Talking about infection in surgeries and methods of prevention

1. SURGICAL SITE INFECTION IN
OBSTETRICS AND GYNAECOLOGY:
prevention and management
Tog article April 2021

2. INTRODUCTION
 After the introduction of antisepsis and antibiotics in the 19th century, subsequent advances have
made surgery even safer
 Some of these advances include good surgical techniques and safe anaesthesia
 Despite this, surgical site infection (SSI) has remained a problem, with huge implications for
patient care and safety. SSI may lead to severe morbidity and mortality, with prolonged
hospitalization and enormous economic costs for both patients and healthcare systems
 Factors associated with increased rates of SSIs include antibiotic resistant pathogens and chronic
disorders such as diabetes , alcoholism , obesity and immunosuppression
 In obstetrics SSIs may be associated with prolonged labor , emergency caesarean section and
multiple vaginal examinations
 common pathogen include Gram- positive and G-negative organisms such as staphylococcus
aureus and E-coli respectively

3. DEFINITION
 SSI is defined as an infection of the superficial or deep skin incision, or of an organ or
space, occurring up to 30 days after surgery if no implant was left behind, or within 1
year if an implant was left in place
 For superficial wound infection, at least one of the following:
• Purulent effluent or exudate with organisms identified
• Presence of one of the following: pain, redness, localized swelling, tenderness or
heat
• Diagnosis of a superficial wound infection by a surgeon or an attending physician

4. Cross-section of abdominal wall illustrating the classification of
surgical site infection by the Centers for Disease Control (CDC)

5. DEFINITION
 For deep wound infection, at least one of the following:
• Purulent exudate from a deep wound incision
• Spontaneous dehiscence of a deep incisional wound or a wound deliberately
opened in the presence of pyrexia >38°C, localized pain, or tenderness
• Evidence of abscess or infection involving deep wound incisions found on
direct examination of the wound, during re-operation, radiologically or on
histology
• Diagnosis of a deep incisional wound infection by a surgeon or an attending
physician

6. DEFINITION
 For organ or space infection, at least one of the following:
• Purulent exudate from a drain placed in the organ or space via a stab
wound
• Organism isolated from the organ or space
• Evidence of abscess or infection involving the organ or space found on
direct examination of the wound, during re-operation, radiologically or
on histology
• Diagnosis of an organ or space wound infection by a surgeon or an
attending physician

7. WOUND CLASSIFICATION
 Clean: a wound made under sterile conditions where there are no organisms present and the skin is
likely to heal without complications, or an incision in which no inflammation is encountered in a surgical
procedure, without a break in sterile technique, and during which the respiratory, alimentary or
genitourinary tracts are not entered (e.g. skin incision for ovarian cystectomy).
 Clean contaminated: a wound made under sterile conditions but in which the respiratory,
gastrointestinal, genital or urinary tract is entered under controlled conditions and without unusual
contamination, or an incision through which the respiratory, alimentary or genitourinary tract is entered
under controlled conditions but with no contamination encountered (e.g., skin incision at hysterectomy
or caesarean section).
 Contaminated: typically an open, fresh or accidental wound or an incision undertaken during an
operation in which there is a major break in sterile technique or gross spillage from the gastrointestinal
tract, or an incision in which acute, non-purulent inflammation is encountered. Open traumatic wounds
that are more than 12 to 24 hours old also fall into this category (obstetrics and gynaecology surgery in
which the bowel is opened either deliberately or accidentally).
 Dirty or infected: a wound with devitalized tissues with organisms pre-existing in the surgical field
before surgery (e.g., laparotomy for pelvic collection).

8. OPERATION CLASSIFICATION
clean
-Sterile condition
-No inflammation
-no enter(RT,GI,GU)
-ovarian cystectomy
-laparoscopy/cystoscopy
Risk of infection :2%
Clean
contaminated
-Sterile condition
-No inflammation
-enter(RT,GI,GU)
-hysterectomy
-C/S
Risk of infection :5-15%
Contaminated
-gross GIT spillage
-acute inflammation
-Open traumatic wound
12-24 hr
-OB & GYNE surgery +
bowel is opened
Risk of infection > 15%
Dirty/
infected
-devitalized tissues
-pus
-pre-existing organism
in the field before
surgery
Laparotomy for pelvic
collection
Risk of infection > 30%

9. EPIDEMIOLOGY
The incidence of all SSI varies depending on the population, risk
factors, type and duration of surgery.
 The incidence is lower in high income countries than in low-
income countries.
This is also varied according to the type of surgery it was highest
after large bowel surgery (8.7%) , bile duct , liver and pancreas
surgery (6.8%) and small bowel surgery (6.7%) and lowest after
knee replacement surgery (0.5%).

10. RISK FACTORS

11. MICROBIOLOGY
 various organisms are responsible for SSIs, causing symptoms by inducing
changes in several inflammatory and complement system pathways
 Some of these organisms are endogenous commensals normally found on
the skin, in the gastrointestinal tract and in the genital tract.
 The most common causative pathogens isolated are enterobacterales
(formerly known as enterobacteriaceae), Staphylococcus aureus and
coliforms such as Escherichia coli and Proteus mirabilis.
 The organism most commonly responsible for SSI after CS is S. aureus.

12. MICROBIOLOGY
 In obstetrics and gynaecology, the
microorganisms most frequently responsible for
SSIs are polymicrobial aerobes and anaerobes,
which are often from both the skin and the
genital tract flora.
 These micro-organisms may come from the skin
or ascend from the vagina (if it is opened, as at
hysterectomy).
 Genital infections such as bacterial vaginosis,
and infection with Neisseria gonorrhoea,
Chlamydia trachomatis or mycoplasma can lead
to ascending infections following transvaginal or
transcervical procedures.
Organisms responsible for surgical site
infection in obstetrics and gynaecology

13. PREVENTION

15. PATIENT FACTORS
 Identifying and managing modifiable risk factors such as lifestyle
changes (smoking cessation, alcohol intake reduction and
maintaining a normal weight before surgery) have been shown to
reduce the incidence of SSI.
 Furthermore, adequate glycaemic control, avoiding
immunosuppression, optimising haemoglobin status and good
nutrition all enhance wound healing and reduce the risk of SSIs.
 A reduction in preoperative hospitalization has been shown to
prevent the development of comorbid conditions and also to
reduce the incidence of SSIs.

16. PREOPERATIVE FACTORS
Nasal decolonization
 Evidence from studies has shown a reduction in the incidence of SSI in
patients who underwent nasal decontamination with an antiseptic
compared with placebo.
 NICE recommends that decolonisation with mupirocin should depend on
the type of surgery and patient factors such as MRSA status.
 It is considered good practice to screen for MRSA status and to
decontaminate women undergoing surgery in obstetrics and gynaecology.

17. PREOPERATIVE FACTORS
Preoperative bathing
 A large study showed a reduction in SSI rate in favour of bathing with 4% chlorhexidine
gluconate over no washing (relative risk [RR] 0.36; 95% confidence interval [CI] 0.17–0.79).
 Based on these data, preoperative bathing or showering is recommended good practice because it
reduces skin colonisation by flora, especially at the surgical site.
Hair removal
 NICE discourages routine preoperative hair removal because it is not considered cost effective
and does not prevent SSI.
 However, NICE advises that if hair removal is necessary, it should be done using electric
clippers with single-use heads rather than razors because razors have been shown to increase the
risk of SSI
 However, the studies from which this conclusion was made were small, so further research is
needed

18. PREOPERATIVE FACTORS
Antimicrobial prophylaxis for caesarean section
 Compared with the control arm, the use of prophylactic antibiotics was shown to reduce the rate of wound
infection by 61% (RR 0.39, 95% CI 0.32–0.48), endometritis by 62% (RR 0.38, 95% CI 0.34–0.42) and
serious maternal infectious complications by 69% (RR 0.31, 95% CI 0.19–0.48)
 It is therefore recommended that routine antibiotics should be given prior to starting the CS, but if
Augmentin is to be used, it should be given after cord clamping.
Antimicrobial prophylaxis for hysterectomy
 The overall effect of prophylactic antibiotics was to decrease the risk of postoperative infection from about
16% to 1–6%. This was also true for vaginal hysterectomy.
 In obstetric and gynaecological surgery, prophylactic IV antibiotics are recommended to be administered
within 60 minutes of the skin incision.
 Prolonged surgery is associated with a higher rate of SSI
 Redosing is therefore recommended if:
 Surgery is prolonged (>3 hours) and
 Blood loss is more than 1500 ml

19. Suggested recommended prophylactic antibiotics for obstetrics and gynaecology surgery

20. EXAMPLES OF PRE-OPERATIVE ANTIBIOTICS
PROCEDURE ANTIBIOTECS
Assisted vaginal delivery: Single prophylactic dose of Amoxicillin and clavulanic acid I.V
Third& fourth perineal
tear
IV Amoxicillin or co-amoxiclav +metronidazole(antibiotic with anaerobic cover)
.postoperative: oral broad spectrum antibiotics+ metronidazole by 5 days orally
Manual removal of the
placenta
Same like 3rd &4th degree perineal tear
Laparoscopy Not recommended if no direct access from the abdominal cavity to the uterine cavity
or vagina
Uro-gynecological
procedures
Co-amoxiclav +GentamicinSTAT<1 hour pre-procedure
.Gentamycin can be used alone, especially in case of penicillin allergy
IUCD Routine use not recommended .When use in cases of gonorrhea—seek advice from
GUM
Mastitis Flucloxacillin

21. INTRAOPERATIVE FACTORS
Hand washing
 Hand decontamination with chlorhexidine or povidone before surgery has been
shown to reduce the load of resident skin flora, with a subsequent reduction in the
incidence of SSI.
 In this respect, alcohol rubbing and scrubbing with povidone-iodine have been shown
to be of similar efficacy.
 Hand-scrubbing for a minimum of 3 minutes has been shown to reduce colony-
forming units of microorganisms over hand-scrubbing for just 2 minutes.
Gloves
 There is inadequate evidence to suggest that single- or double-gloving affects the
incidence of SSI differently; nevertheless, the use of double gloves is recommended
to protect the surgeon.
 Furthermore, double-gloving reduces the risk of needle-stick injuries to the surgeon.

22. INTRAOPERATIVE FACTORS
Gowns and drapes
 Although there is insufficient evidence that
surgical gowns reduce the rate of SSIs,
their use is recommended good practice
because they reduces contamination of the
surgical field with possible sources of
infection.
 Iodophor-impregnated incise drapes are
therefore recommended, unless the patient
is allergic to iodine.

23. INTRAOPERATIVE FACTORS
Skin preparation
 Skin antiseptics have been shown to reduce the number of microflorae,
especially those not removed by soap and water. Chlorhexidine has been widely
used for skin antisepsis and is said to be bacteriostatic, while alcohol-based
preparations are bactericidal and evaporate quickly
 For abdominal hysterectomy, the use of chlorhexidine gluconate in alcohol has
also been associated with a 30% reduction in SSI compared with povidone-
iodine
 Alcohol-based povidone-iodine is recommended as second-line if chlorhexidine
is contraindicated
 Waiting for 3 minutes for the skin preparation to dry has been shown to reduce
the load of colony-forming units of bacteria on the anterior abdominal wall
compared with waiting for 1 minute or 5 minutes.
 chlorhexidine-alcohol should be applied (using gentle back and forth strokes)
for 2 minutes for moist sites (inguinal fold and vulva) and 30 seconds for dry
sites (abdomen) and allowed to dry for 3 minutes.

24. INTRAOPERATIVE FACTORS
Vaginal preparation
 Using antiseptics to clean the vagina may therefore reduce the risk of
SSI caused by vaginal flora
 ACOG guidelines recommend vaginal cleansing with either 4%
chlorhexidine gluconate or povidone-iodine before hysterectomy or
vaginal surgery, although only the latter is approved by the Food and
Drug Administration (FDA)
Skin incision
 The most studied incisions are the lower transverse straight line (Joel
Cohen) and the curved (Pfannenstiel) incision.
 Cochrane reviews comparing the two incisions have shown that the Joel
Cohen incision is associated with less postoperative pain, fever,
analgesic requirement and blood loss, as well as shorter operating time
and hospital stay

25. INTRAOPERATIVE FACTORS
Negative pressure wound therapy
 Negative pressure wound therapy (NPWT) is a wound
management technique in which a vacuum dressing is applied
to promote healing.
 It involves using a sealed wound dressing attached to a pump,
which creates a negative pressure environment in the wound.
This increases blood flow to the area and draws out excess
fluid from the wound.
 It provides continuous negative pressure of 80– 125 mmHg
over a 5–7-day period and allows for even distribution of
pressure over the wound. NPWT has been shown to stimulate
formulation of granulation tissue, increase blood flow, reduce
oedema, improve wound contraction and protect against
external contamination.
 Its use has been shown to reduce the rate of SSI in patients at
increased risk, such as the morbidly obese; smokers; and those
of advanced age, with underlying illnesses or with diabetes.
 It is recommended by NICE.

26. INTRAOPERATIVE FACTORS
Intra-caesarean section procedures and surgical site infection
 Closure of the uterine incision and peritoneum
 Closing the uterus in either one or two layers has not been shown to influence the rate of SSIs or
endometritis.
 Attention to haemostasis and the use of drains has been shown to reduce intra-abdominal
collection and hence pelvic abscess.
 Subcutaneous tissue closure
 A Cochrane review showed that closure of subcutaneous (SC) fat is associated with a reduced rate
of haematoma or seroma formation compared with non-closure (RR 0.52; 95% CI 0.33–0.82) and
also of ‘wound complication’ (haematoma, seroma, wound infection or wound separation; RR
0.68; 95% CI 0.52–0.88).
 This is only beneficial if the SC fat is more than 2 cm deep.
 Wound closure and dressing
 Sutures and staples are mainly used for wound closure and a review of RCTs found that
subcuticular closure is associated with less wound infection compared with the use of staples.
 With regards to the type of suture material used, antimicrobial coated sutures such as triclosan
may reduce the risk of SSI, particularly in abdominal surgeries, compared with plain sutures.

27. SPECIAL CIRCUMSTANCES
Gynaecological oncology
 The principles to consider are similar to those with any gynaecological surgery. The use of ‘surgical
site infection reduction bundles’ has been demonstrated, just as in nongynaecological cases, to reduce
the risk of SSI.
 The elements of this bundle include antimicrobial prophylaxis, skin preparation, avoiding
hypothermia and surgical drains and reducing intraoperative hyper glycaemia.
 With regards to drains and tubes, there is insufficient evidence to recommend their routine use as part
of the SSI reduction bundle; they may indeed cause harm as these foreign bodies can act as a conduit
for bacteria.
Immunocompromised patients
 Immunocompromised patients undergoing surgery should usually be offered prophylactic antibiotics
in line with standard recommendations.
 It is, however, critical that these patients are screened for opportunistic and asymptomatic infections
that would require treatment to reduce the risk of SSIs.

29. SPECIAL CIRCUMSTANCES
Co-existing lower genital tract infections
 Minimising avoidable factors that increase SSI and therefore postoperative morbidity should be
routine for patients undergoing elective surgery.
 Coexisting infections should therefore be treated prior to surgery; however, where the surgery
cannot be postponed, the risks of the infections must be discussed with the patient and, in addition
to routine antimicrobial prophylaxis, a full treatment course for the infection should be offered.
 In case of incidental bacterial vaginosis diagnosed prior to surgery, it is advisable to treat for 5–7
days.
 Where the treatment encroaches onto scheduled surgery, it should be continued to complete the
course after surgery.
 It is, however, not considered a contraindication for surgery.

30. POSTOPERATIVE FACTORS
 With regard to wound care following surgery, an aseptic non-touch
technique should be used for changing or removing dressings.
 Furthermore, wound cleansing should be done with sterile saline for up
to 48 hours after the surgery
 Patients should be advised to shower safely 48 hours after surgery.
 If the wound has separated, or has been surgically opened to drain pus,
tap water should be used to clean it after 48 hours.
 An important risk factor for SSI is immobilisation and prolonged
hospitalisation.
 In fact, various care bundles incorporating individual aspects of SSI
prevention have been developed to reduce SSI rates.

31. Comparisons of recommendations for preventing surgical site infections between guideline
.

32. Comparisons of recommendations for preventing surgical site infections between guideline

33. Comparisons of recommendations for preventing surgical site infections between guideline

34. MANAGEMENT OF SURGICAL SITE INFECTION
 Typically, SSIs develop within 4–7 days postoperatively, especially after a CS.
 Clinically, superficial wound infection may be suggested by erythema and
tenderness with induration at the site of infection.
 Endometritis may present as abdominal pain, heavy lochia, abnormal vaginal
discharge and/or purulent discharge.
 A high index of suspicion based on history, a clinical examination and a review of
vital signs is crucial.
 Any fever >38°C on at least two occasions, at least 4 hours apart more than 24
hours after surgery should be evaluated for infection.
 Not every SSI requires treatment with antibiotics; minor or superficial infections
may only require removal of sutures, abscess drainage and topical antisepsis.
 After taking necessary microbiological swabs from the wound and vagina, blood
cultures, complete blood count and a C-reactive protein (CRP) assay, the use of
antibiotics (broad-spectrum in most cases) is the mainstay of treatment.

35. MANAGEMENT OF SURGICAL SITE INFECTION
 Imaging may also be required to exclude intra-abdominal collection; this is usually in the
form of a transabdominal or transvaginal ultrasound scan. A CT scan may be more
informative when ultrasound is inconclusive.
 The first line antibiotics regimen is typically a combination of a penicillin, such as co-
amoxiclav (amoxicillin and clavulanic acid), or a cephalosporin and metronidazole given in
the absence of severe penicillin allergy (which must be excluded in the history).
 This combination covers S. aureus and anaerobes, which are the most common causes of
SSI.
 Clindamycin or vancomycin can be given if there is severe allergy to penicillin; however,
these do not provide as broad a spectrum cover as co-amoxiclav.
 For infections with which the patient remains febrile after 24–48 hours of antibiotics,
gentamycin can be added.
 In obstetrics and gynaecology, superficial incisional SSI in the form of wound infection is
most commonly caused by S. aureus and presents as cellulitis. It is best treated with a
penicillin-based preparation, such as flucloxacillin.

36. MANAGEMENT OF SURGICAL SITE INFECTION
 Deep-seated SSIs, such as pelvic cellulitis (lateral extension of the vaginal cuff
cellulitis into the parametrium) and pelvic abscesses, may need surgical
exploration of the wound and drainage of the abscess, as well as a peritoneal
saline wash with the insertion of a drain – particularly for large pelvic
collections.
 Radiological drainage can be done in patients with risk factors against repeat
laparotomy or surgical exploration, especially women with multiple
comorbidities.
 Although the evidence is sparse, negative pressure dressing has been used with
good results in patients with complete abdominal incisional wound
dehiscence.
 Some wounds may require debridement and secondary closure.

37. NECROTISING FASCIITIS
 Necrotising fasciitis is an uncommon SSI that has been reported to occur in about 1.8 in
1000 cases following CS.
 It is commonly caused by polymicrobial organisms; aerobic, anaerobic or mixed.
 Three common distinct Necrotising fasciitis syndromes are:
 Type I, or polymicrobial
 Type II, or group A streptococcal
 Type III gas gangrene, or clostridial myonecrosis.
 Type II is the most common in obstetrics and gynaecology.
 Organisms associated with Necrotising fascitis include bacteriodes, Clostridium sp.,
Peptostreptococcus sp., enterobacterales, coliforms, Proteus sp., Pseudomonas sp.,
Klebsiella sp. and MRSA.
 Type II necrotising fasciitis is common in patients with immunosuppression, diabetes,
vascular insufficiency or chronic alcoholism, or who have undergone transplant or are on
steroids.

38. NECROTISING FASCIITIS
 Though uncommon, typically, the patient will present with pain that is not
commensurate with clinical signs.
 The clinical features that should raise suspicion post-surgery include
cellulitis that fails to respond to antibiotics, oedema beyond the area of
erythema, the development of ecchymosis or vesicles over an area of
cellulitis and the presence of gas in tissues, as demonstrated by palpation
(crepitus).
 Imaging will be diagnostic, particularly CT, MRI or plain X-ray showing
the presence of gas in soft tissues, as well as defining the extent of the
inflammation.
 This condition is rapidly progressive; the mainstay of treatment is
antibiotics therapy(possible regimens including a combination of
penicillin G and an aminoglycoside if renal function is normal, as well as
clindamycin to cover streptococci and staphylococci, gram-negative
bacilli and anaerobes) and surgical debridement.

39. CONCLUSION
 Surgical site infection presents a huge burden
on healthcare systems and the patient.
 Despite advances in antibiotic prophylaxis and
treatment with improved wound care, SSI
remains a perisurgical problem.
 The key to reducing the incidence and burden
lies in prevention, which includes modification
of patient-related factors, preoperative
optimisation, peri- and intraoperative
measures, aggressive postoperative vigilance
and treatment of heralding infections.

40. THANK YOU , ANY QUESTION ?