Something new to undergraduate

1. Surgical site infection
Presented by
DR.MD AB QUIYUM
PHASE A,HEPATOBILIARY SURGERY

2. History
• Egyptian…………………….putrefaction
• Greek and Assyrian…..prophylaxis
• Hippocrates……………...wine and vinegar
• Romans……………………..drain of pus
• Koch’s postulate……….organism concept /germ theory
• Semmelluiz………………..hand washing
• Magic Bullet…………….sulphonamide
• Allexander……………..penicillin…….antiseptic surgery….aseptic surgery

3. DEFINATION
• Bacterial
contamination of
wound during or after
surgery usually 30 days
and one year for
prosthetic surgery.

4. Terminology
• 1. Contamination
• 2 Colonization
• 3. Infection

5. TYPE
• The Centers for Disease Control and Prevention (CDC) classifications of SSI
as follows:
• Superficial incisional SSI - Infection involves only skin and subcutaneous
tissue of incision
• Deep incisional SSI - Infection involves deep tissues, such as fascial and
muscle layers; this also includes infection involving both superficial and
deep incision sites and organ/space SSI draining through incision
• Organ/space SSI - Infection involves any part of the anatomy in organs and
spaces other than the incision, which was opened or manipulated during
operation

7. Other Classification
• ETIOLOGY……
• A. Primary
• the wound is primary site of infection
• B. secondery
• Following a complication that is not directly related to wound.
• Severity…..
• A. minor
• B. major

8. Cont..
• Time…
• A. Early
• Infection present within 30 days of procedure
• B. Intermediate
• Occurs between one and three month
• C. Late
• Present more than three months after surgery

10. COMMON ORGANISM

11. Factor affecting SSI
• A. Patient factor
• B. Pre operative factor
• C. Operative characters
• D. post operative factors

12. • Factors that determine whether a wound will
• become infected
• Host response
• Virulence and inoculum of infective agent
• Vascularity and health of tissue being invaded (including
• local ischaemia as well as systemic shock)
• Presence of dead or foreign tissue
• Presence of antibiotics during the ‘decisive period’

13. • Causes of reduced host
resistance to infection
• Metabolic: malnutrition (including
obesity), diabetes,
• uraemia, jaundice
• Disseminated disease: cancer and
acquired
• immunodeficiency syndrome (AIDS)
• Iatrogenic: radiotherapy,
chemotherapy, steroids
Risk factors for increased risk of wound
infection
Malnutrition (obesity, weight loss)
Metabolic disease (diabetes, uraemia,
jaundice)
Immunosuppression (cancer, AIDS, steroids,
chemotherapy
and radiotherapy)
Colonisation and translocation in the
gastrointestinal tract
Poor perfusion (systemic shock or local
ischaemia)
Foreign body material
Poor surgical technique (dead space,
haematoma)

14. PATHOGENESIS

15. Clinical feature:
• A superficial incisional SSI may produce pus from the wound site.
Samples of the pus may be grown in a culture to find out the types of
germs that are causing the infection.
• A deep incisional SSI may also produce pus. The wound site may
reopen on its own, or a surgeon may reopen the wound and find pus
inside the wound.
• An organ or space SSI may show a discharge of pus coming from a
drain placed through the skin into a body space or organ. A collection
of pus, called an abscess, is an enclosed area of pus and disintegrating
tissue surrounded by inflammation. An abscess may be seen when the
surgeon reopens the wound or by special X-ray studies.

16. Superficial incisional SSI
• characterized by the following:
Occurs within 30 days after the operation
Involves only the skin or subcutaneous tissue
Includes at least one of the following: (a) purulent drainage is present (culture
documentation not required); (b) organisms are isolated from fluid/tissue of the
superficial incision; (c) at least one sign of inflammation (eg, pain or tenderness,
induration, erythema, local warmth of the wound) is present; (d) the wound is
deliberately opened by the surgeon; (e) the surgeon or clinician declares the wound
infected
Note: A wound is not considered a superficial incisional SSI if a stitch abscess is
present; if the infection is at an episiotomy, a circumcision site, or a burn wound;
or if the SSI extends into fascia or muscle

17. Deep incisional SSI
• characterized by the following:
Occurs within 30 days of the operation or within 1 year if an implant is
present
Involves deep soft tissues (eg, fascia and/or muscle) of the incision
Includes at least one of the following: (a) purulent drainage is present
from the deep incision but without organ/space involvement; (b) fascial
dehiscence or fascia is deliberately separated by the surgeon because of
signs of inflammation; (c) a deep abscess is identified by direct
examination or during reoperation, by histopathology, or by radiologic
examination; (d) the surgeon or clinician declares that a deep incisional
infection is present

18. Organ or space SSI
• is characterized by the following:
Occurs within 30 days of the operation or within 1 year if an
implant is present
Involves anatomic structures not opened or manipulated during
the operation
Includes at least one of the following: (a) purulent drainage is
present from a drain placed by a stab wound into the
organ/space; (b) organisms are isolated from the organ/space by
aseptic culturing technique; (c) an abscess in the organ/space is
identified by direct examination, during reoperation, or by
histopathologic or radiologic examination; (d) a diagnosis of
organ/space SSI is made by the surgeon or clinician

19. SCORING SYSTEM ( for wound assessment)
• A. ASEPSIS scoring
• B. SOUTHAMPTON wound assessment scale.

22. SIGN OF NECROTIZING INFECTION
• 1.Odema beyond area of erythema
• 2.crepitus
• 3.skin blistering
• 4.fever (often absent)
• 5.Greyish discharge
• 6.focal skin gangrene
• 7.shock ,coagulopathy, multi organ failure

23. TREATMENT
1.Proper antibiotic according to culture
sensitivity.
2.Efflux of purulent material and pus
If facia is intact
……Debridement
irrigation with N/S
packed to its base with saline moistened
gauze
If fascia separated
drainage or reoperation

24. PREVENTION
A.Pre operative
b. OT discipline
C.During operation
D.Post operative

26. Prophylactic antibiotics should be initiated within one hour before surgical incision,
or within two hours if the patient is receiving vancomycin or fluoroquinolones.
Patients should receive prophylactic antibiotics appropriate for their specific
procedure.
Prophylactic antibiotics should be discontinued within 24 hours of surgery
completion (within 48 hours for cardiothoracic surgery).
Postoperative 6 a.m. blood glucose levels should be controlled (200 mg per dL
[11.10 mmol per L] or less) in patients undergoing cardiac surgery.
Surgical site hair removal should be appropriate for the location and procedure
(e.g., clippers, depilation, no hair removal).
Patients undergoing colorectal surgery should be normothermic (96.8°F [36°C] or
greater) within the first 15 minutes after leaving the operating room.
(the core infection prevention measures)

27. Avoiding surgical site infections
• Staff should always wash their hands between patients
• Length of patient stay should be kept to a minimum
• Preoperative shaving should be done immediately before
• surgery
• Antiseptic skin preparation should be standardised
• Attention to theatre technique and discipline
• Avoid hypothermia perioperatively and ensure supplemental
• oxygenation in recovery

28. Preoperative care:
prophylactic
antibiotic :
consider side
effect and possible
side effect ,timing

30. The 7 S Bundle was created by Maureen Spencer,
RN, M.Ed, Infection Preventionist Consultant.
• 1.safe or practice
• 2.screen
• 3. Shower
• 4.Skin preparation
• 5.solution
• 6.suture
• 7.skin incision preparation

31. Conclusion
• In spite of the use of prophylactic antibiotics, SSIs are still a
real risk of surgery and represent a substantial burden of
disease for both patients and healthcare services in terms of
morbidity, mortality and economic cost.

32. THANK YOU ALL