></ul></ul><ul><ul><li>@ Increasing levels of HbA1c and SSI rates </li></ul></ul><ul><ul><li>@ Increased glucose levels (>200 mg/dL) </li></ul></ul><ul><li>Nicotine use </li></ul><ul><ul><li> Delays primary wound healing </li></ul></ul><ul><ul><li> Increase the risk of SSI </li></ul></ul><ul><li>Steroid use </li></ul><ul><ul><li> Controversial </li></ul></ul>
  15. 22. <ul><li>Malnutrition </li></ul><ul><ul><li> Theoretical arguments: increase the SSI risk </li></ul></ul><ul><ul><li> Two randomized clinical trials: preoperative </li></ul></ul><ul><ul><li>“ nutritional therapy” did not reduce incisional and </li></ul></ul><ul><ul><li>organ/space SSI risk. </li></ul></ul><ul><li>Prolonged preoperative hospital stay </li></ul><ul><li>Preoperative nares colonization with S. aureus </li></ul><ul><ul><li>Mupirocin ointment: Controversial </li></ul></ul><ul><li>Perioperative transfusion </li></ul><ul><ul><li> No scientific basis </li></ul></ul>
  16. 23. Preop factors <ul><li>Preoperative antiseptic showering </li></ul><ul><li>Preoperative hair removal </li></ul><ul><li>Patient skin preparation in the operating room </li></ul><ul><li>Preoperative hand/forearm antisepsis </li></ul><ul><li>Antimicrobial prophylaxis </li></ul>
  17. 24. <ul><li>Preoperative antiseptic showering </li></ul><ul><ul><li> Decreases skin microbial colony counts </li></ul></ul><ul><ul><li> No evidance of benefit to reduce SSI rates </li></ul></ul><ul><li>Preoperative hair removal </li></ul><ul><ul><li> Shaving: </li></ul></ul><ul><ul><li>@ immediately before the operation: SSI rates 3.1% </li></ul></ul><ul><ul><li>@ shaving within 24 hours preoperatively: 7.1% </li></ul></ul><ul><ul><li>@ having performed >24 hours: SSI rate > 20%. </li></ul></ul><ul><ul><li> Depilatories: </li></ul></ul><ul><ul><li>@ lower SSI risk than shaving or clipping </li></ul></ul><ul><ul><li>@ hypersensitivity reactions </li></ul></ul>
  18. 25. <ul><li>Patient skin preparation in the operating room </li></ul><ul><ul><li> Most common used: Alcohol solutions </li></ul></ul><ul><ul><li>Chlorhexidine gluconate </li></ul></ul><ul><ul><li>Iodophors </li></ul></ul><ul><li>Preoperative hand/forearm antisepsis </li></ul>
  19. 26. Prophylactic antibiotics <ul><li>Class 1 = Clean </li></ul><ul><li>Class 2 = Clean contaminated </li></ul><ul><li>Class 3 = Contaminated </li></ul><ul><li>Class 4 = Dirty infected </li></ul>Prophylactic antibiotics indicated Therapeutic antibiotics
  20. 27. Wound Classification Antibiotic PCN Allergy I 1 st generation Cephalosporin Vancomycin Clindamycin II-Biliary,GU, Upper Digestive 1 st generation Cephalosporin Vancomycin Clindamycin II-Distal Digestive 2 nd generation Cephalosporin Aztreonam and Clindamycin/Flagyl III/IV Generally Therapeutic
  21. 28. Once the incision is made, antibiotic delivery to the wound is impaired. Must give before incision! ABX
  22. 30. Operative characteristics <ul><li>Operating room environment </li></ul><ul><li>Surgical attire and drapes </li></ul><ul><li>Asepsis and surgical technique </li></ul>
  23. 31. <ul><li>Operating room environment </li></ul><ul><ul><li>Ventilation </li></ul></ul><ul><ul><ul><li>@ Positive pressure with respect to corridors and </li></ul></ul></ul><ul><ul><ul><li>adjacent areas </li></ul></ul></ul><ul><ul><li>Environmental surfaces </li></ul></ul><ul><ul><li>@ Rarely implicated as the sources of pathogens </li></ul></ul><ul><ul><li>important in the development of SSIs. </li></ul></ul><ul><ul><li>@ Important to perform routine cleaning of these surfaces </li></ul></ul><ul><ul><li> Conventional sterilization of surgical instruments </li></ul></ul><ul><ul><li>@ Inadequate sterilization of surgical instruments has </li></ul></ul><ul><ul><li>resulted in SSI outbreaks </li></ul></ul>
  24. 32. <ul><li>Surgical attire and drapes </li></ul><ul><ul><li> The use of barriers: </li></ul></ul><ul><ul><li>@ patient : minimize exposure to the skin, mucous </li></ul></ul><ul><ul><li>membranes, or hair of surgical team members </li></ul></ul><ul><ul><li>@ surgical team members : protect from exposure to </li></ul></ul><ul><ul><li>blood and bloodborne pathogens. </li></ul></ul><ul><li>Asepsis and surgical technique </li></ul><ul><ul><li> Rigorous adherence to the principles of asepsis by all scrubbed personnel </li></ul></ul><ul><ul><li> Excellent surgical technique: reduce the risk of SSI. </li></ul></ul><ul><ul><li> Drains: increase incisional SSI risk. </li></ul></ul>
  25. 33. Postoperative issues <ul><li>Incision care </li></ul><ul><ul><li> The type of postoperative incision care </li></ul></ul><ul><ul><li>@ closed primarily: the incision is usually covered </li></ul></ul><ul><ul><li>with a sterile dressing for 24 to 48 hours. </li></ul></ul><ul><ul><li>@ left open to be closed later: the incision is packed </li></ul></ul><ul><ul><li>with a sterile dressing. </li></ul></ul><ul><ul><li>@ left open to heal by second intention: packed with </li></ul></ul><ul><ul><li>sterile moist gauze and covered with a sterile </li></ul></ul><ul><ul><li>dressing. </li></ul></ul>
  26. 34. <ul><li>Treatment surgical site infection </li></ul><ul><li> Efflux of purulent material and pus </li></ul><ul><li> Fascia is intact: </li></ul><ul><li>debridement </li></ul><ul><li>Irrigated with N/S and </li></ul><ul><li>packed to its base with saline-moistened gauze </li></ul><ul><li> Fascia separated: drainage or reoperation </li></ul><ul><li>Most SSIs: healing by secondary intention </li></ul>
  27. 35. <ul><li>Discharge planning </li></ul><ul><ul><li> The intent of discharge planning: </li></ul></ul><ul><ul><li>maintain integrity of the healing incision, </li></ul></ul><ul><ul><li>educate the patient about the signs and symptoms </li></ul></ul><ul><ul><li>of infection, </li></ul></ul><ul><ul><li>advise the patient about whom to contact to report </li></ul></ul><ul><ul><li>any problems. </li></ul></ul>
  28. 36. Thankyou