Surgical Site Infection

1. SURGICAL SITE INFECTION
INTERN Dr. AMIT POUDEL

2. WHAT IS SURGICAL SITE INFECTION?
• A surgical site infection is an infection that occurs in the wound
created by an invasive surgical procedure.
• It leads to
increased morbidity
increased mortality
Increased duration of hospital stay (7 days on an average)
increased cost

3. Types of SSI
• Superficial incisional SSI
• Deep incisional SSI
• Organ / space SSI

4. Superficial incisional SSI
• Infection occurs within 30 days after surgical procedure
AND
• Involves only skin and subcutaneous tissue of the incision
AND
• Patient has at least 1 of the following:
• a. Purulent drainage from the superficial incision
• b. Organism isolated from an aseptically-obtained culture of fluid or tissue
• c. Superficial incision that is deliberately opened by a surgeon and is culture
positive or not cultured and patient has at least one of the following signs or
symptoms: pain or tenderness, localized swelling, redness, heat
• d. Diagnosis of superficial SSI by surgeon or attending physician

5. Do not report the following condition as SSI
• Stitch abscess (minimal inflammation and discharge confined to the
points of suture penetration)
• Infection of an episiotomy or newborn circumcision site
• Infected burn wound
• Incisional SSI that extends into the fascial and muscle layers.

6. Deep Incisional SSI
• Infection occurs within 30 days after the operation if no implant is left in place or
within 1 yr. if implant is in place and the infection appears to be related to the
operation.
AND
• Involves deep soft tissues of the incision, e.g., fascial & muscle layers
AND
• Patient has at least 1 of the following:
a. Purulent drainage from deep incision
b. Deep incision spontaneously dehisces or opened by surgeon and is culture
positive or not cultured and fever >38 C, localized pain or tenderness (Note: a
culture negative finding does not meet this criterion)
c. Abscess or other evidence of infection found on direct exam, during invasive
procedure, by histopathologic exam or imaging test
d. Diagnosis of deep SSI by surgeon or attending physician

7. Organ Space SSI
• Infection occurs within 30 days after the operation if no implant is left in place or
within 1 yr. if implant is in place and the infection appears to be related to the
operation.
AND
• Infection involves any part of the body, excluding the skin incision, fascia, or muscle layers
that is opened or manipulated during the operative procedure
AND
• Patient has at least 1 of the following:
a. Purulent drainage from drain placed into the organ/space
b. Organism isolated from an aseptically-obtained culture of fluid or tissue in the
organ/space
c. Abscess or other evidence of infection found on direct exam, during invasive
procedure, or by histopathologic or exam or imaging test
d. Diagnosis of an organ/space infection by a surgeon or attending physician

8. Further classification
• Severity
a) Minor
discharge without cellulitis or deep tissue destruction
b) Major
Pus discharge with tissue breakdown ,
Partial or total dehiscence of the deep fascial layers of
wound
Systemic illness is present.

9. 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

10. Pathophysiology
• Micro-organisms are normally prevented from causing infection in tissues
by
• mechanical: intact epithelium
• chemical: low gastric pH;
• humoral: antibodies, complement and opsonins;
• cellular: phagocytic cells, macrophages, polymorphonuclear
cells and killer lymphocytes.
……….may be compromised by any comorbid condition of the patient,
surgical intervention and treatment leading to SSI.

12. Risk factors for developing SSI
• Patient factor
• Local factor
• Microbial factor

13. Patient factor
• Older age
• Immunosuppression
• Obesity
• Diabetes mellitus
• Chronic inflammatory process
• Malnutrition
• Peripheral vascular disease
• Smoking
• Anaemia
• Radiation
• Steroid use

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

15. Microbial factor
• Wound Class
• Prolonged hospitalization (leading to nosocomial organisms)
• Resistance

16. Wound Class

17. Common pathogen in surgical patients

18. Wound assessment
• ASEPSIS
• SOUTHAMPTON
• enable surgical wound healing to
be graded according to specific
criteria, usually giving a
numerical value, thus providing
more objective assessment of
wound

19. ASEPSIS wound
scoring system

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

21. Southampton
scoring system

22. SENIC Risk Index (the study of the effect of nosocomial infection control)
• Abdominal operation
• Operation greater than
2 hours
• Class III or IV surgical
wounds
• Three or more
diagnosis at time of
discharge
Risk of Infection
0 1%
1 3.6%
2 9%
3 17%
4 27%

23. Management of surgical site infection
• Most SSIs respond to the removal of sutures with drainage of pus if present
and, occasionally, there is a need for debridement and open wound care.
• Incomplete sealing of the wound edges can often be managed by using a
delayed primary or secondary suture or closure with adhesive tape, but in
larger open wounds the granulation tissue must be healthy with a low bio-
burden of colonizing or contaminating organisms if healing is to occur.

24. Prevention of SSI
• Pre-op factors
• Intra-op factors
• Post-op factors

25. Pre-op factors
• Preoperative antiseptic showering
• Preoperative hair removal
• Patient skin preparation in the operating room
• Preoperative hand/forearm antisepsis( Alcohol solution, Chlorhexidine
gluconate, Iodophors)
• Antimicrobial prophylaxis

26. Antibiotic prophylaxis
• Give antibiotic prophylaxis to patients before:
• clean surgery involving the placement of a prosthesis or
implant
• clean-contaminated surgery
• contaminated surgery.
Do not use antibiotic prophylaxis routinely for clean non-prosthetic
uncomplicated surgery.
•Consider giving a single dose of antibiotic prophylaxis intravenously on
starting anaesthesia.

27. Wound
Classification
Antibiotic Penicillin Allergy
I
1st generation
Cephalosporin
Vancomycin Clindamycin
II-Biliary,GU, Upper
Digestive
1st generation
Cephalosporin
Vancomycin Clindamycin
II-Distal Digestive
2nd generation
Cephalosporin
Aztreonam and
Clindamycin/metronidazole
III/IV Generally Therapeutic

29. Point to remember
Once the
incision is made,
antibiotic
delivery to the
wound is
impaired. Hence
must given
before incision!

30. Intra operative factors
• Operating room environment
Temperature: 68o-73oF, depending on normal ambient temp
Relative humidity: 30%-60%
Air movement: from “clean to less clean” areas
• Surgical attire and drapes
• Asepsis and surgical technique

31. Post operative factors
• Incision care
 The type of postoperative incision care
@ closed primarily: the incision is usually covered with a sterile dressing for
24 to 48 hours.
@ left open to be closed later: the incision is packed with a sterile dressing.
@ left open to heal by second intention: packed with sterile moist gauze and
covered with a sterile dressing.

32. • Changing dressings
Use an aseptic non-touch technique for changing or removing
surgical wound dressings.
• Postoperative cleansing
•Use sterile saline for wound cleansing up to 48 hours after surgery.
•Advise patients that they may shower safely 48 hours after surgery.
•Use tap water for wound cleansing after 48 hours if the surgical
wound has separated or has been surgically opened to drain pus.
•Topical antimicrobial agents for wound healing by primary intention

33. Severe inflammatory response syndrome and
sepsis
SIRS
Two of:
hyperthermia (> 38°C) or hypothermia (< 36°C)
tachycardia (> 90 /min, no β-blockers) or tachypnea (> 20 /min)
white cell count > 12 × 109 / l or < 4 × 109 l
• Sepsis is SIRS with a documented infection
• Severe sepsis or sepsis syndrome or MODS is sepsis with evidence of one or more
organ failures [respiratory (acute respiratory distress syndrome), cardiovascular
(septic shock follows compromise of cardiac function and fall in peripheral vascular
resistance), renal (usually acute tubular necrosis), hepatic, blood coagulation systems
or central nervous system]

34. Surviving sepsis
• Initial evaluation and infection issues
• Initial resuscitation ( cvp :8-12 mm hg, MAP>65 mm hg and urine output>0.5
ml/kg/hr)
• Diagnosis ( via appropriate cultures)
• Antibiotic therapy ( BSAb at the beginning then organism specific)
• Source control
• Hemodynamic support and adjunctive therapy
• Fluid therapy
• Vasopressor/inotropic therapy ( MAP> 65) (nor epi and dopamine)
• Steroids
• Recombinant human activated protein c (in adults with sepsis induced organ
dysfunction)

35. • Other supportive therapy
• Blood product administration (if hb < 7 gm%)
• Mechanical ventilation(TV- 6 ml/kg, PEEP-to avoid collapse and pleateu
pressure < 30 mm hg)
• Glucose control
• Prophyllaxis ( stress ulcers and dvt)

36. To sum it up
• SSI is an infected wound or deep organ space
• SIRS is the body’s systemic response to an infected wound
• MODS is the effect that the infection produces systemically
• MSOF is the end-stage of uncontrolled MODS
• MSOF ultimately leads to death.

37. Thank you.