Surgical Site Infection (Obstetrics and Gynaecology)

1. Presenter: Mah JM
Supervisor: Dr Jerry
Surgical site infection in
obstetrics and gynaecology:
prevention and management
TOG 2021

2. Question 1
• What is the type of wound classification when bowel injury occurred during
caesarean section?
A. Clean
B. Clean contaminated
C. Contaminated
D. Dirty

3. Question 2
• What is the most common organism present in SSI after Caesarean section?
A. S. Aureus
B. E Coli
C. Streptococcus sp.
D. Enterococcus sp.

4. Question 3
• What is the recommendation when there is an incidental finding of bacterial
vaginosis prior to surgery?
A. Do not need treatment as it is an incidental finding
B. Start treatment for 5-7 days and delay surgery
C. Start treatment for 5-7 days and continue with the planned surgery
D. No need treatment but defer the surgery

5. Question 4
• Which of the following is NOT recommended as measures to reduce SSI?
A. Advise patient to bathe the day before or on the day of surgery
B. Hand scrubbing for a minimum of 2 minutes
C. The use of subcuticular sutures for wound closure as compared to staples
D. ERAS protocol

7. Definition
• Infection of the superficial or deep skin incision, or of an organ
or space, occurring up to 30 days after surgery (within 1 year if
an implant was left behind)
• Symptoms and signs
• Purulent effluent or exudate with organism identified
• Pain, redness, localised swelling, tenderness or heat
• Wound dehiscence with fever, pain or tenderness
• Evidence of abscess or infection involving deep wound
• Purulent exudate from a drain placed in the organ or space

8. Wound
classification

9. Epidemiology
• 2-6% of surgeries in high-income countries, higher in low-income countries
• 1.6% SSI after abdominal hysterectomy (audit of SSI in NHS 2017/2018) vs
8.7% in large bowel surgery, 6.8% in bile duct, liver and pancreas, small bowel
surgery, 0.5% in knee replacement surgery (lowest)
• 2.7% following hysterectomy in USA (2/3 were superficial incisional infections -
vaginal cuff cellulitis; 1.1% were deep and organ-space SSIs - vaginal cuff
abscess, peritonitis and pelvic abscess)
• SSI rate following CS vary worldwide 3-15%

10. Risk factors

11. Microbiology
• Enterobacterales (most common) - 30.2%
• Staphylococcus aureus - 22.9%
• Coliforms eg Escherichia coli - 19.6%
• Proteus mirabilis - 13.3%

12. In Obs and Gyn
• Polymicrobial aerobes and
anaerobes (from skin and genital
tract flora)
• Genital infections (bacterial
vaginosis/Neisseria
gonorrhea/Chlamydia
trachomatis/Mycoplasma) -
ascending infections
• Most common organism for SSI after
CS - S. Aureus (40.4%), E Coli
(13.3%), Streptococcus sp. (7.4%),
Enterococcus sp., Pseudomonas sp.
Microbiology

13. Prevention
Patient factors
• Modifiable: smoking cessation, alcohol reduction, maintaining normal weight
• Adequate glycemic control
• Avoid immunosuppression
• Optimise hemoglobin status
• Good nutrition
• Prevent preoperative hospitalisation

14. Prevention
Preoperative factors
• Nasal decolonisation: Positive S. Aureus especially MRSA carriers increased risk of SSI
• NICE recommends decolonisation with mupirocin
• Preoperative bathing
• Recommended good practice as it reduces skin colonisation by flora
• To bathe or shower with a plain or an antimicrobial soup, either the day before or on
the day of surgery
• Hair removal
• WHO recommends if absolutely necessary, should be carried out using a clipper

15. Prevention
Antimicrobial prophylaxis
• For CS
• Reduces the incidences of SSI, endometritis and serious maternal infectious complications by 60-70%
• Administration of first-generation cephalosporins reduces risk of postoperative wound infection by 62% and endometritis by 58%
• Administer within 60 minutes of a CS
• For hysterectomy
• NICE recommends a single dose of IV prophylactic antibiotics at induction of anaesthesia for surgical procedures
• When the wound is infected, antibiotics must be more prolonged
• Prolonged surgery higher SSI: 28% for surgery lasting more than 2 hours
• Significant blood loss (>1500mls) higher SSI
• Redosing recommended if surgery prolonged (>3 hours) and blood loss >1500mls
• Morbidly obese women, higher or indeed double the standard dose of antibiotics (standard dose of cefazolin is 2g, for those who weigh >120kg, this
should be 3g)
• Not recommended in clean, non-prosthetic, uncomplicated surgeries (diagnostic laparoscopy, ovarian cystectomy or laparoscopic sterilisation)

17. Preventions
Intraoperative factors
• Hand washing
• Recommend to wash hands with an antiseptic solution and single-use nail brush before the first operation,
subsequent operations wash with either an antiseptic solution or an alcoholic hand-rub
• Hand scrubbing for a minimum of 3 minutes shown to reduce colony-forming units of microorganisms
• Skin preparation
• For CS and abdominal hysterectomy: Chlorhexidine in alcohol more superior to povidone-iodine
• NICE recommends skin preparation with alcohol-based chlorexidine before skin incision and ensure alcohol-based
solutions dry by evaporation if diathermy is used. Alcohol-based povidone-iodine recommended as second-line if
chlorhexidine is contraindicated
• Waiting for 3 minutes for the skin preparation to dry can reduce the load of colony-forming units of bacteria
• 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

18. Preventions
Intraoperative factors
• Vaginal preparation
• Vaginal preparation immediately before CS significantly reduced incidence of endometritis (NICE have not yet
recommended this practice, several concerns including exposure of foetus to iodine, vaginal staining and allergy to iodine)
• Skin incision
• Joel Cohen: less postoperative pain, fever, analgesic requirement, blood loss, shorter operating time and hospital stay
(compared to pfannenstiel)
• No difference in terms of wound infection and febrile complications
• Negative pressure wound therapy (NPWT)
• Increase blood flow to the area and draw out excess fluid from the wound
• Reduce bacteria contamination and increases vascular perfusion and lymphatic clearance around surgical sites
• Reduce SSI rate in patients with increased risk ie morbidly obese, advanced age, diabetes

21. Preventions
Intra-caesarean section procedures and SSI
• Closure of the uterine incision and peritoneum
• Closure of uterus in one or two layers has not been shown to influence SI
• Closure or non-closure of the peritoneum has no impact on SSI
• Attention to haemostasis and use of drains reduce intra-abdominal collection
• Subcutaneous tissue closure
• Reduce rate of hematoma and wound complication (only beneficial if SC fat is >2cm deep)
• Wound closure and dressing
• Subcuticular closure associated with less wound infection compared to staples
• Antimicrobial coated sutures reduce risk of SSI

22. Special circumstances
• Gynaecological oncology
• Many patients are immunocompromised, hence the use of SSI reduction
bundles to reduce SSI
• Anaerobic coverage recommended where the bowel is entered during surgery
• Intraoperative hypothermia can increase SSI
• Co-existing lower genital tract infections
• Incidental BV diagnosed prior to surgery, advisable to treat for 5-7days, no
contraindication to proceed with surgery

23. Postoperative factors
• Aseptic non-touch technique used for changing or removing dressings
• Wound cleansing with sterile saline for up to 48 hours after surgery
• Advise to shower safely 48 hours after surgery
• No evidence of prolonging use of prophylactic antibiotics
• ERAS protocol

24. Management of SSI
• SSI develops within 4-7days postoperatively
• Any fever >38C on 2 occasions, at least 4 hours apart >24hours after surgery should be
evaluated for infection
• Take microbiological swabs from wound and vagina, blood cultures, complete blood count
and CRP assay
• Use broad-spectrum antibiotics
• A review of antibiotic treatment warranted in the face of clinical progress and availability of
microbiological culture results
• Imaging to exclude intra-abdominal collection with transabdominal or transvaginal
ultrasound scan (CT scan when USG is inconclusive)

25. Management
• First line antibiotics regimen: co-amoxiclav, or cephalosporin and metronidazole
(cover S. Aureus and anaerobes)
• Clindamycin or vancomycin if there is severe allergy to penicillin
• If patient remain febrile after 24-48 hours go antibiotics, gentamicin can be added
• Superficial incisional SSI presents as cellulitis - flucloxacillin
• Deep-seated SSI (pelvic cellulitis and abscesses) - may need surgical exploration
and drainage with peritoneal saline wash with insertion of drain
• Collaborate with tissue viability team for wound management

26. Necrotising fasciitis
• Uncommon, 1.8 in 1000 cases following CS
• Type 1 (polymicrobial), type 2 (group A Streptococcal), type 3 (gas gangrene)
• Type 2 most common in O&G
• Risk factors: patients with immunosuppression, diabetes, vascular insufficiency or chronic alcoholism,
undergone transplant or on steroids
• Diagnose with imaging: presence of gas in soft tissues
• Rapidly progressive
• Antibiotics: penicillin G and aminoglycoside + clindamycin to cover streptococci and staphylococci, gram
negative bacilli and anaerobes
• Surgical debridement

27. Question 1
• What is the type of wound classification when bowel injury occurred during
caesarean section?
A. Clean
B. Clean contaminated
C. Contaminated
D. Dirty

28. Question 1
• What is the type of wound classification when bowel injury occurred during
caesarean section?
A. Clean
B. Clean contaminated
C. Contaminated
D. Dirty

29. Question 2
• What is the most common organism present in SSI after Caesarean section?
A. S. Aureus
B. E Coli
C. Streptococcus sp.
D. Enterococcus sp.

30. Question 2
• What is the most common organism present in SSI after Caesarean section?
A. S. Aureus
B. E Coli
C. Streptococcus sp.
D. Enterococcus sp.

31. Question 3
• What is the recommendation when there is an incidental finding of bacterial
vaginosis prior to surgery?
A. Do not need treatment as it is an incidental finding
B. Start treatment for 5-7 days and delay surgery
C. Start treatment for 5-7 days and continue with the planned surgery
D. No need treatment but defer the surgery

32. Question 3
• What is the recommendation when there is an incidental finding of bacterial
vaginosis prior to surgery?
A. Do not need treatment as it is an incidental finding
B. Start treatment for 5-7 days and delay surgery
C. Start treatment for 5-7 days and continue with the planned surgery
D. No need treatment but defer the surgery

33. Question 4
• Which of the following is NOT recommended as measures to reduce SSI?
A. Advise patient to bathe the day before or on the day of surgery
B. Hand scrubbing for a minimum of 2 minutes
C. The use of subcuticular sutures for wound closure as compared to staples
D. ERAS protocol

34. Question 4
• Which of the following is NOT recommended as measures to reduce SSI?
A. Advise patient to bathe the day before or on the day of surgery
B. Hand scrubbing for a minimum of 2 minutes
C. The use of subcuticular sutures for wound closure as compared to staples
D. ERAS protocol

35. The End